Respiratory syncytial virus (RSV) is a very common virus that leads to mild, cold-like symptoms in adults and older healthy children. It can be more serious in young babies, especially to those in certain high-risk groups.

RSV; Palivizumab; Respiratory Syncytial Virus Immune Globulin

RSV is the most common germ that causes lung and airway infections in infants and young children. Most infants have had this infection by age 2. Outbreaks of RSV infections most often begin in the fall and run into the spring.

RSV is spread easily by physical contact. Touching, kissing, and shaking hands with an infected person can spread RSV. The disease spreads from person to person through contact with contaminated tiny droplets or objects that the droplets have touched.

RSV can live for a half an hour or more on hands. The virus can also live for up to 5 hours on countertops and for several hours on used tissues. RSV often spreads very rapidly in crowded households and day care centers.

The infection can occur in people of all ages.

Risks include:

• Attending day care
• Being exposed to tobacco smoke
• Having school-aged siblings
• Living in crowded conditions

• Bluish skin color due to a lack of oxygen (cyanosis)
• Breathing difficulty or labored breathing
• Cough
• Croupy cough (often described as a "seal bark" cough)
• Fever
• Nasal flaring
• Rapid breathing(tachypnea)
• Shortness of breath
• Stuffy nose
• Wheezing

Note: Symptoms vary and differ with age. Infants under age 1 are most severely affected and often have the most trouble breathing. Older children usually have only mild, cold-like symptoms. Symptoms usually appear 4 - 6 days after coming in contact with the virus.

Rapid tests for this virus can be done on a fluid sample taken from the nose at many hospitals and clinics.

Antibiotics do not treat RSV. Mild infections go away without treatment. Infants and children with a severe RSV infection may be admitted to the hospital so they can receive oxygen, humidified air, and fluids by IV.

A breathing machine (ventilator) may be needed.

RSV infection can, in rare cases, cause death in infants. However, this is unlikely if the child is seen by a health care provider early in the course of the illness.

More severe RSV disease may be seen in:

• Premature infants
• Infants with chronic lung disease
• Infants whose immune system does not work well
• Infants with certain forms of heart disease

In older children and adults, the disease will usually be mild.

Some evidence suggests that children who have had RSV bronchiolitis are at increased risk for asthma.

In young children, RSV can cause:

• Bronchiolitis
• Croup
• Ear infections
• Lung failure
• Pneumonia

Call your health care provider if breathing difficulties or other symptoms of this disorder appear. Any breathing difficulties in an infant are an emergency. Seek medical attention right away.

A simple way to help prevent RSV infection is to wash your hands often, especially before touching your baby. It is important to make certain that other people, especially caregivers, take precautions to avoid giving RSV to your baby. The following simple steps can help protect your baby:

• Insist that others wash their hands with warm water and soap before touching your baby.
• Have others avoid contact with the baby if they have a cold or fever. If necessary, have them wear a mask.
• Be aware that kissing the baby can spread RSV infection.
• Try to keep young children away from your baby. RSV is very common among young children and easily spreads from child to child.
• Do not smoke inside your house, car, or anywhere near your baby. Exposure to tobacco smoke increases the risk of RSV illness.

Parents of high-risk young infants should avoid crowds during outbreaks of RSV. Moderate-to-large outbreaks are often reported in the local news and newspapers to provide parents with an opportunity to avoid exposure.

The drug Synagis (palivizumab) is approved for the prevention of RSV disease in children younger than 24 months who are at high risk for serious RSV disease. Ask your doctor if your child is at high risk for RSV and whether this medicine should be given.

Committee on Infectious Diseases. Modified recommendations for use of palivizumab for prevention of respiratory syncytial virus infections. Pediatrics. 2009;124:1694-1701.

Simoes E, Groothuis JR, Carbonell-Estrany X, Rieger C, Mitchell I, Fredrick LM, Kimpen J, et al. Palivizumab prophylaxis, respiratory syncytial virus, and subsequent recurrent wheezing. J Pediatr. 2007;151:34-42.

Cincinnati Children's Hospital Medical Center. Evidence based clinical practice guideline for medical management of bronchiolitis in infants less than 1 year of age presenting with a first time episode. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2006 May. 13 p.

Mcintosh K. Respiratory syncytial virus. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier;2007:chap 257.

Bronchopulmonary dysplasia (BPD) is a chronic lung condition that affects newborn babies who were either put on a breathing machine after birth or were born very early (prematurely).

BPD; Chronic lung disease - children; CLD - children

Bronchopulmonary dysplasia (BPD) occurs in severely ill infants who have received high levels of oxygen for long periods of time or who have been on a breathing machine ( ventilator).

It is more common in infants born early (prematurely), whose lungs were not fully developed at birth.

Risk factors include:

• Congenital heart disease
• Prematurity, usually in infants born before 32 weeks of gestation
• Severe respiratory or lung infection
• Other severe illness in the newborn that needs to be treated with oxygen or a ventilator

The risk of severe BPD has decreased in recent years.

