Management of Titubation
The management of titubation focuses on treating the underlying neurological cause while providing supportive care to prevent respiratory complications and aspiration, with particular attention to airway protection given the elevated risk of difficult intubation in these patients. 1
Immediate Assessment and Risk Stratification
Identify the underlying etiology as titubation is a symptom of neurological dysfunction, not a disease itself—common causes include cerebellar disorders (olivopontocerebellar atrophy), Guillain-Barré syndrome variants (Fisher syndrome, pharyngeal-cervical-brachial variant), multiple sclerosis, and paraneoplastic syndromes 2, 3, 4, 5, 6
Assess airway risk immediately as patients with titubation and associated neurological deficits should be considered potentially difficult airways, particularly if intubation becomes necessary 1
Evaluate for bulbar dysfunction, dysphagia, and respiratory muscle weakness which commonly accompany titubation in conditions like Guillain-Barré variants 2, 4
Airway Protection and Respiratory Management
Position the patient with head elevated at 30 degrees to optimize respiratory function and reduce aspiration risk 1
Pre-oxygenate thoroughly before any airway manipulation due to potential for rapid desaturation in neurologically compromised patients 1
If intubation is required, use videolaryngoscopy as first-line technique and ensure the most experienced operator available performs the procedure 7
Prepare for difficult airway with backup equipment including supraglottic airways and cricothyrotomy kit readily available 7
Supportive Care Measures
Encourage early mobilization to prevent deterioration in neurological and respiratory function 1
Implement respiratory physiotherapy to prevent complications such as atelectasis, particularly in patients with limited mobility 1
Monitor continuously for signs of respiratory compromise including stridor, obstructive breathing patterns, or agitation 8
Treatment of Underlying Conditions
For Guillain-Barré syndrome variants with titubation: Consider intravenous immunoglobulin (IVIg) therapy, which may be effective for ataxia; in refractory cases with multiple antibodies, combined IVIg and high-dose intravenous steroid-pulse therapy may be beneficial 2
For paraneoplastic opsoclonus-myoclonus syndrome: Multimodal immunotherapy treatment along with treatment of the underlying malignancy can result in partial remission of neurological symptoms 5
Address associated complications such as SIADH (which can occur with Fisher syndrome) with hyperosmotic saline infusion and fluid restriction as needed 2
Critical Pitfalls to Avoid
Never overlook potential airway complications in patients with neurological disorders presenting with titubation, as this can lead to increased morbidity and mortality 1
Do not neglect respiratory care and mobilization, as this leads to secondary complications like atelectasis 1
Avoid assuming the vestibular-ocular reflex is intact—patients with titubation may have impaired compensatory mechanisms leading to oscillopsia even without nystagmus 6