What is the primary management for a patient with Guillain-Barré Syndrome (GBS) requiring tracheostomy (trach) and percutaneous endoscopic gastrostomy (PEG)?

Management of GBS Patients Requiring Tracheostomy and PEG

For GBS patients requiring tracheostomy and PEG, perform early tracheostomy (ideally before 14 days of intubation) to reduce ventilator-associated pneumonia risk, and place PEG as the preferred gastrostomy method for nutritional support, with both interventions guided by respiratory function monitoring and swallowing assessment. 1, 2, 3

Tracheostomy Timing and Indications

Early tracheostomy should be strongly considered in GBS patients who cannot lift their arms from the bed at 1 week after intubation, or who have axonal subtype/unexcitable nerves on electrophysiology. 1

Risk Stratification for Prolonged Ventilation

• Use the Erasmus GBS Respiratory Insufficiency Score (EGRIS) to calculate probability (1-90%) that a patient will require ventilation within 1 week 1
• Apply the "20/30/40 rule": patient requires intubation if vital capacity <20 ml/kg, maximum inspiratory pressure <30 cmH₂O, or maximum expiratory pressure <40 cmH₂O 2, 4, 5
• Single breath count ≤19 predicts need for mechanical ventilation 4, 5

Tracheostomy Timing Evidence

• Delayed tracheostomy (≥14 days after intubation) significantly increases ventilator-associated pneumonia risk (odds ratio 8.2, p=0.029) 3
• Mean duration of mechanical ventilation in GBS is approximately 49 days, with tracheostomy typically performed at 11 days post-intubation 6
• 89% of mechanically ventilated GBS patients ultimately require tracheostomy 3
• Median tracheostomy duration is 39 days, with successful decannulation in the vast majority of patients 7

Tracheostomy Safety Profile

• Tracheostomy is safe and well-tolerated in GBS patients, including children 7
• Major complications are rare: tracheal stenosis occurs in <2% of cases 6
• No tracheostomy-related deaths reported in major series 6, 7
• All patients in pediatric series were successfully decannulated at first attempt 7

PEG Placement Strategy

PEG is the preferred gastrostomy method for GBS patients requiring long-term nutritional support. 1

PEG vs Alternative Methods

• PEG remains the most appropriate enteral access for medium- and long-term nutrition 1
• For patients with significant respiratory impairment (FVC <50%), radiologically inserted gastrostomy (RIG) by an expert team may be safer 1
• RIG has the advantage of placement safety even with severe respiratory compromise, but carries higher tube-related complication rates due to narrow diameter and poor fixation 1

Timing Considerations for PEG in GBS

• Approximately 28% of GBS patients develop dysphagia requiring tube feeding during acute phase 8
• Gastrostomy tubes could not be removed in 29% (2 of 7) of GBS patients who underwent PEG, indicating risk of long-term dependence 8
• Mean duration of nasal tube feeding before PEG consideration is 62 days 8
• Early discussion and placement without unnecessary delay is recommended 1

Respiratory Function and PEG Safety

• Traditional recommendations suggest PEG placement with FVC >50% of predicted values 1
• However, PEG can be performed safely in patients with worse respiratory function when non-invasive ventilation support is provided during the procedure 1
• Avoid PEG when FVC <30% and consider alternative palliative approaches 1

Critical Monitoring During ICU Stay

Respiratory Monitoring

• Continuous vital capacity measurement is essential as respiratory failure develops in up to 30% of GBS patients 2, 9
• Monitor for use of accessory respiratory muscles 4
• Serial arterial blood gas measurements if respiratory compromise suspected 4
• Regular assessment of cough strength and swallowing function to prevent aspiration 1, 2, 4

Autonomic Dysfunction Surveillance

• Continuous ECG monitoring for arrhythmias 5
• Blood pressure monitoring for hypertension/hypotension 5
• Monitor bowel and bladder function 2, 5
• Dysregulation of autonomic nerves affects cardiovascular stability and is a major cause of mortality 2

Immunotherapy Concurrent with Supportive Care

Initiate IVIg (0.4 g/kg/day for 5 days) as early as possible, even in patients requiring tracheostomy and PEG. 1, 2, 5

• IVIg and plasma exchange are equally effective but IVIg is easier to administer and more widely available 1, 5
• Treatment should not be delayed while awaiting tracheostomy or PEG placement 1, 5
• Corticosteroids alone are not recommended and may have negative effects 1, 4, 5

Complication Prevention

Ventilator-Associated Pneumonia

• Ventilator-associated pneumonia occurs in 56% of mechanically ventilated GBS patients and is associated with prolonged ventilation 3
• Most pneumonia cases are aspiration-related, emphasizing importance of early PEG placement 3
• Early tracheostomy (<14 days) significantly reduces pneumonia risk 3

Other Complications

• Atelectasis develops in 49% of mechanically ventilated GBS patients 3
• Deep vein thrombosis prophylaxis is essential 2
• Pressure ulcer prevention through regular repositioning 2
• Pain management is crucial as it significantly impacts quality of life 2, 5

Prognosis and Decannulation/PEG Removal

• 80% of GBS patients regain independent walking ability at 6 months 5
• Mortality is 3-10%, primarily from cardiovascular and respiratory complications 5
• Tracheostomy tubes remain in place for ≥110 days in approximately 33% (5 of 15) of GBS patients requiring tracheostomy 8
• Of patients requiring both tracheostomy >110 days, 80% (4 of 5) also required PEG 8
• Successful decannulation is achievable in the vast majority of patients 7

Key Pitfalls to Avoid

• Do not delay tracheostomy beyond 14 days of intubation as this significantly increases pneumonia risk 3
• Do not wait for obvious dyspnea before intubating—respiratory failure can develop rapidly without clear clinical signs 4
• Avoid medications that worsen neuromuscular function: β-blockers, IV magnesium, fluoroquinolones, aminoglycosides, and macrolides 4
• Do not assume all GBS patients will recover swallowing function—approximately 29% with PEG cannot have it removed 8