RESPIRATORY REHABILITATION IN ACUTE CARE OF PATIENTS WITH NEUROPARALYTIC SNAKE ENVENOMATION: CASE SERIES

Abstract

Background: Snakebite is an environmental hazard associated with significant morbidity and mortality. Neurotoxic envenomations have the potency to cause a broad spectrum of presentations starting from ptosis and ophthalmoplegia to respiratory arrest. These patients require ventilatory assistance in addition to administration of anti-snake venom (ASV) and other supportive measures. Mechanically ventilated patients are at risk for retained secretions due to endotracheal intubation disrupting mucociliary escalator, relative immobility of mechanically patient confined to bed can lead to postoperative atelectasis, impaired cough, and retained secretions and thereby physical therapy may be indicated for patients in the intensive care setting. Materials and Methods: A total of twenty four consecutive patients ranging in age from 25-45 years, who required, mechanical ventilation for respiratory muscle paralysis, secondary to snake envenomation, seen during three months period, recruited from various ICU’s were included in the study. All the patients included were mechanically ventilated on Hamilton Evita ventilator, on volume control (CMV) mode with PEEP<10 cmH 2 O and had stable hemodynamics with heart rate = 60-100 beats/min; MABP = 70-110mm Hg. Patients received chest physiotherapy intervention twice in a day. Effects of physiotherapy treatment were studied on static lung compliance (C ST ), oxygenation ratio (PaO 2 :FiO 2 ratio), partial pressure of carbon dioxide in arterial blood (PaCO 2 ) , cologarithm of activity of dissolved hydrogen ions in arterial blood (pH) and chest X-rays. Measurements of dependent variables were recorded (PRE) before commencement of treatment, 30 minutes and 60 minutes after treatment. Physiotherapy intervention included bronchial hygiene therapy and manual hyperinflation using Mapleson-C circuit. Results: Analysis of variance showed that there was highly significant improvement in C ST mean values (p<0.01) and significant improvement in PaCO 2 mean values (p<0.05). However, pH and PaO 2 :FiO 2 ratio could not reach statistical significance. Comparing mean values with critical difference, significant critical difference was observed between mean values at PRE and Post-30, and between PRE and Post-60 time intervals (p<0.05) for C ST , PaO 2 :FiO 2 ratio and PaCO 2 , respectively. Conclusion: Respiratory rehabilitation of patients with neuroparalytic snake envenomation can be effectively achieved with employment of various physiotherapeutic techniques including manual hyperinflation and bronchial hygiene therapy.