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RSV is a very common virus that causes coughs and colds. For most people it is mild, but it can cause serious chest infections in two groups: babies and young children (where it is the main cause of bronchiolitis) and older adults or people with heart and lung conditions. It spreads easily in the cooler months. New vaccines and antibody treatments now protect the most vulnerable. This page explains RSV, who is at risk, and how it is prevented and managed.
Definition
Respiratory syncytial virus (RSV) is a common seasonal respiratory virus that infects the airways. For most people it causes an ordinary cold, but it is the leading cause of lower-respiratory infection in infants and a major cause of severe illness in older adults and those with chronic heart or lung disease. Its clinical profile changed substantially in the 2020s with the arrival of effective immunisation for both ends of the age range.
Pathophysiology
How RSV damages the airway
RSV infects the ciliated epithelium of the upper and then lower airways. Infected cells fuse into multinucleated masses — the syncytia that give the virus its name — before sloughing into the airway lumen. The combination of shed cells, mucus, oedema and inflammatory infiltrate obstructs airways mechanically rather than through bronchospasm, which is why bronchodilators are largely ineffective.
Why infants are worst affected
In the very small airways of an infant, that same volume of debris and swelling produces disproportionate obstruction, air trapping and patchy collapse — the picture of bronchiolitis. Infants also have limited respiratory reserve, fatigue quickly with increased work of breathing, and cannot coordinate feeding with a raised respiratory rate, so feeding failure often precedes respiratory failure.
Why re-infection happens throughout life
Immunity after RSV infection is incomplete and short-lived, so re-infection occurs every few years across the lifespan. In older adults and people with chronic disease each re-infection can cause pneumonia or destabilise the underlying condition, and RSV is a substantially under-recognised trigger of COPD and heart failure exacerbation.1
Co-morbidities
Severe RSV clusters with prematurity, chronic lung disease of prematurity, congenital heart disease, neuromuscular disease, Down syndrome and immunodeficiency in infants. In adults it clusters with COPD, asthma, heart failure, coronary disease, diabetes, chronic kidney disease, frailty and immunosuppression — all conditions RSV can acutely destabilise, so the presenting problem is frequently an exacerbation rather than the viral illness itself.
Prevalence
RSV is close to universal: almost all children are infected by the age of two, and most have had two infections. It circulates mainly in the cooler months, though seasonality was disrupted by pandemic-era measures and has not entirely resettled. It is the leading cause of infant hospitalisation in Australia and a significant cause of winter hospitalisation and death in adults over 65 — a burden comparable to influenza in that age group, and for many years substantially under-appreciated because testing was not routine.
Causes and risk factors
- Infection with respiratory syncytial virus, spread by respiratory droplets and by contaminated hands and surfaces, where the virus survives for hours.
- Age — under six months, and over 65 years.
- Prematurity and chronic lung or congenital heart disease in infants.
- Chronic cardiorespiratory disease, diabetes and immunosuppression in adults.
- Crowding, childcare attendance and having school-aged siblings, which bring the virus into the household.
- Tobacco smoke exposure, which increases severity in infants.
- Not being immunised where maternal vaccination or infant monoclonal antibody is available.
Symptoms
Typical features
Runny nose, sneezing, cough, sore throat, low-grade fever and, when the lower airways are involved, wheeze. In most children and adults this is an unremarkable cold lasting a week to ten days, with cough persisting longer.
In infants
Cough and wheeze progressing over two to three days to fast or laboured breathing, chest wall recession, nasal flaring, grunting and reduced feeding. Very young infants may present with apnoea before any respiratory signs. Symptoms typically peak around days three to five.
In older adults
Frequently indistinguishable from influenza: cough, breathlessness, wheeze and fatigue, often with less fever. The presentation is commonly a decompensating chronic condition — an exacerbation of COPD, worsening heart failure, or a fall and delirium in a frail patient — rather than an obvious viral illness.
Warning signs
Diagnosis
Why diagnosis matters
Identifying RSV explains the illness, guides isolation to protect vulnerable contacts, avoids unnecessary antibiotics, and — in adults — correctly attributes an exacerbation that would otherwise be treated as bacterial. It also increasingly identifies people who should be offered vaccination before the next season.
