ICU · Neurocritical Care
Myasthenia gravis crisis and neuromuscular respiratory failure
Also known as Myasthenic crisis · Cholinergic crisis · Neuromuscular respiratory failure · Plasmapheresis · IVIG for myasthenia
Myasthenic crisis in the ICU — impending and manifest crisis (MGFA class V) per the international consensus guidance, precipitants (Columbia cohort), BiPAP before hypercapnia, intubation for bulbar failure, predictors of prolonged ventilation and extubation failure, PLEX or IVIg (Gajdos trial, Cochrane, US cohort), corticosteroid timing, MuSK-MG, and long-term therapy (MGTX thymectomy, rituximab, eculizumab).
Checked against its sources on 8 Oct 2026
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Red flags
- Manifest crisis is worsening weakness requiring intubation or NIV to avoid intubation — manage in ICU or step-down
- PCO2 over 45 mmHg at BiPAP initiation predicted BiPAP failure — start NIV before hypercapnia
- Pronounced bulbar weakness may necessitate intubation to prevent upper airway obstruction
- PLEX cannot be used in sepsis; IVIg is contraindicated in renal failure, hypercoagulable states or immunoglobulin hypersensitivity
- Corticosteroids may transiently worsen weakness — consider waiting for PLEX or IVIg to work first
Meet the patient
A 38-year-old woman with AChR-antibody MG presents after three days of worsening dysphagia, a nasal voice and dyspnoea following a respiratory infection. She has a weak cough and pooled secretions. The questions are whether she is heading for the tube, and what triggered the crisis — most patients presenting with crisis have an identifiable risk factor.[15][4]
References23ShowHide
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