• Bluish skincolor
• Chronic cough
• Rapid breathing
• Shortness of breath

• Arterial blood gas
• Chest CT scan
• Chest x-ray
• Pulse oximetry

IN THE HOSPITAL:

A breathing machine (ventilator) is usually needed to send pressure to the lungs to keep the baby's lung tissue inflated, and to deliver more oxygen. Pressures and oxygen levels are slowly reduced. After being weaned from the ventilator, the infant may continue to get oxygen by a mask or nasal tube for several weeks or months.

Infants with BPD are usually fed by tubes inserted into the stomach (NG tube). These babies need extra calories due to the effort of breathing. Infants may need to limit fluids, and may be given medications that remove water from the body (diuretics) to keep the lungs from filling with fluid. Other medications can include corticosteroids, bronchodilators, and surfactants.

Parents of these infants need emotional support, because it can take time for the disease to get better, and the infant may need to stay in the hospital for a long time.

AT HOME:

Infants with BPD may need oxygen therapy for weeks to months after leaving the hospital. It is very important for all infants with chronic lung disease to receive enough calories as they recover. Many will need tube feedings or special formulas.

Preventing your child from getting colds and other respiratory infections, such as respiratory syncytial virus, is very important for their health.

A simple way to help prevent RSV infection is to wash your hands often, especially before touching your baby. It's important to make certain that other people, especially care givers, take precautions to avoid giving RSV to your baby. The following simple steps can help protect your baby:

• Insist that others wash their hands with warm water and soap before touching your baby.
• Have others avoid contact with the baby if they have a cold or fever. If necessary, it may be helpful to wear a mask.
• Be aware that kissing the baby can spread RSV infection.
• Try to keep young children away from your baby. RSV is very common among young children and easily spreads from child to child.
• Do not smoke inside your house, car, or anywhere near your baby. Exposure to tobacco smoke increases the risk of RSV illness.

Parents with high-risk young infants should avoid crowds during outbreaks of RSV. Moderate-to-large outbreaks are often reported in the local news and newspapers to provide parents with an opportunity to avoid exposure.

The drug Synagis (palivizumab) is approved for prevention of RSV disease in children younger than 24 months of age who are at high risk for serious RSV disease. Ask your doctor if your child is at high risk for RSV and whether this medicine should be given.

Babies with bronchopulmonary dysplasia get better slowly over time. It's possible for infants to need oxygen therapy for many months. Some infants with this condition might not survive. Some children are left with chronic lung damage.

Babies who have had BPD are at a greater risk for having recurrent respiratory infections, such as pneumonia, bronchiolitis, and respiratory syncytial virus(RSV) that require a hospital stay. Many of the airway (bronchiole) changes in babies with bronchopulmonary dysplasia will not go away.

Other potential complications in babies who have had BPD are pulmonary hypertension, poor growth, and developmental problems.

If your baby had BPD, watch for any breathing problems. Call your health care provider if you see any signs of a respiratory infection.

To help prevent BPD:

Prevent premature delivery whenever possible.

Take the baby off the breathing assistance early, if possible, and use a substance that helps open the baby's lungs (surfactant).

Bancalari, EH. Dysplasia and Neontal Chronic Lung Disease. In: Fanaroff AA, Martin RJ, eds. Neonatal-Perinatal Medicine: Diseases of the Fetus and Infant. 8th ed. Philadelphia, Pa: Mosby Elsevier; 2006: part 7.

Cincinnati Children's Hospital Medical Center. Evidence based clinical practice guideline for medical management of bronchiolitis in infants less than 1 year of age presenting with a first time episode. Cincinnati (Ohio) Children's Hospital Medical Center; 2006, May: 13.

Meissner HC, Long SS. American Academy of Pediatrics Committee on Infectious Diseases and Committee on Fetus and Newborn. Revised indications for the use of palivizumab and respiratory syncytial virus immune globulin intravenous for the prevention of respiratory syncytial virus infections. Pediatrics. 2003;112:1447-52.

Bronchiolitis is swelling and mucus buildup in the smallest air passages in the lungs (bronchioles), usually due to a viral infection.

Bronchiolitis usually affects children under the age of 2, with a peak age of 3 - 6 months. It is a common, and sometimes severe illness. Respiratory syncytial virus (RSV) is the most common cause. Other viruses that can cause bronchiolitis include:

• Adenovirus
• Influenza
• Parainfluenza

The virus is transmitted from person to person by direct contact with nasal fluids, or by airborne droplets. Although RSV generally causes only mild symptoms in an adult, it can cause severe illness in an infant.

Bronchiolitis is seasonal and appears more often in the fall and winter months. It is a very common reason for infants to be hospitalized during winter and early spring. It is estimated that by their first year, more than half of all infants have been exposed to RSV.

Risk factors include:

• Exposure to cigarette smoke
• Age younger than 6 months old
• Living in crowded conditions
• Lack of breast-feeding
• Prematurity (being born before 37 weeks gestation)

Some children have infections with few or minor symptoms.

Bronchiolitis begins as a mild upper respiratory infection. Over a period of 2 - 3 days, it can develop into increasing respiratory distress with wheezing and a "tight" wheezy cough.

