MS and breathing problems

Gasping for Breath: When MS Attacks Your Lungs

How MS Affects the Lungs

There are a number of ways that MS can lead to breathing problems, including the following:

Lesions in the Brain As multiple sclerosis progresses, lesions in your brain and spine can affect almost every aspect of your physical functioning. It’s possible that brain lesions could change your lung function, says Zulma Hernandez-Peraza, MD, neurologist at the University of Illinois Hospital and Health Sciences System in Chicago.

Lesions that disrupt the signals from the brain to the lungs can result in a condition known as central sleep apnea, in which breathing stops and restarts repeatedly during sleep. Symptoms of central sleep apnea include waking up abruptly with shortness of breath, having shortness of breath that improves with sitting up, insomnia, daytime sleepiness, and chest pain at night.

A more common form of sleep apnea, where the upper airway becomes intermittently obstructed, can also occur in people with MS if the muscles that normally keep the airway open become slack due to lesions in the brain. Obstructive sleep apnea is associated with snoring.

Spinal Lesions These can also restrict your ability to get air in and out of the lungs, says neurologist Staley Brod, MD, professor of neurology at the Medical College of Wisconsin in Milwaukee.

“A lesion in the cervical spine creates the ‘MS hug’ sensation, which can cause the feeling of shortness of breath,” adds Dr. Hernandez-Peraza. “This is usually just an unpleasant perception. When tested, the oxygen levels in your blood should be normal.”

The MS hug is caused by spasms in the intercostal muscles, the small muscles between the ribs.

Muscle Weakness and Spasticity “Weakness can affect breathing,” says Dr. Brod. When the muscles that help with inhaling and exhaling are weak, you may not be able to breathe deeply enough to bring in the oxygen you need. Spasticity in those muscles contributes to the problem.

Medication One of the side effects of the MS disease-modifying drug Gilenya (fingolimod) is a reduction in some measures of lung function. Some types of medication, such as tranquilizers, muscle relaxants, and opioids, can also slow or reduce breathing.

Life with the MS hug

The beginnings of the hug

It starts as a sharp pain in my spine, sometimes I can walk it off but this time it turns into something worse.

The pain creeps around to my abs and the rest of my body starts to swell. Now the pain is an angry throbbing. I have to get my clothes off, I have to be sick, I have to writhe around the floor in agony. I can’t breathe, I can’t move, I need codeine, I can’t speak, I need a wee and all this happens suddenly and exactly at the same time.

Coping with the pain

I crawl to the bathroom and deal with whatever mess occurs. Now I can feel the spasms in my abs and in between those would be a chance to breathe. But my breathing is shallow due to feeling like a tight band is being pulled around my abs, and I can’t stop crying which isn’t helping. I haven’t mentioned the loud belching and the trapped wind that seems to arrive with this agony.

My wife wants to help, she gets me water and codeine, she reminds me it will pass. She comforts me as much as she can, sometimes my skin is in too much pain to be touched. The dog is upset and pacing around. In between spasms and crying I comfort the dog, pretend to be ok and move to another room so she can’t see the next wave of pain.

This lasts until the codeine kicks in. I spend the rest of the day sleeping or watching TV. Sometimes it’s not as bad, sometimes it’s worse. Apparently this is the MS hug.

When did it start?

I was diagnosed with MS five years ago. It’s aggressive relapsing remitting and I have a Tysabri infusion every four weeks.

The MS hug started over a year ago. Recently I’ve found specific exercises that prevent this happening as much and I make sure I do my exercises every day. They involve deep breathing and engaging the pelvic floor muscle.

How to manage the MS hug

There are drugs I could take but I’d have to take them every day. Also, I’ve been on them before and I’m not willing to put up with the side effects. I’ve spoken to my neurologist about it a lot and we agree taking strong codeine when it happens is the best way forward for me at the moment. I will keep re-evaluating the situation depending on the frequency of the attacks.

Before I had an MS hug I wondered what it was and if I’d maybe had one but not noticed. Now I know that would not be possible. I usually try and find a positive angle for a blog but there’s nothing positive about an MS hug. The best I can come up with is if people are aware of it they understand if you can’t commit to some activities and they can send you good wishes and emotional support.

