Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

mild or self-limited illness

1st line – outpatient or inpatient supportive care

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ACUTE
|
mild or self-limited illness
1st line – 

outpatient or inpatient supportive care

For most infants RSV disease is usually mild and self-limited, and can be treated in the outpatient setting. Outpatient care requires diligent follow-up to ensure the patient is not deteriorating.

Treatment is largely supportive regardless of setting, with a focus on improving oxygenation and ventilation and providing adequate nutritional support. No available treatment shortens the course of bronchiolitis or hastens the resolution of symptoms.[8] Infants are obligate nose breathers, and nasal obstruction is a frequent problem. Simple nasal toilet with saline drops and a suction bulb can significantly improve the work of breathing.

High-risk infants include those with history of prematurity, age <6 months at start of RSV season, chronic lung disease, complex congenital heart disease, or immune deficiency. These patients require closer observation and, frequently, admission to the hospital.

Symptomatic therapy for healthy adults is usually sufficient, as the disease is usually confined to the upper respiratory tract and is self-limited.

For adults with mild RSV illness, therapy is also largely supportive and targeted at relieving symptoms.

Consider – nebulized hypertonic saline

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ACUTE
|
mild or self-limited illness
Consider – 

nebulized hypertonic saline

Treatment recommended for SOME patients in selected patient group

Nebulized hypertonic saline is of potential benefit in reducing symptoms of mild or moderate bronchiolitis in the hospital setting.[125] Given the relatively long period of use required to achieve improvement, nebulized hypertonic saline is not recommended for use in the emergency department.[2][126][127]

Plus – treatment of underlying disease ± corticosteroid

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ACUTE
|
mild or self-limited illness
|
with atopy, asthma, or chronic lung disease
Plus – 

treatment of underlying disease ± corticosteroid

Treatment recommended for ALL patients in selected patient group

Routine management of coexistent asthma or COPD should continue in accordance with a stepwise approach to therapy.

Corticosteroids are not effective in routine management of RSV infection. The American Academy of Pediatrics guidelines on bronchiolitis management recommend against the routine use of corticosteroids for this condition.[2]

Corticosteroids may be beneficial in patients with atopy, asthma, or chronic lung disease.

For adults with mild RSV illness, especially for patients with COPD or asthma, corticosteroids are tried, but no studies have shown a benefit.

Primary options

prednisone: children: 1-2 mg/kg/day (maximum 60 mg/day) orally given in 2 divided doses for 3-10 days; adults: 40-80 mg/day orally given in 1-2 divided doses for 3-10 days

Consider – bronchodilator

Back
ACUTE
|
mild or self-limited illness
|
with atopy, asthma, or chronic lung disease
Consider – 

bronchodilator

Treatment recommended for SOME patients in selected patient group

Bronchodilators (e.g., albuterol, ipratropium) should not be used routinely in the management of bronchiolitis.[2][51]

Bronchodilators may be of benefit for patients with asthma, COPD, or severe disease.

Bronchodilators may transiently improve oxygen saturation and work of breathing, but have not been shown to decrease hospital admissions, length of stay, or length of oxygen therapy.[121][122][123][124] [ Cochrane Clinical Answers logo ]

Consider – ribavirin ± intravenous immune globulin (IVIG)

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ACUTE
|
mild or self-limited illness
|
at risk of severe disease due to HSCT or other severe immunodeficiency
Consider – 

ribavirin ± intravenous immune globulin (IVIG)

Treatment recommended for SOME patients in selected patient group

Oral ribavirin has been used in immune deficient adults (predominantly transplant recipients and cancer patients with severe RSV disease), although it is not approved for this indication.[128]​​ Its early use in adult bone marrow transplant patients has reduced morbidity and mortality in this patient subset.[129]

Adults with RSV infection who are older, immune deficient, or have comorbidities may also benefit.

IVIG may be added to ribavirin for immune deficient patients at high risk for progression to severe lower respiratory tract disease.[128][129][130]​​

Ribavirin is not recommended for routine use in children with bronchiolitis.[8][107]

Ribavirin is available as an inhalation solution for the treatment of RSV in some countries. Studies with aerosolized ribavirin therapy demonstrated a small increase in oxygen saturation in small clinical trials; however, a decrease in the need for mechanical ventilation or a decrease in the length of stay was not shown. Because of limited evidence for a clinically relevant benefit, potential toxic effects, and high cost, routine use of aerosolized ribavirin is not recommended.[8]

Primary options

ribavirin: consult specialist for guidance on dose

Secondary options

ribavirin: consult specialist for guidance on dose

and

immune globulin (human): consult specialist for guidance on dose

moderate illness

1st line – inpatient supportive care

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ACUTE
|
moderate illness
1st line – 

inpatient supportive care

Signs of moderate illness in infants include hypoxemia (oxygen saturations <90% to 92%), tachypnea, increased work of breathing (nasal flaring, intercostal retractions, head bobbing), inadequate feeding, and dehydration. Patients should be admitted for further care and observation.[2] Hypoxemia should be treated with warm, humidified oxygen through nasal cannula or mask.

