Guillain Barré Case Study: Diagnosis and Treatment (2025)

Guillain-Barré Syndrome (GBS) is a rare but serious autoimmune disorder in which the body’s immune system mistakenly attacks the peripheral nerves.

This condition can lead to muscle weakness, numbness, and even paralysis, often progressing rapidly and requiring urgent medical intervention. While the exact cause of GBS remains unclear, it is frequently triggered by infections or certain medical conditions.

In this case study, we will explore the diagnosis and treatment of a patient who presented with the hallmark signs and symptoms of Guillain-Barré Syndrome, providing insight into the clinical approach for managing this complex and life-threatening condition.

Guillain-Barré Syndrome Clinical Scenario

You are called to the emergency room to assess a 55-year-old male patient weighing 89 kg. Over the past week, he has experienced progressively worsening mobility in his feet, which has now spread to his legs. He also reports shortness of breath. The patient has no significant medical history but did recover from a parainfluenza virus infection three weeks ago. He arrived alone, without family members, and has no known allergies or medications.

Physical Examination Findings

HEENT

• Patient appears pale with slight cyanosis.
• Anxiety and diaphoresis (sweating) are present.
• Signs of nasal flaring, indicating respiratory distress.
• Pupils are round and reactive to light.
• Trachea is midline, with no jugular venous distention.

Chest Assessment

• Auscultation reveals diminished breath sounds in the apices and crackles at the lung bases.
• Bilateral, equal chest expansion.
• Normal anterior-posterior chest diameter.
• Chest percussion reveals dullness at the lung bases, suggesting fluid or atelectasis.
• No tactile fremitus on palpation.
• Mild retractions are visible, indicating increased work of breathing.
• Abdomen is soft and tender.

Extremities

• Capillary refill time is delayed at 5 seconds.
• No signs of digital clubbing or pedal edema.
• Fingers show slight cyanosis.
• Minimal movement in the legs, with no reflexes present at the ankles or knees.

Vital Signs

• Heart rate: 112 beats/min (tachycardia)
• Respiratory rate: 26 breaths/min (tachypnea)
• Blood pressure: 135/90 mmHg
• SpO2: 88% (indicating hypoxemia)

Radiology

• Chest X-ray: Atelectasis in the lung bases.

ABG Results

• pH: 7.30 (indicating acidosis)
• PaCO2: 60 mmHg (hypercapnia)
• PaO2: 55 mmHg (hypoxemia)
• HCO3-: 30 mEq/L (elevated bicarbonate, compensating for respiratory acidosis)

Diagnosis

The patient is highly likely to have Guillain-Barré Syndrome (GBS) based on several key findings:

• History of viral infection: The patient’s recent illness with the parainfluenza virus is significant because GBS is often triggered by an immune response following an infection.
• Ascending paralysis: The patient’s progressive weakness, starting in the feet and moving upward through the legs, is a hallmark of GBS. This characteristic ascending paralysis is commonly described as paralysis from the “ground to the brain.”
• Absent reflexes: The absence of reflexes in the ankles and knees further supports a diagnosis of GBS, as this condition often leads to areflexia (loss of reflexes).
• Atelectasis: Signs of atelectasis, including crackles, dullness on percussion, and x-ray findings, suggest diaphragmatic paralysis, a common complication of GBS. This paralysis impairs the patient’s ability to take deep breaths, leading to alveolar collapse.
• Other vital signs: The presence of tachypnea, tachycardia, and hypertension are additional findings that may be related to autonomic dysfunction in GBS.
• ABG results: The patient’s hypercapnia (PaCO2 60 mmHg) and hypoxemia (PaO2 55 mmHg) indicate inadequate ventilation and oxygenation, consistent with respiratory muscle weakness.
• Capillary refill: Delayed capillary refill time (5 seconds) is another sign of poor oxygenation and reduced circulation.

Confirming the Diagnosis of Guillain-Barré Syndrome

Two key tests are used to confirm the diagnosis of Guillain-Barré Syndrome:

• Nerve conduction test (NCT): In patients with GBS, nerve conduction studies often show evidence of acute inflammatory demyelinating polyneuropathy, which is a classic feature of the syndrome.
• Cerebrospinal fluid (CSF) analysis: Most patients with GBS will have elevated CSF protein levels with a normal white blood cell count, a finding known as albuminocytologic dissociation.

Assessing Respiratory Muscle Strength

It is crucial to assess the patient’s respiratory muscle strength in Guillain-Barré Syndrome as respiratory failure is a common complication.

