Talking All Things Cardiopulm
This podcast is designed to discuss heart and lung conditions, treatment interventions, research, current trends, expert opinions and patient experiences.The goal is to learn, inspire and bring Cardiopulm to the forefront of conversation.
Talking All Things Cardiopulm
Episode 96: RSV is it Droplet? or Contact? or Both?
As the winter season comes to an end, we review 1 of the 4 major viruses that has been rampant this year. Though RSV is officially on the decline, it is still very present in our communities and hospitals.
Join us as we discuss virus transmission and possible precautions, that you may say in your setting. Is it Droplet or is it Contact? That seems to be a question these days and there seems to be some unclear writing on the wall. So let’s break it down.
In this episode:
- Discuss pathophysiology of RSV
- Transmission of RSV
- Current precautions for RSV: Droplet vs. Contact
- Signs and symptoms of RSV
- Current treatment available for RSV
- New vaccines available for RSV
- PT considerations for treating a patient with RSV
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Welcome to Talking All Things Cardiopulm. I am your host, dr Rachele Burriesci, physical therapist and board-certified cardiopulmonary clinical specialist. This podcast is designed to discuss heart and lung conditions, treatment interventions, research, current trends, expert opinions and patient experiences. The goal is to learn, inspire and bring cardiopulm to the forefront of conversation. Thanks for joining me today, and let's get after it. Today's episode is brought to you by Jane, a clinic management software and EMR. As a clinic owner, your main priority should be caring for your patients, not worrying about rising EMR costs. That's why Jane has come up with a new balance plan which includes the essential features you need to run your clinic without any of the extra stuff you don't. With the balance plan, you'll get really helpful features like one-on-one telehealth, email appointment reminders and unlimited customer support. It's a great fit for new or growing practitioners who are booking up to 20 appointments a month, and the best part is that Jane pays for itself with the cost of just one appointment. So head over to janeapp backslash pricing to check out their plan, starting at just $39 a month. And if you're ready to get started, don't forget to use my code cardiopulm1mo at the time of signup for a one month grace period applied to your new account. Thanks again, jane. All right, welcome back.
Rachele Burriesci:We are in the last week of February. I think this might be the first time I say that time is not flying. The last month or so has felt a little bit arduous, a little bit, I don't know tricky to navigate. Just in general, the political climate is quite volatile and there's a lot of things going on in the healthcare space and CDC and WHO that can really just be concerning across the board. So what I wanted to talk about today was actually RSV. It's one of those topics I've had on my list to cover for quite some time. It's something that we typically see in the winter months, usually spikes somewhere around December, january, but never seems to be an overwhelming concern to some extent. So I think I've just always, you know, it happens, it goes away and I haven't really decided to jump in. But this week I don't know. I just feel like we're just like constantly being gaslit and that's not a word I like to throw around.
Rachele Burriesci:But I had a patient who's positive RSV chart, reviewed them, saw that they had precautions listed, didn't even like consider that it wasn't going to be droplet. I get to the room and it only has contact precautions on the room and I was like, huh, that's weird. So sometimes you know, if they do a respiratory panel and it hasn't come in yet they might put people on like preventative precautions. Sometimes it just hasn't gotten changed yet. It's very rare that you see the lesser of the precautions posted before like rule out, so just like kind of raise a little red flag. I was a little confused by it. I actually went back double checked myself, make sure I was A going into the right room, that this person was confirmed RSV and tried to get a hold of the nurse to talk about it before going in, but she wasn't available. So I still utilize droplet precautions with this person and we were on a floor that typically has patients with cystic fibrosis and other immune, immunocompromised persons. So I was following Droplet until told otherwise but just was like had just like this little bit of. Am I missing something? So RSV? Respiratory syncytial oh, I knew I was going to blow it.
