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NEUROLOGICAL REVIEW

SECTION EDITOR: DAVID E. PLEASURE, MD

Supportive Care for Patients With


Guillain-Barré Syndrome
Richard A. C. Hughes, MD; Eelco F. M. Wijdicks, MD; Estelle Benson; David R. Cornblath, MD; Angelika F. Hahn, MD;
Jay M. Meythaler, MD; John T. Sladky, MD; Richard J. Barohn, MD; James C. Stevens, MD

A
multidisciplinary consensus group searched MEDLINE from 1966 to May 2003, ex-
tracted relevant references, and prepared recommendations on supportive care for Guil-
lain-Barré syndrome. In the absence of randomized controlled trials, we agreed on rec-
ommendations by consensus based on observational studies and expert opinion. In
the acute phase in bed-bound adult patients, the group recommended the use of heparin and gradu-
ated pressure stockings to prevent deep vein thrombosis, monitoring for blood pressure, pulse,
autonomic disturbances, and respiratory failure, and the timely institution of artificial ventilation
and tracheostomy. Pain management is difficult, but carbamazepine or gabapentin may help. The
cautious use of narcotic analgesics may be needed. Disabled patients should be treated by a mul-
tidisciplinary rehabilitation team and should receive an assistive exercise program. Persistent fa-
tigue following Guillain-Barré syndrome is common and may be helped by an exercise program.
Because of a very small and possibly only theoretical increase in the risk of recurrence following
immunization, the need for immunization should be reviewed on an individual basis. More re-
search is needed to identify optimal methods for all aspects of supportive care.
Arch Neurol. 2005;62:1194-1198
A recent practice parameter recom- 15% of patients with GBS die from this syn-
mended either intravenous immunoglob- drome2-6 and nearly 20% have a persistent
ulin or plasma exchange, but not cortico- disability.5 Death from GBS occurs mostly
steroids, as appropriate treatments for adults in mechanically ventilated patients. Sup-
and probably children with severe Guillain- portive care remains the mainstay of treat-
Barré syndrome (GBS) within 2 weeks from ment, but the evidence for the methods of
onset.1 Most patients in the trials of these supportive care is inadequate and consen-
treatments have had the demyelinating form sus guidelines for treatment have not been
of the disease, and the benefits of treat- published.
ment in uncommon subgroups, such as
those with axonal disease, cannot be dis- EVIDENCE REVIEW
tinguished. Despite immunotherapy, 4% to
The consensus group of 6 neurologists with
Author Affiliations: Department of Clinical Neuroscience, King’s College, London, a special interest in GBS, 1 physical medi-
England (Dr Hughes); Department of Neurology, Mayo Clinic, Rochester, Minn cine specialist, 1 evidence-based medicine
(Dr Wijdicks); Guillain-Barré Syndrome Foundation International, Wynnewood, specialist, and 1 patient advocate met and
Pa (Mrs Benson); Department of Neurology, Johns Hopkins University School of decided which questions to review.
Medicine, Baltimore, Md (Dr Cornblath); London Health Sciences Center, London, We searched MEDLINE from 1966 on-
Canada (Dr Hahn); Department of Physical Medicine and Rehabilitation, ward (last search in May 2003) for articles
University of Alabama, Birmingham (Dr Meythaler); Division of Neurology, Emory
including the term polyradiculoneuritis, lim-
University School of Medicine, Atlanta, Ga (Dr Sladky); Department of Neurology,
University of Kansas Medical Center, Kansas City (Dr Barohn); and Fort Wayne ited by human and cross-referenced with the
Neurological Center, Fort Wayne, Ind (Dr Stevens). terms therapy, pain, nutrition, diet, pulmo-
Financial Disclosure: Dr Cornblath has consulted for Pfizer Inc, who makes nary ventilation, tracheostomy, artificial res-
Neurontin (gabapentin), and Ortho-McNeil Pharmaceutical Inc, who makes Ultram piration, autonomic nervous system, dysau-
(tramadol). tonomia, arrhythmia, neurogenic bladder,