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Pneumonia, MS link investigated


4/23/1999 – Dr. Subramaniam Sriram is probing the relationship between certain pneumonias and multiple sclerosis. (photo by Donna Jones Bailey)

Researchers in the Vanderbilt Multiple Sclerosis Center are exploring the relationship between a common organism responsible for community-acquired pneumonias and Multiple Sclerosis.

The Vanderbilt research focuses on the role of Chlamydia pneumoniae, also known as C. pneumoniae, believed to be the cause of 20 to 30 percent of cases of pneumonia in a community setting, in the development of MS.

“The idea that infection may be a cause of MS is not a new theory and stems from the fact that an environmental cause of the disease has been known by a number of indirect evidences,” said Dr. Subramaniam Sriram, William C. Weaver Professor of Experimental Neurology and director of the Multiple Sclerosis Center.

Sriram will present his findings on April 23 at the American Academy of Neurology meeting in Toronto.

Previously, researchers have looked at a virus as the infectious agent that may cause MS.

“That has never panned out,” Sriram said. “The clinical and pathologic presentation is one of a chronic infection. That’s why we come back to an infectious cause over and over again.”

The new theory is that Chlamydia, a relatively newly discovered organism, may act as a trigger toward the development of MS, Sriram said.

The Vanderbilt research team began to look at Chlamydia two years ago when Sriram saw a patient with MS who had failed non-conventional immunosuppressive and immunomodulatory therapies.

Following discussions with Drs. Charles W. Stratton, associate professor of Pathology, and William M. Mitchell, professor of Pathology, he decided to explore the chance that a Chlamydia agent might be responsible for MS.

“We explored this in this one gentleman and were successful in culturing the organism,” Sriram said. “He subsequently made a fairly dramatic recovery from his MS with long-term antibiotic therapy.”

However, Sriram said it is too early to make the assumption that the antibiotics made a difference in the man’s illness.

“Extreme caution should be exercised in making causal associations between anecdotal success and what the disease does as part of its natural course. Since MS is known for its spontaneous remissions it is difficult to conclude in one patient that the antibiotics he received was responsible for his recovery. However, in his case, the improvement was so dramatic that we decided to explore the issue further.”

Armed with a pilot grant from the National Multiple Sclerosis Society, the Vanderbilt research team has studied a more extensive group of patients over the past two years. The organism was found in the central nervous system of a majority (90 to 95 percent) of the MS patients who were tested.

Evidence from a number of angles points to the presence of Chlamydia, Sriram said.

“This observation is interesting and is breaking new ground for a number of reasons,” Sriram said. “Even when other associations with viral organisms have been entertained, the degree of association has never been so high as with Chlamydia pneumoniae. We can demonstrate the evidence by a number of means – by culture, or by PCR techniques — that show there are antibodies to this organism present in the spinal fluid of these patients,” he said.

The Vanderbilt research has also shown that the organism is present early in the disease course and appears to persist.

The next step is a larger study, sponsored by the National MS Society, to be conducted over a three-year span.

“We will be studying 50 patients and prospectively following them over three years,” Sriram said. “We will be looking at the brains of MS patients who have died from the disease or in whom a brain biopsy was done to show the presence of the organism,” he said, adding that preliminary evidence in autopsies of MS patients who have died from other causes shows the organism can be detected in the brain.

About one-half million people in the United States have MS. There are about 2,000 patients in the Middle Tennessee area. About 1,200 of those patients are seen at the Vanderbilt center.

Sriram said the research may show that Chlamydia may not be directly responsible for the disease.

“Many people believe MS is an autoimmune disease and that the organism may initiate an immune response that goes ahead and does the damage although the organism itself does not secrete any toxin or harmful compounds. The disease may be the inadvertent injury in the body’s attempt to get rid of the organism.”

Sriram said he is “cautiously optimistic” about what answers the research may provide.

“It’s just too early to say,” he said. “Given the fact that the history of an infectious etiology has been very difficult to prove in the past, and prior organisms that were entertained as potential candidates have not been proven to be the cause, enormous caution needs to be exercised in showing the relationship between the organism and the disease before Chlamydia pneumoniae can be directly implicated as a causative agent in MS.”