Rachele Burriesci:Respiratory syncytial virus it's so hard to say like full sentence is the third most common respiratory virus that we see specifically seasonally annually and it is known as a droplet precaution type disorder. From my knowledge, from seeing other patients, I mean, I recently had a few handful of patients they're all on droplets so just had like this little bit of a red flag like what is happening here. So just to kind of jump forward into this, how RSV is spread is via respiratory droplets Like that is a fact, spreads via respiratory droplets and or fomites, and those fomites again are droplets that basically persist on inanimate objects. So we can spread via talking, singing, coughing, sneezing, right All of the same things that we've been talking about with some of the other respiratory disorders. And if I was to cough on my hand, touch the doorknob, cough directly onto another inanimate object and someone else touches said inanimate object and then touches their eye, their face, their mouth, what have you? It can spread that way.
Rachele Burriesci:So two primary ways to spread RSV or via respiratory droplets into the mouth, nose and actually I'm sorry, let me back that up Eyes, nose and mouth is, as of, apparently the rarest for this diagnosis and or contact. So droplet precautions are supposed to cover the mucous membranes mouth, nose, eyes and contact is going to help prevent spread via contaminated surfaces. Okay, each virus lasts on inanimate objects for their own periods of time. So for, on your hand, apparently, rsv lasts about up to an hour and on fomites, up to about six hours. So contact, touching things, putting it to your mouth, is one of the primary ways that RSV is spread.
Rachele Burriesci:With that being said, it is also spread via respiratory droplets, and so I had brought up the CDC precaution document. I think it was maybe two episodes ago it was either during the flu A or the TB talk that I did and it went down on CDC for probably three weeks, maybe four weeks, and then it came back. So I felt really good about it coming back, but was just kind of curious if there was any changes to it. It doesn't look like it has been changed, but anyway, I use this document quite a bit. It has a number of different diagnoses. It shows you which precautions should be utilized for each diagnosis, gives some of the caveat sort of situations as well, and, from my understanding, rsv has always been droplet. And in this document it also says that RSV is one of the only diagnoses where they were looking at eyewear for droplet precautions, and so eyewear is still in this indeterminate decision for droplet. Same thing Years ago, depending on which hospital you're in, droplet was always mask and eyewear.
Rachele Burriesci:I have worked in other places where the sign was just for mask. So the question is is how likely are you to spread droplet in the mucous membranes of the eyes? I think it really depends. I think we honestly need more research on all of it. Right, we need more research on the size of droplet for a number of different diagnoses. We need more research on the size of droplet for a number of different diagnoses. We need more research on appropriate protection for potentially coughing into someone's face, right?
Rachele Burriesci:So, as a PT, some people might say, well, you're not going to be doing aerosol producing activities like maybe, suctioning or, you know, changing out a vent or something along those lines. But I would like to very much disagree with that Number one. We do breathing exercises, we do coughing activity, and I will say that if I have a patient that has RSV flu RSV flu, covid, fill in the blank on any other respiratory problem I will definitely be doing breathing exercises and airway clearance techniques, and I will tell you that patients are not very good about avoiding breathing into your face and or coughing directly at you, and especially when you have an active diagnosis like this where you're just kind of coughing you, and especially when you have an active diagnosis like this where you're just kind of coughing. Sometimes it's hard to prevent getting coughed on. So I would love to see more research.
Rachele Burriesci:But droplet definitely mask, probably eyewear. I would prefer it, honestly, okay. So, with that being said, with RSV most diagnoses they'll say how it mostly transmits, right? So, like flu can transmit droplet, aerosol or contact. Droplet is the primary way For RSV. It can spread via droplet and or contact, and some of the studies are saying mostly contact. But everything you read in the pathogenesis of RSV states that it's spread via respiratory droplet. So anyway, I felt truly gaslit.
Rachele Burriesci:Afterwards. I actually went to find the nurse because this patient was just walking in the hallway without a mask on. He actually took his oxygen off. So it was actually a very, very big deal. I kind of rerouted this person back to his room, gave him the whole song and dance about wearing his oxygen because he was desatting way low off of it and was chatting with the nurse about the current precautions and she's like yeah, I'm super confused. I assumed this was going to be droplet. We're trying to look into it. Fast forward to I don't know the other day and had another RSV patient on droplet and contact precautions and I was like, whew, we're back to regular you more than ever really just being able to dig deep on these things and look even at older resources, newer resources, comparing back and forth, is going to be something that we have to do on a regular basis, which makes me a little bit nervous, just in general. With that being said, let's talk more about RSV.
