Case study-Myasthenia gravis/Gullaine Barre Syndrome

Dr Santosh Kumar Bhaskar

Case study-Myasthenia gravis/Gullaine Barre Syndrome

BASICS

A CASE

A 5 ft 2 in., 115-lb, 67-year-old woman with a history of myasthenia gravis was brought to her physicians office by her daughter. She complained of progressive muscle weakness.

Physical examination revealed that she demonstrated drooping eyelids and difficulty talking and swallowing. She was unable to walk more than a step or two.

QWhat is the relationship between height and mechanical ventilation?

She was transferred to the hospital, where she was given edrophonium (Tensilon), which improved her muscle function for 10 to 15 minutes.

On admission, her vital signs were unremarkable. Her maximum inspiratory pressure (MIP) was -60 cm H2O, and her vital capacity (VC) was 1.8 L (predicted was 3.3 L). Her SpO2 on room air was 96%.

Why is vital capacity so important in neuromuscular disorders?

Lung volume

Could noninvasive positive pressure ventilation (NIV) be used in this situation?

Yes

NIV SETTING

How much pressure ? IPAP ?? EPAP???

TO BEGIN WITH LOW PRESSURES SUCH AS IPAP=10,EPAP=5 CM OF H20, AND THEN READJUST.

FIO2? USUALLY LOW AS LUNGS ARE MORE OR LESS NORMAL

DO THEY NEED BACKUP RATE?Yes , back up rate of 10-12/mt

Monitoring ?

Spontaneous tidal volume and respiratory rate

Vital capacity and maximal inspiratory pressure

Periodic arterial blood gases

Anticholinesterase therapy was administered, and MIP and VC were monitored every 8 hours.

The nursing staff reported that the patient was having trouble swallowing when she ate and they feared that she would aspirate. MIP and VC values progressively declined. After being hospitalized for 24 hours, her MIP was 25 cm H2O and VC was 1.0 L.

ABGs on room air were as follows: pH = 7.36; PaCO2 = 48 mm Hg; PaO2 = 62 mm Hg; HCO3 = 27 mEq/L.

Could noninvasive positive pressure ventilation (NIV) be used in this situation?

Now what

Will you intubate or not?

The patient should be intubated and ventilated.

Invasive ventilation settings

What would be the mode,rate,tidal volume, inspiratory time,PEEP,FiO2,Flow waveform?

ANSWER IS ----------------------------------------

CMV (A/C),VCV,VT