|Year : 2013 | Volume
| Issue : 2 | Page : 48-51
Outcome of mechanical ventilation in patients of Guillain-Barre syndrome: An audit from a tertiary care centre
Afzal Azim, Sanjay Singhal, AK Baronia, M Gurjar, B Poddar, RK Singh
Department of Critical Care Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
|Date of Web Publication||19-Jul-2013|
Department of Critical Care Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow - 226 014, Uttar Pradesh
Background: About a third of patients with Guillain-Barre Syndrome (GBS) presents with acute respiratory failure requiring invasive mechanical ventilation. We studied the outcome of patients with GBS. Material and Methods: A retrospective data extraction was done on clinical records of 103 patients with diagnosis of GBS admitted in intensive care unit (ICU) over a period of 7 years. All patients requiring ICU admission and mechanical ventilation for more than 48 h were included in the study. Demographic profile, clinical characteristics, treatment given, duration of mechanical ventilation, ICU acquired infections, incidence of pressure sores, and length of ICU stay was noted. Results: Eighty six patients fulfilled the inclusion criteria. The mean age of patients was 32.4 (± 18.12) years. Mean duration of ICU stay was 28.9 (± 26.99) days. Majority (82%) of our patients were male. The most common co-morbidities were diabetes mellitus and hypertension. Axonal neuropathy was the most common (76%) lesion. Autonomic dysfunction was present in 35% of patients. Fifty two percent of patients received immunoglobulin therapy while 64% of required mechanical ventilation for more than 14 days. Tracheostomy was performed in 85% of patients. Ventilator associated pneumonia (VAP) was seen in 33% of patients, blood stream infection in 11% and urinary tract infection in 7%. Forty percent of patients developed bed sore grade 1-2. Seven (8.3%) patients died perhaps due to complications including VAP and sepsis. Conclusions: GBS has a good outcome despite prolonged mechanical ventilation and ICU stay.
Keywords: Guillain-Barre syndrome, mechanical ventilation intensive care unit, pneumonia, sepsis
|How to cite this article:|
Azim A, Singhal S, Baronia A K, Gurjar M, Poddar B, Singh R K. Outcome of mechanical ventilation in patients of Guillain-Barre syndrome: An audit from a tertiary care centre. Sahel Med J 2013;16:48-51
|How to cite this URL:|
Azim A, Singhal S, Baronia A K, Gurjar M, Poddar B, Singh R K. Outcome of mechanical ventilation in patients of Guillain-Barre syndrome: An audit from a tertiary care centre. Sahel Med J [serial online] 2013 [cited 2020 Feb 29];16:48-51. Available from: http://www.smjonline.org/text.asp?2013/16/2/48/115256
| Introduction|| |
Guillain-Barre syndrome (GBS) is an acute onset, immune-mediated disorder of peripheral nervous system that usually begins abruptly with distal, relatively symmetrical paresthesias followed quickly by progressive limb weakness. Patients with GBS may also have involvement of cranial nerves and phrenic nerve manifesting as facial or pharyngeal weakness and diaphragmatic weakness, respectively.  Approximately, 20-30% patients with GBS require intensive care unit (ICU) and invasive mechanical ventilation because of respiratory muscle or oropharyngeal weakness. ,, Mortality reported from GBS was ~5%, which may be as high as 20% in mechanically ventilated patients.  We conducted this study to determine the outcome of mechanically ventilated patients of GBS in our ICU.
| Material and methods|| |
The medical records of all GBS patients with respiratory failure who required mechanical ventilation and were admitted to the ICU of our institution were retrospectively evaluated. Patient characteristics, including age, sex, comorbid illness, precipitating events, duration of weakness, bulbar involvement (impaired gag reflex, dysphagia, dysarthria), autonomic dysfunction (exceptional blood pressure fluctuations, heart rate variability, unexplained cardiac arrhythmia), type of electrophysiological lesion on admission (demyelinating, axonal or mixed), duration of mechanical ventilation and need for tracheostomy were recorded.
The primary outcome measures were the duration of mechanical ventilation, ICU stay, hospital mortality, hospital acquired infection (ventilator associated pneumonia [VAP], blood stream infection, urinary tract infection [UTI]), other complications like bed sore.
