Tuesday, 3 March 2015

Breathing problems in MS - the unseen entity

Respir Med. 2015 Feb 12. pii: S0954-6111(15)00021-9. doi: 10.1016/j.rmed.2015.01.018. [Epub ahead of print]

Respiratory dysfunction in multiple sclerosis.



Respiratory dysfunction frequently occurs in patients with advanced multiple sclerosis (MS), and may manifest as acute or chronic respiratory failure, disordered control of breathing, respiratory muscle weakness, sleep disordered breathing, or neurogenic pulmonary edema. The underlying pathophysiology is related to demyelinating plaques involving the brain stem or spinal cord. Respiratory complications such as aspiration, lung infections and respiratory failure are typically seen in patients with long-standing MS. Acute respiratory failure is uncommon and due to newly appearing demyelinating plaques extensively involving areas of the brain stem or spinal cord. Early recognition of MS patients at risk for respiratory complications allows for the timely implementation of care and measures to decrease disease associated morbidity and mortality.

Full-size image (42 K)
An MS plaque (arrows) in the medulla, the breathing center of the brain can lead to acute breathing difficulties

We don't routinely assess for breathing difficulties in our patients during their OPD visits. The things we do check for are relapses, walking problems, cognitive difficulties, bowel/bladder dysfunction, including urinary tract infections. This may lead most to believe that it doesn't exist or is not serious. If anything, the opposite is true. 

In general breathing problems occur in MSers with advanced stage of disease. It is thankfully rare in ambulatory/walking MSers. Rarly, it occurs acutely in RRMS, caused by MS plaques in the cervical cord or medulla (see above picture).

Over the past year, I looked after two MSers with breathing difficulties, both heavily disabled (EDSS 8.5-9.0), but requiring in-patient care primarily because of their breathing. First MSer would go silent mid conversation, turning blue around the lips - after momentary panic our initial thoughts were that it was a seizure, but his O2 probe showed that his SATS (O2 saturation) had dropped to 40% - this was Cheyne-Stokes breathing. Second MSer in fact had epilepsy but worsening seizure control due to recurrent aspiration pneumonia (chest infections resulting from breathing in secretions from the mouth or stomach into the lungs). 

It is therefore not surprising that breathing problems account for 47% of all deaths in MS. The standardized mortality ratio is 2.79 (95% CI 2.44 - 3.18) i.e. almost three times more likely die prematurely due to breathing difficulties.

It is therefore critical to recognize those at greater risk and initiate appropriate measures in a timely manner. Pointers to potential breathing problems:
  • a weak cough
  • swallowing difficulties
  • difficulty controlling breathing
  • shortness of breath and excessive daytime sleepiness 
  • shortness of breath on lying flat
  • sleep disordered breathing (obstructive/central sleep apnoea)
The above can be worsened by MS-related fatigue, drugs or nerve conduction block due to elevated body temperature. 

And general considerations in management include:
  • prompt treatment of chest infections
  • influenza and streptococcal pneumonia vaccinations
  • smoking cessation
  • avoidance of sedatives

Specific measures include:
    • chest physiotherapy and cough assist devices in those with a weak cough
    • non-invasive ventilation for acute failure in breathing or those with nocturnal sleep difficulties for long-term support of symptoms
    • targeted respiratory muscle training exercises to boost strength and endurance (can be administered over 4-12 weeks)


  1. I couldn't breath right all night when I had a nasty relapse with a brainstem lesion. I had to go and sit downstairs in the lounge for many hours as it was cooler and less stuffy than my bedroom. I also had sleep apneoa during that relapse.

  2. I hope lung cancer is ruled out when patients have breathing problems.

    1. Interesting you should say that, cough/in particular coughing up blood is more sensitive of lung ca than SOB. They can present with pneumonia, by causing an obstruction but can be missed on a cxr as a result. Lung cancers often have to grow to a particular size before they cause obstruction or be present high in the lung where they compress the nearby bronchi, or invade the pleura (lung lining) causing an effusion, thereby causing breathing difficulties. Therefore shortness of breath can be late feature of lung cancer.

      Medically speaking there is shortness of breath due to structural causes, i.e. problems in the lung structure itself and due to the mechanics of breathing. A respiratory/neurology doctor will know that the combination of symptoms listed above are due to abnormal mechanics of breathing, i.e. it's neurological.

    2. Thanks for your response. We need doctors that investigate our symptoms even when we don't have a cough and don't smoke.

    3. Unexplained weight loss without a cough, shortness of breath when lying down can be a sign of lung cancer. That's why so many people are dying because it doesn't always present with obvious symptoms.

  3. Most do not realise that breathing can be affected in MS, I posted this article to increase everyone's awareness of this.

    1. Yes, I realise you need to make everyone aware, but it's also important to stress not all symptoms are caused by MS.

    2. Agree, every symptom has a multitude of causes. That's why we have differential diagnoses. This is what 'House' does in all of his episodes! You have to work through the list of most probable causes.

  4. It doesnt mention lungs completely filling up n blocking breathing..my mom is currently in icu n she just had to have a bronchial flush. She has relapsing /remiting multiple sclerosis. They sent a culture of the stuff. It was thick n brownish in color.

  5. My husband is suffering from rrms since 7years.6months back onwards he is also having breathing problem whenever he gets attack.plz help me.i am not knowing what to do.

  6. My husband has been diagnosed with Bilo Concentric Sclerosis. He gets breathing attacks every now and then (we think it is muscle spasms in his lungs) mostly so bad, that he passes out for a view seconds. Almost like having a seizure.

  7. My husband has had breathing difficulties for 2.5 years. His autonomic system is messed up, temp, bp, HR all over the place. HE is a CO2 retainer, on bipap at night. In the last month, his Oxygen saturation levels have gone from 94-99. No one can explain this other than to say this is a good thing. But he is having episodes of confusion, personality change, etc., if he goes too long without the bipap. Also suddenly bloody nose, several times for long period of time. Weird. And the doctors just look at me and shrug. Why would his lung function suddenly get better? Makes no sense

  8. Very helpful post, I have been having breathing problems since relapse 4 years ago.

    1. Forgot I had been here before. I have looked it up again due to a flair up, seems memory is playing up too! ;-)

  9. My husband is in critical condition unable to speak or breath. He has Primary Progressive Multiple Sclerosis and is a paraplegic. He is 55 years of age and has had this disease since he was 38 years of age. My heart aches for him. Watching him suffer so and on so much morphine for the pain. Not certain what is happening except he wants to come home. And that he will once they can stabilize his pain. MS is sucking his life out of him. Is this the beginning of the end of my husband of 32 years? I am so confused.


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