# Situation: A 41-year-old man is admitted to the medical ward with weakness that began in both feet 3 days ago and has now reached his thighs. He had diarrhea 2 weeks earlier. His knee and ankle reflexes are absent, and he reports tingling in both feet. Guillain-Barré syndrome (GBS) is suspected. The nurse reviews his assessments on the second hospital day: 8:00 AM — vital capacity 38 mL/kg, heart rate 88/min, blood pressure 128/80 mmHg, oxygen saturation (SpO2) 98% 8:00 PM — vital capacity 17 mL/kg, heart rate 104/min, blood pressure 146/90 mmHg, SpO2 97%, weak cough Which conclusion is MOST accurate?

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> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 41-year-old man is admitted to the medical ward with weakness that began in both feet 3 days ago and has now reached his thighs. He had diarrhea 2 weeks earlier. His knee and ankle reflexes are absent, and he reports tingling in both feet. Guillain-Barré syndrome (GBS) is suspected.

The nurse reviews his assessments on the second hospital day:
8:00 AM — vital capacity 38 mL/kg, heart rate 88/min, blood pressure 128/80 mmHg, oxygen saturation (SpO2) 98%
8:00 PM — vital capacity 17 mL/kg, heart rate 104/min, blood pressure 146/90 mmHg, SpO2 97%, weak cough
Which conclusion is MOST accurate?

## 보기

1. His breathing is adequate because his oxygen saturation is normal
2. His higher blood pressure shows pain that needs an analgesic first
3. His faster heart rate shows anxiety that needs reassurance first
4. His breathing muscles are failing and he may soon need intubation **✔ 정답**

**정답: 4**

## 해설

In GBS, respiratory muscle weakness is tracked with vital capacity; a fall to below about 20 mL/kg, especially with a weak cough, is a common threshold for intubation. SpO2 stays normal until late, so a normal reading does not mean breathing is adequate. Heart rate and blood pressure swings are also expected from autonomic instability, but the falling vital capacity is the most urgent finding.

## 심화 해설

Core clinical reasoning

Guillain-Barré syndrome (GBS) is an immune-mediated polyradiculoneuropathy that ascends from the distal lower extremities toward the trunk, and the most dangerous consequence is neuromuscular respiratory failure [2][3]. In this patient, the sensory and motor findings—weakness beginning in both feet, absent knee and ankle reflexes, and tingling—fit the classic ascending pattern. The critical change between the two assessments is the vital capacity (VC) falling from 38 mL/kg to 17 mL/kg, accompanied by a newly weak cough. This is not a stable patient with normal oxygenation; it is a patient whose respiratory muscles are deteriorating.

In GBS, a vital capacity below about 20 mL/kg—especially when the cough is weak—is a widely used bedside threshold for elective intubation. The rationale is that VC reflects inspiratory muscle strength, while an effective cough requires expiratory and bulbar muscle function. When both are compromised, the patient cannot clear secretions or protect the airway, and respiratory arrest may occur abruptly [2][4].

Watch out! Oxygen saturation remains normal until very late in neuromuscular respiratory failure. A SpO2 of 97–98% only means that oxygen exchange is still occurring; it says nothing about the patient’s ability to keep breathing. By the time desaturation appears, the patient is often already near respiratory collapse. Therefore, option 1 is incorrect because normal SpO2 does not indicate adequate ventilation in GBS.

Why heart rate and blood pressure are not the priority

The rise in heart rate from 88/min to 104/min and blood pressure from 128/80 mmHg to 146/90 mmHg is real, but it is best explained by autonomic instability, which is common in GBS because the immune attack also involves autonomic nerve fibers [3][4]. Tachycardia and blood pressure lability can occur without pain or anxiety. Options 2 and 3 incorrectly attribute these vital sign changes to pain or anxiety and would delay the definitive intervention. While autonomic dysfunction itself can be dangerous, it is not the most immediate threat here compared with a VC of 17 mL/kg and a weak cough.

Clinical decision pathway

| Assessment finding | Interpretation in GBS | Nursing priority |
| --- | --- | --- |
| Vital capacity 38 mL/kg at 8:00 AM | Above the commonly cited intubation threshold; continue close monitoring | Serial spirometry or bedside VC every 2–4 hours |
| Vital capacity 17 mL/kg at 8:00 PM | Below the approximately 20 mL/kg threshold; indicates failing inspiratory muscles | Prepare for elective intubation and ICU transfer |
| Weak cough | Expiratory and bulbar muscle weakness; impaired secretion clearance and airway protection | NPO status, suction ready, anticipate aspiration risk |
| SpO2 97–98% | Normal gas exchange despite hypoventilation risk; not reassuring in neuromuscular disease | Do not use SpO2 alone to rule out respiratory failure |
| Heart rate 104/min, BP 146/90 mmHg | Autonomic instability, not necessarily pain or anxiety | Monitor for arrhythmias and BP swings; intubation takes priority |

Why elective intubation matters

The goal in GBS is to intubate before the patient decompensates. Emergency intubation in a patient with severe respiratory muscle weakness carries a higher risk of aspiration, hypoxia, and hemodynamic instability [2]. A systematic review of spirometry in GBS supports the use of bedside pulmonary function parameters—particularly VC—to predict the need for intensive care unit admission and intubation with ventilation . The falling VC in this scenario is therefore the most accurate indicator that the patient may soon require mechanical ventilation.

Key point! In GBS, the decision to intubate is based primarily on respiratory mechanics—vital capacity, cough strength, and signs of bulbar weakness—not on oxygen saturation or blood gas values alone. A VC below approximately 20 mL/kg with a weak cough is a strong signal to secure the airway electively before respiratory failure becomes an emergency [2][4].References (research sources)

- [2]Respiratory complications of rapidly progressive neuromuscular syndromes: Guillain-Barré syndrome and myasthenia gravis.Research articleYavagal DR, Mayer SA (2002) · DOI: 10.1055/s-2002-33030

- [3]Acute Management of Guillain-Barré Syndrome: A Narrative Review.Research articleCameron A, Agrawal DK. (2026) · DOI: 10.26502/aimr.0256

- [4]Critical insights for intensivists on Guillain-Barré syndrome.Research articleWeiss N, Marois C, Le Guennec L, Rohaut B, Demeret S. (2025) · DOI: 10.1186/s13613-025-01464-w

## 임상 시나리오

GBS Respiratory MonitoringVital capacity guides intubation timing
In Guillain-Barré syndrome, track vital capacity serially. A fall below 20 mL/kg—especially with weak cough—is a threshold for elective intubation.

SpO2 remains normal until late in neuromuscular respiratory failure. A reading of 97–98% does not mean ventilation is adequate.

CautionDo not wait for desaturation. Tachycardia and hypertension may reflect autonomic instability, but falling vital capacity is the most urgent finding.

## 핵심 개념

- **Vital capacity** — Maximum air exhaled after maximal inspiration; reflects inspiratory muscle strength
- **Guillain-Barre syndrome** — Immune-mediated ascending polyradiculoneuropathy causing weakness and areflexia
- **Autonomic instability** — Dysregulation of heart rate and blood pressure common in GBS
- **Elective intubation** — Planned airway protection before respiratory failure becomes emergent
- **Neuromuscular respiratory failure** — Respiratory muscle weakness leading to hypoventilation despite normal oxygenation

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