High-flow nasal cannula (HFNC) support is safe. There is no clear evidence that initiating support with HFNC is more effective than standard oxygen therapy with a mask, either in shortening hospital length-of-stay or preventing ICU admissions, although studies have been conflicting. Given the current state of uncertainty and the higher resources needed for HFNC therapy, its use outside of clinical trials should be limited to infants who have failed standard oxygen therapy.[118] 

Careful attention should be given to intravascular fluid and nutritional support. Infants with poor feeding or significantly elevated work of breathing or respiratory rate should be fed by nasogastric or nasojejunal tube or receive intravenous fluids.[2]

High-risk infants include those with a history of prematurity, age <6 months at start of RSV season, chronic lung disease, complex congenital heart disease, or immune deficiency. These patients require closer observation and frequent admission to the hospital.

Adults who are older, immune deficient, or have comorbidities may have moderate illness and should be managed with supportive care while exacerbations of underlying illnesses are addressed.

Consider – nebulized hypertonic saline

Back
ACUTE
|
moderate illness
Consider – 

nebulized hypertonic saline

Treatment recommended for SOME patients in selected patient group

Nebulized hypertonic saline is of potential benefit in reducing symptoms of mild or moderate bronchiolitis in the hospital setting.[125] Given the relatively long period of use required to achieve improvement, nebulized hypertonic saline is not recommended for use in the emergency department.[2][126][127]

Plus – treatment of underlying disease ± corticosteroid

Back
ACUTE
|
moderate illness
|
with atopy, asthma, or chronic lung disease
Plus – 

treatment of underlying disease ± corticosteroid

Treatment recommended for ALL patients in selected patient group

Routine management of coexistent asthma or COPD should continue in accordance with a stepwise approach to therapy.

Corticosteroids are not effective in routine management of RSV infection.

The American Academy of Pediatrics guidelines on bronchiolitis management recommend against the routine use of corticosteroids for this condition.[2]

Corticosteroids may be beneficial in patients with atopy, asthma, or chronic lung disease.

In adults who are older, immune deficient, or have comorbidities, corticosteroids may be beneficial.

Primary options

prednisone: children: 1-2 mg/kg/day (maximum 60 mg/day) orally given in 2 divided doses for 3-10 days; adults: 40-80 mg/day orally given in 1-2 divided doses for 3-10 days

Consider – bronchodilator

Back
ACUTE
|
moderate illness
|
with atopy, asthma, or chronic lung disease
Consider – 

bronchodilator

Treatment recommended for SOME patients in selected patient group

Bronchodilators (e.g., albuterol, ipratropium) should not be used routinely in the management of bronchiolitis.[2][51]

Bronchodilators may be of benefit for patients with asthma, COPD, or severe disease.

Bronchodilators may transiently improve oxygen saturation and work of breathing, but have not been shown to decrease hospital admissions, length of stay, or length of oxygen therapy.[121][122][123][124] [ Cochrane Clinical Answers logo ]

Consider – ribavirin ± intravenous immune globulin (IVIG)

Back
ACUTE
|
moderate illness
|
at risk of severe disease due to HSCT or other severe immunodeficiency
Consider – 

ribavirin ± intravenous immune globulin (IVIG)

Treatment recommended for SOME patients in selected patient group

Oral ribavirin has been used in immune deficient adults (predominantly transplant recipients and cancer patients with severe RSV disease), although it is not approved for this indication.[128]​​ Its early use in adult bone marrow transplant patients has reduced morbidity and mortality in this patient subset.[129]

Adults with RSV infection who are older, immune deficient, or have comorbidities may also benefit.

IVIG may be added to ribavirin for immune deficient patients at high risk for progression to severe lower respiratory tract disease.[128][129][130]​​

Ribavirin is not recommended for routine use in children with bronchiolitis.[8][107]

Ribavirin is available as an inhalation solution for the treatment of RSV in some countries. Studies with aerosolized ribavirin therapy demonstrated a small increase in oxygen saturation in small clinical trials; however, a decrease in the need for mechanical ventilation or a decrease in the length of stay was not shown. Because of limited evidence for a clinically relevant benefit, potential toxic effects, and high cost, routine use of aerosolized ribavirin is not recommended.[8]

Primary options

ribavirin: consult specialist for guidance on dose

Secondary options

ribavirin: consult specialist for guidance on dose

and

immune globulin (human): consult specialist for guidance on dose

severe illness

1st line – supportive care in intensive care unit (ICU)

Back
ACUTE
|
severe illness
1st line – 

supportive care in intensive care unit (ICU)

Infants with refractory hypoxemia, progressive respiratory distress, or frank respiratory failure should be transferred to the pediatric ICU. Patients often improve with noninvasive mechanical ventilation such as nasal continuous positive airway pressure but may require endotracheal intubation with mechanical ventilation.[119] 

Hypoxemia should be treated with warm, humidified oxygen through a nasal cannula or mask, with noninvasive ventilation or mechanical ventilation as required.

