myasthenia gravis and its management

1. MYASTHENIA GRAVIS
AND ITS MANAGEMENT
-BY SHWETA SHARMA
M.SC. NURSING
I YEAR
AIIMS,JODHPUR

2. INTRODUCTION
• The word myasthenia gravis is derived from the greek word ‘mys’
meaning "muscle" and ‘asthenia’ meaning "weakness", and the latin
word ‘gravis’ meaning "serious".
• Myasthenia gravis is an autoimmune disease which results from
antibodies that block or destroy nicotinic acetylcholine receptors at the
junction between the nerve and muscle.
• It is characterized by weakness and rapid fatigue of any of the muscles
under your voluntary control.
• The most commonly affected muscles are those of the eyes, face and
muscles used for swallowing.

5. EPIDEMIOLOGY
• Myasthenia gravis affects 50 to 200 per
million people worldwide.
• The overall incidence rate of MG has been
constant and is estimated at 2.1 to 5.0 per
100,000 people per year in India.
• Myasthenia gravis occurs in all ethnic
groups and both genders.
• It most commonly affects women under 40
and people from 50 to 70 years old of
either sex, but it has been known to occur at
any age.

6. ETIOLOGY
•Idiopathic
•Genetic link
•Error in the transmission of nerve impulses to
muscles
•Auto antibodies
•Thymoma

7. FACTORS THAT CAN WORSEN
MYASTHENIA GRAVIS
•Fatigue
•Illness
•Stress
•Extreme heat
•Some medications — such as beta blockers, calcium
channel blockers, quinine and some antibiotics

8. PATHOPHYSIOLOGY

9. CLASSIFICATION
• When diagnosed with myasthenia gravis, a person is
assessed for his or her neurological status and the level of
illness is established. This is usually done using the
accepted Myasthenia Gravis Foundation of
America Clinical Classification Scale.

12. CLINICAL MANIFESTATIONS
Eye muscles
•Drooping of one or both eyelids (ptosis)

13. • Double vision (diplopia), which may be horizontal or vertical, and improves or
resolves when one eye is closed
• Peek sign- sustained tight closure of the eyelids can induce fatigue of the
orbicularis oculi muscles resulting in the white sclera of the eye slowly becoming
apparent under the partially open eye.

14. Face and throat muscles
•Impair speaking
•Cause difficulty swallowing(dysphagia)
•Affect chewing

15. • Change facial expressions- For example, your smile
might look like a snarl.

16. Neck and limb muscles
•Myasthenia gravis can also cause weakness
in your neck, arms and legs. Weakness in
your legs can affect how you walk. Weak
neck muscles make it hard to hold up your
head.

19. DIAGNOSTIC EVALUATION
•History taking,physical and neurological
examination
•Ice test

21. SINGLE-FIBER ELECTROMYOGRAPHY
(EMG)

22. • IMAGING SCANS
• PULMONARY
FUNCTION TESTING
• EDROPHONIUM
TEST/ TENSILON
TEST

23. MEDICAL MANAGEMENT
• Anticholinesterase medications- mestinon or
pyridostigmine
• Immunosuppressive drugs- prednisone,
azathioprine, mycophenolate mofetil, tacrolimus, and
rituximab
•Plasmapheresis and intravenous
immunoglobulin

24. PLASMAPHERESIS
MACHINE

25. SURGICAL MANAGEMENT
•THYMECTOMY

26. NURSING MANAGEMENT
NURSING ASSESSMENT
•Assess the severity of myasthenia gravis by asking the patient about
fatigability, what body parts are affected, and how severely they are
affected, and how severely they are affected.
•Assess the patient’s coping abilities and strategies and understanding
of the disorder.
•Objective data should include respiratory rate and depth, oxygen
saturation, arterial blood gas analysis, pulmonary function tests and
evidence of respiratory distress in patients with acute myasthenic crisis.
•Assess muscle strength.

27. NURSING DIAGNOSIS
1.Ineffective airway clearance related to intercostal muscle
weakness and impaired cough and gag reflex as evidenced by inability
to remove airway secretions, ineffective or absent cough, shortness of
breath, abnormal respiratory rate, rhythm and depth, etc.
Goal- patient will maintain clear, open airways.
2.Impaired verbal communication related to weakness of the
larynx, lips, mouth, pharynx and jaw as evidenced by difficulty in
maintaining the usual communication pattern.
Goal- patient will restore normal communication pattern.