How is it diagnosed?
RSV is usually a clinical diagnosis in season, particularly in infants where the pattern is characteristic. PCR or rapid antigen testing on a nasal or nasopharyngeal swab confirms it where the result changes management — in hospital, in high-risk patients, or for infection control. Multiplex respiratory panels test simultaneously for influenza, SARS-CoV-2 and other viruses, which is often more useful than an RSV-specific test.
Assessment of severity
Severity is judged clinically rather than by test result: respiratory rate, work of breathing, oxygen saturation, hydration and feeding in infants; oxygen saturation, respiratory rate, confusion and functional decline in older adults. Chest X-ray is reserved for suspected pneumonia or an atypical course, since routine imaging in bronchiolitis leads to unnecessary antibiotics.
Investigations for related conditions
In severe or atypical cases, assessment looks for secondary bacterial infection and for a destabilised underlying condition — blood gases, inflammatory markers, natriuretic peptides where heart failure is possible, and echocardiography or spirometry once recovered. In infants with recurrent or unusually severe disease, congenital heart disease, immunodeficiency and cystic fibrosis are considered.
Management
Management and goals
Goals are to maintain oxygenation and hydration, avoid unnecessary and potentially harmful interventions, treat any destabilised underlying condition, and protect vulnerable contacts. In most cases the correct management is careful supportive care and clear safety-netting.
Supportive care
Fluids, rest, small frequent feeds in infants, nasal saline and clearing the nose before feeds, and antipyretics for comfort. Oxygen is given for hypoxaemia. High-flow nasal oxygen is widely used in infants; in a large randomised trial it reduced escalation of care compared with standard oxygen, though it did not shorten oxygen therapy or hospital stay, so it is a rescue therapy rather than a first-line one.2
What does not work
This is as important as what does. Nebulised hypertonic saline produces at best a marginal effect on length of stay and is not routinely recommended.3 Bronchodilators do not improve oxygen saturation, admission rates or duration of illness in bronchiolitis and are not recommended.4 Corticosteroids, antibiotics and chest physiotherapy are likewise not indicated in typical RSV bronchiolitis. Restraint here is active management, not passivity.
Treating the destabilised condition
In adults the substantive treatment is often of the exacerbation RSV has triggered — bronchodilators and corticosteroids for a COPD or asthma flare, diuretics for decompensated heart failure, ventilatory support where required. Antibiotics are reserved for documented or strongly suspected secondary bacterial infection.
Prevention in infants
Two effective approaches now exist. Palivizumab, the earlier monthly monoclonal antibody, was restricted to narrowly defined high-risk infants.5 It has been superseded by nirsevimab, a long-acting monoclonal antibody given as a single dose: it reduced medically attended RSV lower-respiratory infection in preterm infants6 and in healthy late-preterm and term infants,7 making universal infant protection feasible for the first time. Maternal vaccination in late pregnancy is the alternative route, and reduced severe RSV illness in infants in a large international trial.8
Prevention in older adults
RSV vaccines for adults aged 60 and over demonstrated substantial efficacy against RSV lower-respiratory-tract disease in two large randomised trials.9,10 Eligibility and funding are evolving — verify current ATAGI advice and PBS or National Immunisation Program status. Alongside vaccination, hand hygiene, staying away from infants when unwell, and keeping influenza and COVID-19 vaccination current remain the practical measures.
Medications
Medications for RSV
There is no antiviral in routine use; ribavirin is confined to selected severely immunocompromised patients in specialist care. Care is supportive, and drug treatment is directed at complications and at the underlying condition RSV has destabilised.
