​Kembara Xtra - Medicine - Respiratory Syncytial Virus Infection

​Kembara Xtra - Medicine - Respiratory Syncytial Virus Infection 
Acute respiratory tract sickness brought on by the medium-sized, membrane-bound RNA virus known as respiratory syncytial virus (RSV) affects people of all ages.
RSV causes upper respiratory tract infections (URTI) in humans.
RSV typically manifests in infants and children as lower respiratory tract infection (LRTI), which can lead to bronchiolitis and, less frequently, pneumonia, respiratory failure, and death.
Child Safety Considerations
By the age of 24 months, 90–95% of children are infected.
 The most common reason for pediatric bronchiolitis (50–90%) Infants under the age of six months and premature infants are more vulnerable.

Epidemiology 

RSV outbreaks happen every winter (from late October to late January).
Morbidity and mortality: RSV infection causes more than 100,000 hospital admissions each year.
- RSV in children under the age of five resulted in 2.1 million outpatient visits in the US.
Incidence
RSV is the most frequent cause of pneumonia in children (29%), accounting for roughly 33 million LRTI/year and up to 199,000 juvenile fatalities globally.
RSV causes 14,000 annual deaths and 177,000 hospitalizations in the elderly. The COVID-19 pandemic had a substantial influence on RSV presentations to clinical care.
Prevalence
Accurate conclusion impossible

Pathophysiology and Etiology 

The Paramyxoviridae family of viruses includes the single-stranded, negative-sense RNA virus known as RSV.
In the majority of outbreaks, there are simultaneously present two subtypes, A and B, with A subtypes causing more serious disease.
RSV can spread through droplet aerosols or direct contact.
The incubation period is 2 to 8 days, with a mean of 4 to 6.
Recurring infections from natural RSV infections lead to insufficient immunity.
- RSV results in an airway inflammation that is highly neutrophilic.
- Infected cells' cytoplasm is where RSV grows and matures before emerging from the plasma membrane.
- RSV is a significant trigger for asthma attacks and chronic obstructive pulmonary disease (COPD) flare-ups.
Genetics
RSV replicates in apical ciliated bronchial epithelial cells and may be linked to polymorphisms in the cytokine-related genes CCR5, IL4, IL8, IL10, and IL13.
Chemokines, which are produced by the airway epithelium, draw neutrophils.
RISK ELEMENTS
Infants born before 35 weeks' gestation, low birth weight, and male gender; underlying cardiac disease; HIV; Down syndrome; any age group with recurrent asthma; and a significant connection with RSV-associated acute LRTI.
- Young children who are socioeconomically vulnerable
- Adult patients with COPD or functional handicap - Immunodeficiency - Siblings with asymptomatic RSV infection - Secondhand smoke - History of atopy, no nursing - Other risk factors
Attendance at daycare facilities; exposure to indoor and outdoor air pollution; multiple births, malnutrition, and higher altitudes;

Prevention 

The most crucial measure in preventing the spread of RSV is good hand cleanliness. When caring for children with bronchiolitis, use alcohol-based rubs to decontaminate your hands. Hands should be washed with soap and water if alcohol-based rubs are not available.
Isolate patients who have RSV that has been confirmed or that is suspected. Palivizumab is a humanized monoclonal antibody used to treat high-risk kids for severe RSV (2).[A]:
Infants with bronchopulmonary dysplasia who are 1 year or 23 months old and in need of therapy, as well as those born prematurely at 28 weeks, 6 days of gestation or 12 months at the start of the RSV season - Children under the age of 12 months who are receiving medical treatment for cyanotic heart disease or who have moderate to severe pulmonary hypertension. Infants and young children under the age of 24 months who have: - Chronic lung disease (CLD) of prematurity
- Congenital cardiac disease with hemodynamic significance
 Neuromuscular disease or congenital airway anomalies
AAP recommendations (2)[A]:
- Preterm children born between the start of the RSV season and 29 weeks' gestational age (wGA) - Infants with CLD of preterm who are in their first year of life.
- Children under 1 years old who have HS-CHD at the start of the season.
 Dosage: 15 mg/kg IM in a maximum of 5 monthly doses starting in November or December.
Breastfeeding has been shown to drastically lower hospital admissions for respiratory infections.


In hospitalized newborns, the following conditions are common: Pulmonary infiltrates/atelectasis (42.8%);  Medial otitis (25,3%)
 Respiratory failure (14%) and hyperinflation (20.8%)  Hyperkalemia (defined as K+ > 6.0), 10.1% Apnea (8.8%), and bacterial pneumonia (7.6%)


Diagnoses include: Immunization history; family history of respiratory disease; history of prematurity; exposure to secondhand smoke; daycare; the number and ages of siblings; and symptoms in children such as nasal congestion, coughing, and coryza.
Young adults who have URI symptoms manifest with low-grade fever, wheezing, nasal flaring, and chest wall retraction in adults.
- Mild temperature, 90% cough, 40% wheeze

clinical assessment 

Vital signs include fever, tachypnea, grunting, flaring, and retraction, apnea, pulse rate, and pulse oximetry. Dry mucous membranes and dehydrated skin turgor Upper respiratory symptoms include rhinorrhea, nasal congestion, coughing, sneezing, and occasionally fever and myalgia.  Lower respiratory tract involvement with different variations on the bronchiolitis-classic symptoms: - Tachypnea and Rhonchus breath sounds
- The utilization of auxiliary muscles, wheezes, and crackles
Extended expiration

Child Safety Considerations

Young infants with bronchiolitis may develop apnea. Apnea, hypoxia, respiratory failure, reduced oral intake, and hydration status are criteria for hospital admission.