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WEDNESDAY, May 27, 2015 (HealthDay News) — People with multiple sclerosis may have twice the risk of dying prematurely compared to people without MS, a new study suggests.

And the study also found that for people younger than 59 with MS, the risk of an early death seemed to be tripled, compared to people without the disease.

Overall, MS patients live an average 76 years, compared with 83 years for people who don’t have the disease, the study revealed.

“There are some suggestions that survival is improving over time, but there is still a gap of about six years,” said lead author Dr. Ruth Ann Marrie. She is an associate professor of neurology and director of the Multiple Sclerosis Clinic at the University of Manitoba in Winnipeg, Canada.

The most common cause of death was multiple sclerosis itself, or complications related to the disease, the researchers found.

Other health problems could contribute to the early death of MS patients, such as diabetes, high blood pressure, heart disease, depression, bipolar disorder, epilepsy and respiratory illness, according to the findings.

However, these risk factors did not shorten the life span of people with MS any more than they did for people without MS, the study reported.

“At least for me, it affirms the importance of focusing on a healthy lifestyle and avoiding behaviors that could exacerbate the symptoms of MS,” said Tim Coetzee, chief advocacy, services and research officer for the National Multiple Sclerosis Society.

Findings from the study were published online May 27 in the journal Neurology.

While the study made a strong case for multiple sclerosis and earlier death, it did not prove cause-and-effect.

Multiple sclerosis affects a person’s brain and spinal cord by damaging the insulating layer that surrounds and protects nerve cells, according to the U.S. National Institutes of Health.

The damage distorts and blocks messages between the brain and body. This leads to symptoms such as muscle weakness, lack of coordination and balance, vision problems and trouble with thinking and memory.

To weigh the added risk of death posed by multiple sclerosis, researchers reviewed health records in the Canadian province of Manitoba. They tracked almost 6,000 people diagnosed with MS and nearly 29,000 healthy people who were the same sex and age, living in the same areas of Manitoba.

Can You Die From Multiple Sclerosis?

Doctor’s Response

Despite therapies presented in this article, multiple sclerosis is not curable.

  • A minority of people with multiple sclerosis have a very mild form of the disease with little or no disability. Their neurologic disability may barely affect their daily activities, and the disease does not shorten their life span. However, cases of “benign” multiple sclerosis can only be ascertained retrospectively, after many years, and it is therefore not advisable for multiple sclerosis patients doing well to assume this inactive disease state will be permanent.
  • About 65% of people with multiple sclerosis have a relapsing and remitting form of the disease. They have intermittent worsening of their neurologic symptoms that lasts several days or weeks before returning to their original state of health. Some patients, however, are left with residual deficits (residual disability) after some attacks.
  • Most patients with the relapsing and remitting form progress to a stage where relapses become much less frequent, but they continue to accumulate disabling symptoms. This new phase of the disease is termed secondary progressive multiple sclerosis.
  • In about 15% of people with multiple sclerosis, a relapsing and progressing course is found. With this type (relapsing-progressive multiple sclerosis), patients have relapses superimposed on a pattern of continuous progression of disability.
  • About 5% to 10% of people with multiple sclerosis have a pure progressive (primary progressive multiple sclerosis) form. Their disability progresses in the absence of attacks over time.
  • Death usually results from other causes such as pneumonia or heart attacks, especially in patients who are bedridden, at the latest stages of the disease.

For more information, read our full medical article on multiple sclerosis

The Effects of Multiple Sclerosis on Your Body

Multiple sclerosis (MS) is a neurodegenerative and inflammatory immune condition that causes problems throughout the body. It’s caused by a breakdown of the protective cover (myelin sheath) around the nerves. This makes it hard for the brain to communicate to the rest of the body.

The exact cause of MS is still unknown, but doctors do understand the long-term effects and symptoms of MS. Read on to learn more about the effects of MS on your body.

According to the U.S. National Library of Medicine, early multiple sclerosis symptoms tend to show up in adults 20 to 40 years of age. Women are also diagnosed with MS at least twice as often as men. MS is thought to be an autoimmune disease and a progressive neurodegenerative condition. However, the exact cause is unknown and there’s currently no cure, only treatments to manage the symptoms.

