What to assess in a patient with Guillain-Barre (Guillain-Barre Syndrome)?

Critical Assessment Priorities in Guillain-Barré Syndrome

When approaching a patient with suspected Guillain-Barré syndrome, immediately assess respiratory function and autonomic stability, as these determine mortality risk and need for ICU-level care. 1

Immediate Life-Threatening Assessment

Respiratory Function Monitoring

• Measure vital capacity, negative inspiratory force (NIF), and maximum inspiratory/expiratory pressures at presentation and serially. 1
• Apply the "20/30/40 rule": patient is at risk of respiratory failure if vital capacity <20 ml/kg, maximum inspiratory pressure <30 cmH₂O, or maximum expiratory pressure <40 cmH₂O 1
• Single breath count ≤19 predicts need for mechanical ventilation 1
• Note that 10-30% of patients require mechanical ventilation, making this the most critical assessment 2

Autonomic Dysfunction Evaluation

• Perform electrocardiography and continuously monitor heart rate and blood pressure for arrhythmias and blood pressure instability 1
• Assess bowel and bladder function 1
• Two-thirds of deaths occur during recovery phase from cardiovascular and respiratory dysfunction, so maintain vigilance even after initial stabilization 1

Neurological Examination Specifics

Motor Assessment

• Document pattern and progression of weakness: typically bilateral ascending weakness starting in legs, progressing to arms and cranial muscles 3, 4
• Grade muscle strength using Medical Research Council scale in neck, arms, and legs 1
• Check for bilateral facial palsy, a characteristic cranial nerve finding 3, 4
• Assess functional disability using GBS disability scale 1
• Note that weakness reaches maximum disability within 2 weeks in 80% of patients 4, 5

Reflex Examination

• Assess deep tendon reflexes in all limbs: decreased or absent reflexes in paretic limbs occur in 91% initially and eventually in all patients 3, 4, 5
• However, 2% may show persistence of normal reflexes in paretic arms, so normal reflexes don't exclude GBS 5

Sensory Evaluation

• Examine for distal paresthesias or sensory loss, which often precede or accompany weakness 3, 4
• Assess for "sural sparing pattern" (normal sural sensory nerve action potential with abnormal median/ulnar responses), which is typical for GBS 3

Bulbar and Cranial Nerve Function

• Test swallowing and coughing ability to identify aspiration risk 1
• Assess for facial weakness and ophthalmoplegia 1
• Check for corneal reflex in patients with facial palsy to prevent corneal ulceration 1

Pain Assessment

• Specifically ask about pain, as it affects two-thirds of patients and can be muscular, radicular, or neuropathic 1, 3
• Pain is often an early symptom and may involve back and limbs 3, 4

Historical Red Flags

Preceding Events

• Inquire about infections within the preceding 6 weeks, present in approximately two-thirds of patients 3, 4, 6
• Specifically ask about recent diarrhea or respiratory infections 6

Temporal Pattern

• Document time from symptom onset to current presentation: progression typically occurs over days to 4 weeks, usually <2 weeks 4, 5
• Red flag: Reaching maximum disability within 24 hours or progression beyond 4 weeks suggests alternative diagnoses 4
• Red flag: Clinical deterioration after 8 weeks of onset occurs in only 5% and should prompt consideration of acute-onset CIDP 6, 5

Features Suggesting Alternative Diagnosis

• Marked persistent asymmetry of weakness 3
• Bladder dysfunction at onset (autonomic dysfunction typically develops later) 3
• Marked CSF pleocytosis (>50 cells/μl excludes typical GBS) 3, 5
• Fever at onset 5

Psychological and Communication Assessment

• Recognize that patients with GBS, even those with complete paralysis, usually have intact consciousness, vision, and hearing 1
• Screen for anxiety, depression, and hallucinations, which are frequent complications 1
• Be mindful of what is said at bedside and explain procedures to reduce anxiety 1

Common Pitfalls to Avoid

• Do not dismiss GBS based on normal CSF protein in the first week: only 49% have elevated protein on day 1, increasing to 88% after 2 weeks 3, 4
• Do not wait for antibody test results before starting treatment if GBS is suspected 3
• Do not rely on initial electrodiagnostic studies alone: only 59% fulfill criteria for distinct subtype initially 5
• Do not assume symmetric presentation is required: some asymmetry can occur 4