Rachele Burriesci:So RSV spread via respiratory droplets and essentially it affects the cilia within the human airway and RSV itself is known to. It's a single-stranded RNA virus and it has two main proteins that seem to be the culprit in how it spreads its disease. So we have protein G and protein F. Most of these viruses have some sort of protein that is kind of the culprit to infection. So in this situation, the G protein is basically the protein that attaches to the cell and the F protein is basically what causes viral entry into the body, and so our bodies are very capable of fighting off a lot of these viruses, and so our B cells are actually the ones that neutralize RSV and create antibodies to help basically decrease the infection and, um, lower the possibility of getting RSV. The problem with these B cells is that they only last a few months after exposure, so, similar to flu, rsv can technically occur every year. So it's not a long-lasting immunity to said disease, if you were to get it.
Rachele Burriesci:Rsv very much affects the cilia and mucus production. So we all know that cilia are the hair-like structures throughout our respiratory system that basically sweep and push mucus up and out. So RSV basically attacks said cilia. We get cilia loss with this diagnosis. It typically affects both upper and lower respiratory tract and increases mucus hypersecretion. And if you treat these patients specifically in the hospital setting where they actually require hospitalization, they are so junky and their cough is just wet and productive and you're going to hear a lot of ronchi on auscultation. Teaching them cough techniques is going to be of utmost importance, potentially doing airway clearance techniques even percussion, vibration is going to be very helpful for them. But also they get a lot of hyper reactivity of the airways so you might hear a lot of high pitched wheezes. And so RSV can really increase morbidity, mortality in patients with COPD and asthma. Those are like the two big ones that RSV really impacts because it's kind of exaggerating a disease process that is already there and then we're just going to have this acute response to said problem. So those two populations seem to be hit the hardest COPD and asthma. We have significant increase in risk mortality with COPD compared to even flu, and in this patient population they also have an increased risk of cardiovascular events. So lots of different problems in our patients that have other conditions.
Rachele Burriesci:From a clinical presentation perspective, this looks like a lot of the other respiratory diagnoses that we see in this season. So rhinorrhea fancy word for runny nose, as well as nasal congestion, as well as sore throat, and so that's the upper respiratory system symptoms. We also have lower respiratory system Cough 85 to 95% of people with RSV have a cough. Wheezing is very high 33 to 90% as well as dyspnea 51 to 93%. So if you already have an underlying lung disease, this diagnosis can really have big impact From a systemic perspective. We also see fever, fatigue, decreased appetite, right. So, very similar to some of the other respiratory diagnosis, we also have increased risk for respiratory failure in our older adult patients, increased risk of mortality in our elderly patients, and the other diagnosis that is very much impacted by RSV are infants and children.
Rachele Burriesci:So the two primary outliers are infants and children and elderly, and so the reason why infants are highly impacted by this diagnosis is because they have a very underdeveloped respiratory system. When we teach about the infant pulmonary anatomy, basically the primary problem is that they have a very inefficient pulmonary system. They have a flat diaphragm, they have flat ribs, they don't have a mature neck, which means they don't have any accessory muscle ability to sort of compensate for shortness of breath. So infants can be very impacted by this. Their internal respiratory system is also not mature, so very likely that they can have severe atelectasis. Their surfactant production might not be up to par yet. They have smaller tubes, so bronchoconstriction will impact them more.
Rachele Burriesci:And so some signs in general for infants that have respiratory distress are basically everything trying to compensate for their immature pulmonary system. So you're going to see nasal flaring, where their nares really expand out trying to literally suck more air in. You're going to see paradoxical breathing, where the diaphragm is moving in the incorrect direction on inhalation. You will also see intercostal retractions, where you're going to literally see the internal intercostal sucking in between the rib layers during inhale, and you'll also see things like respiratory grunting, neck bobbing. They'll have a lot of difficulty eating and breathing. It's actually one of the things that infants can do simultaneously and when they're sick in these situations are unable to use the compensatory mechanism. So, um, infants highly impacted. They were actually up into 2003.
