Parameters:
(1) dysautonomia (autonomic dysfunction includes unexplained dysrhythmia, blood pressure fluctuations, significant bowel involvement or bladder involvement)
(2) bulbar dysfunction (includes impaired gag reflex, dysarthria, or dysphagia)
(3) aspiration
(4) level of disability (using the Hughes disability scale score)
(5) pulmonary function testing (vital capacity, maximum inspiratory pressure, maximal expiratory pressure)
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Clinical Findings
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Management
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dysautonomia present
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monitor in the ICU
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Hughes disability score < 3, stable or improving, AND
no dysautonomia, AND
no pulmonary function risk factors
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monitor on the ward
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(Hughes disability score >= 3) OR (< 3 and progressing), AND
no dysautonomia, AND
(no bulbar dysfunction) OR (bulbar dysfunction without aspiration), AND
no pulmonary function risk factors
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monitor on the ward
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(Hughes disability score >= 3) OR (< 3 and progressing), AND
no dysautonomia, AND
bulbar dysfunction, AND
aspiration present
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intubate in the ICU
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(Hughes disability score >= 3) OR (< 3 and progressing), AND
no dysautonomia, AND
(no bulbar dysfunction) OR (bulbar dysfunction without aspiration), AND
one or more pulmonary function risk factors present
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monitor in the ICU; consider elective intubation
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where:
• According to the legend of the diagram a Hughes disability score >= 3 indicates that the patient is unable to walk more than 5 meters. This includes the bedridden or chair-bound patient and the patient requiring mechanical ventilation (the last would be monitored in the ICU).
• Pulmonary function risk factors include one or more of the following:
(a) vital capacity < 20 mL/kg
(b) maximal inspiratory pressure < 30 cm H2O
(c) maximal inspiratory pressure < 40 cm H2O
(d) > 30% reduction in vital capacity from baseline
