Myasthenic Crisis

WHAT YOU SHOULD KNOW:

• Myasthenic crisis (MC) is a life-threatening condition where the muscles you use for breathing become very weak. Myasthenic crisis is also called myasthenic gravis crisis. Weakened breathing muscles may cause severe breathing problems and lead to lung failure. MC is the worst form of myasthenia gravis (MG). In MC, the muscles used during breathing and swallowing are weak and do not function properly. When this happens, you may have trouble breathing. You may need a breathing machine to help you breathe and live.
  
  
• Anything that may worsen MG may trigger or lead to MC. Your risk for MC increases with a lung infection, fever, or being stressed. Certain medicines, such as antibiotics, heart medicines, steroids, and anticholinesterase inhibitors may also trigger MC. You may have shortness of breath, difficulty swallowing or talking, and morning headaches. Imaging tests, blood tests, and pulmonary function tests may be needed. Treatment for MC includes endotracheal (ET) tube placement, IV fluids, and removing factors that may trigger your MC. Immune globulins, steroids, and anticholinesterase inhibitors may also be given. Plasma exchange to remove the antibodies (body substances) in your blood causing MC may also be needed.
  
  
• MC is an emergency condition, and you may die if it is not treated right away. Treating MC may make your muscles stronger so you can breathe better. Treatment may prevent your lungs from failing.

CARE AGREEMENT:

You have the right to help plan your care. Learn about your health condition and how it may be treated. Discuss treatment options with your caregivers to decide what care you want to receive. You always have the right to refuse treatment.

RISKS:

• You may have an allergic response to the medicines used to treat your MC. Medicines may also cause you to throw up, have stomach pains, and have loose bowel movements. Your bones may become weak, and certain blood cells in your body may decrease in number. You may also have abnormal heartbeats. Immunosuppressive medicines may increase your risk for infection. They may also cause your symptoms to worsen before they get better. Immune globulins may cause headaches, chills, muscle pain, kidney failure, and high blood pressure.
  
  
• Treatments may cause weight gain, tremors, mood changes, hair loss, and muscle twitching or cramps. Your risk of having hepatitis (swollen liver), skin cancer, and other tumors may also increase. You may have problems keeping fat and sugar levels in your blood normal. Needing a ventilator to breathe may damage your lungs or cause a lung infection. Plasma exchange may decrease your blood pressure or cause bleeding problems. The catheter (tube) used during plasma exchange may cause sepsis (a blood infection). Even with treatment, problems such as abnormal heartbeats or a blood clot in your lungs may cause death.
  
  
• If your MC left untreated, your breathing muscles may continue to weaken. It may be very hard for you to breathe on your own, and you lungs may stop functioning. Not treating your MC may also cause death. Ask your caregiver if you have questions about your condition, medicines, or care.

WHILE YOU ARE HERE:

Informed consent:

A consent form is a legal document that explains the tests, treatments, or procedures that you may need. Informed consent means you understand what will be done and can make decisions about what you want. You give your permission when you sign the consent form. You can have someone sign this form for you if you are not able to sign it. You have the right to understand your medical care in words you know. Before you sign the consent form, understand the risks and benefits of what will be done. Make sure all your questions are answered.

IV:

An IV (intravenous) is a small tube placed in your vein that is used to give you medicine or liquids.

Intravenous fluids:

Intravenous (IV) fluids may be given to prevent your blood pressure from becoming too low. IV fluids may also help replace any lost fluids and electrolytes (salts) from your body. Conditions such as a fever may cause you to lose fluids from your body.

Rest:

Keep the head of your bed raised to help you breathe easier. You can also raise your head and shoulders up on pillows or rest in a reclining chair. If you feel short of breath, let caregivers know right away.

Breathing support:

You may need any of the following:

• Oxygen: You may need extra oxygen to help you breathe easier. It may be given through a plastic mask over your mouth and nose. It may be given through a nasal cannula, or prongs, instead of a mask. A nasal cannula is a pair of short, thin tubes that rest just inside your nose. Tell your caregiver if your nose gets dry or if the mask or prongs bother you. Ask your caregiver before taking off your oxygen.
  
  
• Ventilator: A ventilator is a special machine that helps you breathe if you cannot breathe well on your own. You may have an endotracheal tube (ET) tube in your mouth or nose. It goes into your windpipe to keep your airway open and help you breathe. It may be attached to a ventilator, and you may get extra oxygen through your ET tube. You will not be able to talk while the ET tube is in place.
  
  
• Bilevel positive airway pressure: Bilevel positive airway pressure (BiPAP) is a device that helps you breathe easier. BiPAP is also called non-invasive ventilation because oxygen can be given without using a tube in your throat.
  
  
• Suctioning: You may have secretions (phlegm or spit) that need to be suctioned out of your airway. If you have muscle weakness from your MC, you may have a hard time coughing out your secretions. Removing secretions may help you breathe easier. You may need suctioning with or without an ET tube in place.

