Simple bedside predictors of mechanical ventilation in patients with Guillain-Barre syndrome

doi:10.1016/j.jcrc.2013.10.026

Journal of Critical Care

Volume 29, Issue 2, April 2014, Pages 219-223

https://doi.org/10.1016/j.jcrc.2013.10.026 Get rights and content

Abstract

Objective

The objective of the study is to develop and validate a predictor score for assessing the requirement of mechanical ventilation (MV) in patients with Guillain-Barre syndrome (GBS).

Study design

The study was conducted in patients admitted with GBS in neurointensive care unit in a tertiary care hospital. The demographic, clinical factors, electrophysiological, and spirometric data of all consecutive patients were prospectively collected. The study was undertaken in 2 stages. In the first stage, data were collected for development of a predictor score. In the second stage, the score developed was validated on a separate set of patient data.

Results

The data collected were compared between the 2 groups (ventilated vs nonventilated). On univariate analysis, time taken to reach maximum deficit, neck weakness, bulbar weakness, facial weakness, single breath count (SBC), forced vital capacity, and phrenic nerve latency predicted the need for MV. On multivariate analysis, only neck weakness, bulbar weakness, SBC, and forced vital capacity were independent predictors of MV. There was a good correlation between SBC and the spirometric tests and phrenic nerve distal motor latency, as reflected in receiver operating characteristics curve. The predictor score developed using the regression coefficient of independent predictors showed that the best cutoff score for prediction of ventilation was 60 (sensitivity, 0.95; 1 – specificity, 0.065). Internal cross validation of the neck weakness, SBC, and bulbar palsy (NSB) score showed good correlation (Pearson R = 0.76; P = .00). There was no statistically significant difference between predicted and observed outcomes (sensitivity, 95%; specificity, 93%).

Conclusion

Several independent risk factors were found to predict the requirement for MV in patients with GBS at admission. However, after scoring and analyzing them, it was found that combining a few of them was more useful to predict the need for MV. A model using NSB score, developed using clinical variables, accurately predicted the requirement of MV. In addition, among the NSB score parameters, simple bedside SBC could adequately assess the adequacy of vital capacity.

Introduction

Respiratory failure requiring mechanical ventilation (MV) is the most common and serious complication of Guillain-Barre syndrome (GBS) [1], [2], [3]. The reported incidence of patients developing respiratory failure ranges from 20% to 30% [1], [4], [5], [6]. Clinical parameters such as rapid disease progression, bulbar dysfunction, bifacial weakness, neck weakness, proximal weakness in upper limbs and autonomic instability predict the future need for MV in GBS. However, clinical parameters alone may not accurately predict the need for MV in these patients. Studies have shown that forced vital capacity (FVC) less than 20 mL/kg predicted the need for MV in these patients [5], [6], [7]. The results of the studies regarding phrenic nerve electrophysiological testing in anticipating respiratory failure have been inconsistent. A retrospective study showed that reduced amplitude of phrenic nerve compound motor action potential (CMAP) correlated with reduction in vital capacity and subsequent need for MV [8], [9]. In another study, no such correlation was found [10]. Thus, it would be useful to combine the clinical neurologic predictors with the respiratory parameters to accurately predict the same. In addition, a published report stressed upon single breath count (SBC) as a simple bedside measure of vital capacity to assess the respiratory reserve in patients with neuromuscular paralysis [11]. Such bed side tools would be useful in GBS as it may not be feasible to perform all clinical investigations repeatedly and at all locations.

This prompted the authors to prospectively study potential associations of clinical, phrenic nerve electrophysiology, respiratory test findings (FVC) with subsequent need for MV and to develop a simple bedside predictor score and validate this in patients with GBS. This would help to triage the patients to appropriate level of care and facilitate early intervention and prevent consequences such as aspiration, chest infection, and respiratory failure.