Immunisation as the main pharmacological advance
The substantive pharmacology in RSV is now preventive rather than therapeutic, and in Australia it reaches patients through three separate programmes. Maternal vaccination (Abrysvo) is funded on the National Immunisation Program and recommended in every pregnancy from 28 weeks, giving the infant passive protection for around its first six months. Nirsevimab (Beyfortus), a long-acting monoclonal antibody, is funded by states and territories for eligible infants through the RSV season, and for young children with risk conditions entering a second season. Adult vaccination changed in May 2026: Arexvy is now funded on the National Immunisation Program for everyone aged 75 and over, and for Aboriginal and Torres Strait Islander adults from 60. Worth knowing when a patient asks why they are not eligible — vaccination is recommended more widely than it is funded: adults aged 60–74 and younger adults with risk conditions are advised to consider it on private prescription, with Arexvy registered from 50 years and Abrysvo from 60. Programme dates and infant eligibility windows differ between states and reset each season. For a physiotherapist working with older adults or chronic respiratory disease, checking and prompting RSV immunisation status is a reasonable and useful part of a review.
Living with RSV
Recovery at home
Most people recover fully within one to two weeks, with cough often lingering two to four weeks. Rest, fluids and paced return to activity are the substance of it. Fatigue after RSV in older adults is frequently underestimated and can take a month or more to resolve.
Caring for a baby at home
Small frequent feeds, clearing the nose before feeding, keeping the baby upright when settled, a smoke-free environment, and knowing the warning signs above. Parents should be told explicitly that the cough will outlast the illness and that days three to five are usually the worst, so they can judge whether the course is expected or deteriorating.
Protecting vulnerable household members
Hand hygiene, not sharing cups or utensils, keeping unwell visitors and older siblings away from young babies, and immunisation of those eligible. In residential aged care, prompt recognition and isolation limit outbreaks that carry appreciable mortality.
Chronic lung and heart disease
People with COPD, asthma, bronchiectasis or heart failure should treat an RSV illness as an exacerbation trigger: start the action plan, monitor oxygen saturation if they have an oximeter, and seek review early rather than waiting. Recovery of exercise tolerance frequently lags symptom resolution by weeks.
Prognosis
The outlook is excellent for healthy children and adults, with full recovery the norm. Severe disease and death concentrate in high-risk infants and in older adults with co-morbidity, and it is those groups that benefit most from the new preventive options. A proportion of infants hospitalised with RSV bronchiolitis go on to have recurrent viral wheeze in early childhood, and an association with later asthma is well described though causation remains debated. In older adults, an episode of severe RSV frequently marks a step down in functional trajectory that does not fully recover — which is an argument for rehabilitation rather than reassurance.
Role of the physiotherapist
In uncomplicated infant bronchiolitis, chest physiotherapy is not recommended. A Cochrane review found that neither conventional techniques nor slow passive expiratory techniques improved severity, oxygen requirement or length of stay, and the interventions distress the infant.11 Declining to treat, and explaining why to families and referrers who expect treatment, is the correct clinical action.
The role in adults and complex patients is substantial. Where RSV precipitates an exacerbation of COPD, bronchiectasis or neuromuscular disease, airway clearance is indicated on the merits of that underlying condition, along with breathing retraining, positioning and support with non-invasive ventilation where used. Where RSV causes pneumonia or respiratory failure, standard acute cardiorespiratory management and early mobilisation apply.
Afterwards, reconditioning is the main task, particularly in older adults, where a week of illness and bed rest can cost months of independence. Graded cardiorespiratory rehabilitation, strength work and falls-risk review are more valuable than any acute chest technique. Selected infants with neuromuscular disease or an ineffective cough are assessed individually by a specialist paediatric team — the exception that proves the rule, not a reason to treat routinely.
Part 1 · References
- Falsey AR, Hennessey PA, Formica MA, Cox C, Walsh EE. Respiratory syncytial virus infection in elderly and high-risk adults. N Engl J Med 2005;352(17):1749–1759.
- Franklin D, Babl FE, Schlapbach LJ, et al. A randomized trial of high-flow oxygen therapy in infants with bronchiolitis. N Engl J Med 2018;378(12):1121–1131.
- Zhang L, Mendoza-Sassi RA, Wainwright C, Klassen TP. Nebulised hypertonic saline solution for acute bronchiolitis in infants. Cochrane Database Syst Rev 2017;(12):CD006458.
- Gadomski AM, Scribani MB. Bronchodilators for bronchiolitis. Cochrane Database Syst Rev 2014;(6):CD001266.