28. 3.Impaired physical mobility related to voluntary muscle
weakness as evidenced by inability to move purposefully within physical
environment, including bed mobility, transfers, and ambulation.
Goal- patient will demonstrate measures to increase mobility.
4.Activity intolerance related to muscle weakness and fatigability
as evidenced by difficulty in performing activities of daily living.
Goal- patient will exhibit tolerance during physical activity.
5.Disturbed body image related to ptosis, change in facial
expression as evidenced by patient’s focusing behaviour on changed
body part/function.
Goal- patient will verbalize acceptance of self.

29. COMPLICATIONS
•Myasthenic crisis
•Thymus gland tumours
•Other disorders-
Underactive or overactive thyroid
Autoimmune conditions

30. PREVENTION OF COMPLICATIONS
•Give yourself plenty of rest.
•Avoid strenuous, exhausting activities.
•Avoid excessive heat and cold.
•Avoid emotional stress.
•Get vaccinated against common infections, such as influenza.
•Work up with your doctor to monitor your reactions to prescription
medications. Some drugs commonly prescribed for other problems,
such as infections, heart disease or hypertension, may make
myasthenia gravis worse.

31. RESEARCH ARTICLES
• 1.Medication adherence in patients with myasthenia gravis in
brazil: a cross-sectional study.
• A cross-sectional cohort study was conducted by Vitturi BK, Pellegrinelli A
and Valerio BCO on 58 consecutive patients with myasthenia gravis from a
university-affiliated referral hospital in São Paulo, Brazil.
• The purpose of this study was to capture the prevalence and the associated
factors of non-adherence to pharmacological treatment in patients with
myasthenia gravis. There were 26 (44.8%) patients’ adherent to treatment.
• Low adherence was associated with poor educational attainment, longer time of
disease and greater daily number of pills (p < 0.05). The study concluded
that patients with poor compliance to treatment presented worse
quality of life and increased neuropsychiatric symptoms (p < 0.05).

32. 2.Rituximab as induction therapy in refractory myasthenia gravis: 18-
month follow-up study.
A retrospective study was performed by Singh N, Goyal V on patients with
myasthenia gravis referred to the All India Institute Of Medical Sciences (AIIMS), Delhi
from January 2012 to December 2017 with follow-up of at least 6 months.
Eight refractory myasthenia gravis patients (six AchR positive and two
musk-positive) were identified on oral corticosteroids and azathioprine. After four
cycles of rituximab, all patients showed a dose reduction of whom seven were
completely tapered off prednisone and there was a 53.8% dose reduction in
azathioprine. All patients were continued on AZA after RTX infusion unless
contraindicated. In this small retrospective study, rituximab was used as
induction therapy and results suggest that repeated rituximab
infusions may not be necessary as it adds to cost of therapy.

34. CONCLUSION
• As discussed throughout the presentation, learning about myasthenia
gravis and its management will help nurses to care for a myasthenia
gravis patient.
• Nurses can do assessment of a myasthenia gravis patient, classify the
level of disease, observe the sign and symptoms, provide the necessary
nursing care and support the patient psychologically.
• Nurses can also counsel the patients and their family for various options
available in treatment for myasthenia gravis.

35. REFERENCES
• Janice L. Hinkle, Kerry H. Cheever. Brunner and Suddarth’s textbook of Medical
Surgical Nursing. 2015. New delhi. Wolters Kluwer.13th edition. Volume 2. Pg. No.
• 2. Lewis. Medical Surgical Nursing assessment and management of clinical
problems.2015. New Delhi. Elsevier. 2nd edition. Volume II. Pg. No. 1495-1497.
• 3. Joyce M. Black, Jane Hokanson Hawks. Medical Surgical Nursing Clinical
Management of Positive Outcomes.2015. New Delhi. Reed Elsevier India Private
Limited. Volume II. Pg. No. 1916-1918.
• 4. Pubmed. Medication adherence in patients with myasthenia gravis in brazil: a cross-
sectional study. Available from https://www.ncbi.nlm.nih.gov/pubmed/31555980 [ cited
4 oct 2019]
• 5. Pubmed. Rituximab as induction therapy in refractory myasthenia gravis: 18-month
follow-up study. Available from https://www.ncbi.nlm.nih.gov/pubmed/30919039 [cited
4 oct 2019]

37. RECAPITULATION
• What is the main cause of myasthenia gravis?????
• What are the common symptoms of myasthenia gravis?????
• What are the complications of myasthenia gravis?????
• What is the surgical procedure for myasthenia gravis?????

38. •Write down nursing care plan for a patient
with myasthenia gravis having 3 nursing
diagnosis.