Guillain-Barré Syndrome

Acute inflammatory polyradiculoneuropathy: ascending symmetrical weakness with absent or reduced reflexes, developing over days, often two to four weeks after a diarrhoeal or respiratory illness. The saturation probe will not warn you. Neuromuscular…

Ascending weakness — serial FVC, not saturations

The pathway

1 · Recognise the pattern

Ascending, symmetrical weakness over hours to days
Reflexes reduced or absent — the single most useful sign, and it takes ten seconds
Sensory symptoms are mild relative to the weakness
Often 2–4 weeks after a diarrhoeal (Campylobacter) or respiratory illness
Back and limb pain is common and misleads

2 · Measure the FVC, and keep measuring it

Forced vital capacity at the bedside, not peak flow and not saturations
20 ml/kg or below is a major escalation trigger — involve critical care and consider elective ventilation
Lower values, and a falling trend, make intubation more likely — but the number is one input, not a rule
Weigh it with bulbar weakness, cough strength, work of breathing and the direction of travel
Repeat at least 4-hourly while progressive or at risk, more often if deteriorating, per local critical care guidance
A normal SpO₂ is reassuring about oxygenation only, and stays normal until late

3 · Watch the swallow and the autonomics

Bulbar weakness — nasal speech, wet voice, pooling secretions. Nil by mouth until assessed
Autonomic instability: swinging blood pressure, arrhythmia, ileus, urinary retention
Cardiac monitoring if there are autonomic features

4 · Confirm, but do not wait to treat

Lumbar puncture: albuminocytological dissociation — raised protein with normal cell count. May be normal in the first week
Nerve conduction studies — often normal early
MRI spine if there is a sensory level or bladder involvement, to exclude cord compression

5 · Treat

IVIG 0.4 g/kg/day for 5 days, or plasma exchange — equally effective, not combined
Best within 2 weeks of onset in walking patients, 4 weeks if non-ambulant
Corticosteroids are NOT recommended in GBS — they have not been shown to improve outcome and should not be given
Check IgA level before IVIG where local policy requires it

6 · Supportive care is most of it

VTE prophylaxis — immobility plus inflammation
Pain is often severe and neuropathic; gabapentinoids rather than escalating opioids
Pressure areas, physiotherapy, bowel and bladder care
Explain the trajectory — weakness may continue to progress for days to weeks, usually reaching its nadir within 4 weeks, before recovery begins

Drugs

Drug	Dose	Route	Notes
Immunoglobulin (IVIG)	0.4 g/kg/day for 5 days	IV	First line where available. Not combined with plasma exchange — no added benefit.
Plasma exchange	5 exchanges over ~2 weeks	Procedure	Equally effective alternative to IVIG. Availability usually decides.
Gabapentin or pregabalin	Per BNF, titrated	PO	Neuropathic pain is prominent and under-treated. Escalating opioids will not fix it.
Corticosteroids	Not recommended	—	Corticosteroids are not recommended in GBS — they have not been shown to improve outcome. Reaching for them is the common error.

When to escalate

FVC at or below 20 ml/kg, or falling on serial measurement — critical care now,Bulbar weakness or an unsafe swallow — nil by mouth, anaesthetic and SALT review,Autonomic instability — cardiac monitoring, and discuss with critical care,A sensory level or bladder involvement — image the cord before assuming GBS

Reference: NICE CKS Guillain-Barré syndrome; Association of British Neurologists / national GBS management guidance. Local neurology and critical care pathways take precedence.

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