Phys Vivas · neurological
Guillain-Barre Syndrome — Viva Defence
Structured DCE viva for Guillain-Barré syndrome: respiratory decision-making, disease-modifying therapy, the corticosteroid question, autonomic monitoring, CSF interpretation and prognosis.
On this page
Study tools
Target exams
Long case viva defence
Candidate's opening statement (model answer)
"Mr Davies is a 54-year-old mechanic with four days of progressive symmetric ascending weakness and areflexia two weeks after Campylobacter enteritis. He cannot walk, his vital capacity is falling and he has bilateral facial weakness. This is Guillain-Barré syndrome; my priorities are respiratory failure, autonomic instability and immunotherapy."[1]
Examiner probing questions and model answers
Q1: "His saturations are normal. Why not watch him on the ward?"[1]
"Because he meets ICU criteria — imminent respiratory insufficiency and bulbar weakness. The 20/30/40 rule flags risk at VC under 20 mL/kg, MIP under 30 or MEP under 40 cmH2O. In Lawn's series rapid progression, bulbar dysfunction, bilateral facial weakness or dysautonomia made ventilation highly likely, and no clinical feature predicted the pattern of decline, so I measure serially and intubate electively. EGRIS estimates his risk of ventilation in the first week."[1][3][4]
Q2: "What disease-modifying therapy, and what is the evidence?"[2]
"IVIg 0.4 g/kg/day for 5 days within 2 weeks, or plasma exchange 12-15 L in four to five exchanges within 4 weeks — EAN/PNS 2023 has no preference. The 1997 international trial found PE, IVIg and the combination equivalent, so I give one, not both."[2][5]
Q3: "Why not add methylprednisolone?"[6]
"Methylprednisolone 500 mg daily for 5 days with IVIg gave 68 versus 56 per cent improvement, P = 0.06 — not significant on the primary analysis. Cochrane found no benefit, and EAN/PNS recommends against oral steroids strongly and IV methylprednisolone weakly."[6][7][2]
References8ShowHide
- [1]Leonhard SE, Mandarakas MR, Gondim FAA, et al. Diagnosis and management of Guillain-Barré syndrome in ten steps. Nature reviews. Neurology, 2019.PMID 31541214
- [2]van Doorn PA, Van den Bergh PYK, Hadden RDM, et al. European Academy of Neurology/Peripheral Nerve Society Guideline on diagnosis and treatment of Guillain-Barré syndrome. European journal of neurology, 2023.PMID 37814552
- [3]Lawn ND, Fletcher DD, Henderson RD, et al. Anticipating mechanical ventilation in Guillain-Barré syndrome. Archives of neurology, 2001.PMID 11405803
- [4]Walgaard C, Lingsma HF, Ruts L, et al. Prediction of respiratory insufficiency in Guillain-Barré syndrome. Annals of neurology, 2010.PMID 20517939
- [5]Randomised trial of plasma exchange, intravenous immunoglobulin, and combined treatments in Guillain-Barré syndrome. Plasma Exchange/Sandoglobulin Guillain-Barré Syndrome Trial Group. Lancet (London, England), 1997.PMID 9014908
- [6]van Koningsveld R, Schmitz PI, Meché FG, et al. Effect of methylprednisolone when added to standard treatment with intravenous immunoglobulin for Guillain-Barré syndrome: randomised trial. Lancet (London, England), 2004.PMID 14738791
- [7]Hughes RA, Brassington R, Gunn AA, et al. Corticosteroids for Guillain-Barré syndrome. The Cochrane database of systematic reviews, 2016.PMID 27775812
- [8]van Koningsveld R, Steyerberg EW, Hughes RA, et al. A clinical prognostic scoring system for Guillain-Barré syndrome. The Lancet. Neurology, 2007.PMID 17537676