Diagnosis of GBS was established clinically and supported by laboratory and electrophysiological tests.  The need of tracheal intubation and mechanical ventilation was assessed by clinical examination (conscious level of patient, respiratory rate, depth of breathing, use of accessory muscles, presence of paradoxical respiration, single breath count and upper airway reflexes), arterial blood gas analysis and chest radiography.  All patients were ventilated by synchronized intermittent mandatory ventilation (SIMV) with pressure support. All patients also received other supportive care like adequate nutrition, low molecular weight heparin to prevent venous thrombosis, humidification of inspired air, frequent turning on the bed to prevent bed sore, limb physiotherapy and chest physiotherapy to prevent atelectasis. Intravenous immunoglobulin (IVIG) was administered in a dose of 400 mg/kg daily for 5 days depending upon the indication and financial condition of patients. Early tracheostomy was performed if the patient was predicted to have prolonged mechanical ventilation. Weaning was done after gradual reduction in SIMV rate and the level of pressure support. Patient was extubated after successful T-piece trial and normal bulbar reflexes.
| Results|| |
Of the 103 patients with GBS admitted during the study period, 86 (83.5%) required mechanical ventilation 71 (82.6%) of which were male. The mean age of all patients was 32.4 (± 18.12 provide SD) years. The most common co-morbidities were diabetes mellitus and hypertension. Autonomic dysfunction was found in 30 (35%) patients. Nerve conduction velocity (NCV) revealed axonal neuropathy as the predominant lesion [Table 1]. All patients were offered immunoglobulin therapy (IVIG), but only forty-five patients (52.3%) received IVIG because of financial constraints. The duration of ICU stay were <7 days in 9 (10.5%), 7-14 days in 22 (25.6%), 15-21 days in 11 (12.8%) and >21 days in 44 (51.1%) patients. Fifty five (64%) patients required prolonged mechanical ventilation (>14 days). Tracheostomy was done in 73 patients (85%) [Table 2].
Mortality and hospital related complication
Majority of patients requiring prolonged ICU stay developed hospital related complication [Table 2]. The most common complication was ventilator associated pneumonia (VAP), observed in 26 patients (30.2%). Some patients 15 (17.4%) developed sepsis due to Blood stream infection in 9 patients (10.5%) and UTI in 6 patients (7.0%) while 34 (40%) developed bed sore (grade 1-2) over the sacral area. Of the 86 patients studied, 7 (8.3%) died presumably due to ICU related infection.
| Discussion|| |
GBS is equally common in men and women and can occur at any age  as illustrated in our study population. Patients with a severe form of GBS requiring mechanical ventilation need to be admitted in ICU. GBS patients who require mechanical ventilation are at high risk of developing complications such as VAP, bacteremia, and pulmonary embolism. Specific therapy, catheterization and monitoring devices in ICU may further increase the GBS related morbidity.
Patients with GBS have normal lung physiology making mechanical ventilation easy unless pulmonary complications supervene. The major reason for mechanical ventilation is respiratory muscle weakness and inability to clear secretions. It is recommended that patients should be intubated if the vital capacity falls to approximately 15 mL/Kg or if there is difficulty in clearing secretions.  However, in keeping with the protracted course of the disease, the duration of mechanical ventilation is prolonged with a mean of 4-12 weeks in different studies. ,,, In the current report, 64% of patients required prolonged mechanical ventilation >14 days.
Early tracheostomy is recommended for patients requiring prolonged ventilator weaning. It also facilitates secretion clearance.  In a recent randomized trial involving patients predicted to need mechanical ventilation for more than 14 days, early tracheostomy allowed for less sedation and was associated with a lower incidence of VAP, shorter mechanical ventilation, shorter ICU stay, and dramatically lower hospital mortality. , As in previous studies, , majority of patients in the present study received tracheostomy.
Most complications in critically ill patients with GBS are not related to the basic or primary disease. The most common complication noted in these patients is VAP which tends to increase progressively in frequency as the duration of mechanical ventilation increases. Other nosocomial infection including UTI and infections through intravenous lines are also common. Deaths resulting from GBS are nowadays uncommon. In our study, 8.3% of patients died. A retrospective study among Ethiopian patients showed mortality of 25.9% among all patients admitted with the diagnosis of GBS.  The higher mortality in this study might be because of inadequate intensive care facility and high frequency of human immunodeficiency virus (HIV) positivity among the study population HIV positivity  Another retrospective study from Canary Island showed a mortality rate of 8.2% which is similar to our study despite the fact that only 17.8% of patients required assisted ventilation as compared to 100% in our study. 
A report from Aragon Country showed an overall mortality rate of 10% in GBS patients (ventilated and non-ventilated). This is slightly higher than the mortality recorded in the current report.  In the western or developed world the mortality of GBS ranges from 1 to 8%.  This contrast higher mortality rate reported from some Indian centers perhaps because of less equipped ICU. ,, Death in GBS is usually attributable to pneumonia, sepsis, adult respiratory distress syndrome, and less frequently autonomic instability or pulmonarys embolism. 
| Conclusion|| |
Patients of severe GBS with respiratory failure often require prolonged respiratory support and ICU care. Despite protracted course, our results show that the prognosis of mechanically ventilated patients with GBS seems good prognosis. However, being a retrospective analysis, the may not be a true representation of disease outcome.