This can be evaluated by measuring:

• Maximum inspiratory pressure (MIP)
• Vital capacity (VC)

To perform these tests, the following equipment is required:

• Closed pressure manometer for MIP.
• Wright’s respirometer for VC.
• Filter and mouthpiece for the patient.

Note: These assessments, typically conducted by respiratory therapists, provide valuable information about the patient’s respiratory muscle strength. If the patient’s MIP and VC values are significantly decreased, indicating respiratory muscle weakness, they may require intubation and mechanical ventilation to support breathing.

Treatment

In the event of imminent respiratory failure in a patient with Guillain-Barré Syndrome, mechanical ventilation may be required. To safely manage the patient’s airway, the following equipment is necessary:

• Mechanical ventilator
• Personal protective equipment (PPE)
• Suction machine and vacuum source
• Sterile suction catheters
• Yankauer tip suction catheter
• Bag valve mask (BVM)
• Colorimetric CO2 detector
• Laryngoscope with blade
• Endotracheal tubes (multiple sizes)
• Stylet
• Stethoscope
• Tape or tube holder
• 10 mL syringe
• Magill forceps
• Water-soluble lubricating gel
• Oropharyngeal airway

Note: Once the endotracheal tube is successfully inserted, a chest x-ray should be performed to confirm proper tube placement.

Initial Ventilator Settings for Guillain-Barré Syndrome

Following intubation, it’s crucial to set appropriate ventilator parameters. The recommended initial settings for patients with Guillain-Barré Syndrome include:

• Frequency: 10–20 breaths/min
• Tidal volume: 445–715 mL (6–8 mL/kg of ideal body weight)
• FiO2: 30–60%, or matching the previous FiO2 prior to intubation (up to 100% if needed)
• PEEP: 4–6 cmH2O
• I:E ratio: 1:2 to 1:4
• Sensitivity: -1 to -2
• Flow rate: 40–60 L/min
• Mode: Pressure control (20–30 cmH2O, not exceeding 30 cmH2O)

Note: On the Clinical Simulation Exam (CSE), the emphasis is more on selecting the appropriate ventilator settings rather than the specific mode. While choosing a mode is important, the key focus is on ensuring your settings effectively support the patient’s needs. So, when taking the exam, prioritize adjusting the settings for optimal patient care and don’t stress too much about selecting the exact mode.

Cough Assist

One common challenge in patients with Guillain-Barré Syndrome is their inability to generate an effective cough due to weakened respiratory muscles. This can lead to secretion retention, atelectasis, and respiratory infections.

A mechanical insufflator-exsufflator (MIE), also known as a cough assist device, is recommended for these patients. This machine delivers alternating positive and negative pressure, simulating a natural cough and helping to remove secretions when the patient is unable to do so effectively.

Lung Expansion Therapy

Patients with neuromuscular disorders like Guillain-Barré Syndrome often struggle with lung expansion due to diaphragmatic paralysis, which can lead to atelectasis.

To prevent alveolar collapse, lung expansion therapy may be indicated, including:

• Deep breathing/directed cough
• Incentive spirometry (IS)
• Continuous positive airway pressure (CPAP)
• Positive airway pressure (PAP)
• Intermittent positive pressure breathing (IPPB)

Airway Clearance Therapy

For patients with neuromuscular weakness, airway clearance therapy is essential to prevent the buildup of mucus and secretions. Without adequate cough strength, secretions can accumulate and cause complications like infections and atelectasis.

Recommended airway clearance techniques 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)

Additional Treatment Methods

• Home oxygen therapy: May be necessary if the patient experiences hypoxemia after discharge.
• Cardiopulmonary rehabilitation: Helps the patient regain lost strength and mobility during recovery.
• Intravenous immunoglobulins (IVIG): Used to fight infections, particularly in patients with antibody deficiencies.
• Plasmapheresis: A procedure that filters the blood, removing plasma and harmful antibodies that contribute to the nervous system damage seen in Guillain-Barré Syndrome.

Note: By implementing these treatments, respiratory failure can be managed effectively, and the patient can recover with fewer complications.

Final Thoughts

Guillain-Barré Syndrome is a severe condition that can lead to paralysis, respiratory failure, and, in extreme cases, death. For respiratory therapists, it is crucial to recognize the signs and symptoms early to ensure timely intervention and prevent complications.

The hallmark feature of ascending paralysis—starting in the feet and progressing upward through the legs, torso, and arms—distinguishes Guillain-Barré Syndrome from other conditions.

This progressive paralysis can affect the diaphragm and other breathing muscles, which is why it is vital for respiratory therapists to understand and manage this condition.