RSV is Not a New Problem!
But for a few, it's a huge problem.
The wave of respiratory syncytial virus, or RSV, has crashed on our medical shores, a great frothing, wheezing, snotty mess of sick infants, children and adults.
I have fond memories of RSV during residency at Methodist Hospital of Indiana. I trained in emergency medicine at that venerable teaching center. One year while I was an intern on my pediatrics rotation we faced another RSV tsunami. Over the course of one 24 hours shift, my resident and I admitted 50 infants and small children with RSV. I remember starting in the ER in the morning and finishing the next morning on an upper floor of the hospital, surrounded by sick children, worried parents and overworked nurses and physicians. All we could do was give the best care we could, caffeinate and laugh hysterically.
While typically a disease of infants and small children, adults also contract this. Both groups can get very sick with wheezing and shortness of breath. In fact, infants and adults over 65 can, and do, die from this disease. For adults it is especially problematic for those who already have heart or lung disease. The virus simply stresses their already compromised respiratory capacities. (Sounds like something else we’ve lately experienced, don’t it?')
Here’s a discussion from the CDC:
https://www.cdc.gov/rsv/index.html
The problem right now is (and cue my broken record), there just aren’t enough beds in our hospitals, or enough staff to take care of everyone in the best possible way.
What I have noticed is that in the COVID era, we’re all dialed into testing. It seems as if a patient interacting with the healthcare system will either have a COVID test ordered by their physician, or request one themselves, no matter what physical complaint they have. They are tested because it will be diagnostic when they have relevant symptoms, or because it will help staff known where to admit them, or will determine whether or not they can return to work, or maybe just because it’s being used to track the virus in the community. It seems that even those without symptoms seem to get tested.
This has now been translated, unfortunately, into our handling of RSV. Thanks to ever frantic media outlets in dire need of relevance and clicks, coupled with our general anxiety about respiratory illness, everyone seems to want an RSV test.
‘I’ve got this cold and I want to know if I have that RSV!’
‘My doctor said I might have RSV and should go to the ER!’
‘My daughter was sent home from third grade and the school said we should have her tested for RSV.’
‘The urgent care said I have RSV and need to get checked out in the ER!’
Obviously, it is important to test infants and children with cough, fever, increased work of breathing like retractions, or wheezing.
Here’s a nice video of some moderate retractions, from Children’s Healthcare of Atlanta if you want to watch:
The good thing is, we sort of know what it looks like when adults struggle to breath. Furthermore, adults tend to say ‘I’m short of breath,’ or simply can’t speak, and it helps us to know what to do. As with kids, adults with wheezing, shortness of breath with exertion (or at rest), adults with cough and fever, with cough shortness of breath and chest pain are all concerning and may need RSV testing, as well as testing for Influenza and COVID-19.
These facts are even more true for infants and adults with underlying asthma, emphysema, heart disease, diabetes, cancers (or other things that limit their immunity).
What I want everyone to understand, however is this: for the overwhelming number of people with RSV, the infection will be an annoying cold that gets better without anything but symptom control. As such, knowing whether or not you have it isn’t that relevant.
Snotty nose? Cough? Fever? No shortness of breath or wheezing? Not an infant or older adult? No underlying illness that might affect immunity or breathing? Then it really doesn’t matter if you have an RSV test or not. Frankly, it doesn’t really matter if you have RSV or not. There are so many respiratory illnesses out there that we couldn’t possibly test for all of them in a way that was 1) useful or 2) cost effective. Just think of them as annoying relatives that visit every year and use you to stay alive.
This is important because we do not have infinite resources in our clinics or hospitals. So it would be helpful if people would maybe, just maybe, consider not going to the ER to be tested for RSV unless symptoms and history warrant it. Frankly, if you go and sit in the waiting room for hours, you’ll catch the virus (and maybe some others) whether you already had it or not!
We’re in a tight spot these days. If you’re sick, if you’re distressed and think you’re in danger, by all means come to the ER.
If you’re mainly curious, and just feel like you have a bad cold, then don’t worry whether it’s RSV or not. Odds are good it will go away on its own no matter what you do. Or, as one of my medical school professors said, ‘with a little tincture of time.’
And if you’re a physician seeing patients who might have RSV, please consider local conditions before sending your patient to the ER. Do you think they’ll need to be admitted if they’re positive? Fine. If they need to be admitted, can they be directly admitted without the ER? Can they go home on nebulizer treatments or oxygen? Can they be rechecked tomorrow? In the hospital, as I alluded, they may be exposed to influenza or COVID, or to bacterial pneumonia or a host of other things.
RSV is pretty bad, pretty early this year. Influenza is already upon us and we still have sporadic COVID-19 cases. We’re going to have a long, stressful respiratory illness season. So be careful and let’s all do everything we can to navigate the mess. We’ve done it for ages and we can do it again.
Edwin