Management of myasthenic crisis

Admit to intensive care unit

Measure VC frequently, as often as every two hours if respiratory status is deteriorating

Consider elective intubation based upon overall clinical status, particularly in the presence of any of the following conditions:

Declines in serial measures of VC below 15 to 20 mL/kg ideal body weight
Declines in serial measurements of MIP less negative than –25 to –30 cmH₂O (ie, 0 to –30 cmH₂O)
Clinical signs of respiratory distress
Evidence of progressive respiratory acidosis
Difficulty handling oral secretions

Withdraw anticholinesterase medications temporarily to avoid excess airway secretions for patients who are intubated

Seek and treat any precipitating or contributing factors, particularly infections

Begin rapid therapy with plasma exchange or IVIG

Begin immunomodulating therapy with high-dose glucocorticoids (eg, prednisone 60 to 80 mg per day); consider azathioprine, mycophenolate mofetil, or cyclosporine if glucocorticoids are contraindicated or previously ineffective

After starting immunomodulating therapy and resuming anticholinesterase medications, consider weaning from mechanical ventilation when respiratory muscle strength is improving (ie, VC >15 to 20 mL/kg and MIP more negative than –25 to –30 cmH₂O) in patients with an adequate cough and manageable respiratory secretions

VC: vital capacity; IVIG: intravenous immune globulin; MIP: maximal inspiratory pressure.

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Management of myasthenic crisis