Jennifer Spillane, London

This was a practical talk on neurocritical care for neuromuscular respiratory failure, focused on what neurologists need to recognise, communicate and monitor.

The central framing was Robin Howard’s useful distinction: patients enter neurocritical care because of failure to wake or failure to wean. This talk focused on the second: bulbar and ventilatory failure in disorders such as GBS, myasthenia gravis, ALS and myopathies.

Key take-home messages

1. Respiratory failure is often recognised too late.
Waiting for CO₂ retention or acidosis is too late. Earlier warning signs include tachypnoea, weak cough, inability to speak full sentences, accessory muscle use, falling vital capacity, neck flexion weakness, paradoxical abdominal movement when lying flat, and poor single-breath count.

2. Trend matters more than a single number.
A vital capacity below 15–20 ml/kg suggests severe respiratory muscle weakness, but a falling trajectory should prompt early ICU discussion even before the absolute threshold is reached.

3. Bulbar failure changes everything.
Respiratory metrics alone are not enough. Patients with secretion burden, weak cough or impaired airway protection may need ICU earlier. The case of the GBS patient suctioning his own secretions was a stark reminder that bulbar deterioration can become dangerous very quickly.

4. Neurologists have a critical ICU role.
Not to “run the ventilator”, but to:

  • recognise impending neuromuscular respiratory failure
  • make or refine the diagnosis
  • identify treatable disease
  • explain likely trajectory and prognosis to ICU colleagues
  • ask the right questions about vital capacity, bulbar function, cough, secretions and weaning
  • support care after ICU discharge.

5. Many patients arrive in ICU without a prior diagnosis.
The speaker stated that around 55% of patients presenting to ICU with neuromuscular respiratory failure do not have a known diagnosis beforehand. GBS and myasthenia are common causes; notably, up to 40% of myasthenic crises may be first presentations.

| Sign up to the ACNR email newsletter here |

6. ICU stays are long — but outcomes can be good.
This was one of the most important messages. Neuromuscular ICU patients may remain ventilated for weeks or months. Mean ICU stay was quoted as approaching 60 days in GBS and around 20 days in myasthenia, with some patients requiring far longer. But mortality is not necessarily higher than general ICU populations, and long-term functional outcome can be surprisingly good.

7. Age alone should not be used pessimistically.
The speaker emphasised that older patients do not necessarily wean more slowly or have higher mortality purely because of age.

8. Tracheostomy should not be feared.
A strong practical message: delayed tracheostomy is often regretted more than early tracheostomy. It may shorten ICU stay, improve communication, aid mobilisation, and help separate bulbar from ventilatory failure.

9. Extubation failure in myasthenia is common.
The speaker quoted that 25% of intubated myasthenia patients fail extubation, often because they look well in the morning ward round but fatigue later in the day.

10. The danger does not end at ICU discharge.
Substantial mortality and morbidity can occur after ICU discharge. Neurologists need to monitor for deterioration, nocturnal hypoventilation, tracheal stenosis, psychological harm, communication problems and lack of step-down support.

The most striking point was the mismatch between how long these patients may need ICU support and how well many can eventually do. A patient ventilated for months does not necessarily have a poor prognosis.

Also useful was the practical reminder that neurologists should be able to speak ICU language: ask whether the patient is generating breaths, what ventilator mode they are on, whether vital capacity is being measured, what the cough and secretion burden are like, and whether bulbar and ventilatory weaning are being approached separately.

The historical section on polio was not just background: it showed that the fundamentals of neuromuscular respiratory care have barely changed – meticulous monitoring, airway protection, secretion management, gradual weaning, communication, physio and patience.

Conclusion

The overall conclusion was that neuromuscular respiratory failure is treatable, but only if recognised early and managed patiently. Neurologists are essential in ICU because they understand diagnosis, reversibility, prognosis and the long trajectory of recovery.

The practical message for neurologists: measure vital capacity, look for bulbar failure, escalate early, keep communicating prognosis to ICU colleagues, and do not abandon follow-up once the patient leaves ICU.

| Sign up for our online community for neurology specialists |