Rachele Burriesci:And so some of the articles I was reading about RSV to see if there was any big changes in medication, and such ones written as of 2023, still indicated that there were no vaccines available for RSV, no antibodies available for older adults. There was actually only two available for children, and then also a preventative medication for infants and pregnant women. That is no longer true, and so, as of 2023 and 2024, there are now three vaccines available for RSV. Primary indications are for people older than 60 years old who are at greater risk, and all adults greater than 75 years old are currently listed for important use of vaccine because they have a high mortality rate overall. So, overall, this is still a newer vaccine, so there's still more information that is going to be coming out about them, but they give two-year protection but, as indicated, they're still learning, as this is a newer vaccine that was approved.
Rachele Burriesci:So how do we prevent spreading RSV? Very similar to the other respiratory diagnoses that we talked about. Right, if you are actively sick, stay home. If you have a fever, stay home. If you are sort of past that infectious phase but you're still coughing. Wear a mask when you're out and about. If you are dealing with a person who has RSV, you yourself should wear a mask when you're out and about. If you are dealing with a person who has RSV, you yourself should wear a mask. And if you're in the hospital setting, depending where you are, mask and eyewear and contact precautions. Right, those are the two primary precautions that you're going to see. Make sure that you're cleaning surfaces within your home. Again, this can be spread via fomites, which means inanimate objects that can last for over six hours at a time. So make sure that we are cleaning surfaces, especially highly used surfaces. And, of course, hand washing. Hand washing or hand sanitizer is effective in this patient population.
Rachele Burriesci:From a time perspective, this diagnosis peaks two to three days after onset. Typically four to seven days after exposure you become symptomatic and you're typically contagious for three to eight days. So they're all sort of in the same timeframe, about a week in general, but two to three days is usually peak, and then it can last up to eight days. You can technically be contagious maybe one to two days beforehand. There's some variability in those numbers. So, peak two to three days after onset, typically get sick four to seven days after exposure can last three to eight days infectious, infectious, wise. So just some things to kind of keep in mind across the board. Okay, let's see if I missed anything else. Oh, some other risk factors. So we talked about basically infants and elderly are your primary risk factors. Some other things to kind of put into the mix. Or more specific prematurity age, less than two months.
Rachele Burriesci:Again, that immature respiratory system underlying chronic heart and lung disease, having chronic neurologic or metabolic disorders, history of Down syndrome, any sort of immune deficiency, living in crowded conditions, indoor smoke, pollution, and then a big one which kind of loops back into the immune deficiency are patients with transplant. So, just keeping that in mind, as it is a higher rate Overall, from a testing perspective, this is another respiratory diagnosis that can be nasal swabbed. I would love I know that they do this in some places. Actually it was during I think it was like 2021, 2022, when we still had COVID testing centers. There were some places that were out of pocket that tested all three COVID, flu and RSV. This would be a wonderful thing to have in a home kit right, sort of give you a little bit more information, able to translate that to the physician if you're calling in for it, because they are treated a little bit differently and they have some different things available for each, and so I think it is important to know which one you have right. In some ways you're going to do the same things to protect yourself and others from it, but also it is a good thing to sort of know whether you have one versus the other.
Rachele Burriesci:Management for RSV typically is very supportive in nature Fluids, antipyretics, potentially oxygen supplementation, especially if a person is hospitalized. That is something that I do see quite a bit, especially when we have mucus as a primary obstruction. It's really important to clear those airways to actually allow for good gas exchange. But hopefully that O2 requirement decreases over time. There are antivirals available. Again, it was mostly for children previously. I still don't think that is available for adults and it can help shorten clinical symptoms I think one to two days was the number that they said in helping with decreasing the overall infection. So supportive measures is the primary way to treat RSV. So just to kind of recap RSV is spread via droplet. It is also spread via fomite, so droplet precautions and contact precautions are the two primary precautions that you will see in the hospital setting for patients that have RSV.