What we do know is that it affects the nervous system and gradually impacts the whole body. The body’s immune cells attack healthy nerve tissue over time, affecting the body’s internal systems to respond healthily.

Primary versus secondary MS symptoms

Most of the problems described above are primary symptoms associated with MS. This means that they’re directly caused by the nerve damage resulting from attacks to the myelin sheath. Some primary symptoms can be treated directly by trying to slow the nerve damage and prevent MS attacks.

However, once nerve damage exists, secondary symptoms can arise. Secondary MS symptoms are common complications of primary MS symptoms. Examples include UTIs that result from weak bladder muscles, or a loss of muscle tone that results from an inability to walk.

Secondary symptoms can often be treated effectively, but treating the source of the problem can prevent them altogether. As the disease progresses, MS will inevitably cause some secondary symptoms. Secondary symptoms can often be well-managed with medication, physical adaptation, therapy, and creativity.

Nervous system

When someone has MS, their body’s immune system slowly attacks its own myelin sheath, which is composed of the cells that surround and protect the nervous system including the spinal cord and brain. When these cells are damaged, the nerves are exposed and the brain has difficulty sending signals to the rest of the body.

The disconnection between the brain and the organs, muscles, tissues, and cells served by the damaged nerves causes symptoms such as:

  • dizziness
  • vertigo
  • confusion
  • memory problems
  • emotional or personality changes

Depression and other changes in the brain can be a direct result of MS or an indirect result from the difficulty of coping with the condition.

In rare or advanced cases, nerve damage can cause tremors, seizures, and cognitive problems that closely resemble other neurodegenerative conditions such as dementia.

Vision and hearing loss

Vision problems are often the first sign of MS for many people. Double vision, blurriness, pain, and problems seeing contrast can begin suddenly and affect one or both eyes. In many cases, vision problems are temporary or self-limiting, and likely result from nerve inflammation or fatigue of the eye muscles.

Although some people with MS experience permanent vision problems, most cases are mild and can be effectively treated with steroids and other short-term treatments.

Rarely, people with MS may experience hearing loss or deafness caused by damage to the brainstem. These types of hearing problems usually resolve on their own, but can be permanent in some cases.

Speaking, swallowing, and breathing

According to the National MS Society (NMSS), up to 40 percent of people with MS have speech problems. These include:

  • slurring
  • poor articulation
  • volume control issues

Such effects often occur during relapses or times of fatigue. Other speech problems can include changes in voice pitch or quality, nasality, and hoarseness or breathiness.

Speech problems can be caused by breathing difficulties that are brought on by weak or damaged nerves that control muscles in the chest. Difficulty controlling the muscles involved in breathing can begin early in the disease and worsen as MS progresses. This is a dangerous yet rare complication of MS that often can be improved through work with a respiratory therapist.

Swallowing problems are less common than speech difficulties, but can be far more serious. They may occur when nerve damage weakens muscles and hinders the body’s ability to control the muscles involved in swallowing. When proper swallowing is disrupted, food or drink can be inhaled into the lungs and increase your risk for infections, such as pneumonia.

Coughing and choking when eating and drinking can be signs of swallowing problems and should be evaluated immediately. Speech or language therapists can often help with trouble speaking and swallowing.

Muscle weakness and balance issues

Many people with MS experience effects to their limbs. Damage to the myelin sheath often results in pain, tingling, and numbness of the arms and legs. Problems with hand-eye coordination, muscle weakness, balance, and gait may occur when the brain has trouble sending signals to the nerves and muscles.

These effects may start slowly and then worsen as nerve damage progresses. Many people with MS first feel “pins and needles” and have difficulty with coordination or fine motor skills. Over time, limb control and ease of walking may become disrupted. In these cases, canes, wheelchairs, and other assistive technologies can aid in muscle control and strength.

Skeletal system

People with MS are at higher risk of developing osteoporosis due to common MS treatments (steroids) and inactivity. Weakened bones can make individuals with MS susceptible to fractures and breaks. Although conditions like osteoporosis can be prevented or slowed through physical activity, diet, or supplementation, weak bones can make MS balance and coordination problems even riskier.

