What is the acute management of Guillain-Barré syndrome when there is rising respiratory effort failure?

• A. IVIG or plasmapheresis; close respiratory monitoring; supportive care including possible mechanical ventilation.
• B. High-dose corticosteroids alone.
• C. Empirical antibiotics and antivirals.
• D. Immediate surgical decompression.

Answer: (A)

When Guillain-Barré syndrome is developing respiratory compromise, the focus is twofold: neutralize the immune attack and protect the airway. Immunotherapy with intravenous immunoglobulin or plasmapheresis is given promptly because both therapies remove or neutralize the antibodies driving the nerve inflammation and can shorten the course of weakness. At the same time, close respiratory monitoring is essential because weakness can rapidly progress to failure of the ventilatory muscles. Track measurements of respiratory function (for example, vital capacity and blood gases) and be prepared to provide mechanical ventilation if there are signs of impending failure (rising CO2, hypoxemia, or increasing work of breathing).

Corticosteroids given alone do not improve outcomes in Guillain-Barré and are not a preferred sole therapy. Antibiotics and antivirals are not indicated unless there is a concomitant infection, and surgical decompression is not applicable to Guillain-Barré, which is not a compressive process.