Rachele Burriesci:Precautions that you will see in the hospital setting for patients that have RSV. Primary symptoms upper and lower respiratory, runny nose, congestion, sore throat as well as productive cough, possible wheezing, especially if you have underlying COPD and asthma. Fever, fatigue, anorexia typically last three to eight days, peaking somewhere at that two to three day marker. Most people can pretty much get by with typical supportive measures increased fluid production, potentially antipyretics. Some may require hospitalization and or oxygen supplementation due to dyspnea, respiratory failure and things of that nature. Recently we have some new vaccines available for RSV, so more to come on that. But there are three vaccines officially available for RSV that are to potentially last and cover a person for up to two years' time. That number may increase as we sort of see how it works across the board and just from a pathogenesis perspective, this is a disease process that really attacks the cilia in the epithelial airways and creates increased mucus secretion. So those are the primary things that you're going to see.
Rachele Burriesci:From a PT perspective, you want to do a thorough chest exam on this patient population auscultate. Likely you're going to hear positive bronchi, sometimes known as low-pitched coarse wheezes. You will also hear high-pitched wheezes Very likely to hear both, especially in our patients that have underlying COPD and asthma. This patient also might be on supplemental oxygen, especially if you're seeing them in the hospital setting. So very important to monitor SpO2 with activity that we are monitoring continuously as we're starting to increase activity. If this person is in the hospital setting and they are outside of their room, they should be wearing a mask to help prevent spread of said respiratory droplets and so very important to continue to monitor SpO2 with that. Especially if someone is dysmyc at rest, they might have increased dyspnea or decreased reserve wearing a mask because there is a little bit of an increase in resistance to breathing with that. If wearing a mask is not possible, stay in the room, increase frequency of ambulation in the room to keep your patient safe and also increase their capacity. Definitely check a vital site blood pressure response with activity as well. It might be hyper exaggerated.
Rachele Burriesci:And cough assessment. This is a huge one. Assess their cough, pay attention to their cough when they're spontaneously coughing. A lot of times what you see is they start fatiguing and it becomes more of this expiratory phase of cough where they're not getting any inhale and even though they're really junky and wet sounding, they're not getting anything out, and so that can be multifactorial, where we have potentially tight tubes, which makes it hard to move said mucus, and we have fatigue from coughing and we are lacking overall mechanics, right, we lose inhale, we're losing glottal closure, so that we're actually cuing these patients to improve their cough as well.
Rachele Burriesci:Huff cough is a great technique to throw into this. I use it quite a bit in patients that you know don't have sternal precautions or post-thoracotomy or anything like that. I use it quite a bit for patients who are having increased mucus production, increased coughing in general. It gives another technique. It provides a sort of milking activity of the airways to help move that mucus out in a different manner and it's very useful, it's very productive. So just another tool to use with this patient population.
Rachele Burriesci:But definitely make sure that you're teaching pacing with breathing, that you're educating on the importance of wearing oxygen when they currently need it. I will say this from every rooftop known to man if you need oxygen at rest, you need it with activity. So make sure that you are educating your patient on this. We shouldn't be tanking every time we say walk to the bathroom, because we're removing our oxygen just for that short little walk to the bathroom. If you need oxygen at rest, you need it with activity. Make sure that we're educating and then we're progressing mobility in a progressive sort of way. This is not the person that you try to go max distance without assessing oxygen until they're short of breath and need full recovery time. This is someone that you're pacing. This is someone that you're using interval training with. This is someone that you're going to set up for success so we can slowly decline oxygen needs versus needing to up it every time they fatigue or do too much. Right, this is all part of what we do in education and something that I want to see more of us doing because it is so important for our patients.
Rachele Burriesci:All right, I think that's all I have for you today. Hopefully that was helpful. All right, I think that's all I have for you today. Hopefully that was helpful. If you have any questions about RSV, please reach out to me. I hope you all have a wonderful day, stay safe, be kind and thank you so much for spending time with me and listening and learning. Whatever you have to do, I get after it.
