A 53-year-old man rapidly developed quadriplegia and tachypnoea (figure 1). Electrophysiologic studies showed demyelinating features consistent with Guillain-Barré syndrome. He required a tracheostomy and gastrostomy.

Paradoxical breathing, also known as thoracoabdominal asynchrony, was seen (see online video). Normally during inspiration, the abdomen and chest expand in a synchronised fashion. During inspiration a downward movement of diaphragm pushes the abdominal contents out as the ribs are lifted and moved out, causing both chest and abdomen to rise. With diaphragmatic paralysis, the diaphragm moves up rather than down during inspiration, and the abdomen moves in during chest rise.1 ,2 The neuromuscular respiratory failure follows a predictable pattern: failure of diaphragm and intercostal …