EARLY MOBILIZATION IN A MECHANICALLY VENTILATED PATIENT WITH MYASTHENIA GRAVIS IN THE INTENSIVE CARE UNIT: CASE REPORT

ANGELA CRISTINA DE LIMA, ZILDAMARA BEZERRA LIMA, ALEXANDRE SATOSHI INAGAKI, THEREZA CHRISTINA DE SOUZA PINTO, ALINE EVANGELISTA DE OLIVEIRA DE PAULA, LUCAS DOS ANJOS ROSSONI

Resumo


Introduction: Myasthenia gravis is an autoimmune disorder characterized by fluctuating muscle weakness
and fatigue. The ocular, facial and bulbar muscles are most often involved. Respiratory muscle failure with
need of mechanical ventilation is known as myasthenic crisis. Objective: The objective of this study was
to report the effects of early mobilization and inspiratory muscles training in a mechanically ventilated
patient with Myasthenia gravis (MG) in the Intensive Care Unit (ICU). Case Report: A fourty-two years old
woman was diagnosed with Myasthenia gravis two months before admission in intensive care unit.
Disphagia and respiratory symptoms such as persistent cough and dyspnea appeared seven days before
admission. Despite treatment with levofloxacina, the respiratory symptoms worsened and she was
reffered to ICU. The patient showed disfagia and dyspnea, without need of oxygen supplement. The
patient also showed normal peripheral muscle strenght. Twelve hours after admission in ICU she
presented acute respiratory failure resulting in intubation and mechanical ventilation. The patient was
ventilated with volume controlled ventilation and after daily sedation withdral she was ventilated with
pressure support ventilation. The patient was treated with immunoglobulin along five days. After two
days in mechanical ventilation the patient was extubated and was handled with non-invasive ventilation
(NIV) due to the risk of failure in weaning. Maximal inspiratory pressure was -25cmH2O and Tobin Index
was 101. After 2 days using intermittent NIV the patient was re-intubated due to a new episode of acute
respiratory failure. The patient received physcal therapy treatment three times a day and was submitted
to an early mobilization programme that included: joint mobilization techniques, active exercises, sitting
in bed, balance exercises, gait trainig, cycloergometer exercises and supervised walking. A progressive
inspiratory muscle trainnig programme was performed three times a day acoording to inspiratory maximal
pressure evaluation. After nine days the patient was successfully extubated. Maximal inspiratory pressure
was -45 cmH20 andTobin Index was 87. The patient was discharged from intensive ICU four days after
extubation and seventeen days after admission. The patient was able to move in bed, stand up and walk
short distances without help. Oxygen supplementation was not needed and dysphagia and dyspnea were
absent. Maximal inspiratory pressure was 100 cmH2O. Conclusion: Early mobilization programme associated with inspiratory muscles training facilitated mechanical ventilation weaning and funcional
performance. NIV did not avoid re-intubation in this case and this report suggest that it should be carefully
indicated.




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Referências


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