Prognosis and risk factors of early onset pneumonia in ventilated patients with Guillain–Barré syndrome

Risk Stratification and Management of Acute Respiratory Failure in Patients With Neuromuscular Disease

OBJECTIVES

Guillain-Barré syndrome (GBS) and myasthenia gravis (MG) are the most common causes of acute neuromuscular respiratory failure resulting in ICU admission. This synthetic narrative review summarizes the evidence for the prediction and management of acute neuromuscular respiratory failure due to GBS and MG.

DATA SOURCES

We searched PubMed for relevant literature and reviewed bibliographies of included articles for additional relevant studies.

STUDY SELECTION

English-language publications were reviewed.

DATA EXTRACTION

Data regarding study methodology, patient population, evaluation metrics, respiratory interventions, and clinical outcomes were qualitatively assessed.

DATA SYNTHESIS

No single tool has sufficient sensitivity and specificity for the prediction of acute neuromuscular respiratory failure requiring mechanical ventilation. Multimodal assessment, integrating history, examination maneuvers (single breath count, neck flexion strength, bulbar weakness, and paradoxical breathing) and pulmonary function testing are ideal for risk stratification. The Erasmus GBS Respiratory Insufficiency Score is a validated tool useful for GBS. Noninvasive ventilation can be effective in MG but may not be safe in early GBS. Airway management considerations are similar across both conditions, but dysautonomia in GBS requires specific attention. Extubation failure is common in MG, and early tracheostomy may be beneficial for MG. Prolonged ventilatory support is common, and good functional outcomes may occur even when prolonged ventilation is required.

CONCLUSIONS

Multimodal assessments integrating several bedside indicators of bulbar and respiratory muscle function can aid in evidence-based risk stratification for respiratory failure among those with neuromuscular disease. Serial evaluations may help establish a patient's trajectory and to determine timing of respiratory intervention.

Outcome of Guillain-Barré syndrome with bulbar palsy

BACKGROUND

Elective intubation is advocated in Guillain-Barré syndrome (GBS) with bulbar palsy to prevent aspiration pneumonia and lung collapse. We evaluate the outcome of GBS patients with bulbar palsy, and also compare the risks and benefits of intubation and MV in them.

METHODS

187 GBS patients with bulbar palsy from a cohort of 547 GBS registry were analyzed. Detailed clinical records and peak disability on a 0-6 GBS Disability Scale (GBSDS) were noted. The patients were intubated if arterial blood gas (ABG) analysis revealed hypoxia, hypercarbia or acidosis. The patients with normal ABG parameters were fed by nasogastric tube, and nursed in lateral position. Occurrence of pneumonia, in-hospital death and outcomes at 6-months were classified as complete (GBSDS <2), partial (GBSDS 2-3) and poor (GBSDS >3).

RESULTS

76/187(40.6%) patients required MV, and they had a shorter duration of illness (p = 0.007), higher peak disability (p < 0.001), autonomic dysfunction (p < 0.001) and more frequently received IVIg (p = 0.02). Pneumonia (63% vs 10.8%; p < 0.001) and in-hospital deaths (7.9% vs 1.8%; p = 0.06) were more frequent in MV group compared to nasogastric fed group. At 6-months,104 (55.6%) patients recovered completely. On multivariate analysis, the independent predictors of poor outcome were peak disability [Adjusted Odds Ratio (AOR) 9.84, 95% Confidence Interval (CI) 3.15-30.74, p < 0.0001], day of hospitalization from disease onset (AOR 1.09, 95% Cl 1.01-1.01; p=0.009) and requirement of MV (AOR 0.10; 95% 0.02-0.50; p = 0.005).

CONCLUSION

GBS patients with bulbar palsy may be managed by nasogastric feeding and nursing in lateral position without increasing the risk of pneumonia. Mechanical ventilation based on ABG does not worsen outcomes of GBS with bulbar palsy.

A retrospective analysis of the clinical profile and factors associated with mortality and poor hospital outcomes in adult Guillain-Barre syndrome patients

Guillain-Barré syndrome (GBS) is an acute autoimmune polyneuropathy with substantial geographic variations in demography, antecedent events, clinical manifestations, electrophysiological sub-types, diagnostic findings, treatment modalities, and prognostic indicators. However, there is limited contemporary data on GBS patient profiles and prognostic factors from low-resource settings like Ethiopia. The objective of this study is to investigate the clinical profile, factors associated with mortality, and hospital outcomes among GBS patients admitted to Tikur Anbessa Specialized Hospital (TASH) in Addis Ababa, Ethiopia. A retrospective cross-sectional study was conducted among 60 GBS patients admitted to TASH from January 2018 to December 2022. Data on demographics, clinical features, treatments, complications, and outcomes were extracted from medical records. Bivariate and multivariate logistic regression analyses identified factors associated with mortality and poor hospital outcomes. The cohort had a mean age of 28.5 years, with 76.7% aged 14-34 years. Males comprised 61.7% of cases. Ascending paralysis (76.7%) was the predominant presentation. Absent or reduced reflexes were seen in 91.7% of patients. The most common antecedent event was gastroenteritis (26.7%), followed by upper respiratory tract infection (URTI) (15%) and vaccination (11.7%). The mean interval from symptom onset to hospital presentation was 8.77 days, and the peak symptom severity was 4.47 days. The axonal variant (75.5%) was the most common subtype, followed by the demyelinating variant (24.5%). Intravenous immunoglobulin was administered to 41.7% of patients. Respiratory failure requiring invasive mechanical ventilator (MV) support occurred in 26.7% of cases. The mortality rate was 10%, with mechanical ventilation being the only factor significantly associated with mortality (95% CI 2.067-184.858; P < 0.010). At discharge, 55% had a good outcome, and 45% had a poor outcome, according to the Hughes Functional Disability Scale (HFDS). Mechanical ventilation (AOR 0.024, 95% CI 0.001-0.607) and a GBS disability score > 3 (AOR 0.106, 95% CI 0.024-0.467) were factors significantly associated with poor hospital outcomes. GBS in this cohort primarily affected individuals of young age, commonly preceded by gastroenteritis and characterized by a high frequency of the axonal variant. Mechanical ventilation was found to be significantly linked to mortality. Alongside mechanical ventilation requirements, severe disability upon presentation emerged as a crucial determinant of poor outcomes upon discharge, underscoring the importance of early identification of high-risk patients and prompt interventions.

