RSV/Bronchiolitis: The story behind the wheeze Beth Condley, CPNP-AC, MSN

1. RSV/Bronchiolitis: The story behind the wheeze Beth Condley, CPNP-AC, MSN

2. Objectives • Determine underlying pathophysiology of RSV/bronchiolitis • Determine most appropriate and up to date guidelines on therapy for RSV/bronchiolitis • Determine recent changes in treatment for RSV/bronchiolitis • Determine whether adults develop RSV infections

3. Epidemiology of RSV • According to the American Academy of Pediatrics, about 125,000children are hospitalized with RSV each year in the United States, and about 500 of them die. A serious RSV infection is a frightening experience for parents and their baby.

4. Epidemiology • Annual outbreaks of RSV infection typically occur between October and May, with the peak effect falling in January and February • Peak incidence occurs in children younger than 12 months • Three months is the mean age of infants hospitalized with RSV infection.

5. Epidemiology • Nearly 100% of children experience an RSV infection within 2 RSV seasons, and 1% are hospitalized • Among healthy full-term infants, 80% of hospitalizations occur in the first year, and 50% of hospitalizations occur in children aged 1-3 months • The cost of hospitalization for bronchiolitis in children younger than 1 year is estimated to be more than $700 million per year

6. Oklahoma Trends The National Respiratory and Enteric Virus Surveillance System (NREVSS)

7. This Winter has been NUTS! • Integris Baptist – Pediatrics 10 West Statistics • December 2010 • Total floor admissions 134 • Respiratory admissions 15 (11%) • January 2011 • Total floor admissions 170 • Respiratory admissions 74 (44%) • February 2011 • Total floor admissions 141 • Respiratory admissions 73 (52%)

8. Pathophysiology of Bronchiolitis Inflamed airways and mucus production cause the already tiny airways to become even smaller…

9. Pathophysiology • Most cases (93%) occur between November and April, however, sporadic cases can occur year round • Attack rates within families are as high as 45% and are even higher in day care centers • Rates of hospital-acquired infection range from 20-47%

10. Pathophysiology • Previous infection with the common etiologic viruses does not confer immunity • Repeated infections with different forms of RSV in the same child are common

11. Incubation • The incubation period ranges from several days to weeks, depending on the infection causing the bronchiolitis • The incubation period for RSV is 3 to 5 days in most patients

12. Incubation • Another factor making the spread of RSV unavoidable is the period of viral shedding • Viral shedding may occur 1 to 2 days before symptoms become apparent and last as long as 2 weeks after symptom onset

13. Contagiousness • RSV/Bronchiolitis is contagious. • The germs spread in tiny drops of fluid from an infected person’s mouth or nose. • These droplets become airborne via sneezes, coughs, or laughs, and can also end up on things the person has touched, such as tissues or toys.

14. Typical Symptoms • Congestion and runny nose • Cough • Wheezing, cyanosis, grunting • Difficulty breathing • Mild fever • Irritability • Vomiting, especially post-tussive • Production of large amounts of secretions • Decreased feeding or drinking

15. Typical Symptoms for Adults • Runny nose • Cough • Congestion • Low grade fever (<100 degree Fahrenheit) • General malaise

16. Increased Risk of Developing Serious RSV Infection Include: • Premature infants and infants less than 6 weeks of age • Infants with congenital heart disease • Infants with chronic lung conditions • i.e. bronchopulmonary dysplasia and cystic fibrosis • Immunodeficiency • Lower socioeconomic status; crowded living conditions • Exposure to passive cigarette smoke • Attendance in daycare • Presence of older siblings in the home • Infants who are not breastfed

17. Home Treatment • Time to recover and plenty of fluids • Cool mist vaporizer or humidifier to help loosen mucus in the airways • Bulb syringe and saline drops – especially prior to feedings • Treat fever with acetaminophen or ibuprofen and make the child more comfortable

18. Aspirin • Treat fever using a nonaspirin fever medicine line acetaminophen or ibuprofen. • Aspirin should not be used in children with viral illnesses, as such use has been associated with Reye’s syndrome, a life-threatening illness.

19. Time to visit the Doctor/NP/PA/CNS…. • Breathing becomes rapid, especially if accompanied by retractions or wheezing • Decreased PO intake or urine output • Sleepier than normal • High Fevers • Worsening cough • Appears fatigued or lethargic

20. Respiratory Distress

21. Hospital Admission Criteria • Oxygen saturations less than 94% • Respiratory distress • RR >60 bpm or retractions at rest • Infant or child unable to eat • Hypercarbia • Apnea or risk of apnea • Lethargic appearance • Pneumonia on CXR • Age < 2 mos or history of prematurity • Underlying cardiopulmonary disease or immunosuppression

22. Treatment • General supportive measures are the gold standard of care and are the mainstays of treatment for bronchiolitis • That means supplemental O2, IV fluids, and frequent suctioning • Patients should be made as comfortable as possible • Cardiorespiratory monitoring as well as pulse oximetry are essential

23. Treatment • Supplemental humidified oxygen should be administered if the saturations are <94% on room air or if the child looks like they are struggling • Antibioticsare not indicated unless bacterial infection is suggested • Does the patient look toxic? Have high fevers? Have an infiltrate on CXR? Have a high WBC count?