A growing body of evidence suggests that vitamin D deficiencies may play an important role in the development of MS. Although its exact impact on individuals with MS isn’t yet well understood, vitamin D is vital to skeletal health and immune system health.

Immune system

MS is thought to be an immune-mediated disease. This means that the body’s immune system attacks healthy nerve tissue, which causes nerve damage throughout the entire body. Immune system activity seems to result in the inflammation responsible for many MS symptoms. Some symptoms may flare up during an episode of immune system activity and then resolve when the episode or “attack” ends.

Some research is investigating whether suppressing the immune system with medication will slow the progress of MS. Other therapies try to target particular immune cells to prevent them from attacking the nerves. However, drugs that suppress the immune system may make people more vulnerable to infection.

Some nutrient deficiencies may affect immune health and worsen MS symptoms. However, most MS physicians only recommend special diets when a specific nutrient deficiency is present. One common recommendation is a vitamin D supplement — this also helps prevent osteoporosis.

Digestive system

Problems with bladder and bowel functions commonly occur in MS. Such issues can include:

  • constipation
  • diarrhea
  • loss of bowel control

In some cases, diet and physical therapy or self-care strategies can reduce the impact of these problems on daily life. Other times, medications or more intense intervention may be necessary.

The use of a catheter may occasionally be necessary. This is because nerve damage affects how much urine those with MS can comfortably hold in the bladder. This can result in spastic bladder infections, urinary tract infections (UTIs), or kidney infections. These problems can make urination painful and very frequent, even overnight or when there’s little urine in the bladder.

Most people can effectively manage bladder and bowel problems and avoid complications. However, serious infections or hygiene problems may arise if these problems are left untreated or unmanaged. Discuss any bladder or bowel issues and treatment options with your doctor.

Reproductive system

MS doesn’t directly impact the reproductive system or fertility. In fact, many women find that pregnancy offers a nice reprieve from MS symptoms. However, the NMSS reports that 2-4 out of 10 women will experience a relapse during the postpartum period.

However, sexual dysfunction, such as difficulty experiencing arousal or orgasm, is common in people with MS. This can be caused by nerve damage or by MS-related emotional problems such as depression or low self-esteem.

Fatigue, pain, and other MS symptoms can make sexual intimacy awkward or unappealing. However, in many cases, sexual problems can be addressed successfully through medication, over-the-counter aids (such as lubricant), or a bit of advanced planning.

Circulatory system

Circulatory system problems are rarely caused by MS, although weak chest muscles can lead to shallow breathing and low oxygen supply. However, lack of activity due to depression, difficulty using muscles, and a preoccupation with treating other problems may prevent people with MS from focusing on the risk of cardiovascular disease.

A study published in the journal Multiple Sclerosis found that women with MS have a significantly increased risk of cardiovascular problems such as heart attack, stroke, and heart failure. However, physical therapy and regular physical activity may help alleviate MS symptoms and reduce cardiovascular risk.

Treating MS from head to toe

While there’s no cure for multiple sclerosis, a wide variety of medications, herbal remedies, and dietary supplements may help alleviate symptoms. Treatment can also modify the disease by preventing its progression and overall effects on your body.

MS affects everyone differently. Each person experiences a unique set of symptoms and responds to treatments individually. Therefore, you and your doctors should customize your treatment regimen to address your MS symptoms specifically and alter it as the disease progresses or relapses. A carefully designed treatment plan can help make MS more manageable.

The automatic nervous system is part of the central nervous system. It controls vital functions, one of which is breathing, which we do without thinking. According to the National Multiple Sclerosis Society, it is unusual for MS to affect the nervous system and therefore breathing.

How Multiple Sclerosis affects breathing

However, patients with MS will experience muscle weakness. This affects all parts of the body, including the breathing muscles. These muscles, mainly the diaphragm and intercostals begin to lose their strength and stamina. As a result, breathing becomes more difficult and breathing in and out feels like hard work. Consequently, this adds to the feeling of fatigue, which is already a debilitating symptom of Multiple Sclerosis. Furthermore, the weakness of the breathing muscles may also impede speech and voice production.

How to improve breathing strength and stamina

A 2007 study shows that Inspiratory Muscle Training (IMT) significantly increases breathing muscle strength in people with MS. Additionally, IMT improves how well the lungs work in people with Multiple Sclerosis who have minimal to moderate disability.