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urinary incontinence, urination disorders, constipation, physi- by GBS until they have discontinued the ventilatory sup-
cal therapy, occupational therapy, palliative care, support- port and have had their tracheostomy removed or until
ive care, thrombophlebitis, immunization, and recurrence. they have begun to recover without needing either in-
We also searched the Cochrane Library register of ran- tervention. The evidence concerning the method and set-
domized trials (issue 3, 2003) with Guillain-Barré syn- ting of monitoring is insufficient to make specific rec-
drome as the search term. Two members of the group pre- ommendations.
pared draft statements and recommendations that were
circulated through the entire group repeatedly until con- RESPIRATORY MONITORING
sensus was achieved. Our recommendations are, there- AND AIRWAY PROTECTION
fore, consensus statements based on observational stud-
ies of GBS, inferences from randomized controlled trials
Neuromuscular respiratory function becomes compro-
in other conditions, and expert opinion.
mised in 17% to 30% of patients with GBS.6,16,18-21 In some
patients, bulbar dysfunction causes difficulty with clear-
PROPHYLAXIS FOR DEEP VEIN THROMBOSIS
ing secretions, compromising gas exchange and increas-
ing the risk of aspiration.22-24 Clinical features that indi-
Immobilization owing to GBS is a risk factor for the de-
cate fatigue of respiratory muscles are tachypnea, sweating,
velopment of deep vein thrombosis (DVT).7 Time to de-
tachycardia, asynchronous movements of the chest and
veloping DVT or pulmonary embolus varies from 4 to
abdomen, and episodic use of accessory muscles of res-
67 days after onset.7,8 Children have a very low inci-
piration. In 1 case series,22 rapid disease progression, pres-
dence of DVT.9 There is a lack of clinical studies that ad-
ence of bilateral facial palsy, and autonomic dysfunc-
dress methods of prophylaxis against thrombosis in GBS,
tion increased the likelihood of intubation. A study of
duration of prophylaxis, or monitoring of patients at risk
722 patients, of whom 313 required ventilation, identi-
for thrombosis. Observational studies in orthopedic or
fied 6 predictors of the need for ventilation in a multi-
general surgery patients suggest a benefit from subcuta-
variate analysis: time from onset to admission being less
neous heparin (5000 U, 12-hourly) in preventing DVT.9
than 7 days, inability to cough, inability to stand, inabil-
In acutely ill medical patients, prophylactic treatment with
ity to flex the arms or head, and liver enzyme level in-
subcutaneous enoxaparin (40 mg daily) reduced the in-
creases.25 In 196 of the patients with available vital ca-
cidence of DVT from 15% in the placebo group to ap-
pacity measurements, predictors were time from onset
proximately 5% in the treated patients.10 In a recent meta-
to admission being less than 7 days, inability to lift the
analysis, support stockings reduced the risk by almost
head, and vital capacity of less than 60% of that which
70% in patients at moderate risk for development of post-
was predicted. In many patients, a vital capacity (mea-
operative thromboembolism.11
sured volume with forceful exhalation after maximal in-
halation) below 20 mL/kg, a PImax (maximum inspira-
RECOMMENDATION
tory pressure generated after maximal sucking in through
a mouth piece while occluding the nose) of less than 30
Subcutaneous unfractionated or fractionated heparin
cm H2O or a PEmax (maximum expiratory pressure gen-
and support stockings are recommended for nonam-
erated on maximal blowing out) of less than 40 cm H2O
bulant adult patients until they become able to walk
warns of imminent respiratory arrest.26-28 Rapid decline
independently.
in vital capacity (eg, 50% from baseline) may further in-
dicate impending respiratory failure, but this finding needs
CARDIAC AND HEMODYNAMIC MONITORING
confirmation.26,27 Patients with pulmonary infiltrates or
atelectasis generally require intubation and mechanical
Serious and potentially fatal disturbances of autonomic func-
ventilation. Hypoxemia is also an indicator of neuro-
tion, including arrhythmias and extreme hypertension or
muscular respiratory failure. Hypercarbia appears later.21
hypotension, occur in approximately 20% of patients with
Thus, respiratory failure in GBS is common and life threat-
GBS.12,13 Severe bradycardia may be preceded by wide
ening. Emerging diaphragmatic failure can be detected
swings, exceeding 85 mm Hg, of systolic blood pressure
by serial clinical observation or respiratory function tests.
from day to day.14 Bradycardia may be so severe as to cause
Patients who require ventilation are at high risk of suf-
asystole, which may require a cardiac pacemaker.12 Endo-
fering major complications including pneumonia, sep-
tracheal suction or pharmaceutical agents may provoke these
sis, gastrointestinal tract bleeding, pulmonary embolus,
changes.14,15 Other significant autonomic disturbances in
and others. In a series of 114 patients, 60% admitted to
GBS are adynamic ileus, hyponatremia, and deficiencies in
an intensive care unit had major complications in 1 of
bronchial mucosal function. Most, but not all, dysauto-
these categories.29
nomic complications occur among patients with ad-
vanced generalized weakness and respiratory failure.16 In
1 prospective study,17 a reduction in beat-to-beat varia- RECOMMENDATION
tion in heart rate predicted subsequent dysautonomia.
Respiratory function should be monitored in patients with
RECOMMENDATION GBS, but there is insufficient evidence to recommend spe-
cific methods. Weaning from the ventilator should be
Monitoring of pulse and blood pressure is recom- guided by improvement in strength and serial pulmo-
mended in patients who are becoming severely affected nary function tests.