Medicines:

You may be given the following medicines:

• Anti-ulcer medicine: Your caregiver may give you this medicine to prevent stress ulcers and bleeding from your stomach.
  
  
• Anticholinesterase medicine: Anticholinesterase is medicine that increases the amount of acetylcholine in your muscles. Acetylcholine is a special body chemical that helps your muscles and nerves communicate (talk to each other) better. It helps you get stronger. You may also take this medicine with steroids. Do not stop taking these medicines without your caregivers OK.
  
  
• Blood thinners: This medicine helps stop blood clots from forming in your veins. This may be given as a shot under your skin. Blood thinners make it easier for you to bleed or bruise. When this medicine is given, use a soft toothbrush to prevent bleeding gums. If you shave, use an electric shaver.
  
  
• Immune globulins: Immune globulins can be used to treat many different problems. It may be given to help your immune system fight infection. It may also help if your body does not produce enough of certain kinds of blood cells. This medicine may help if your system fights something in your blood or body that it should not. Ask your caregiver for more information about how immune globulin medicine may help you.
  
  
• Immunosuppressive therapy: These medicines may be given to decrease muscle weakness and slow down your immune system. The immune system protects your body from infections and diseases. The immune system may see normal cells as abnormal. These medicines may prevent your immune system from causing symptoms of MC.
  
  
• Supplements: Certain medicines used to treat MC may cause your bones to weaken. Your caregiver may give you vitamin D and calcium to help prevent bone loss and fractures. Ask your caregiver for more information about these supplements.

Monitoring:

• Heart monitor: This is also called an ECG or EKG. Sticky pads placed on your skin record your heart's electrical activity.
  
  
• Pulse oximeter: A pulse oximeter is a device that measures the amount of oxygen in your blood. A cord with a clip or sticky strip is placed on your finger, ear, or toe. The other end of the cord is hooked to a machine. Never turn the pulse oximeter or alarm off. An alarm will sound if your oxygen level is low or cannot be read.
  
  
• Vital signs: Caregivers will check your blood pressure, heart rate, breathing rate, and temperature. They will also ask about your pain. These vital signs give caregivers information about your current health.

Tests:

• Blood gases: This is also called an arterial blood gas, or ABG. Blood is taken from an artery (blood vessel) in your wrist, arm, or groin. Your blood is tested for the amount of oxygen and carbon dioxide in it. The results can tell caregivers how well your lungs are working.
  
  
• Blood tests: You may need blood taken to give caregivers information about how your body is working. The blood may be taken from your hand, arm, or IV.
  
  
• Chest x-ray: This is a picture of your lungs and heart. Caregivers use it to see how your lungs and heart are doing. Caregivers may use the x-ray to look for signs of infection like pneumonia, or to look for collapsed lungs. Chest x-rays may also show fluid around your heart and lungs.
  
  
• Pulmonary function tests: Pulmonary function tests, also called PFTs, help caregivers learn how well your lungs work. PFTs may also help your caregivers decide on the best treatment for you. During the tests, you breathe into a mouthpiece connected to a machine. The machine measures how much air you breathe in and out over a certain amount of time. This helps caregivers to see how well your lungs are moving and working.
  
  
• Swallow study: This study is done to make sure liquids and food do not enter your airway when you swallow. This may be needed after caregivers remove your ET tube. Ask your caregiver for more information about a swallow study.

Treatment options:

• Compression stockings: Your caregiver may order compression stockings for you to wear. These are tight elastic stockings that put pressure on your legs. The pressure is highest near your toe and decreases as it goes toward your thigh. Wearing pressure stockings helps push blood back up to your heart and keeps clots from forming. Ask your caregiver for more information about using compression stockings.
  
  
• Plasma exchange: This removes plasma (fluid portion) from your blood, and replaces it with plasma from a donor (another person). Liquid saline may also be used to replace your plasma. An IV tube is put in your vein and some of your blood is removed. A special machine spins and separates the plasma from the blood cells. Your plasma is then taken out and replaced by donor plasma or saline. The blood cells, and replacement plasma or saline are then put back in your body through an IV. Ask your caregiver for more information about plasma exchange as a treatment option.
  
  
• PEG tube: This is also called a feeding tube, G-tube, or gastrostomy tube. A small, flexible tube is put into a small cut in your abdomen. The end of the tube goes into your stomach which is stitched closed to seal the tube. It may also be placed using an endoscope (a long thin tube passed through the mouth and down into the stomach). The PEG tube is used to give you liquids, food, and medicine. You may need a PEG tube if you are on a ventilator for a long period of time. You may also need a PEG tube if you are having problems swallowing.
  
  
• Tracheostomy: A tracheostomy is a tube to help you breathe. It is put into your trachea (windpipe) through a small opening in your neck called a stoma. This is done if you need to use the ventilator for a long period of time. Ask your caregiver for more information about why you may need a tracheostomy.

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The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.

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