Deltoid muscle strength and autonomic dysfunction as independent risk factors for invasive mechanical ventilation in patients with Guillain-Barré syndrome

BACKGROUND

Almost a third of patients with Guillain-Barré Syndrome (GBS) require mechanical ventilation, increasing mortality by 15-30% and proving poor functional outcomes. The Erasmus GBS Respiratory Insufficiency Score (EGRIS) is the most frequently used scale to assess probability of respiratory insufficiency within the first week of admission. We aim to determine other clinical and electrophysiological prognostic factors for invasive mechanical ventilation (IMV) in patients with GBS.

MATERIAL AND METHODS

A cross-sectional ambispective cohort study was carried out in a referral center in Mexico City, from January 2015 to December 2019. Baseline demographics, MRC score, Hughes scale, EGRIS, dysautonomia and nerve conduction studies were performed on admission in GBS patients that required IMV. A multivariable analysis for IMV and a survival analysis for independent walk in prolonged-IMV (>14 days) were performed.

RESULTS

Forty-nine (32%) out of 153 GBS patients required IMV. Statistically significant prognostic factors in multivariable analysis were deltoid muscle strength ≤2 [OR 7.1 (1.6-31.1)], EGRIS [OR 2.5 (1.3-4.6)] and autonomic dysfunction [OR 6.6 (2.0-22.0)]. Electrodecrement <1 mV in the compound muscle action potential (CMAP) of distal motor median nerve was more prevalent in prolonged-IMV patients (44.8% vs. 21%, p = .049). A significant minor prevalence of prolonged-IMV patients regain independent walk at 6 months using the Kaplan-Meier method (log rank test p < .001).

CONCLUSIONS

We provide new specific clinical (deltoid muscle strength and autonomic dysfunction) and electrophysiological variables to discriminate GBS patients that will require IMV.

The neutrophil-to-lymphocyte ratio as a prognostic biomarker in Guillain-Barre syndrome: a systematic review with meta-analysis

Background and objectives

Guillain-Barre syndrome (GBS) is an immune-mediated neuropathy. This has raised the possibility that the neutrophil-lymphocyte ratio (NLR) may be a biomarker of its activity. We conducted a systematic review and meta-analysis to summarize the evidence of NLR as a potential biomarker for GBS.

Methods

We systematically searched databases (PubMed, Ovid-Medline, Embase, Scopus, Web of Science, SciELO Citation Index, LILACS, and Google Scholar) until October 2021 for studies evaluating pre-treatment NLR values in GBS patients. A meta-analysis using a random-effects model to estimate pooled effects was realized for each outcome and a narrative synthesis when this was not possible. Subgroup and sensitivity analysis were realized. GRADE criteria were used to identify the certainty of evidence for each result.

Results

Ten studies from 745 originally included were selected. Regarding GBS patients versus healthy controls, a meta-analysis of six studies (968 patients) demonstrated a significant increase in NLR values in GBS patients (MD: 1.76; 95% CI: 1.29, 2.24; I2 = 86%) with moderate certainty due to heterogeneity of GBS diagnosis criteria used. Regarding GBS prognosis, assessed by Hughes Score ≥ 3, NLR had a sensitivity between 67.3 and 81.5 and a specificity between 67.3 and 87.5 with low certainty due to imprecision, and heterogeneity. In relation to respiratory failure, NLR had a sensitivity of 86.5 and specificity of 68.2 with high and moderate certainty, respectively.

Discussion

With moderate certainty, mean NLR is higher in GBS patients compared to healthy controls. Furthermore, we found that NLR could be a prognostic factor for disability and respiratory failure with low and moderate certainty, respectively. These results may prove useful for NLR in GBS patients; however, further research is needed.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42021285212.

A vital parameter? Systematic review of spirometry in evaluation for intensive care unit admission and intubation and ventilation for Guillain-Barré syndrome

BACKGROUND

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.

METHOD

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.

RESULTS

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.

CONCLUSIONS

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.

Guillain-Barré Syndrome with Lethal Outcome Following COVID-19 Vaccination - Case Report Supported by Autopsy Examination

Objective:

After the outbreak of the global pandemic caused by SARS-CoV-2 infection at the end of the year 2019, it took one year to start vaccination against this infection with products from various manufacturers. As of November 2021, more than 8 billion vaccine doses against COVID-19 have been administered, which is essentially linked to a spike in adverse events reports following these vaccinations, including a number of neurological adverse events.

Case Report:

We report a case of a 71-year-old patient with lethal fulminant onset of Guillain-Barré syndrome after the second dose of mRNA vaccine tozinameran. This is, to our best knowledge, the first case report of this adverse event supported by autopsy and histological examination. The patient presented with progressive ascending weakness and paresthesia, with typical cytoalbuminologic dissociation in cerebrospinal fluid and severe motoric and sensitive axonal-demyelinating polyneuropathy on electromyography. The patient’s history and complex diagnostic workup did not reveal any other possible causative factors. The patient did not respond to the treatment with intravenous immunoglobulins and died 10 days later due to aspiration bronchopneumonia as a complication of respiratory muscles paralysis.

Conclusion:

Most of the reported adverse reactions following COVID-19 vaccination include mild or moderate events noticed in the post-vaccination period; however, reports of possible lethal outcomes are no exception. Still, the overall incidence of GBS after vaccination does not significantly exceed its incidence in the general population. Each such report should be carefully examined by a team of specialists to prevent overestimation of lethal adverse events linked to vaccinations, especially in fatalities that happen in the post-vaccination period.

International validation of the Erasmus GBS Respiratory Insufficiency Score

Objective

This study aimed to validate the Erasmus Guillain–Barré Syndrome Respiratory Insufficiency Score in the International Guillain–Barré Syndrome Outcome Study cohort, and to improve its performance and region‐specificity.

