Application of noninvasive positive pressure ventilation to respiratory complications of severe tetanus: a case report

Abstract

Respiratory failure because of muscle spasms is a major sequela of tetanus. Spasms can be controlled with sedation and adjunctive treatment, albeit at the expense of respiratory drive and weakness. Invasive ventilation under deep sedation with intensive care unit admission is the best practice. Where invasive ventilation is unavailable and when patients decline intubation, the management of muscle spasms and respiratory failure is extremely limited, with low survival rates. Herein, we present a case of severe tetanus in a 90-year-old female farmer who declined intubation and whose respiratory failure was managed with noninvasive positive pressure ventilation (NPPV) with a moderate dose of continuous benzodiazepine infusion to treat spasms. Compared with invasive ventilation, NPPV reduces the duration of ventilatory support and the risk of nosocomial pneumonia. Because spontaneous respiratory drive of the patient was maintained to trigger ventilation, pressure control ventilation was initiated. In previous references to tetanus management, the application of NPPV has not been mentioned. NPPV is a treatment option for patients with tetanus who are not intubated owing to limited medical resources or do-not-intubate orders for older patients.

Keywords: midazolam; noninvasive positive pressure ventilation; spasm; tetanus.