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With RSV, it’s time for primary care to step up to the plate

Every pediatrician is familiar with this endemic seasonal virus, expecting to see several cases in their office during the winter months and maybe even admit the occasional one for inpatient care. Even amongst the latter, most do well and recover without incident, though the stay can be prolonged.

However, the respiratory syncytial virus — when it causes pneumonia and bronchiolitis (inflammation of the small airways — can result in serious illness and even fatality, especially in infants, ex-premature babies, and young children with comorbidities.

The U.S. is presently experiencing an unusual epidemic of RSV in terms of timing and severity that is filling pediatric hospital beds with bronchiolitis patients. This is at a time when the number of pediatric beds is falling as smaller hospitals have closed their non-profitable pediatric units.

Many children’s hospitals are near capacity, and some have closed to non-urgent surgery to free up beds. Emergency departments are being flooded. In some hospitals, patients are being boarded in the ED.

The epidemic is but part of a current “triple epidemic” of respiratory diseases: COVID, influenza, and RSV. There is no vaccine, although the flu shot does provide some protection. Hospitals need to prepare for a possible extreme onslaught of children with respiratory illnesses.

The older infant with mild bronchiolitis can often be cared for by her primary care pediatrician in a standard pediatric ward or unit. Care is largely supportive, maintaining hydration with intravenous fluids and oxygenation with a nasal cannula or headbox oxygen as the illness slowly resolves. Though the infants are intensely wheezy, traditional bronchodilators rarely provide relief, and steroids don’t help. There are few acute diseases that make both pediatricians and parents feel so helpless.

Some children require a higher level of care. An intermediate care unit (IMCU) rather than the PICU is adequate for most of these. IMCUs provide bronchiolitis care where more sophisticated means of oxygenation are required — for example, non-invasive positive pressure ventilation (CPAP, BIPAP) or high-flow humidified oxygen, but not full ventilation.

In May 2022, the American Academy of Pediatrics updated its recommendation on these units in the journal Pediatrics.

Unfortunately, IMCUs are rare outside hospitals that have PICUs, where they often serve as step-up/step-down units. Smaller hospitals would have trouble establishing such units due to cost and a deficiency of expertise. Sophisticated respiratory support requires equipment along with appropriately trained nurses and respiratory therapists, and few primary care pediatricians have the necessary skill set, meaning that hospitalists would need to be employed.

Hospitals that still maintain pediatric beds are often reluctant to care for infants with even mild bronchiolitis. In my experience, the degree of respiratory distress observed is alarming to nursing staff and respiratory therapists, who may press for transfer to a higher level of care, even though oxygenation and hydration are being well maintained. Everyone just feels uncomfortable and helpless.

Parents will often push for transfer; they observe that “nothing is being done.” That is: no antibiotics, medications, or nebulizer therapy if their pediatrician is following current guidelines. They believe that bigger or children’s hospitals will have more to offer when, in fact, step-up care is not needed. This puts a further load on these centers, which are now flooded with patients that could safely be cared for locally.

Nevertheless, general hospitals with small pediatric units need to prepare themselves to care for bronchiolitis sufferers whom they might more usually transfer out.

Pediatricians on staff at the hospital should meet with respiratory therapists and decide on a standard protocol for managing these cases. They would do well to adopt the Children’s Hospital of Philadelphia (CHOP) inpatient clinical pathway for bronchiolitis, available online. These hospitals might consider upping their level of respiratory support by acquiring devices that deliver heated, humidified high-flow oxygen therapy, such as the one manufactured by Vapotherm. These are not difficult to use and can reduce the work of breathing and improve oxygenation in some cases.

All in all, it promises to be a miserable winter season for pediatrics with an emphasis on respiratory illness. Community primary care pediatricians need to step up to the plate.

Martin C. Young is a pediatric endocrinologist.


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