The infant's breathing rate may increase (tachypnea), and the infant may become irritable or anxious-looking. If the disease is severe enough, the infant may turn bluish (cyanotic), which is an emergency.

As the effort of breathing increases, parents may see the child's nostrils flaring with each breath and the muscles between the ribs retracting (intercostal retractions) as the child tries to breathe in air. This can be exhausting for the child, and very young infants may become so tired that they have difficulty maintaining breathing.

Symptoms include:

• Bluish skin due to lack of oxygen (cyanosis)
• Cough, wheezing, shortness of breath, or difficulty breathing
• Fever
• Intercostal retractions
• Nasal flaring in infants
• Rapid breathing (tachypnea)

Signs include:

• Decreased blood oxygen
• Wheezing and crackling sounds heard through stethoscope exam of chest

Tests include:

• Blood gases
• Chest x-ray
• Nasal fluid cultures (to determine which virus is present)

Sometimes, no treatment is necessary.

Supportive therapy can include:

• Chest clapping
• Drinking enough fluids. Breast milk or formula are okay for children younger than 12 months. Offer warm lemonade or apple juice if your child is over 4 months.
• Breathing moist (wet) air helps loosen the sticky mucus that may be choking your child. You can use a humidifier to moisten the air your child is breathing. Follow the directions that come with the humidifier.
• Getting plenty of rest
• Do not let anyone smoke in the house, car, or anywhere near your child.

Antibiotics are not effective against viral infections. Most medications have little effect on bronchiolitis. Children in the hospital may need oxygen therapy and fluids given through a vein (IV) to stay hydrated.

In extremely ill children, antiviral medications (such as ribavirin) are used in rare cases.

Usually, the symptoms get better within a week, and breathing difficulty usually improves by the third day. The mortality rate is less than 1%.

• Airway disease, including asthma, later in life
• Respiratory failure
• Additional infection, such as pneumonia

Call your health care provider immediately, or go to the emergency room if the child with bronchiolitis:

• Becomes lethargic
• Develops a bluish color in the skin, nails, or lips
• Develops rapid, shallow breathing
• Has a cold that suddenly worsens
• Has difficulty breathing
• Flares nostrils or retracts chest muscles in an effort to breathe

Most cases of bronchiolitis are not easily preventable because the viruses that cause the disorder are common in the environment. Careful attention to hand washing, especially around infants, can help prevent the spread of respiratory viruses.

Family members with an upper respiratory infection should be especially careful around infants. Wash your hands often, especially before handling the child.

At this date, there is no RSV vaccine available. However, there is an effective product, called palivizumab (Synagis), for infants who are at high risk of developing severe disease from RSV. Ask your child's doctor whether this medication is right for your child.

Watts KD, Goodman DM. Wheezing, bronchiolitis, and bronchitis. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier;2007:chap 388.

American Academy of Pediatrics Subcommittee on the Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis. Pediatrics. 2006;118:1774-1793.

Viral pneumonia is an inflammation (irritation and swelling) of the lungs caused by infection with a virus.

See also:

• Atypical pneumonia
• Influenza
• Mycoplasma pneumonia
• Respiratory syncytial virus

Pneumonia - viral

Pneumonia is an infection of the lung that affects 1 out of 100 people annually. Viral pneumonia is caused by one of several viruses, including influenza, parainfluenza, adenovirus, rhinovirus, herpes simplex virus, respiratory syncytial virus, hantavirus, and cytomegalovirus.

People at risk for more serious viral pneumonia typically have weakened immune systems. This includes young children, especially those with heart defects, and the elderly. The following also weaken the immune system and raise the risk for pneumonia:

• HIV
• Medications that suppress the immune system
• Organ transplant

• Chills
• Clammy skin
• Cough
• Fatigue
• Fever
• Headache
• Joint stiffness
• Muscle stiffness and aching
• Nausea and vomiting
• Sore throat
• Shortness of breath
• Sweating

Persons with suspected pneumonia should have a complete medical evaluation, including a thorough physical exam and a chest x-ray -- especially since the physical exam may not always distinguish pneumonia from acute bronchitis or other respiratory infections.

Depending on the severity of illness, additional studies may be done, include:

• Complete blood count (CBC)
• Blood cultures
• Blood tests for antibodies to specific viruses
• Bronchoscopy
• Open lung biopsy (only done in very serious illnesses when the diagnosis cannot be made from other sources)
• Sputum culture

Some of the more serious forms of viral pneumonia can be treated with antiviral medications. Antibiotics are not effective.

Treatment may also involve:

• Increased fluids
• Oxygen
• Use of humidified air

A hospital stay may be necessary to prevent dehydration and to help with breathing if the infection is serious.

Most cases of viral pneumonia are mild and get better without treatment within 1 - 3 weeks, but some cases are more serious and require hospitalization.

More serious infections can result in respiratory failure, liver failure, and heart failure. Sometimes, bacterial infections occur during or just after viral pneumonia, which may lead to more serious forms of pneumonia.

Call your health care provider if symptoms of viral pneumonia develop.

Vaccines against the flu and RSV are available for those at high risk for viral pneumonia.

Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44:S27-S72.

Limper AH. Overview of pneumonia. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 97.