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TIMING AND METHOD OF TRACHEOSTOMY in half. First-line drugs that were used were acetamino-
phen and nonsteroidal anti-inflammatory drugs. How-
The mean duration of ventilation in various treatment trials ever, 75% of the patients additionally required oral or par-
has ranged between 15 and 43 days, suggesting that a pro- enteral opioids and 30% of the patients were treated with
portion of patients can be spared from receiving a trache- intravenous morphine infusions (range, 1-7 mg/h). Ten
ostomy.28,30-32 Early tracheostomy increases patient com- percent of the patients received tricyclic antidepres-
fort and airway safety and may help weaning. On the other sants and a further 10% received carbamazepine as ad-
hand, surgical tracheostomy results in permanent disfig- juvant treatments for neuropathic pain during the later
urement and has sometimes been associated with life- course of the illness. In a randomized, double-blind, cross-
threatening hemorrhage, infection, accidental dislodge- over trial involving 18 participants, gabapentin (15 mg/kg
ment of the tube, fatal procedure-related necrotizing daily) or placebo was given by a nasogastric tube for 7
mediastinitis, chyle fistula due to a thoracic duct perfora- days before switching to the alternate treatment.44 There
tion, and a cosmetically unacceptable, hypertrophic ke- was prompt substantial and significant relief of pain and
loid tracheostomy scar. More recently, percutaneous di- reduction in the need for rescue medication. In a similar
latational tracheostomy has been introduced, but this study45 of 12 patients, greater pain relief was obtained
technique has not been compared with traditional trache- from carbamazepine (300 mg daily for 3 days) than from
ostomy in GBS. In a randomized trial in patients selected placebo. Excellent relief of intractable and severe pain
for elective tracheostomy, percutaneous dilatational tra- by epidural infusions of morphine (1- to 4-mg morphine
cheostomy was superior.33 The procedure involves a small bolus injections every 8-24 hours) has been reported in
skin incision and then insertion of a cannula into the tra- a single case study.46 Opioid analgesics may aggravate au-
chea, followed by dilators of gradually increasing size un- tonomic gut dysmotility and bladder distention.47,48
til the desired tracheostomy tube can be accommodated.
Percutaneous tracheostomy may reduce the risk of acci- RECOMMENDATION
dental extubation owing to the fact that it fits more snugly
around the stoma. A better cosmetic outcome may result Simple analgesics or nonsteroidal anti-inflammatory drugs
from a smaller skin incision.34-36 may be tried but often do not provide adequate pain re-
A newly introduced pulmonary function ratio has been lief. Single small randomized controlled trials support the
used to predict the need for tracheostomy.37 Daily vital use of gabapentin or carbamazepine in the intensive care
capacity and maximal inspiratory and expiratory pres- unit for the treatment of pain in the acute phase of GBS.
sures were summed to create an integrated pulmonary Appropriate narcotic analgesics may be used but re-
function score. A pulmonary function ratio was calcu- quire careful monitoring of adverse effects in the setting
lated, which represents the pulmonary function score at of autonomic denervation. Adjuvant therapy with tricy-
day 12 after intubation divided by the pulmonary func- clic antidepressant medication, tramadol, gabapentin, car-
tion score at the day of intubation. This study found that bamazepine, or mexilitene may aid in the long-term man-
at day 12 with a pulmonary function ratio of less than 1, agement of neuropathic pain.
it is highly unlikely that patients will be weaned from the
ventilator within 3 weeks and tracheostomy should be MANAGEMENT OF BLADDER
performed. The sensitivity of a pulmonary function ra- AND BOWEL DYSFUNCTION
tio of less than 1 for predicting that the duration of ven-
tilation would be more than 3 weeks was 70%, and the Constipation occurs frequently in bed-bound patients.
specificity and positive predictive value were 100%. Approximately half of the patients develop adynamic il-
eus in the acute phase, often but not invariably in con-
RECOMMENDATION junction with other features of dysautonomia.47 In other
instances, the risk is increased by long-term immobili-
The decision to place a tracheostomy may be postponed zation, incremental doses of opiates for pain control, or
for 2 weeks. If after 2 weeks the pulmonary function tests preexisting causes such as prior abdominal procedures.
do not show any significant improvement from baseline, Bladder function has only been studied infrequently
tracheostomy should be performed. If the pulmonary func- in the acute phase of GBS, partly because most patients
tion test tends to improve above baseline, tracheostomy are catheterized as part of their general nursing care to
could be deferred for an additional week, allowing the pa- maintain bodily hygiene and to avoid bladder disten-
tient to attempt to be weaned from the ventilator. Percu- tion. Voiding is more frequently compromised with axo-
taneous tracheostomy may be preferred in centers with nal types of GBS. Urodynamic studies have documented
adequate experience in using the technique. bladder areflexia and disturbed bladder sensation.49