Methods

We examined data from the first 1,500 included patients, aged ≥6 years and not ventilated prior to study entry. Patients with a clinical variant or mild symptoms were also included. Outcome was mechanical ventilation within the first week from study entry. Model performance was assessed regarding the discriminative ability (area under the receiver operating characteristic curve) and the calibration (observed vs predicted probability of mechanical ventilation), in the full cohort and in Europe/North America and Asia separately. We recalibrated the model to improve its performance and region‐specificity.

Results

In the group of 1,023 eligible patients (Europe/North America n = 842, Asia n = 104, other n = 77), 104 (10%) required mechanical ventilation within the first week from study entry. Area under the curve values were ≥0.80 for all validation subgroups. Mean observed proportions of mechanical ventilation were lower than predicted risks: full cohort 10% versus 21%, Europe/North America 9% versus 21%, and Asia 17% versus 23%. After recalibration, predicted risks for the full cohort and Europe/North America corresponded to observed proportions.

Interpretation

This prospective, international cohort study validated the Erasmus Guillain–Barré Syndrome Respiratory Insufficiency Score, and showed that the model can be used in the full spectrum of Guillain–Barré syndrome patients. In addition, a more accurate, region‐specific version of the model was developed for patients from Europe/North America. ANN NEUROL 2022;91:521–531

Effect of Early Tracheostomy on Mortality of Mechanically Ventilated Patients with Guillain-Barré Syndrome: A Nationwide Observational Study

Background

Patients with Guillain–Barré syndrome (GBS) who require mechanical ventilation (MV) are regarded as candidates for early tracheostomy because of the high risk of prolonged MV; however, the association between early tracheostomy and favorable outcomes in patients with GBS remains unclear. In this study, we evaluated the association between early tracheostomy and outcomes in mechanically ventilated patients with GBS.

Methods

This retrospective observational study included adult patients with GBS identified in the Japanese Diagnosis Procedure Combination national inpatient database from July 1, 2010, to March 31, 2018, who initiated MV within the first week of admission and who received MV for more than 1 week. Early tracheostomy was defined as tracheostomy performed within 7 days of MV. The primary outcome was in-hospital mortality, and the secondary outcomes were 28-day mortality, nosocomial pneumonia, length of hospital stay, length of intensive care unit (ICU) stay, duration of MV, duration of sedation, duration of analgesia, duration of delirium, and total hospitalization costs. Propensity scores for early tracheostomy were calculated using a logistic regression model on the following variables: age; sex; body mass index; Japan Coma Scale status at admission; Charlson comorbidity index score; comorbidity of chronic pulmonary disease; complication of pneumonia at admission; complication of hyponatremia at admission; neurological presentation at admission; ambulance use; referral from other hospitals; treatment year; days from hospital admission to MV initiation; ICU admission until the day of MV initiation; and treatments until the day of MV initiation. Stabilized inverse probability of treatment weighting analyses was performed to compare the outcomes between patients with and without early tracheostomy.

Results

Among 919 eligible patients, 654 patients (71%) underwent tracheostomy, with 136 patients (15%) receiving early tracheostomy. Overall, the median time from initiation of MV to tracheostomy was 12 days (interquartile range 8–15 days). After stabilized inverse probability of treatment weighting, early tracheostomy was not associated with lower in-hospital mortality (risk difference 0.4%; 95% confidence interval − 5.6 to 6.7%) compared with patients without early tracheostomy. There were no significant differences in 28-day mortality (risk difference − 1.3%; 95% confidence interval − 3.5 to 0.9%) and incidence of nosocomial pneumonia (risk difference − 2.6%; 95% confidence interval − 9.1 to 4.2%) between the two groups. None of the other secondary outcomes differed significantly between the groups.

Conclusions

Early tracheostomy was not significantly associated with decreased mortality or morbidity in patients with GBS requiring MV for more than 1 week.

Prediction models for mechanical ventilation and outcome in Guillain-Barré syndrome

Various prediction models have been formulated to predict the need for mechanical ventilation (MV). In this study, we compare the sensitivity and specificity of Erasmus GBS Respiratory Insufficiency Score (EGRIS) and Sharshar score with single breath count (SBC) at 2 Hz to assess their usefulness in predicting MV and functional outcome. The primary outcome was prediction of MV and relative usefulness of all three models based on sensitivity and specificity. The secondary outcome was functional recovery at 6 months using the cut off points for MV and functional outcome at 6months was assessed using Hughes scale and categorized as good (<2) and poor (≥2). The median age was 30 years, and 64 (69.6%) were males. The sensitivity and specificity of EGRIS score was 78.1% and 67.2%, Sharshar score was 75.0% and 64.1%, and SBC at 2 Hz was 78.1% and 75.0%. The area under the receiver operating curves was maximum for SBC at 2 Hz (0.86) compared to other models, although insignificant. EGRIS score < 5 had better functional recovery compared to those with score ≥ 5 (66% vs 34%, p = 0.001). Similarly, in Sharshar score, 23/59 (39%) with score ≥ 4 had good recovery compared to 36 (61%) with score < 4 (p = 0.01). All the three models have comparable predictive values for MV. Outcome prediction is the best with EGRIS.

Risk factors for the severity of Guillain-Barré syndrome and predictors of short-term prognosis of severe Guillain-Barré syndrome

Guillain-Barré syndrome (GBS) is a neurological disorder characterized by paralysis. Identifying the severity, appropriate therapeutic method, and prognosis of GBS at an early stage is highly important. This study aimed to investigate the modifiable risk factors for the severity of GBS and consequent need for mechanical ventilation (MV) and to identify clinical predictive factors for poor short-term outcomes of severe GBS. 155 GBS patients who were admitted to the Affiliated Yantai Yuhuangding Hospital of Qingdao University during 2014–2020 were enrolled. Demographic, clinical, therapeutic and evolutionary data were collected and were then analyzed using univariate and multivariate regression analyses. Our analytic data demonstrated that the significant clinical predictors of severe GBS were recent history of surgery, older age, cranial nerve impairment, and elevated levels of liver enzymes (p < 0.05). Furthermore, autonomic dysfunction, lower Medical Research Council (MRC) score at nadir, and elevated levels of liver enzymes were significantly associated with MV for severe GBS (p < 0.05), and lower MRC score at nadir and autonomic dysfunction remained significant predictors of MV in severe GBS (p < 0.05). Lastly, recent history of surgery, lower MRC score at admission and at nadir, requirement for MV, and pneumonia during hospitalization were significantly associated with the short-term outcome of severe GBS and that lower MRC score at admission and need for MV were confirmed to be predictors of poor short-term prognosis (p < 0.05). Of note, this study suggested that recent history of surgery is a predictor of severity in GBS patients and is associated with the poor short-term prognosis of severe GBS.

Predicting Mechanical Ventilation Using the EGRIS in Guillain-Barré Syndrome in a Latin American Country

BACKGROUND

Up to one fifth of patients with Guillain-Barré syndrome (GBS) require mechanical ventilation (MV). The Erasmus GBS Respiratory Insufficiency Score (EGRIS) is a clinical predictive model developed in Europe to predict MV requirements among patients with GBS. However, there are significant differences between the Latin American and European population, especially in the distribution of GBS subtypes. Therefore, determining if the EGRIS is able to predict MV in a Latin American population is of clinical significance.

METHODS

We retrospectively analyzed clinical and laboratory data of 177 patients with GBS in three Peruvian hospitals. We performed a multivariate logistic regression of the factors making up the EGRIS. Finally, we evaluated the EGRIS discrimination through a receiver operating characteristic curve and determined its calibration through a calibration curve and a Hosmer-Lemeshow test, a test used to determine the goodness of fit.

RESULTS

We found that 14.1% of our patients required MV. One predictive factor of a patient's need for early MV was the number of days between the onset of motor symptoms and hospitalization. The Medical Research Council sum score did not alter the likelihood of early MV. Bulbar weakness increased the likelihood without showing statistical significance. In contrast, facial weakness was a protective factor of it. The EGRIS was significantly higher in patients who required early MV than in those who did not (P = 0.018). It showed an area under the curve (AUC) of 0.63, with an insignificant Hosmer-Lemeshow test result.

CONCLUSIONS

Although the EGRIS was higher in patients who required early MV than in those who did not, it only showed a moderate discrimination capacity (AUC = 0.63). Facial weakness, an item of the EGRIS, was not found to be a predictive factor in our population. We suggest assessing whether these findings are due to subtype predominance and whether a modified version of the EGRIS could improve performance.

Early mechanical ventilation in patients with Guillain-Barré syndrome at high risk of respiratory failure: a randomized trial

Introduction

About 30% of patients with Guillain-Barré syndrome become ventilator dependent, of whom roughly 75% develop pneumonia. This trial aimed at assessing the impact of early mechanical ventilation (EMV) on pneumonia occurrence in GBS patients. We hypothesize that EMV will reduce the incidence of pneumonia.

Methods

This was a single centre, open-label, randomized controlled trial performed on two parallel groups. 50 intensive care unit adults admitted for Guillain-Barré syndrome and at risk for acute respiratory failure. Patients were randomized to early mechanical ventilation via face-mask or endotracheal intubation owing to the presence or absence of impaired swallowing (experimental arm), or to conventional care (control arm). The primary outcome was the incidence of pneumonia up to intensive care unit discharge (or 90 days, pending of which occurred first).

Findings

Twenty-five patients were randomized in each group. There was no significant difference between groups for the incidence of pneumonia (10/25 (40%) vs 9/25 (36%), P = 1). There was no significant difference between groups for the time to onset of pneumonia (P = 0.50, Gray test). During follow-up, there were 16/25 (64%) mechanically ventilated patients in the control group, and 25/25 (100%) in the experimental arm (P < 000·1). The time on ventilator was non-significantly shorter in the experimental arm (14 [7; 29] versus 21.5 [17.3; 35.5], P = 0.10). There were no significant differences between groups for length of hospital stay, neurological scores, the proportion of patients who needed tracheostomy, in-hospital death, or any serious adverse events.

Conclusions

In the present study including adults with Guillain-Barré syndrome at high risk of respiratory failure, we did not observe a prevention of pneumonia with early mechanical ventilation. Trial registration: ClinicalTrials.gov under the number NCT00167622. Registered 9 September 2005, https://clinicaltrials.gov/ct2/show/NCT00167622?cond=Guillain-Barre+Syndrome&cntry=FR&draw=2&rank=1

Comparative Outcomes of Respiratory Failure Associated with Common Neuromuscular Emergencies: Myasthenia Gravis versus Guillain-Barré Syndrome

Background and objectives: Myasthenia gravis (MG) and Guillain-Barré Syndrome (GBS) are autoimmune neuromuscular disorders that may present as neuromuscular emergencies requiring mechanical ventilation and critical care. Comparative outcomes of these disease processes, once severe enough to require mechanical ventilation, are not known. In this study, we compared the patients requiring mechanical ventilation in terms of in-hospital complications, length of stay, disability, and mortality between these two disease entities at a national level. Materials and Methods: Mechanically ventilated patients with primary diagnosis of MG (n = 6684) and GBS (n = 5834) were identified through retrospective analysis of Nationwide Inpatient Sample (NIS) database for the years 2006 to 2014. Results: Even though mechanically ventilated MG patients were older (61.0 ± 19.1 versus 54.9 ± 20.1 years) and presented with more medical comorbidities, they had lower disease severity on admission, as well as lower in-hospital complications sepsis, pneumonia, and urinary tract infections as compared with GBS patients. In the multivariate analysis, after adjusting for confounders including treatment, GBS patients had significantly higher disability (odds ratio (OR) 15.6, 95% confidence interval (CI) 10.9-22.2) and a longer length of stay (OR 3.48, 95% CI 2.22-5.48). There was no significant difference in mortality between the groups (8.45% MG vs. 10.0% GBS, p = 0.16). Conclusion: Mechanically ventilated GBS patients have higher disease severity at admission along with more in-hospital complications, length of stay, and disability compared with MG patients. Potential explanations for these findings include delay in the diagnosis, poor response to immunotherapy particularly in patients with axonal GBS variant, or longer recovery time after nerve damage.

Electrophysiological Subtypes and Prognostic Factors of Guillain-Barre Syndrome in Northern China

Objectives: To assess the epidemiology of different electrophysiological subtypes of Guillain-Barre syndrome (GBS) and investigate the factors affecting the prognosis of the acute motor axonal neuropathy (AMAN) subtype in northern China.

Methods: According to the National Institute of Neurological Disorders and Stroke diagnostic criteria for GBS, 104 consecutive GBS patients were recruited from the Department of Neurology of the Second Hospital of Hebei Medical University, China from 2014 to 2018.

Results: Based on nerve conduction studies (NCSs), AMAN was the most common subtype in Northern China, accounting for 58 patients (55.8%). AMAN patients had significantly higher prevalence of antecedent diarrhea, longer duration of hospitalization, and slightly slower recovery than those with acute inflammatory demyelinating polyneuropathy (AIDP), but there was no statistical difference in disease severity or short-term prognosis between AMAN and AIDP. Based on multivariate regression analysis, AMAN patients with antecedent diarrhea (OR = 0.16, 95% CI: 0.03–0.756, p = 0.021) or conduction blocks (CBs) (OR = 0.033, 95% CI: 0.001–0.787, p = 0.035) had dramatically better short-term prognosis. Decreased compound action potential with distal stimulation (dCMAP) amplitude was associated with significant slower speed of recovery(OR = 8.31, 95% CI: 2.55–27.10, p = 0.02).

Conclusion: AMAN is still the most common subtype of GBS in northern China. A decline in dCMAP amplitude is predictive factor of a slow recovery and poor outcome of GBS. Diarrhea and CBs may be the factors for better short-term prognosis in AMAN patients in Northern China.

Predictors of respiratory failure in patients with Guillain-Barré syndrome: a systematic review and meta-analysis

OBJECTIVE

To systematically review the literature regarding the ability of clinical features to predict respiratory failure in patients with Guillain-Barré syndrome (GBS).

DATA SOURCES

We searched the PubMed and Ovid MEDLINE databases with the search terms "guillain barre syndrome" OR "acute inflammatory demyelinating polyneuropathy" OR "acute motor axonal neuropathy" OR "acute motor sensory axonal neuropathy" AND "respiratory failure" OR "mechanical ventilation". We excluded articles that did not report the results of original research (eg, review articles, letters), were case reports or series (ten or fewer patients), were not available in English, reported research in paediatric populations (16 years of age or younger), or were interventional studies. Article quality was assessed with the Newcastle-Ottawa quality assessment scale.

DATA SYNTHESIS

Thirty-four relevant studies were identified. Short time from symptom onset to hospital admission (less than 7 days), bulbar (odds ratio [OR], 9.0; 95% CI, 3.94-20.6; P < 0.001) or neck weakness (OR, 6.36; 95% CI, 2.32-17.5; P < 0.001), and severe muscle weakness at hospital admission were associated with increased risk of intubation. Facial weakness (OR, 3.74; 95% CI, 2.05-6.81; P < 0.001) and autonomic instability (OR, 6.40; 95% CI, 2.83-14.5; P < 0.001) were significantly more frequent in patients requiring intubation in our meta-analyses; however, the differences were not statistically significant in individual multivariable analysis studies. Four predictive models have been developed to assess the risk of respiratory failure for patients with GBS, each with good to excellent discriminative power (area under the receiver operating characteristic curve, 0.79-0.96).

CONCLUSIONS AND RELEVANCE

Early identification of GBS patients at risk of respiratory failure could reduce the rates of adverse outcomes associated with delayed intubation. Algorithms that predict a patient's risk of subsequent respiratory failure at hospital admission appear more reliable than individual clinical variables.

Swallowing and swallowing-breathing interaction as predictors of intubation in Guillain-Barré syndrome

BACKGROUND

Bulbar weakness and respiratory impairment have been associated with increased morbidity in retrospective studies of Guillain-Barré syndrome (GBS) patients. The aim of this study was to prospectively explore the relationship between subclinical swallowing impairment, respiratory function parameters, the necessity to intubate patients and the development of early postintubation pneumonia in patients with GBS in the intensive care unit (ICU).

METHODS

Respiratory, swallowing, and tongue strength parameters were measured in 30 consecutive adults (51.7 ± 18.1 years old), hospitalized for GBS in the ICU of a teaching hospital. Twenty healthy volunteers were recruited as a control group. The primary outcomes were intubation and pneumonia during the ICU stay.

RESULTS

Nineteen patients (65.5%) had piecemeal swallowing, and 19 (65.5%) had impaired breathing-swallowing interaction, of which, respectively, 47.4% and 52.6% had a clinically apparent swallowing impairment. Swallowing impairment was associated with lower values of respiratory function, but not with peripheral motor weakness. Tongue protrusion strength was correlated with respiratory parameters and swallowing impairment. Ten patients were intubated and six developed pneumonia. Age, BMI, severe axial involvement, respiratory parameters (vital capacity and respiratory muscle strength), tongue protrusion strength, and clinical swallowing impairment were predictors of intubation.

CONCLUSIONS

Swallowing impairment was present early after ICU admission in over 80% of patients and was an important predictor of intubation. A systematic clinical evaluation of swallowing should be carried out, eventually combined with an evaluation of tongue protrusion strength, along with the usual assessment of neurological and respiratory function, to determine the severity of the GBS.

Comparison of suction above cuff and standard endotracheal tubes in neurological patients for the incidence of ventilator-associated pneumonia and in-hospital outcome: A randomized controlled pilot study

Background:

Ventilator-associated pneumonia (VAP) is a common complication with endotracheal intubation. The occurrence of VAP results in significant mortality and morbidity. Earlier studies have shown reduction in the incidence of VAP with subglottic secretion drainage. The incidence of VAP in neurologically injured patients is higher and can impact the neurological outcome. This study aimed to compare the incidence of VAP with standard endotracheal tube (SETT) and suction above cuff endotracheal tube (SACETT) in neurologically ill patients and its impact on clinical outcome.

