Neuromuscular disorders and acute respiratory failure

Noninvasive and invasive mechanical ventilation for neurologic disorders

Patients with acute neurologic injuries frequently require mechanical ventilation due to diminished airway protective reflexes, cardiopulmonary failure secondary to neurologic insults, or to facilitate gas exchange to precise targets. Mechanical ventilation enables tight control of oxygenation and carbon dioxide levels, enabling clinicians to modulate cerebral hemodynamics and intracranial pressure with the goal of minimizing secondary brain injury. In patients with acute spinal cord injuries, neuromuscular conditions, or diseases of the peripheral nerve, mechanical ventilation enables respiratory support under conditions of impending or established respiratory failure. Noninvasive ventilatory approaches may be carefully considered for certain disease conditions, including myasthenia gravis and amyotrophic lateral sclerosis, but may be inappropriate in patients with Guillain-Barré syndrome or when relevant contra-indications exist. With regard to discontinuing mechanical ventilation, considerable uncertainty persists about the best approach to wean patients, how to identify patients ready for extubation, and when to consider primary tracheostomy. Recent consensus guidelines highlight these and other knowledge gaps that are the focus of active research efforts. This chapter outlines important general principles to consider when initiating, titrating, and discontinuing mechanical ventilation in patients with acute neurologic injuries. Important disease-specific considerations are also reviewed where appropriate.

Neurologic complications in critically ill pregnant patients

Neurologic complications in a critically ill pregnant woman are uncommon but some of the complications (such as eclampsia) are unique to pregnancy and the puerperal period. Other neurologic complications (such as seizures in the setting of epilepsy) may worsen during pregnancy. Clinical signs and symptoms such as seizure, headache, weakness, focal neurologic deficits, and decreased level of consciousness require careful consideration of potential causes to ensure prompt treatment measures are instituted to prevent ongoing neurologic injury. Clinicians should be familiar with syndromes such as pre-eclampsia, eclampsia, stroke, posterior reversible encephalopathy syndrome, and reversible cerebral vasoconstriction syndrome. Necessary imaging studies can usually be performed safely in pregnancy. Scoring systems for predicting maternal mortality are inadequate, as are recommendations for neurorehabilitation. Tensions can arise when there is conflict between the interests of the mother and the interests of the fetus, but in general maternal health is prioritized. The complexity of care requires a multidisciplinary and multiprofessional approach to achieve best outcome in an often unexpected situation.

Spectrum of Guillain-Barré syndrome in tertiary care hospital at Kolkata

Objective:

In childhood Guillain–Barré syndrome (GBS), the clinical profiles using intravenous immunoglobulin (IVIg) in addition to supportive care were studied.

Materials and Methods:

This was a retrospective analysis of 139 children with severe GBS admitted to our respiratory care unit managed with the IVIg as an adjunct intervention to conventional supportive and respiratory care.

Results:

In our case series of 139 cases, motor weakness was the most common presenting feature. Antecedent illness was found in 66.7% of cases in the preceding two weeks, which included nonspecific illness, acute respiratory infection, diarrhea, and chickenpox. At onset, sensory symptoms (pain and paresthesia) were noted in 59% of the cases and limb weakness in 77%. On admission, a majority (61.54%) were in Hughes neurological disability grading stage V; all had limb weakness at the peak deficit, autonomic disturbance was seen in 35.8%, and bulbar palsy in 52%. Duration of illness was less than three weeks in 67% of cases. The mean duration of ventilation was 21.5 days (range, 5-60 days).

Conclusions:

Male preponderance and motor weakness was the most common presenting illness and a majority achieved full recovery in our series. Although IVIg may be useful in the treatment of GBS, the key issue is excellent intensive care unit management.