This case study will explore the diagnosis and treatment of an adult patient who presented with signs and symptoms of Guillain-Barré syndrome.
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Guillain Barré Syndrome Clinical Scenario
You are called to the emergency room for the assessment of a 55-year-old male patient who weighs 89 kg. Over the past week, the patient experienced decreased mobility in his feet that spread up throughout his legs. He has also been experiencing shortness of breath. The patient has no notable medical history but was sick with the parainfluenza virus three weeks ago. He arrived alone with no other family members present. It should also be noted that the patient has no allergies and does not take any medications at home.
On physical examination, the patient showed the following signs and symptoms:
- The patient appears pale and with slight signs of cyanosis.
- He appears anxious and is showing signs of diaphoresis.
- He is showing signs of nasal flaring.
- His pupils are round and reactive to light.
- His trachea is positioned in the midline.
- There are no signs of jugular venous distention.
- Auscultation reveals diminished breath sounds in the lung apices and crackles in the bases.
- He has bilateral, equal chest expansion.
- He has a normal anterior-posterior chest diameter.
- Chest percussion reveals a dull sound in the lung bases.
- Palpation returns no tactile fremitus.
- He is showing signs of mild retractions.
- His abdomen is soft and tender.
- His capillary refill time is 5 seconds.
- There are no signs of digital clubbing or pedal edema.
- His fingers are slightly cyanotic.
- There is minimal movement in his legs and no reflex present in his ankles or knees.
- Heart rate: 112 beats/min
- Respiratory rate: 26 breaths/min
- Blood pressure: 135/90 mmHg
- SpO2: 88%
Laboratory and Radiology Results
- Chest x-ray: Atelectasis in the lung bases
- ABG results: pH 7.30, PaCO2 60 mmHg, PaO2 55 mmHg, HCO3- 30 mEq/L
What is the Diagnosis?
Based on the information given, the patient likely has Guillain-Barré syndrome. The key findings that point to this diagnosis are:
- History of a viral disease: It is known that the patient recently had the parainfluenza virus. This is essential information because Guillain-Barré syndrome is an immune response that can be triggered by an infection.
- Ascending paralysis: The patient experienced paralysis that began in his feet and spread upward throughout his legs. This is a hallmark sign of Guillain-Barré syndrome, which is characterized by paralysis that ascends from the “ground” to the “brain.”
- Reflexes: The patient has no reflexes in the ankles and knees, which is another sign of paralysis.
- Atelectasis: The patient shows multiple signs of atelectasis, including crackles on auscultation, dull sounds on percussion, and his chest x-ray. Guillain-Barré syndrome is known for diaphragmatic paralysis. This prevents the patient from taking deep breaths, which results in alveolar collapse.
- Other vital signs: Tachypnea, tachycardia, and hypertension are all key findings.
- ABG results: His blood gas results show hypercapnia and hypoxemia, which is due to inadequate oxygenation and ventilation.
- Capillary refill: A decreased capillary refill time is a sign of decreased oxygenation.
How to Confirm the Diagnosis of Guillain-Barré Syndrome
There are two tests used to confirm the diagnosis of Guillain-Barré syndrome. These include:
- Nerve conduction test (NCT): Patients with Guillain-Barré syndrome will show signs of acute inflammatory demyelinating polyneuropathy.
- Cerebral spinal fluid analysis (CSF): Most patients with Guillain-Barré syndrome will have increased CSF values and a normal white blood cell count.
Respiratory Muscle Strength
It is also important to assess the patient’s respiratory muscle strength. This can be done by measuring the maximum inspiratory pressure (MIP) and vital capacity (VC). This requires the following equipment:
- Closed pressure manometer for MIP
- Wright’s respirometer for the VC
- Filter and mouthpiece for the patient
These tests are performed by respiratory therapists and provide valuable information about the patient’s condition.
If the patient has decreased MIP and VC values and thus weakened respiratory muscles, they may require intubation and mechanical ventilation.
Treatment for Guillain-Barré Syndrome
If respiratory failure is imminent and mechanical ventilation is indicated, you will need the following equipment:
- Mechanical ventilator
- PPE (gloves, gowns, masks, face shields, etc.)