Methods:

Fifty-four patients with neurological illnesses aged ≥18 years and requiring intubation and/or ventilation and anticipated to remain on ETT for ≥48 h were randomized to receive either SETT or SACETT. All the VAP preventive measures were similar between two groups except for the difference in type of tube.

Results:

The data of 50 patients were analyzed. The incidence of clinical VAP was 20% in SETT group and 12% in SACETT group; (P = 0.70). The incidence of microbiological VAP was higher in the SETT group (52%) as compared to SACETT group (44%) but not statistically significant; (P = 0.78). There was no difference between the two groups for measured outcomes such as duration of intubation, mechanical ventilation, and Intensive Care Unit stay.

Conclusions:

In this pilot study in neurological population, a there was no significant difference in incidence of clinical and microbiological VAP was seen between SETT and SACETT, when other strategies for VAP prevention were similar. Other outcomes were similar with use of either tube for intubation.

Predictors for mechanical ventilation and short-term prognosis in patients with Guillain-Barré syndrome

INTRODUCTION

Guillain-Barré syndrome (GBS) is an immune-mediated disorder of the peripheral nervous system. Respiratory failure requiring mechanical ventilation (MV) is a serious complication of GBS. Identification of modifiable risk factors for MV and poor short-term prognosis in mechanically ventilated patients with GBS may contribute to the individualized management and may help improve the outcome of the patients.

METHODS

We retrospectively analyzed the clinical data of 541 patients who were diagnosed with GBS from 2003 to 2014. Independent predictors for MV and short-term prognosis in mechanically ventilated patients were identified via multivariate logistic regression analysis.

RESULTS

The mean age was 41.6 years with a male predilection (61.2%). Eighty patients (14.8%) required MV. Multivariate analysis revealed that shorter interval from onset to admission (p < 0.05), facial nerve palsy (p < 0.01), glossopharyngeal and vagal nerve deficits (p < 0.01) and lower Medical Research Council (MRC) sum score at nadir (p < 0.01) were risk factors for MV; disease occurrence in summer (p < 0.01) was a protective factor. As to prognostic factors, absence of antecedent infections (p < 0.01) and lower MRC sum score at nadir (p < 0.01) were predictors of poor short-term prognosis in mechanically ventilated patients regardless of treatment modality. We further investigated the predictors of poor short-term prognosis in patients requiring MV with different nadir MRC sum scores. Combined use of intravenous corticosteroids with intravenous immunoglobulin (odds ratio 10.200, 95% confidence interval 1.068-97.407, p < 0.05) was an independent predictor of poor short-term prognosis in mechanically ventilated patients with a nadir MRC sum score from 0 to 12 points, regardless of existence of antecedent infection.

CONCLUSIONS

Clinical predictors of MV and poor short-term prognosis in mechanically ventilated GBS patients were distinct. Add-on use of intravenous corticosteroids was a risk factor for poor short-term prognosis in mechanically ventilated patients with a nadir MRC sum score from 0 to 12 points.

A novel virtual motor rehabilitation system for Guillain-Barré syndrome. Two single case studies

INTRODUCTION

This article is part of the Focus Theme of Methods of Information in Medicine on "New Methodologies for Patients Rehabilitation".

OBJECTIVES

For Guillain-Barré patients, motor rehabilitation programs are helpful at the onset to prevent the complications of paralysis and in cases of persistent motor impairment. Traditional motor rehabilitation programs may be tedious and monotonous, resulting in low adherence to the treatments. A Virtual Motor Rehabilitation system has been tested in Guillain-Barré patients to increase patient adherence and to improve clinical results.

METHODS

Two people with Guillain-Barré performed 20 rehabilitation sessions. We tested a novel system based on Motor Virtual Rehabilitation in three periods of time (baseline evaluation, final evaluation, and follow-up. In the training program, the participants carried out a specific treatment using the Active Balance Rehabilitation system (ABAR). The system is composed of customizable virtual games to perform static and dynamic balance rehabilitation.

RESULTS

Significant improvements in clinical results were obtained by both participants, with significant results in the static balance clinical test of the Anterior Reach test in the standing position and unipedal stance time. Other significant results were found in dynamic balance clinical tests in the Berg Balance Scale test and the 30-second Sit-to-Stand test. With regard to acceptance of the system, both patients enjoyed the experience, and both patients thought that this system was helpful for their rehabilitation.

CONCLUSIONS

The results show that Virtual Motor Rehabilitation for Guillain-Barré patients provides clinical improvements in an entertaining way.

[Guillain-Barré syndrome in the critical care unit in the last 10 years]

OBJECTIVES

The Guillain-Barré syndrome (GBS) is an acute inflammatory polyradiculoneuropathy, which constitutes an important proportion of acute flaccid paralysis cases. Our objective was to present the clinical characteristics of patients with the GBS who required admission to a critical care unit.

METHODS

A retrospective study over a period of ten years was conducted on patients with GBS, who were admitted to the critical care unit in a tertiary hospital. The proportion of patients requiring connection to mechanical ventilation (MV) and associated complications was analysed, along with certain clinical features which implied a more severe illness and worse functional recovery.

RESULTS

MV was required in 58.8% of cases (mean duration 29.8 days). Nine patients received tracheostomy. Pulmonary complications were observed in all patients that needed MV (50% tracheobronchitis and 50% ventilator-associated pneumonia). MV is associated with pulmonary complications (P=.001) and those, in turn, to the development of sepsis (P=.006). Only one patient died (5.88%). No relationship was found between advanced age, MV, comorbidity, sepsis, or hemodynamic complications and the mortality of GBS.

CONCLUSIONS

Death in these patients results from pulmonary complications, sepsis and less frequently due to autonomic dysfunction or pulmonary embolism. Emphasising the importance of their prevention, detection and management.