Rehydration and nutrition can be accomplished by enteral or parenteral routes, depending on the degree of disease severity and other clinical considerations. In the UK, the National Institute for Health and Care Excellence recommends giving fluids by nasogastric or orogastric tube in babies and children with bronchiolitis if they cannot take enough fluid by mouth. Alternatively, it recommends intravenous isotonic fluids to babies and children who do not tolerate nasogastric or orogastric fluids or have impending respiratory failure.[51]

High-risk infants include those with a history of prematurity, age <6 months at start of RSV season, chronic lung disease, complex congenital heart disease, or immune deficiency.

Adults who are older, immune deficient, or have comorbidities may progress to severe illness requiring ICU admission, with respiratory support and intravenous and nutritional support.

Consider – intravenous immune globulin (IVIG)

Back
ACUTE
|
severe illness
Consider – 

intravenous immune globulin (IVIG)

Treatment recommended for SOME patients in selected patient group

IVIG can be considered in immune deficient patients (e.g., people with cancer or hematopoietic stem cell transplant recipients) with disseminated viral disease.[128][129]

Use of IVIG or RSV-IG treatment alone did not significantly shorten the duration of hospitalization of infants with RSV bronchiolitis and/or pneumonia.[143][144] [ Cochrane Clinical Answers logo ] However, IVIG has been employed as a final resort in deteriorating, critically ill patients with disseminated disease with multiple viruses (e.g. varicella, cytomegalovirus). 

Primary options

immune globulin (human): consult specialist for guidance on dose

Consider – ribavirin

Back
ACUTE
|
severe illness
Consider – 

ribavirin

Treatment recommended for SOME patients in selected patient group

Oral ribavirin has been used in immune deficient adults (predominantly transplant recipients and cancer patients with severe RSV disease), although it is not approved for this indication.[128]​​​ Its early use in adult bone marrow transplant patients has reduced morbidity and mortality in this patient subset.[129]

Adults with RSV infection who are older, immune deficient, or have comorbidities may also benefit.

The use of ribavirin in conjunction with intravenous immune globulin (IVIG) for the treatment of patients with RSV disease has been studied.[130]​​​​​ A meta-review reported that recipients of dual therapy (aerosolized ribavirin with either IVIG or palivizumab) had less progression to lower respiratory tract infection than those patients who received aerosolized ribavirin alone.[128]

Ribavirin is not recommended for routine use in children with bronchiolitis.[8][107]

Ribavirin is available as an inhalation solution for the treatment of RSV in some countries. Studies with aerosolized ribavirin therapy demonstrated a small increase in oxygen saturation in small clinical trials; however, a decrease in the need for mechanical ventilation or a decrease in the length of stay was not shown. Because of limited evidence for a clinically relevant benefit, potential toxic effects, and high cost, routine use of aerosolized ribavirin is not recommended.[8]

Primary options

ribavirin: consult specialist for guidance on dose

Plus – treatment of underlying disease ± corticosteroid

Back
ACUTE
|
severe illness
|
with atopy, asthma, or chronic lung disease
Plus – 

treatment of underlying disease ± corticosteroid

Treatment recommended for ALL patients in selected patient group

Routine management of coexistent asthma or COPD should continue in accordance with a stepwise approach to therapy.

Corticosteroids are not effective in routine management of RSV infection.

The American Academy of Pediatrics guidelines on bronchiolitis management recommend against the routine use of corticosteroids for this condition.[2]

Corticosteroids may be beneficial in patients with atopy, asthma, or chronic lung disease.

In adults who are older, immune deficient, or have comorbidities, corticosteroids may be beneficial.

Primary options

prednisone: children: 1-2 mg/kg/day (maximum 60 mg/day) orally given in 2 divided doses for 3-10 days; adults: 40-80 mg/day orally given in 1-2 divided doses for 3-10 days

Consider – bronchodilator

Back
ACUTE
|
severe illness
|
with atopy, asthma, or chronic lung disease
Consider – 

bronchodilator

Treatment recommended for SOME patients in selected patient group

Bronchodilators (e.g., albuterol, ipratropium) should not be used routinely in the management of bronchiolitis.[2][51]

Bronchodilators may be of benefit for patients with asthma, COPD, or severe disease.

Bronchodilators may transiently improve oxygen saturation and work of breathing, but have not been shown to decrease hospital admissions, length of stay, or length of oxygen therapy.[121][122][123][124] [ Cochrane Clinical Answers logo ]

Consider – antibiotics

Back
ACUTE
|
severe illness
|
requiring intubation
Consider – 

antibiotics

Treatment recommended for SOME patients in selected patient group

Infants who have severe RSV bronchiolitis and require intubation have a 26% risk of bacterial pneumonia. These infants may benefit from initiation of antibiotics pending culture results.[2][107][131][132] Routine administration of empiric antibiotic therapy to infants with RSV bronchiolitis is not recommended, because the risk of concomitant bacterial infection is very low (0.2%). [ Cochrane Clinical Answers logo ] [8]

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer