The use of a novel nanomembrane-based therapeutic plasma exchange (TPE) has been shown to reduce prolonged invasive mechanical ventilation (IMV) during acute exacerbations in patients with myasthenia gravis (MG), according to a new study published in the Journal of Clinical Medicine.

A single-center, retrospective, and before-and-after study were conducted among patients with MG with impending or manifested myasthenic crisis (MC) who were admitted to an academic neuro-intensive care unit in a Sofia, Bulgaria, hospital between January 1999 and December 2019.

MG is an autoimmune disease in which antibodies bind to the postsynaptic acetylcholine receptors or related molecules in the neuromuscular junction, which is associated with fluctuating muscle weakness. In MC—a severe presentation of MG—patients experience a rapid deterioration in muscle control.

Novel nanomembrane-based technology, which has been approved by the American Society for Apheresis, is a minimally invasive treatment that is characterized by the rapid control of quantitative/ qualitative abnormalities of plasma and blood components with the use of a semipermeable nanomembrane that localizes immunologically active compounds on its surface.

Inclusion criteria of the current study were as follows: (1) any acute exacerbation of muscle weakness that leads to neuromuscular respiratory failure requiring noninvasive ventilation (NIV), IMV, or both; (2) the presence of severe dysphagia with the risk for aspiration; and (3) walking distance of less than 5 m.

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A total of 36 consecutive patients aged 18 and over years with MG with acute exacerbations, who were deemed Myasthenia Gravis Foundation of America Class IV/IVB and Class V, were enrolled in the current study. Overall, 24 participants comprised the conventional treatment group, and 12 participants comprised the nanomembrane-based TPE group.

TPE or intravenous immunoglobulins (IVIG) infusions were used in those with impending/manifested MC, particularly among patients at high risk for prolonged IMV and in those who tolerated NIV. Clinical improvement was evaluated with the use of the Myasthenia Muscle Score (MMS), with a range of 0 to 100.

The primary outcome measures included rates of implemented TPE, IVIG, and corticosteroid immunotherapies; NIV/IMV; early tracheotomy; MMS scores; extubation time; length of hospital stay; complications; and rates of mortality.

Per univariate analysis, IMV use was significantly lower in the nanomembrane-based TPE arm than in the conventional treatment arm (42% vs 83%, respectively; P =.02). Per multivariate analysis with the use of binary logistic regression, TPE and NIV were shown to be independent predictors of short-term (less than 7 days) respiratory support (P =.014 and P =.002, respectively).

“The novel TPE technology moved our clinical practice towards proactive rather than protective treatment in reducing prolonged IMV during MG acute exacerbations,” the investigators concluded.


Tonev D, Georgieva R, Vavrek E. Our clinical experience in the treatment of myasthenia gravis acute exacerbations with a novel nanomembrane-based therapeutic plasma exchange technology. J Clin Med. 2022;11(14):4021. doi:10.3390/jcm11144021