PAIN MANAGEMENT RECOMMENDATION

Retrospective observational analyses of GBS case series Daily abdominal auscultation for development of gut si-
have documented pain as an early symptom, with an in- lence and monitoring of opioid administration are rec-
cidence ranging from 33% to 71%.38-43 One study exam- ommended. In addition to suspension of gut-feeding na-
ined incidence and intensity of pain prospectively and sogastric and rectal tubes, erythromycin or neostigmine
quantified the response to medical pain intervention.41 may be effective in treating adynamic ileus.50 Promotil-
Pain was reported by 89% of the patients and was severe ity agents are contraindicated in patients with dysauto-

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nomia. Bladder catheterization is often needed as part of ported recurrent symptoms within 6 weeks after immu-
the intensive care of severely affected patients. A sterile, nization, but it was possible to deduce with 95% confidence
closed urinary drainage system should be used with avoid- that the chance of developing GBS severe enough to re-
ance of breaking the seal to obtain urinary samples and quire hospital admission was less than 1.2%.65 In 2 pre-
irrigation of the bladder. viously reported cases, recurrence occurred following swine
influenza vaccine.66 Recurrent attacks of chronic inflam-
REHABILITATION matory demyelinating polyradiculoneuropathy have fol-
lowed tetanus toxoid immunization.67,68
Although most patients with GBS need rehabilitation, there
are no long-term rehabilitation outcome studies or com- RECOMMENDATION
parisons of different methods.51 In neuromuscular dis-
ease, overfatiguing the affected motor unit in therapy may Immunizations are not recommended during the acute
impede recovery and cause paradoxical weakening.52,53 At- phase of GBS and probably not during a period, possi-
tention needs to be paid to many details that cannot be bly of 1 year, after the onset of the disease. After that,
summarized briefly. There is a danger of muscle shorten- immunizations need not be withheld, but the need for
ing and joint contractures.51 Prolonged immobilization the immunization should be reviewed on an individual
leads to a reduction of blood volume and increased epi- basis. If GBS occurs within 6 weeks after a particular im-
sodes of postural hypotension.54 For some immobilized pa- munization, consideration should be given to avoiding
tients, a tilt table has been useful.51 Weight loss and sig- that immunization in that individual in the future.
nificant sensory loss make patients susceptible to peripheral
nerve compression and the development of decubitus ul- CONCLUSION
cers, requiring proper bed positioning with frequent pos-
tural changes.51 In patients noted to have immobilization This review has highlighted the need for more research
hypercalcemia, early mobilization was correlated with a into all aspects of supportive care for GBS.
therapeutic drop in the serum calcium levels.55 In the acute
stage, patients lose weight. During recovery, they regain
weight owing to reduced activity levels.55,56 Accepted for Publication: June 15, 2004.
Correspondence: Richard A. C. Hughes, MD, Depart-
RECOMMENDATION ment of Clinical Neuroscience, King’s College, Guy’s Hos-
pital, London SE1 1UL, England (richard.a.hughes@kcl
Treatment in the acute phase should include an indi- .ac.uk).
vidual program of gentle strengthening involving iso- Author Contributions: Study concept and design: Hughes,
metric, isotonic, isokinetic, and manual resistive and pro- Wijdicks, Benson, Cornblath, Hahn, Barohn, and Stevens.
gressive resistive exercises. Rehabilitation should be Acquisition of data: Hughes, Wijdicks, Hahn, Meythaler,
focused on proper limb positioning, posture, orthotics, Sladky, and Stevens. Analysis and interpretation of data:
and nutrition. Hughes, Wijdicks, Cornblath, Hahn, Meythaler, and
Stevens. Drafting of the manuscript: Hughes, Wijdicks,
MANAGEMENT OF FATIGUE Cornblath, Meythaler, and Sladky. Critical revision of the
manuscript for important intellectual content: Hughes,
A large proportion of patients with GBS remain seriously Wijdicks, Benson, Cornblath, Hahn, Meythaler, Barohn, and
affected in their psychosocial functioning even when their Stevens. Statistical analysis: Stevens. Administrative, tech-
physical recovery was complete or when they were left with nical, and material support: Hughes, Wijdicks, Benson, and
only mild residual signs.57,58 Severe fatigue persists in 80% Stevens. Study supervision: Hughes and Wijdicks.
of patients and is unrelated to age, duration, or severity of Disclaimer: Our recommendations must be interpreted
the initial illness.59 Frequency and severity of fatigue in GBS in relation to the needs of the individual patient and the
were comparable with that encountered in other immune- capacity of the individual institution.
mediated neuropathies.59,60 The cause and contributing fac-
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