Please enrich the table further by including the treatment given (Immunoglobulin and tracheostomy).
You may create a table to show the complications. Include outcome (Dead).
| References|| |
|1.||Haymaker WE, Kernohan JW. The Landry-Guillain-Barré syndrome; a clinicopathologic report of 50 fatal cases and a critique of the literature. Medicine (Baltimore) 1949;28:59-141. |
|2.||Chiò A, Cocito D, Leone M, Giordana MT, Mora G, Mutani R, et al. Guillain-Barré syndrome: A prospective, population-based incidence and outcome survey. Neurology 2003;60:1146-50. |
|3.||Hughes RA, Wijdicks EF, Benson E, Cornblath DR, Hahn AF, Meythaler JM, et al. Supportive care for patients with Guillain-Barré syndrome. Arch Neurol 2005;62:1194-8. |
|4.||Lawn ND, Fletcher DD, Henderson RD, Wolter TD, Wijdicks EF. Anticipating mechanical ventilation in Guillain-Barré syndrome. Arch Neurol 2001;58:893-8. |
|5.||Fletcher DD, Lawn ND, Wolter TD, Wijdicks EF. Long-term outcome in patients with Guillain-Barré syndrome requiring mechanical ventilation. Neurology 2000;54:2311-5. |
|6.||Asbury AK, Arnason BG, Karp HR, McFarlin DE. Criteria for diagnosis of Guillain-Barre syndrome. Ann Neurol 1978;3:565-6. |
|7.||Hund EF, Borel CO, Cornblath DR, Hanley DF, McKhann GM. Intensive management and treatment of severe Guillain-Barré syndrome. Crit Care Med 1993;21:433-46. |
|8.||Burns TM. Guillain-Barré syndrome. Semin Neurol 2008;28:152-67. |
|9.||Gnanamuthu C, Ray D. Outcome of patients with fulminant Guillain-Barre syndrome on mechanical ventilatory support. Indian J Chest Dis Allied Sci 1995;37:63-9. |
|10.||Taly AB, Gupta SK, Vasanth A, Suresh TG, Rao U, Nagaraja D, et al. Critically ill Guillain Barre' syndrome. J Assoc Physicians India 1994;42:871-4. |
|11.||Aggarwal AN, Gupta D, Lal V, Behera D, Jindal SK, Prabhakar S. Ventilatory management of respiratory failure in patients with severe Guillain-Barre syndrome. Neurol India 2003;51:203-5. |
|12.||Ali MI, Fernández-Pérez ER, Pendem S, Brown DR, Wijdicks EF, Gajic O. Mechanical ventilation in patients with Guillain-Barré syndrome. Respir Care 2006;51:1403-7. |
|13.||Lawn ND, Wijdicks EF. Tracheostomy in Guillain-Barré syndrome. Muscle Nerve 1999;22:1058-62. |
|14.||Ahrens T, Kollef MH. Early tracheostomy-Has its time arrived? Crit Care Med 2004;32:1796-7. |
|15.||Rumbak MJ, Newton M, Truncale T, Schwartz SW, Adams JW, Hazard PB. A prospective, randomized, study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients. Crit Care Med 2004;32:1689-94. |
|16.||Melaku Z, Zenebe G, Bekele A. Guillain-Barré syndrome in Ethiopian patients. Ethiop Med J 2005;43:21-6. |
|17.||Aladro-Benito Y, Conde-Sendin MA, Muñoz-Fernández C, Pérez-Correa S, Alemany-Rodríguez MJ, Fiuza-Pérez MD, et al. Guillain-Barré syndrome in the northern area of Gran Canaria and the island of Lanzarote. Rev Neurol 2002;35:705-10. |
|18.||Piñol-Ripoll G, Larrodé Pellicer P, Garcés-Redondo M, de la Puerta González-Miró I, Iñiguez Martínez C. Characteristics of Guillain-Barré syndrome in the healthy area III of Aragon Country. An Med Interna 2008;25:108-12. |
|19.||Fulgham JR, Wijdicks EF. Guillain-Barré syndrome. Crit Care Clin 1997;13:1-15. |
|20.||Lawn ND, Wijdicks EF. Fatal Guillain-Barré syndrome. Neurology 1999;52:635-8. |
[Table 1], [Table 2]