Section snippets

Methods

This was a prospective institutional observational study. The study was conducted after institutional ethics committee's approval. The study was conducted in a tertiary care hospital in South India on patients with a clinical diagnosis of GBS. Diagnosis of GBS was based on clinical and electrophysiological criteria [12]. The study was undertaken in 2 stages. In the first stage, data were collected for development of a predictor score (study period was from July 2007 to December 2008). In the

Statistical analysis

Statistical analysis was performed using SPSS version 13.0 (SPSS, Inc, Chicago, Ill). Data were expressed as mean and SD or as proportions (percentage). Correlation between SBC, spirometric tests (FVC, FEV1, and FEV25-75), and phrenic nerve distal motor latency (DML) was performed using Pearson correlation. The data were divided into 2 groups—patients requiring MV (Group MV) and not requiring ventilation (Group NV). Comparison of categorical data between the 2 groups was performed using χ² test

Demographic profile

Sixty-eight patients were admitted with a diagnosis of GBS between July 2007 and December 2008. The demographic and clinical characteristics at admission of 68 consecutive adult patients are shown in Table 1. The comparison of demographic and clinical features, pulmonary function tests, and electrophysiological studies of phrenic nerve between the 2 groups is shown in Table 2.

Neurologic examination

Of 68 patients, 27 patients had demyelinating type of nerve conduction studies, 30 patients had axonal type of Nerve

Discussion

Early prediction of decline in respiratory function and progression to MV is important in GBS. Studies have shown that early anticipation and intervention have reduced the risk of complications and improved outcome [13], [14]. The incidence of MV in this series was 18%, which is consistent with the previous studies. Presence of bifacial weakness, bulbar palsy, neck weakness, autonomic dysfunction, SBC, and latency of phrenic nerve CMAP were associated with need for MV on univariate analysis.

