Guillain–Barré syndrome with impending respiratory failure — MRCEM SBA MCQ

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HardNeurological emergenciesGuillain–Barré syndrome with impending respiratory failureMRCEM SBA

A 46-year-old man attends the emergency department with four days of ascending weakness after a diarrhoeal illness. He can no longer stand unaided. Examination shows symmetrical limb weakness and absent tendon reflexes. During assessment, his speech becomes nasal, he coughs when attempting to swallow water, and his cough is weak. He weighs 70 kg. His forced vital capacity has fallen from 1.55 L to 0.98 L over two hours; repeated measurements are consistent. SpO₂ is 98% on air and his arterial carbon dioxide is normal. An anaesthetist and critical care team are available. Which management plan is most appropriate now?

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Correct answer: D — Arrange controlled intubation and critical care admission; initiate intravenous immunoglobulin.

The rapidly progressive, symmetrical areflexic weakness following diarrhoea strongly suggests Guillain–Barré syndrome. His forced vital capacity is 14 mL/kg and has fallen substantially in two hours. Bulbar dysfunction and a weak cough add an immediate threat to airway protection. **Normal oxygen saturation and carbon dioxide do not justify waiting** for overt respiratory failure: arrange controlled intubation with the critical care team and critical care admission. UK guidance calls for immediate neurological, bulbar and respiratory assessment in rapidly progressive symmetrical weakness; an NHS trust guideline identifies this degree of vital-capacity reduction and bulbar weakness as reasons to consider intubation. ([nice.org.uk](https://www.nice.org.uk/guidance/ng127/chapter/recommendations-for-adults-aged-over-16)) He is unable to walk unaided and is within two weeks of weakness onset, meeting the European guideline’s criteria for intravenous immunoglobulin. Plasma exchange is also an effective treatment, but treatment and airway protection should not wait for cerebrospinal-fluid testing. ([pubmed.ncbi.nlm.nih.gov](https://pubmed.ncbi.nlm.nih.gov/37814552/?dopt=Abstract)) **A** offers immunotherapy but non-invasive ventilation does not secure an airway compromised by swallowing difficulty and a weak cough. **B** would suit a patient with stable respiratory function and no bulbar involvement, not this rapidly deteriorating patient. **C** correctly prioritises the airway, but corticosteroids are not recommended as disease-modifying treatment for Guillain–Barré syndrome. **E** includes a valid alternative immunotherapy, but neurology-ward admission and lumbar puncture before addressing impending respiratory failure are the wrong sequence. ([nnuh.nhs.uk](https://www.nnuh.nhs.uk/publication/download/monitoring-of-patients-with-guillain-barr-syndrome-jcg0350-v3/))

Reference: Suspected neurological conditions: recognition and referral — recommendations for adults aged over 16 (2019) — https://www.nice.org.uk/guidance/ng127/chapter/recommendations-for-adults-aged-over-16 Monitoring of patients with Guillain–Barré Syndrome (Approved 3 February 2022; review date 3 February 2025) — https://www.nnuh.nhs.uk/publication/download/monitoring-of-patients-with-guillain-barr-syndrome-jcg0350-v3/ European Academy of Neurology/Peripheral Nerve Society Guideline on diagnosis and treatment of Guillain-Barré syndrome (December 2023) — https://pubmed.ncbi.nlm.nih.gov/37814552/?dopt=Abstract