- American Academy of Pediatrics Committee on Infectious Diseases. Updated guidance for palivizumab prophylaxis among infants and young children at increased risk of hospitalization for respiratory syncytial virus infection. Pediatrics 2014;134(2):415–420.
- Griffin MP, Yuan Y, Takas T, et al. Single-dose nirsevimab for prevention of RSV in preterm infants. N Engl J Med 2020;383(5):415–425.
- Hammitt LL, Dagan R, Yuan Y, et al. Nirsevimab for prevention of RSV in healthy late-preterm and term infants. N Engl J Med 2022;386(9):837–846.
- Kampmann B, Madhi SA, Munjal I, et al. Bivalent prefusion F vaccine in pregnancy to prevent RSV illness in infants. N Engl J Med 2023;388(16):1451–1464.
- Papi A, Ison MG, Langley JM, et al. Respiratory syncytial virus prefusion F protein vaccine in older adults. N Engl J Med 2023;388(7):595–608.
- Walsh EE, Pérez Marc G, Zareba AM, et al. Efficacy and safety of a bivalent RSV prefusion F vaccine in older adults. N Engl J Med 2023;388(16):1465–1477.
- Roqué-Figuls M, Giné-Garriga M, Granados Rugeles C, Perrotta C, Vilaró J. Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old. Cochrane Database Syst Rev 2023;(4):CD004873.
References are numbered in citation order (Vancouver/BMJ style) and were current at the time of writing. Guidelines are living documents — verify against the latest version before clinical use.
Everything starts with an assessment — your symptoms, breathing, exercise tolerance and daily function measured properly, so what follows is built on your lungs rather than an average.
Clinical evidence
Part 1 covers the same condition without the technical detail. What follows is the evidence base behind it, written for clinicians — the literature, the reasoning and the gaps.
For clinicians: this summary supports clinical reasoning and is not a protocol. Check current guidelines and local policy before applying it, and read it alongside the key references and guidelines directory.
Framing. RSV has changed more in the last three years than in the preceding thirty, and the change is entirely in prevention. Long-acting monoclonal antibody for infants, maternal vaccination in pregnancy and two protein-based vaccines for older adults all now have randomised efficacy data.1,2,3,4 Treatment, by contrast, remains supportive — and the physiotherapy evidence is firmly negative in the group most often referred, infants with bronchiolitis.5
Prevention
- Nirsevimab, a single-dose long-acting monoclonal antibody, reduced medically attended RSV lower respiratory tract infection and hospitalisation in healthy late-preterm and term infants.1,2
- Maternal bivalent RSVpreF vaccination in pregnancy reduced severe RSV illness in infants in the first months of life.3
- Older-adult vaccines work: RSVpreF and adjuvanted RSVPreF3 both reduced RSV-associated lower respiratory tract disease in adults aged 60 and over in large randomised trials.4,6
- Palivizumab remains an option for defined high-risk infants (significant prematurity, chronic lung disease of prematurity, haemodynamically significant congenital heart disease) where nirsevimab is not used.7
Treatment evidence
- Chest physiotherapy does not help infant bronchiolitis: neither conventional percussion and vibration nor slow or forced expiratory techniques improved severity, oxygen requirement or length of stay, and transient adverse events including vomiting, destabilisation and bradycardia were reported.5
- Bronchodilators and systemic corticosteroids confer no benefit in first-presentation bronchiolitis; nebulised hypertonic saline has at best a small, inconsistent effect on length of stay.8,9
- High-flow nasal cannula reduced escalation of care compared with standard oxygen but did not shorten stay or oxygen duration — a rescue therapy rather than first-line.10
- In adults, RSV is a substantial and under-recognised cause of illness, with morbidity in older and chronically ill adults comparable to influenza, and a common trigger of COPD and asthma exacerbations.11
Physiotherapy implications
- Decline routine chest physiotherapy in infant RSV disease and explain the evidence; assessment, escalation and parent education are the appropriate response to the referral.5
- Reserve individual assessment for comorbidity: neuromuscular weakness, tracheostomy, established suppurative lung disease, significant congenital heart disease or chronic lung disease of prematurity — and then alongside the treating team.