Selective digestive tract decontamination decreases time on ventilator in Guillain-Barré syndrome

BACKGROUND

Ventilator-associated pneumonia (VAP) occurs in more than half of mechanically ventilated patients with Guillain-Barré syndrome (GBS) and is associated with prolonged mechanical ventilation (MV). We investigated the impact of selective decontamination of the digestive tract (SDD), an intervention that reduces hospital acquired infections in ICU patients, on duration of MV in GBS and neurological outcome at 6 months.

METHODS

We performed a retrospective study in mechanically ventilated GBS patients in the Netherlands. We compared patients treated with and without SDD. Main outcomes were duration of MV and the ability to walk independently at 6 months. Statistical comparison was done with logistic and ordinal regression analyses.

RESULTS

We included 124 GBS patients on MV at 2 weeks after first symptoms (SDD, n = 54 and non-SDD, n = 70). The median duration of MV without SDD was 42 days (interquartile range, IQR 25-77 days) versus 29 days with SDD (IQR 17-45 days). Median duration of MV for all included patients was 35 days. The adjusted odds ratio (OR) for duration of MV > 35 days in the SDD versus the non-SDD cohort was 0.37 (95% CI 0.17-0.77). SDD did not affect neurological recovery after 6 months from first symptoms. VAP occurred in 12% (95% CI 2-22%) in the SDD cohort and in 47% (95% CI 35-59%) in the non-SDD cohort.

CONCLUSIONS

SDD in mechanically ventilated GBS patients reduced the time on the ventilator, probably by preventing VAP, but did not affect neurological recovery after 6 months.

Relevance of anxiety in clinical practice of Guillain-Barre syndrome: a cohort study

OBJECTIVES

Illness is often associated with anxiety, but few data exist about the prognostic significance of this phenomenon. To address this issue, we assessed whether patient anxiety is associated with subsequent need for intubation in Guillain-Barré syndrome (GBS).

DESIGN

Incident case-cohort study.

SETTING

Acute secondary care in a teaching hospital (France) from 2006 to 2010.

PARTICIPANTS

110 adult GBS patients. Either language barrier or cognitive decline that precluded understanding was considered as exclusion criteria.

PRIMARY OUTCOME

Acute respiratory failure.

INTERVENTIONS

At admission, anxiety and clinical factors (including known predictors of respiratory failure: delay between GBS onset and admission, inability to lift head, vital capacity (VC)) were assessed and related to subsequent need for mechanical ventilation (MV). Anxiety was assessed using a Visual Analogical Scale (VAS), the State Anxiety Inventory form Y1 (STAI-Y1) score and a novel-specific questionnaire, evaluating fears potentially triggered by GBS. Patients were asked to choose which they found most stressful from weakness, pain, breathlessness and uncertainty.

RESULTS

23 (22%) were subsequently ventilated. Mean STAI-Y1 was 47.2 (range 22-77) and anxiety VAS 5.2 (range 0-10). STAI was above 60/80 in 22 (21%) patients and anxiety VAS above 7/10 in 28 (27%) patients. Fear of remaining paralysed, uncertainty as to how the disease would progress and fear of intubation were the most stressful. Factors significantly associated with anxiety were weakness and bulbar dysfunction. STAI-Y1 was higher and uncertainty more frequent in subsequently ventilated patients, who had shorter onset-admission delay and greater weakness but not a lower VC. Uncertainty was independently associated with subsequent MV.

CONCLUSIONS

Early management of patients with GBS should evaluate anxiety and assess its causes both to adjust psychological support and to anticipate subsequent deterioration.

A simple functional marker to predict the need for prolonged mechanical ventilation in patients with Guillain-Barré syndrome

INTRODUCTION

Patients suffering from Guillain-Barré syndrome (GBS) may frequently develop an acute respiratory failure and need ventilatory support. Immune therapy using plasma exchange or immunoglobulins has modified the natural course of the disease and by decreasing the length of the plateau phase, may induce a rapid improvement in ventilatory function. However a substantial proportion of patients still require prolonged mechanical ventilation (MV) and tracheotomy. The present study was designed to search for simple functional markers that could predict the need for prolonged MV just after completion of immune therapy.

METHODS

We analyzed the data collected in a cohort of patients with GBS admitted to the intensive care unit (ICU) of our university hospital between 1996 and 2009. Demographic, clinical, biological and electrophysiologic data, results of sequential spirometry, and times of endotracheal intubation, tracheotomy, and MV weaning were prospectively collected for all patients. Sequential daily neurological testing used standardized data collection by the same investigators all along the study period. Results were compared by single and multiple regression analysis at admission to ICU and at the end of immune therapy, according to the need and duration of MV (≤ or > 15 days).

RESULTS

Sixty-one patients with severe GBS were studied. Sixty-six percent required MV (median length: 24 days). The lack of foot flexion ability at ICU admission and at the end of immunotherapy was significantly associated with MV length > 15 days (positive predictive value: 82%; odds ratio: 5.4 [1.2 - 23.8] and 82%; 6.4 [1.4 - 28.8], respectively). The association of a sciatic nerve motor conduction block with the lack of foot flexion at the end of immunotherapy was associated with prolonged MV with a 100% positive predictive value.

CONCLUSIONS

In patients admitted to ICU with Guillain-Barré syndrome and acute respiratory failure, the lack of foot flexion ability at the end of immune therapy predicts a prolonged duration of MV. Combined with a sciatic motor conduction block, it may be a strong argument to perform an early tracheotomy.

Neuromyopathies in the Critically Ill

After studying this chapter, you should be able to: Be aware of the different neuromuscular disorders that are encountered in the ICU. Know the effects of neuromuscular dysfunction on the respiratory system. Know the proper initial evaluation and management of patients with neuromuscular dysfunction and respiratory failure. Be aware of the various therapies used to treat neuromuscular disorders that are most commonly encountered in the ICU.

Tongue weakness is associated with respiratory failure in patients with severe Guillain-Barré syndrome

OBJECTIVE

Swallowing impairment may worsen respiratory weakness and conduct to respiratory complications such as aspiration pneumonia in Guillain-Barré syndrome (GBS). We prospectively evaluate how tongue weakness could be associated to bulbar dysfunction and respiratory weakness in severe GBS patients.

