Myasthenic Crisis

New bulbar symptoms often matter before the monitor changes. A person with MG who develops dysphagia, nasal speech, a weak cough, orthopnea, or a falling bedside respiratory measurement may be losing ventilatory reserve even while oxygen saturation remains normal. Manifest myasthenic crisis is MG weakness severe enough to require mechanical ventilation; impending crisis is rapid deterioration judged likely to reach that point within days to weeks. Both require monitored or ICU-level care, serial respiratory assessment, and urgent neurology involvement. A closely supervised trial of non-invasive ventilation is appropriate only when airway protection and secretion handling remain adequate, there is no established hypercapnia, and deterioration is not rapid. For a Canadian NP, the immediate task is recognition, emergency referral or admission, medication and trigger review, and coordination with critical care—not outpatient adjustment while respiratory reserve is falling. The clinical sequence is to protect the airway, measure the trajectory, find and remove the precipitant, and deliver PLEX or IVIG with monitored immunotherapy.