US Respiratory Disease Volume 6 reg

Syncytial Virus

Managing Severe Respiratory Syncytial Virus Jennifer L York, MD1

and Paul A Checchia, MD, FAAP, FCCM2

1. Clinical Fellow, Pediatric Critical Care Medicine; 2. Director, Pediatric Cardiac Intensive Care Unit, St Louis Children&#x2019;s Hospital, and Associate Professor of Pediatric Critical Care and Cardiology, Washington University School of Medicine

Abstract

The majority of infants infected with respiratory syncytial virus (RSV) develop mild upper respiratory tract disease; however, more severe disease can occur when the lower respiratory tract becomes involved, with symptoms escalating to include significant wheezing and chest-wall retractions, as well as cyanosis and tachypnea. Extrapulmonary manifestations of RSV disease also have been observed, such as systemic inflammatory response syndrome (SIRS) and arrhythmias. The American Academy of Pediatrics (AAP) recommends that clinicians assess risk factors for severe disease when making decisions regarding the evaluation and management of children with bronchiolitis and has developed clinical practice guidelines to provide an evidence-based approach to the diagnosis and management of bronchiolitis in children between one month and two years of age with detailed recommendations as to which therapies are appropriate for children with more severe RSV disease. As a result of the limitations associated with the management of RSV disease, prevention remains of paramount importance, especially in patients at high risk for severe disease.

Keywords Respiratory syncytial virus, respiratory syncytial virus infections, respiratory tract, management, infant

Disclosure: Paul A Checchia, MD, FAAP, FCCM, has received grant support from MedImmune, Inc. and is a member of their speaker&#x2019;s bureau. Jennifer L York, MD, has no conflicts of interest to declare. Received: September 6, 2010 Accepted: November 23, 2010 Citation: US Respiratory Disease, 2010;6:56&#x2013;9 Correspondence: Paul A Checchia, MD, FAAP, FCCM, Director, Pediatric Cardiac Intensive Care Unit, St Louis Children&#x2019;s Hospital, Associate Professor of Pediatric Critical Care and Cardiology, Washington University School of Medicine, One Children&#x2019;s Place, NWT 8th Floor, St Louis, MO 63110. E: pchecchia@wustl.edu

Respiratory syncytial virus (RSV) infection is associated with a variety of clinical manifestations, ranging from mild cold-like symptoms to more severe disease. The majority of infants infected with RSV develop mild upper respiratory tract disease during their initial RSV infection. However, more severe RSV disease can occur when the lower respiratory tract becomes involved, with symptoms escalating to include significant wheezing and chest-wall retractions, as well as cyanosis and tachypnea in the most severe cases. Extrapulmonary manifestations of RSV disease also have been observed, such as systemic inflammatory response syndrome (SIRS) and arrhythmias. It is important to identify individuals at risk for severe RSV disease so that the most appropriate management strategies can be implemented in a timely manner, reducing the morbidity associated with severe infection. The majority of infants infected with RSV develop mild upper respiratory tract disease during their initial RSV infection. Symptoms generally include cough, runny nose, low-grade fever, and occasional wheezing. The majority of these RSV infections resolve uneventfully, with most children recovering from the illness in one to two weeks.1

In the

most severe cases, hypoxemia, cyanosis, tachypnea, and apneic episodes can occur.2

Between 25 and 40% of children show signs or

symptoms of bronchiolitis or pneumonia during their initial RSV infection,1

56 and research suggests that these numbers may be

increasing. For example, an increase in the rate of annual hospitalizations due to bronchiolitis has been observed. A study by Shay and colleagues3

showed that over a 17-year period there was a significant increase (239%) in annual bronchiolitis-associated hospitalizations in infants below six months of age. Additionally, a 2.4-fold increase in the annual rate of hospitalizations due to bronchiolitis was observed in children younger than one year of age.

There have also been reports of arrhythmias in children infected with RSV, including ventricular tachycardia,5 tachycardia,6&#x2013;8

complex atrial tachycardia,9

In addition to the more common pulmonary symptoms of RSV, a variety of extrapulmonary manifestations, ranging from cardiac involvement to SIRS, have occurred in individuals with severe RSV disease. RSV infection has been associated with myocardial injury, and cardiac manifestations (e.g. myocarditis) have been observed in RSV-infected children.4

supraventricular and complete heart block.10,11

It is well recognized that children with congenital heart disease suffer a much more severe infection with RSV. The incidence of hospitalization with RSV infection of children with congenital heart disease is more than double that of non-cardiac patients.12

These patients have a higher

requirement for supplemental oxygen and invasive ventilation, and have a longer length of stay.

&#xA9; TOUCH BRIEFINGS 2010

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