Other respiratory viral infections include parainfluenza virus, metapneumovirus, influenza virus, rhinovirus, coronavirus, human bocavirus, and adenovirus. Differential diagnosis: Mild illness/URTI.
- It is important to examine the possibility of coinfection with other viruses (such as the adenovirus or influenza), mycoplasma, or bacteria, such as Bordetella pertussis.
- Allergic rhinitis, sinusitis - Croup, worsening of asthma
 Bronchiolitis, asthma, pneumonia, and aspiration of a foreign body

Laboratory Results 
Initial examinations (lab, imaging)
RSV can be diagnosed clinically without the need for further tests or imaging (4)[B]. However, it is advised for hospitalized patients receiving palivizumab as a preventative measure.
- If obtained, normal or increased WBC count RSV virologic testing rarely affects management choices or results.
Septic workups are not required unless the youngster appears toxic.
When acquired, typical CXR results consist of: - Hyperinflation and thickening of the peribronchioles
- Interstitial infiltrates and atelectasis
- Lobar or segmental consolidation
Tests in the Future & Special Considerations
Comparing real-time PCR to tissue culture and antigen detection tests reveals that it is more sensitive and selective.
Other/Diagnostic Procedures
Hospitalization is necessary, ideally in a secondary care level hospital, if there is evidence of insufficient hydration or nutrition, a history of apnea, lethargy, or moderate to severe respiratory distress (such as nasal flaring, tachypnea, grunting, retractions, or cyanosis), and/or a SpO2 92% in room air (3).[A]
Interpretation of Tests
RSV antigen test: Children up to the age of 32 months have a sensitivity range of 72% to 94% and a specificity range of 95-100%, but older kids and adults have a sensitivity range of 0 to 25%.

Treatment for RSV patients consists of supportive care.
Nasal lubrication and suction
 Fever-reducing antipyretics
Treat dehydration (oral, intravenous, or nasal), especially in young children.
 Oxygen for hypoxia, with a limit for supplementation of 92% SpO2

First Line of Medicine
Supportive care is provided, with oxygen when needed.

Next Line

Never provide salbutamol or albuterol to infants or kids who have been diagnosed with bronchiolitis.
Epinephrine should not be given to newborns or kids who have been diagnosed with bronchiolitis.
In any situation, avoid giving systemic corticosteroids to infants who have been diagnosed with bronchiolitis.
In the emergency room, neonates with a bronchiolitis diagnosis shouldn't receive nebulized hypertonic saline.
 Can decide not to give supplementary oxygen to infants and kids with bronchiolitis if their oxyhemoglobin saturation is higher than 90%.Use of chest physical therapy in infants and kids with bronchiolitis is not advised.
Unless there is a concurrent bacterial infection or a strong suspicion of one, avoid giving antibiotics to infants and children who have bronchiolitis.
For infants with a bronchiolitis diagnosis who are unable to maintain hydration orally, clinicians should offer nasogastric or intravenous fluids.
Although routine use of ribavirin is not advised, it may be used in some circumstances.
Suctioning is frequently used to lessen nasopharynx secretions. However, studies have indicated that it lengthens hospital stays, particularly for infants between the ages of 2 and 12 months.


Further Treatments 

Bulb nares suctioning: pediatric considerations
Children under the age of six should not take over-the-counter (OTC) cough and cold drugs.
Use a nasogastric tube to restore appropriate feeding and hydration if a newborn in the hospital is unable to obtain oral feedings.


Alternative Therapies 

There is no evidence to support any complementary, alternative, or integrative therapies.


Admission 

The major objective is to achieve a proper fluid balance and normal oxygen saturation levels. Patients who continue to become worse despite receiving oxygen therapy may benefit from CPAP.
 Of newborns hospitalized with RSV, 5% require mechanical ventilation.
Nursing-related factors and education:
- Inform the family about proper hand washing.
- Environmental surface cleaning - General safety measures
No predetermined criteria exist for discharge; patients must be improving and show - Stable respiratory condition with no need for oxygen
Adequate follow-up and patient education - The capacity to maintain oral intake and hydration status -

Follow-up
Patient monitoring, sufficient hydration, and preservation of oxygen saturation

 Encourage parents to wash their hands with soap and water or alcohol-based hand gels.
During recuperation, wipe down surfaces with gloves and stay away from childcare and kindergarten.


Prognosis The majority of patients fully recover in 7 to 10 days. Re-infection is frequent.

Complications Each year, 400 deaths are related to RSV, with a 1% total mortality rate.
In especially during the first decade of life, infants hospitalized for RSV may be more likely to experience recurrent wheeze, allergic sensitization, and decreased pulmonary function.

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