The effects of Multiple Sclerosis on your body

Healthline, the fastest growing health information site, has created this medically reviewed infographic showing the effects of MS on the body.

The infographic itself provides a quick look at the effects of MS on the body. However, the rest of the article goes on to explain in more depth how this progressive neurodegenerative condition has an impact on the whole body.

Disturbance of respiratory muscle control in a patient with early-stage multiple sclerosis

To the Editor:

Respiratory dysfunction from multiple sclerosis (MS) is most commonly of insidious onset and related to progressive respiratory muscle weakness . Disorders of respiratory muscle coordination are poorly recognised and challenging to diagnose. We present a case of a patient with MS and no clear muscle weakness whose dyspnoea was associated with a disorder of respiratory muscle control. The potential utility of oesophageal manometry for diagnosis of unexplained dyspnoea is highlighted.

A 54-year-old female with relapsing-remitting MS presented with 2 weeks of dyspnoea and orthopnoea. She was ambulatory with a low extended disability score of 1.5.

6 months earlier she started cyclophosphamide for disease progression recognised by magnetic resonance imaging (MRI). A week after her last infusion she developed severe dyspnoea and orthopnoea. She had no other symptoms. Her vital signs were normal. Her laboratory tests and arterial blood gas were unremarkable. Chest computed tomography showed no pulmonary parenchymal disease. Echocardiography was unremarkable. Pulmonary function testing (PFTs) demonstrated severe restriction, with a 14% lower vital capacity in the supine position.

Her dyspnoea and PFTs improved over the following 1–2 months, but she did not return to her baseline level of pulmonary function. Electromyography (EMG) with phrenic nerve conduction studies demonstrated no abnormalities. MRI was prohibited by her orthopnoea. Previously, MRI demonstrated extensive demyelination in the brain and brainstem that was asymptomatic.

Oesophageal manometry was performed to exclude the possibility of bilateral diaphragmatic dysfunction and to elucidate her unexplained dyspnoea. A balloon-catheter was inserted via the nose to position the balloon in the distal oesophagus to estimate pleural pressure. Repeated attempts to perform a forced vital capacity manoeuvre consistently demonstrated fluctuating exhalations, as evidenced by the saw tooth pattern of the flow volume curve (fig. 1a). The simultaneous oesophageal pressure indicated that the expiratory muscle force never achieved the high values (>10–20 cmH2O) required to achieve maximum expiratory flow (fig. 1a). Upper airway dysfunction can cause interruptions in exhalation, but this is usually accompanied by normal or high oesophageal pressures, and thus did not adequately explain our patient’s halting exhalations. Static deflation pressure–volume curves of the lung revealed a normally compliant lung (fig. 1b). Oesophageal pressures during maximal inspiratory efforts against an occluded airway are expected to be most negative at low lung volumes, in our patient they were normally negative at high lung volumes, but were progressively less negative at lower lung volumes, suggesting an inability to activate inspiratory muscles at lower volumes (fig. 1b). This pattern is not consistent with simple inspiratory muscle weakness, but rather with an abnormality of respiratory muscle control, which is also suggested by her halting exhalations. Maximal expiratory efforts against an occlusion showed abnormally low oesophageal pressures, +19 cmH2O (normal value >80 cmH2O). Ultrasound examination of diaphragmatic motion showed no evidence of the paradoxical movement of the diaphragm during inspiration that would indicate diaphragmatic weakness.

Figure 1–

a) Expiratory flow and oesophageal pressure (Poes) versus lung volume during a maximal forced expiration. The Poes is relatively low, inadequate to achieve maximum expiratory flow. Decreases in flow correspond to decreases in expiratory effort, ruling out upper airway obstruction as an aetiology for the fluctuating pattern. Flow fluctuations seen in repeated manoeuvres were consistent with ratchet breathing. b) Static deflation pressure–volume curves of the lung. Two expirations from total lung capacity with intermittent airway occlusion are shown, indicating relatively normal lung compliance. Poes,max: Poes during maximal inspiratory efforts against occlusion indicate inspiratory function of the chest wall. Inspiratory pressures, normally most negative at the lowest lung volumes where the inspiratory muscles are at a mechanical advantage, were most negative at higher lung volumes, reaching -20 cmH2O (nearly normal).