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Respiratory failure is a common and potentially life-threatening complication of neuromuscular diseases. Prompt recognition and accurate diagnosis of new or worsening chronic neuromuscular disease have important clinical management and prognostic implications. In this article, we present an approach to the acute presentation of undifferentiated neuromuscular respiratory failure in the ICU and guidance for determination and respiratory management of the underlying disorder.
A vital parameter? Systematic review of spirometry in evaluation for intensive care unit admission and intubation and ventilation for Guillain-Barré syndrome
2023, Journal of Clinical Neuroscience
Patients with Guillain-Barré syndrome (GBS) may require intensive care unit (ICU) admission for intubation and ventilation (I + V). The means to predict which patients will require I + V include spirometry measures. The aims of this study were to determine, for adult patients with GBS, how effectively different spirometry parameter thresholds predict the need for ICU admission and the requirement for I + V; and what effects these different parameter thresholds have on GBS patient outcomes.
A systematic review was conducted of the databases PubMed, EMBASE, and Cochrane library in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The systematic review was registered prospectively on PROSPERO.
Initial searches returned 1011 results, of which 8 fulfilled inclusion criteria. All included studies were observational in nature. Multiple studies suggest that a vital capacity below 60% of predicted value on admission is associated with the need for eventual I + V. No included studies evaluated peak expiratory flow rate, or interventions with different thresholds for ICU or I + V.
There is a relationship between vital capacity and the need for I + V. However, there is limited evidence supporting specific thresholds for I + V. In addition to evaluating these factors, future research may evaluate the effect of different patient characteristics, including clinical presentation, weight, age, and respiratory comorbidities, on the effectiveness of spirometry parameters in the prediction of the need for I + V.
Single count breath test for the evaluation of respiratory function in Myasthenia Gravis: A systematic review
2023, Journal of Clinical Neuroscience
Myasthenia gravis (MG) can have a variety of respiratory presentations, ranging from mild symptoms through to respiratory failure. The evaluation of respiratory function in MG can be limited by accessibility to testing facilities, availability of medical equipment, and facial weakness. The single count breath test (SCBT) may be a useful adjunct in the evaluation of respiratory function in MG.
A systematic review of the databases PubMed, EMBASE, and the Cochrane Library was conducted from inception to October 2022 in accordance with PRISMA guidelines and was registered on PROSPERO.
There were 6 studies that fulfilled the inclusion criteria. The described method of evaluating SCBT involves inhaling deeply, then counting at two counts per second, in English or Spanish, sitting upright, with normal vocal register, until another breath needs to be taken. The identified studies support that the SCBT has a moderate correlation with forced vital capacity. These results also support that SCBT can assist the identification of MG exacerbation, including via assessment over the telephone. The included studies support a threshold count of ≥ 25 as consistent with normal respiratory muscle function. Although further analysis is needed, the included studies describe the SCBT as a quick bedside tool that is inexpensive and well tolerated.
The results of this review support the clinical utility of the SCBT in assessing respiratory function in MG and describe the most current and effective methods of administration.
Pathophysiological and diagnostic aspects of Guillain-Barré syndrome
2022, Revue de Medecine Interne
Le syndrome de Guillain-Barré (SGB), première cause de neuropathie aiguë acquise, se présente par un déficit sensitivo-moteur flasque ascendant rapidement progressif. Son diagnostic est urgent du fait d’un risque d’atteinte des muscles respiratoires ou d’une dysautonomie chez respectivement 30 % et 10 % des patients. Le diagnostic de SGB repose avant tout sur l’anamnèse et l’évaluation clinique, et les examens complémentaires permettent d’éliminer un diagnostic différentiel et de confirmer secondairement le diagnostic. Le SGB est précédé par un évènement infectieux chez environ 2/3 des patients. Cette infection provoque une réponse immunitaire dirigée contre des antigènes glucidiques de l’agent pathogène et peut entraîner la formation d’anticorps anti-gangliosides. Par mimétisme moléculaire, ces anticorps peuvent se fixer sur des motifs glucidiques structurellement proches présents sur les nerfs de l’hôte. Leur fixation aboutit à un blocage de la conduction nerveuse et/ou une démyélinisation pouvant se compliquer d’une perte axonale. Il a été découvert différents types d’anticorps anti-gangliosides associés à des formes particulières de SGB : le syndrome de Miller-Fisher, la forme diplégie faciale et paresthésies, la forme pharyngo-cervico-brachiale, la forme paraparétique, et l’encéphalite de Bickerstaff. Les différences sémiologiques entre ces formes peuvent s’expliquer par une différence d’expression de ces gangliosides entre les différents nerfs de l’organisme. Dans cette mise au point, nous décrirons la physiopathologie et l’approche diagnostique du SGB et de ses formes particulières.