24. High Flow Nasal Cannula • Compared to non-rebreather • Able to deliver a higher fraction of inspired oxygen • Can provide a small amount of continuous positive airway pressure • May also aid in: • Flushing of the nasopharyngeal dead space, reduced nasal resistance, and increased moisture in the nasal passages

25. What about breathing treatments? • Reasonable to try a trial of an inhaled bronchodilator to determine if the patient will have a response • Albuterol • Racemic Epinephrine • Hypertonic Saline

26. Albuterol • Beta2-Adrenergic Agonist • Mechanism of action: • Relaxes bronchial smooth muscle by acting on beta2-receptors with little effect on heart rate • Does it work? • 30% of the patients will respond to treatments

27. Racemic Epinephrine • Alpha/Beta Agonist • Mechanism of action: • Stimulates alpha-, beta1-, and beta2-adrenergic receptors resulting in relaxation of smooth muscle of the bronchial tree • Does it work? • 30% of patients will respond to treatments

28. Hypertonic Saline • 3% Sodium Chloride • Mechanism of action: • Helps to alleviate airway edema due to the osmotic load in the 3% saline; helps to also mobilize secretions within the airways • Does it work? • 30% of patients will respond to treatments

29. Will this turn into Asthma?

30. RSV and Asthma?

31. Prevention • Frequent Hand Washing • Keep infants away from others who have colds or coughs • Avoid exposing children to cigarette smoke • Prophylaxis with Palivizumab (Synagis) for a selected population

32. Prophylaxis • Infants at high risk for RSV infection, two options are currently available • Palivizumab (Synagis) • Intravenous RSV Immune-globulin (RSV-IG [RespiGam])

33. Candidates for Synagis • Infants and children under the age of 2 who have required treatment for chronic lung disease,such as oxygen, bronchodilators, diuretics, or steroids within 6 months of the start of RSV season • Infants born at or before 28 weeksgestation and who are less than 12 months old at the start of RSV season

34. Candidates for Synagis • Infants born at 29 weeks but before 32 weeks gestation and who are less than 6 months old at the start of RSV season • Infants born at 32 weeks gestation and who are less than 3 months old at the start of RSV season or who are born during RSV season and who have at least one of the following risk factors: • Daycare attendance • Has a sibling in the home less than 5 years old

35. Candidates for Synagis • Certain children who are less than 2 years old with congenital heart, including congestive heart failure, pulmonary hypertension, and cyanotic heart lesions • Certain infants born before 35 weeks with congenital abnormalities of the airway or neuromuscular disease

36. Candidates for Synagis • Some experts consider multiple births, crowded living conditions, family history of asthma, and low birth weight to be additional risk factors to use when considering which 32 to 35 week preemie should receive Synagis

37. Why not everyone?? • Since RSV infections are so common and the symptoms can be so severe, why doesn't everyone get Synagis? • Younger infants, especially if they were born premature, are most at risk for serious complications of RSV infections • The other reason is the COST! Synagis injections cost over $900 per month and requires a monthly injection during RSV season

38. Cost of Prophylaxis $10,305.00 $6,338.00 $19,467.00 $21,151.59 $38,933.75 $127,680.64

39. Average Cost for RSV-related Hospitalization • The average cost for a pediatric stay with RSV as the principal diagnosis is $3,824. • The ALOS is 3.6 days. • This data is based on discharges in calendar year 2010, inpatients, nursing unit of 10W or PICU. • Principal diagnosis is 079.6 respiratory synctial virus, 466.11 acute bronchiolitis due to RSV, or 480.1 pneumonia due to RSV.

40. Prevention is key • Attempting to prevent RSV/bronchiolitis is the main way to combat the disease • Children born in the winter months should be kept away from people with cold or flu-like symptoms • Wash your hands! • Seek treatment when appropriate

41. Resources • Very special thanks to: • Dr. Johnny Griggs • Dr. Bill Banner • Leslie Patatanian, PharmD

42. Resources • Hay, W.W., Levin, M.J., Sondheimer, J.M., Deterding, R.R. (2007) Current Diagnosis and Treatment in Pediatrics, McGraw-Hill: Chicago, IL • Osborn, L.M., DeWitt, T.G., First, L.R., & Zenel, J.A. (2005) Pediatrics, Elsevier-Mosby: Philadelphia, PA • www.guidelines.gov

43. Questions???