Research Applied to Clinical Practice
Respiratory Syncytial Virus (RSV) seems to pop up every year during the winter months and all the clinics, urgent cares, and EDs see their share of patients who become infected with this ubiquitous virus. RSV is a highly contagious and easily transmittable pathogen. An estimated 90,000 hospitalizations and 4,500 deaths each year are associated with RSV (Hall & McCarthy, 1995). It has been attributed to 80% to 85% of yearly bronchiolitis and pneumonia episodes, and has even been obtained from cases of otitis media (Filippell & Rearick, 1993).
The most common methods of transmission are; direct contact with a body fluid containing the virus (i.e. tissues), touching fomites (substances or items capable of absorbing or carrying disease pathogens), or large droplet aerosols produced by sneezing (Halpern, 1992). Studies have shown that the virus can survive for 3 to 4 hours on non-porous surfaces (Loveless, Demers, & Linn, 1995).
Due to its high contagious nature, nearly all infants experience infection from this virus sometime during their first 3 years of life (Oertel, 1996). The signs and symptoms are similar to a prolonged cold (rhinorrhea, pharyngitis, cough, wheezing, crackles, fever, ear aches), and because there are different strains of the virus and exposure only provides limited immunity, re-infections can occur throughout a persons life (Filippell & Rearick, 1993).
The incubation period is 4-6 days and viral shedding usually lasts 3-8 days but for those with immunologic dysfunction shedding can last over 112 days (Filippell & Rearick, 1993). The morbidity and mortality associated with this virus is related to the progression of the signs and symptoms from upper respiratory to lower respiratory tract involvement. The segment of the population susceptible to severe reactions and complications include:
Because it is a virus, the treatment is limited and usually palliative. For those susceptible to severe forms, there is a vaccine which has been developed, an RSV immunoglobin called RespiGam . But it is very expensive, and has only been tested on children. The recommended treatment regime is for 3-5 doses each given IV over a 3 hour period. The first dose to be given before RSV season then monthly over the remainder of the season (Oertel, 1996). Research is still being done on the elderly and those immunocompromised.
Once a patient is deemed to need hospitalization, the treatment regime includes supplemental oxygen, and respiratory support. Studies have shown systemic steroids have proven beneficial, but treatment with antibiotics has proven ineffective and creates more complications (Hall, 1994). Aerosolized bronchodilators have not proven to be very effective in the long term treatment, although, they have shown minor improvement in the acute phase (Hammer, Numa, & Newth, 1995). The only effective treatment to date has been aerosolized Ribavirin. This drug has been in use for over ten years and even up to 1996 there was debate over dosing and exposure time (Loveless, Demers, & Linn, 1995). There have also been studies to disprove the effectiveness of Ribavirin (Zamorski, 1996).
So what does this mean to the clinician?
Anyone of any age can be infected with RSV, since the signs and symptoms are similar to upper respiratory infections and these people are contagious, when they present to your clinic, urgent care or ER, they need to be isolated from the high risk population (stated earlier). This means putting either the infected patient or the high risk patient in a room non-adjoining or totally away form the infected person. It also means not putting a high risk patient in a treatment room that was previously occupied by someone exhibiting signs and symptoms of a URI. For as previously stated, the virus can live for up to 4 hours on surfaces (Filippell & Rearick, 1993, Hall, 1994).
How can RSV be diagnosed?
The fastest and cheapest is an ELISA or EIA diagnostic kit (there are many brands available). These tests are specifically designed to detect RSV antigen from the epithelial cells from a nasopharyngeal specimen. There are other ways to determine the presence of the RSV virus, including serology, culture, radioimmunoassay, and reverse hemagglutination tests, but they are not popular choices for either cost, accuracy or time constraint reasons (Filippell & Rearick, 1993). Another common diagnostic tool is a simple chest x-ray, which can show hyper-insuflation, and/or patchy infiltrates (Hall, 1994).
How to obtain a specimen?
Nasopharyangeal specimens can be obtained either by aspiration or wash technique. Aspiration involves using either a bulb syringe or 5cc to 10 cc syringe with a piece of suction catheter attached and withdrawing at least 0.2ml of discharge. The wash technique involves instilling saline into the nasopharyngeal space then "sucking" it out via syringe or Lukens device, this technique requires at least 1ml of aspirate. The color of either specimen should be uniformly cloudy. This process of specimen collection may stimulate bronchospasm or stridor, therefore, resuscitation equipment and personnel should be nearby (Filippell & Rearick, 1993). Once the specimen is obtained, it should be protected from changes in temperature, as temperature change will affect the accuracy.
Who should be hospitalized?
Any patient who needs supplemental oxygen, or those with a respiratory rate greater than 50/min. (Loveless, Demers, & Linn, 1995).
Proper handwashing technique is one of the keys in preventing nosocomial and autoinoculation infections. The viability of the pathogen to remain active for over 4 hours on surfaces is important to remember. Because it is so easy for staff to go into a room in which there is or was an infected patient, touch a surface then touch their own mucous membranes, and become infected (Halpern, 1992).
What to teach families?
Proper handwashing is key in the home also, although studies have shown that this virus spreads easily in closed environments/homes, and close quarters (especially during winter) (Filippell & Rearick, 1993, Hall, 1994). The parents of high risk children need to be taught the following; Signs and symptoms of decompensation and isolation techniques within the household and community, i.e. keeping infected people away from the child, handwashing of visitors, etc. (Filippell & Rearick, 1993).
It should be noted that this virus commonly spreads rapidly and diffusely throughout a family and community and there are no current effective barriers to prevent the communicability. Therefore, when we are treating a patient exhibiting S/S of a URI, we not only have to treat them palliatively, but also educate them as to their role in helping prevent its spread, paying special attention to those at high risk for decompensation.
Filippell, M.B., & Rearick, T. (1993). Respiratory
syncytial virus. Nursing Clinics of North America, 28 (3), 651-671.
"Research Applied to Clinical Practice: Respiratory
Syncytial Virus (RSV)"
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