Guillain-Barré syndrome (GBS) is the most common cause of acute neuropathy. It usually onset with a rapidly progressive ascending bilateral weakness with sensory disturbances, and patients may require intensive treatment and close monitoring as about 30% have a respiratory muscle weakness and about 10% have autonomic dysfunction. The diagnosis of GBS is based on clinical history and examination. Complementary examinations are performed to rule out a differential diagnosis and to secondarily confirm the diagnosis. GBS is usually preceded by an infectious event in ≈ 2/3 of cases. Infection leads to an immune response directed against carbohydrate antigens located on the infectious agent and the formation of anti-ganglioside antibodies. By molecular mimicry, these antibodies can target structurally similar carbohydrates found on host's nerves. Their binding results in nerve conduction failure or/and demyelination which can lead to axonal loss. Some anti-ganglioside antibodies are associated with particular variants of GBS: the Miller-Fisher syndrome, facial diplegia and paresthesias, the pharyngo-cervico-brachial variant, the paraparetic variant, and the Bickerstaff brainstem encephalitis. Their semiological differences might be explained by a distinct expression of gangliosides among nerves. The aim of this review is to present pathophysiological aspects and the diagnostic approach of GBS and its variants.
Serial single breath count is a reliable tool for monitoring respiratory functions in Guillain-Barré Syndrome
2020, Journal of Clinical Neuroscience
Citation Excerpt :
In our study, SBC correlated best with neck flexors (r = 0.72, P < 0.01). In one study, SBC was done by allowing the patients to count spontaneously without prompting at 2 Hz, and SBC below 19 was an independent predictor of MV [14]. However, this study is limited by lack of objectivity as the counting speed may vary in different patients.
In this study, we correlate single breath count (SBC) with arterial blood gas (ABG) parameters to derive a cutoff point for intubation and mechanical ventilation (MV) in Guillain-Barré Syndrome (GBS). Ninety-four GBS patients underwent serial SBC at 2 Hz using an audio program. ABG was done at admission, and repeated if SBC declined. The patients were intubated based on “the modified intubation criteria” as follows (a + b or c): (a) hypoxia (PaO₂ < 60 mm of Hg on ventimask); (b) hypercarbia (PaCO₂ > 50 mm of Hg); (c) acidosis (pH < 7.3). The primary outcome was the absolute SBC at which patients had ABG alteration needing intubation.
All the patients maintained a desired ABG without respiratory distress till SBC 7. At SBC 5, need for MV could be predicted with a sensitivity of 90.6% and specificity of 95.2%. Admission SBC cut-off of 13 and relative delta SBC at 24 h cut-off of > 20% had a negative predictive value of 88.5% (95% CI 77.0%–96.0%) and 80.8% (95% CI 60.7%–93.4%) respectively for ruling out need of MV.
SBC is a useful non-invasive measure for monitoring respiratory function and guiding ABG analysis. Till SBC 7, repeated ABG may be avoided in GBS.
Coexisting infectious diseases on admission as a risk factor for mechanical ventilation in patients with Guillaine-Barré syndrome
2017, Journal of Epidemiology
Citation Excerpt :
Among those studies, predictors of requiring MV in GBS have been divided into clinical, electrophysiological, and biological factors.6,7 With regard to clinical predictors, disability grade on admission,8 rapid progressive motor weakness,9 bilateral facial weakness,9 bulbar dysfunction,9 dysautonomia,10 and a rapid decrease in vital capacity10,11 have all been identified as risk factors. For electrophysiological factors, nerve conduction block12 and demyelinating form12 have been reported.
The aim of this study was to investigate patient characteristics on admission to hospital that increase the risk of subsequent mechanical ventilation (MV) use for patients with Guillain–Barré syndrome (GBS).
We extracted data from the Japanese Diagnosis Procedure Combination (DPC) database for 4132 GBS patients admitted to hospital. Clinical characteristics of GBS patients with and without MV were compared. Multivariate logistic regression analyses were performed to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) for the associations of requirement for MV with coexisting infectious diseases, after adjustment for potential confounding variables, age, sex, hospital type, and ambulance transportation.
In total, 281 patients required MV, and 493 patients had coexisting respiratory diseases on admission. After adjustment for covariates and stratification by coexisting respiratory diseases, multivariate logistic regression analysis revealed that coexisting cytomegaloviral (CMV) disease (OR 8.81; 95% CI, 2.34–33.1) and herpes simplex viral (HSV) infections (OR 4.83; 95% CI, 1.16–20.1) were significantly associated with the requirement for MV in the group without coexisting respiratory diseases.
Our findings suggest that coexisting CMV and HSV infections on admission might be significantly associated with increased risk of respiratory failure in GBS patients.

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Administration/OutcomesSimple bedside predictors of mechanical ventilation in patients with Guillain-Barre syndrome

Abstract

Objective

Study design

Results

Conclusion

Introduction

Section snippets

Methods

Statistical analysis

Demographic profile

Neurologic examination

Discussion

Ann Emerg Med

Lancet

Supportive care for patients with Guillain-Barré syndrome

Arch Neurol

The morbidity of Guillain-Barré syndrome admitted to the intensive care unit

Neurology

Long-term outcome in patients with Guillain-Barré syndrome requiring mechanical ventilation

Neurology

The challenge of respiratory dysfunction in Guillain-Barré syndrome

Arch Neurol

Anticipating mechanical ventilation in Guillain-Barré syndrome

Arch Neurol

Early predictors of mechanical ventilation in Guillain-Barré syndrome

Crit Care Med

Repeated vital capacity measurements as predictive parameters for mechanical ventilation need and weaning success in the Guillain Barre syndrome

Am Rev Respir Dis

Administration/Outcomes
Simple bedside predictors of mechanical ventilation in patients with Guillain-Barre syndrome