- Suction machine and vacuum source
- Sterile suction catheters
- Yankauer tip suction catheter
- Bag valve mask
- Colorimetric CO2 detector
- Laryngoscope blade
- Endotracheal tubes (multiple sizes)
- Tape or tube holder
- 10 mL syringe
- Magill forceps
- Water-soluble lubricating gel
- Oropharyngeal airway
After the endotracheal tube has been inserted, a chest x-ray is performed to confirm the proper tube placement.
Initial Ventilator Settings for Guillain-Barré Syndrome
After intubation, it’s important to set up the patient with appropriate initial ventilator settings. Here are the recommended guidelines:
- Frequency: 10–20 breaths/min
- Tidal volume: 445–715 mL (i.e., 6–8 mL/kg of ideal body weight)
- FiO2: 30–60%, or the previous FiO2 prior to intubation (up to 100%)
- PEEP: 4–6 cmH2O
- I:E ratio: Between 1:2 and 1:4
- Sensitivity: Between -1 and -2
- Flow rate: 40–60 L/min
- Mode: Pressure control between 20–30 cmH2O (Never exceed 30 cmH2O)
Note: For the Clinical Sims Exam, there is less emphasis on the ventilator mode that you choose but a heavier focus on the ventilator settings you place your patient on. Therefore, when taking the exam, don’t get too caught up in selecting the right mode.
A common symptom in patients with Guillain-Barré syndrome is the inability to generate a cough strong enough to expectorate secretions. This can lead to atelectasis, infections, and other respiratory problems.
A mechanical insufflator-exsufflator (MIE) is a cough assist machine that provides alternating positive and negative pressure to deliver an artificial cough. This is indicated to help remove secretions in patients with inadequate respiratory muscle strength.
Lung Expansion Therapy
Lung expansion therapy is often indicated in patients with neuromuscular disorders to help treat and prevent atelectasis. This is necessary because diaphragmatic paralysis can prevent the patient from taking deep breaths, resulting in alveolar collapse.
Some examples of lung expansion therapy that may be indicated include:
- Deep breathing/directed cough
- Incentive spirometry (IS)
- Continuous positive airway pressure (CPAP)
- Positive airway pressure
- Intermittent positive airway pressure breathing (IPPB)
Airway Clearance Therapy
Airway clearance therapy is a type of respiratory care that helps clear mucus and secretions from the lungs. As previously mentioned, patients with neuromuscular conditions often lack the respiratory muscle strength needed to generate a cough.
This lead to secretion buildup, which is why airway clearance techniques are often indicated. Some examples of the different types include:
- Chest physiotherapy (CPT)
- Positive expiratory pressure (PEP) therapy
- Autogenic drainage
- High-frequency chest wall compression (HFCW)
- Active cycle of breathing technique
- Intrapulmonary percussive ventilation (IPV)
- Mechanical insufflation-exsufflation (MIE)
Other Treatment Methods
- Home oxygen therapy: This would be indicated if the patient is experiencing hypoxemia when discharged.
- Cardiopulmonary rehab: This would be indicated to help the patient regain strength and mobility that was lost during the course of their illness.
- Intravenous immunoglobulins: These are indicated to fight infections in patients with antibody deficiencies.
- Plasmapheresis: This is a medical procedure in which blood is passed through a machine to remove plasma and other factors that are potentially harmful to the nervous system.
Guillain-Barré syndrome is a serious condition that can often lead to paralysis, respiratory failure, and death in severe cases. Respiratory therapists must be able to recognize the signs and symptoms of this condition to properly diagnose and treat the patient.
Ascending paralysis is the key finding in Guillain-Barré syndrome. This means that the paralysis starts in the feet and progresses up the legs, eventually reaching the torso, arms, and the remainder of the body.
This paralysis also affects the diaphragm and other muscles responsible for breathing. That is why this is an important condition for respiratory therapists to be familiar with. Hopefully, this case study has helped! Thanks for reading, and, as always, breathe easy, my friend.
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- Egan’s Fundamentals of Respiratory Care. 12th ed., Mosby, 2020.
- Clinical Manifestations and Assessment of Respiratory Disease. 8th ed., Mosby, 2019.
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- Abdallah, Claude. “Acute Epiglottitis: Trends, Diagnosis and Management.” National Library of Medicine, Saudi J Anaesth, Sept. 2012, www.ncbi.nlm.nih.gov/pmc/articles/PMC3498669.