Brief Alerts
Predicting Respiratory Compromise in GBS
Sources: Lawn ND, et al. Anticipating mechanical ventilation in Guillain-Barré syndrome. Arch Neurol. 2001;58:893-898. Hahn AF. The challenge of respiratory dysfunction in Guillain-Barré syndrome. Arch Neurol. 2001;58:871-872.
Firm guidelines exist for intubating Guillain-Barré syndrome (GBS) patients. When vital capacity drops below 15 mL/kg, arterial Po2 below 70%, or in the presence of severe bulbar weakness or respiratory fatigue, mechanical ventilation is imperative. Can one predict which patients will arrive at this point and thus warrant precautionary intensive care unit (ICU) observation?
Sixty severe GBS patients requiring mechanical ventilation were compared to 54 severe nonventilated GBS patients to determine clinical and electrophysiologic predictors of respiratory failure. No clinical feature foretold the pattern of respiratory decline, including age, gender, preceding gastrointestinal illness, arm paralysis, lung disease, cerebrospinal fluid findings, nerve conduction study abnormalities including inexcitable nerves prior to peak disability, or lack of treatment with immune globulin or plasmapheresis. Bulbar and autonomic dysfunction, peak disability within 7 days of onset of neuropathic symptoms, and bilateral facial paresis was significantly associated with the need for ventilatory support. Importantly, vital capacity less than 20 mL/kg, maximum inspiratory and expiratory pressures less than 30 cm H2O and 40 cm H2O, respectively, or a > 30% decrease in any of these measurements, predicted progression to ventilatory failure. GBS patients should be closely monitored for these parameters and when present, timely transfer to the ICU is warranted with an eye toward elective intubation as needed.
Commentary
Dubbed the 20/30/40 rule, these guidelines add an easily retained and important dimension to the care of GBS patients. Evidence of bulbar dysfunction and aspiration also mandates ICU transfer and intubation. —Michael Rubin
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