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Guillain-Barre Syndrome

Scuba Diving Concerns:

This condition has skeletal muscle weakness which can involve extremity, truncal or bulbar groups and typically evolves over a matter of several hours to a few days can affect diving and boat crew abilities creating safety in the water as well as buddy rescue concerns. In the C. Miller-Fisher variant, ataxia as well as ophthalmoplegia (internal and external) accompany the obligatory findings of areflexia. Dysautonomia may also be present, posing an additional concern regarding tolerance of water pressure and immersion changes, blood pressure and cardiac rhythm disturbances that may be especially life-threatening in the underwater environment.

Return to diving:

Can be considered after full recovery of strength and autonomic nervous system function. Tendon-stretch reflexes may never return but would not prohibit return to diving.

Data needed to decide return to diving:

Neurology or PM&R (physical medicine and rehabilitation) consultation with quantified strength testing of all motor groups and assessment of autonomic nervous system function (orthostatic BP measurements, treadmill testing and, if appropriate, thermal stress testing). Consider performing gear management, entrance and water exit testing and buddy rescue.

Therapy:

Plasmapheresis and/or intravenous immunoglobulin (IVIG) therapy is warranted in those cases which involve weakness progressing to the point of impairing walking or respiratory abilities. Adrenocorticosteroid therapy is not beneficial and may actually worsen the outcome.

Disease notes:

Antecedent flu-like illness within two weeks prior to the onset of neurological symptoms occurs in approximately 65% of cases. This syndrome often occurs in clusters of small epidemic proportions and may have broad spectral presentations ranging from minor (e.g. Bell's palsy) to severe (complete paralysis of all skeletal muscle groups with respiratory and cardiovascular support dependency).

Obviously, diving should not be considered and cannot occur under these conditions.

Some of these patients may experience relapses and progress to chronic inflammatory demyelinating polyneuropathy (CIDP). HIV victims may present with AIDP. Lyme disease may mimic AIDP. The presence of pleocytosis in the CSF is incompatible with AIDP and suggest alternative diagnoses (e.g. sarcoidosis, leptomeningeal lymphomatosis).


Description of diving with Guillain-Barre Syndrome (from 'Aquatetra', a Disabled Diving Center.)

"Thank you for your advice on G-B syndrome.We have taken on board what you have said and would be delighted to hear what your collegues have to say on the subject. With regard to respiratory function we at AQUATETRA have researched this in great depth, mainly because we could not find a doctor who was aware of both diving and spinal cord lesions. Our diver is a C5/6 sensory incomplete tetraplegic. The research that was carried out was for publication with our new book, however we feel that you may be interested. Tetraplegics/Quadriplegics or high level paraplegics have little or no use of their pulmonary muscles, they use their diaphragms and posture to breathe. The main risk is of choking; tetras on dry land can some times choke on their own saliva, not having a normal pulmonary function can not clear there own airway. If this were to happen, a 'quad cough' or Heimlich manoeuvre would be used to clear the airway. Underwater, if a tetra were to choke on a small amount of water, they would in fact be breath-holding, with obvious air embolism risks? To that end, we do not buddy breathe or snorkel; mask removal is practised in very shallow water where there is an escape plan to the surface.

When diving at approximately six meters we have found that tetras have a problem breathing out inverted. As the air in the inverted lungs rises it pushes against the diaphragm, as there are no pulmonary muscles to contract in the plural cavity the air simply restricts the function of the diaphragm, we found this out together at 22 meters in Scotland. Our students do not dive inverted!

The other problem with tetras is from pulmonary barotrauma, pneumothorax, or lung expansion injuries. As long as the diver and student understand the physiology of a high level paralysed diver with regard diving there should be no problems.

As you are aware a diver with a normal pulmonary function should have a lung volume of about 5.59 litres; this measurement will stay almost constant whether the diver is in a seated or a standing position, with a FEV 1 sec of 4.95 or 89%. Good for the non-paralysed diver.

This may interest you; our Guillain-Barre diver has a lung capacity sitting upright of 4.89 litters. He has a lung vital capacity of 5.53 litters upright using his diaphragm and posture and his FEV1 is 4.37- not bad. His lung vital capacity when stood up in a vertical diving position is 4.73, FEV1 is 3.99 litters or 84 % This is due to a low vital capacity. This shows that posture and the restricted pulmonary function in a high- level spinal cord injury can alter the vital capacity, but still be safe for diving. Hydrostatic pressure and cummerbunds used on BCD's increase the FEV even greater.

If a high level paralysed diver is choking our has to carry out an emergency swimming ascent we use an abdominal thrust; it's similar to a Heimlich maneuvre but is done from the front with the paralysed divers head up-mouth open with the regulator in place. Together with the thrust on their abdomen and the change in ambient pressure as they rise, their air way is normally cleared.

To be quite honest the abdominal thrust is used on the ascent just to make sure the diver is breathing out sufficiently. Our ascents and descents are extremely slow.

Other problems are lung squeeze, but as long as the diver descends slowly and breathes normally it should not cause a problem."

Ryan Cowling


 

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