- Deliver what does help in infants: minimal handling with clustered cares, positioning, upper-airway suction only where it is obstructing feeds, observation of work of breathing and feeding, and clear red-flag education.
- In adults, treat the exacerbated underlying disease — bronchodilator optimisation, airway clearance where there is genuine sputum retention in bronchiectasis or COPD, NIV in hypercapnic failure, early mobilisation.11
- Observe contact and droplet precautions and treat nebulisation, high-flow therapy, NIV, suction and cough-provoking techniques as higher-risk procedures; RSV spreads readily on hands and surfaces.
- Escalate apnoea (particularly under two months or ex-premature), grunting, marked recession, feeding below about half of normal intake, persistent desaturation, or exhaustion with a falling respiratory rate.
- Prompt vaccination and immunoprophylaxis for eligible older adults, pregnant women and high-risk infants — a physiotherapy appointment is a legitimate place to check it.3,4
Clinical reasoning
- RSV bronchiolitis is small-airway oedema and cellular debris, not clearable retained secretions — which is precisely why the clearance trials are negative.5
- A crackly, noisy chest in an infant who feeds and saturates well is a feature of the illness, not an indication to treat.
- Deterioration after handling is information: reduce stimulation rather than persist.
- In an adult with RSV, ask what the actual problem is — bronchospasm, secretion retention from underlying disease, consolidation or ventilatory fatigue — because only some of those are physiotherapy problems.
Evidence gaps
- Infants with neuromuscular and chronic respiratory comorbidity are excluded from the physiotherapy trials, so the exception rests on reasoning rather than evidence.5
- How widespread immunoprophylaxis will change the hospital case mix — and therefore who still needs assessment — is not yet known.1,3
- Optimal thresholds for starting and weaning high-flow therapy on the ward remain undefined.10
- Adult RSV rehabilitation needs, and the recovery trajectory after severe adult disease, are poorly described.11
References for the clinical evidence summary
- Hammitt LL, Dagan R, Yuan Y, et al. Nirsevimab for prevention of RSV in healthy late-preterm and term infants. N Engl J Med 2022;386(9):837–846.
- Griffin MP, Yuan Y, Takas T, et al. Single-dose nirsevimab for prevention of RSV in preterm infants. N Engl J Med 2020;383(5):415–425.
- Kampmann B, Madhi SA, Munjal I, et al. Bivalent prefusion F vaccine in pregnancy to prevent RSV illness in infants. N Engl J Med 2023;388(16):1451–1464.
- Papi A, Ison MG, Langley JM, et al. Respiratory syncytial virus prefusion F protein vaccine in older adults. N Engl J Med 2023;388(7):595–608.
- Roqué-Figuls M, Giné-Garriga M, Granados Rugeles C, Perrotta C, Vilaró J. Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old. Cochrane Database Syst Rev 2023;(4):CD004873.
- Walsh EE, Pérez Marc G, Zareba AM, et al. Efficacy and safety of a bivalent RSV prefusion F vaccine in older adults. N Engl J Med 2023;388(16):1465–1477.
- American Academy of Pediatrics Committee on Infectious Diseases. Updated guidance for palivizumab prophylaxis among infants and young children at increased risk of hospitalization for respiratory syncytial virus infection. Pediatrics 2014;134(2):415–420.
- Gadomski AM, Scribani MB. Bronchodilators for bronchiolitis. Cochrane Database Syst Rev 2014;(6):CD001266.
- Zhang L, Mendoza-Sassi RA, Wainwright C, Klassen TP. Nebulised hypertonic saline solution for acute bronchiolitis in infants. Cochrane Database Syst Rev 2017;(12):CD006458.
- Franklin D, Babl FE, Schlapbach LJ, et al. A randomized trial of high-flow oxygen therapy in infants with bronchiolitis. N Engl J Med 2018;378(12):1121–1131.
- Falsey AR, Hennessey PA, Formica MA, Cox C, Walsh EE. Respiratory syncytial virus infection in elderly and high-risk adults. N Engl J Med 2005;352(17):1749–1759.
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