MEASUREMENTS AND MAIN RESULTS

Tongue strength, dysphagia and respiratory parameters were measured in 16 GBS patients at intensive care unit (ICU) admission and discharge and in seven controls. Tongue strength was decreased in the GBS patients compared with the controls. At admission, patients with dysphagia and those requiring mechanical ventilation (MV) had greater tongue weakness. All the patients with initial tongue strength <150 g required MV during ICU stay. Tongue strength correlated significantly with respiratory parameters.

CONCLUSION

This study confirms the strong association between bulbar and respiratory dysfunction in GBS admitted to ICU. Tongue weakness may be present in GBS, especially during the phase of increasing paralysis, and resolves during the recovery phase. Tongue strength and indices of global and respiratory strength vary in parallel throughout the course of GBS. Further studies are needed to assess if, when used in combination with other respiratory tests, tongue strength measurement could contribute to identify patients at high risk for respiratory complications.

Guillain-Barré syndrome and influenza virus infection

BACKGROUND

In Western countries, the cause of 60% of all Guillain-Barré syndrome (GBS) cases remains unidentified. The number of cases of unidentified cause peaks in winter, and these cases are commonly preceded by respiratory tract infection or influenza-like illness. We investigated the triggering role of influenza virus infection.

METHODS

Of 405 patients with GBS who were admitted to a French reference center during 1996-2004, 234 had cases caused by an unidentified agent. We used time-series methods to study the correlation between the monthly incidence of such cases and influenza-like illnesses reported by the Sentinelles surveillance network. We analyzed anti-influenza antibodies using complement fixation testing and hemagglutination-inhibition assays. We studied etiological subgroups using Wilcoxon and Fisher's exact tests.

RESULTS

We found a positive association between the monthly incidence of GBS caused by an unidentified agent and reported influenza-like illnesses. Of 73 patients whose cases occurred during periods in which there was a possible link to influenza, 10 (13.7%) had serological evidence of recent influenza A, and 4 (5.5%) had serological evidence of influenza B. Eight of 10 influenza A-related cases occurred during "major" influenza seasons, and antibodies specific to the current epidemic strain were found in 9 cases. Most patients with influenza A-related cases were aged < 65 years, and none had antiganglioside antibodies. Influenza-related cases differed both from Campylobacter jejuni-related cases, with regard to the lack of need for mechanical ventilation (P = .014), and from the cases caused by an unidentified agent, with regard to the presence of preceding influenza-like illness or respiratory tract infection (P = .015) and longer time from the infectious event to GBS onset (P = .04).

CONCLUSIONS

Influenza viruses are infrequent triggering agents of GBS but may play a significant role during major influenza outbreaks. Influenza-related GBS displays specific features and is not associated with antiganglioside antibody response, which suggests the presence of underlying immune mechanisms.

The morbidity and outcome of patients with Guillain-Barré syndrome admitted to the intensive care unit

One third of patients with Guillain-Barré syndrome (GBS) require admission to the intensive care unit (ICU), associated with significant risk of morbidity, mortality, and incomplete recovery.

METHODS

76 adult patients with GBS admitted to the ICU at a regional referral center over a 20-year period were studied. We determined the frequency, nature, and predictors of complications they experienced while in the ICU; this morbidity was related to long-term functional recovery and time to regain independent ambulation, extracted from longitudinal follow-up data.

RESULTS

ICU stay was a median 21 days and mechanical ventilation (MV) was required in 78% (median duration 28 days). Two-thirds suffered at least one major complication, most commonly pneumonia (54%). Morbidity was strongly associated with MV and male sex. Mortality occurred in only 5 patients (6.5%). Over an average 3 years follow-up, recovery of independent ambulation was seen in 75%, with advanced age being the most powerful predictor of poor outcome. Prolonged MV and severe axonal loss did not preclude a favorable recovery. Time to ambulate was a median 198 days, although recovery could occur as late as ten years after onset; slower recovery was associated with ICU complications, prolonged MV, and early axonal abnormalities.

CONCLUSION

Although patients with GBS suffer significant morbidity during protracted ICU stays, with meticulous supportive care, many make gratifying functional recoveries. In severely afflicted patients, this may only be appreciated after extended follow-up.

Clinical and electrophysiological predictors of respiratory failure in Guillain-Barré syndrome: a prospective study

BACKGROUND

Respiratory failure is the most serious short-term complication of Guillain-Barré syndrome and can require invasive mechanical ventilation in 20-30% of patients. We sought to identify clinical and electrophysiological predictors of respiratory failure in the disease.

METHODS

We prospectively assessed electrophysiological data and clinical factors, including identified predictors of delay between disease onset and admission, inability to lift head, and vital capacity, in patients admitted with Guillain-Barré syndrome. We related these factors to subsequent need for ventilatory support. Neurophysiological findings were classified as demyelinating, axonal, equivocal, unexcitable, or normal. Predictive values of clinical and electrophysiological data were tested using classification trees to build up a predictive model. This model was initially built up in a two-third (fitting set) then validated in a one-third (validation set) of the total sample. The fitting and validation sets were randomly selected. We also assessed the predictive value of this model for disability at 6 months.

FINDINGS

From 1998, to 2006, 154 patients with Guillain-Barré syndrome were included in the study and 34 (22%) were subsequently ventilated. Demyelinating Guillain-Barré syndrome was more common in patients who went on to be ventilated than in those who were not (85%vs 51%, p=0.0003). Vital capacity and the proximal/distal compound muscular amplitude potential (p/dCMAP) ratio of the common peroneal nerve were retained in the tree model, with a probability of needing ventilation of less than 2.5% in patients with a ratio of greater than 55.6% and a vital capacity more than 81% of predicted. A p/dCMAP ratio of the peroneal nerve less than 55.6% and age older than 40 years were retained as independent predictors of disability at 6 months.

INTERPRETATION

Neurophysiological testing is helpful for assessing risk of respiratory failure, which is highest in patients with evidence of demyelination and very low in those without both 55.6% conduction block of the common peroneal nerve and a 20% reduction in vital capacity.