MS is a disease of the central nervous system and consists of acute intermittent episodes of nerve demyelination that stabilise and later partially regress. Demyelination commonly affects the motor pathways, especially of the limbs, resulting in weakness and impaired mobility. Pulmonary complications and infections are another major cause of morbidity in MS, and their attributable mortality is as much as two-fold higher than in the general population . Pulmonary manifestations of MS consist primarily of respiratory muscle weakness that leads to impaired ventilation and poor cough . Several reports have suggested that the expiratory muscles are preferentially involved . The diagnosis of respiratory muscle dysfunction is often made clinically with the aid of standard PFTs. Several studies have shown a consistent decrease in maximal muscle forces in ambulatory asymptomatic patients without additional pulmonary functional abnormalities . There is a correlation between more severe reductions in muscle forces and disease severity . This weakness probably results from progressive demyelination in the descending medullary and cervical upper motor neuron pathways, or involvement of respiratory lower motor neurons in the cervical and thoracic cord . It is also likely to be exacerbated by conditions common in MS and known to lead to impairments in muscle function, such as deconditioning, treatment with corticosteroids, and inflammatory cytokines . Acute onset of respiratory muscle weakness, including isolated bilateral diaphragmatic weakness, has been rarely reported and is associated with acute demyelinating lesions in the medulla or spinal cord. Such acute weakness can remit, as do other neurological manifestation of MS .

As demyelination can affect the brainstem, MS could also result in disorders of respiratory control. Ratchet breathing, characterised by jerky breaths with short apnoeic pauses interrupting airflow, has been associated with localised lesions in the medulla . Few studies have investigated respiratory dyscoordination in MS. Tantucci et al. studied control of breathing and muscle strength in 11 non-dyspnoeic patients with moderate MS. They reported an increased respiratory drive, as assessed by the P0.1 (airway occlusion pressure at 0.1 s), at rest and in response to inspired CO2, but with an associated decreased ventilatory response to CO2 consistent with muscle weakness or chest wall factors. The authors could not determine from the P0.1 measurement alone if there were additional defects in coordination. In a case series, Howard et al. reported six patients with MS and evidence of disordered respiratory control on physical examination. The patients had either an irregular breathing pattern or an inability to voluntarily control ventilation. For one patient, in whom a post mortem examination was performed, demyelination plaques were evident in the brainstem. All patients had either tetraplegia, previous symptoms of demyelination in the brainstem, or advanced respiratory muscle weakness when they presented.

Oesophageal manometry is a minimally invasive test that enables the measurement of isolated lung or chest wall compliance and respiratory muscle forces. With the additional use of gastric manometry or ultrasound, a diagnosis of bilateral diaphragmatic weakness can be made, a diagnosis that is often missed with fluoroscopy alone . Recent evidence has shown the clinical usefulness of oesophageal manometry in the setting of mechanical ventilation and critical illness . In ambulatory patients, it can be a useful adjunct to PFTs in cases of unexplained dyspnoea, especially when there is suspicion of restrictive chest wall factors or respiratory muscle or diaphragmatic impairment.

This highly functional MS patient developed subacute dyspnoea with restriction on PFTs and a reduction of the vital capacity in the supine position without EMG evidence of myopathy or nerve conduction abnormalities. After performing oesophageal manometry, diaphragmatic weakness was adequately excluded, and the patient was noted to have ratchet exhalation, low expiratory pleural pressures, and, most remarkably, an unusual pattern of a least negative maximal inspiratory pressure at the lowest measured lung volume. The normal EMG, diaphragmatic ultrasound and the unusual pattern of low inspiratory pressures argue against muscle weakness as the aetiology, and support MS-related respiratory muscle dyscoordination as a more likely cause. The abnormally low expiratory pressures at all measured lung volumes suggest a more profound dyscoordination of exhalation. The differential impact on expiratory function and the largely spontaneous improvement in the patient’s symptoms also argue for a new MS-associated lesion, presumably in the brainstem, although an MRI could not be performed. We speculate that the supine worsening of her dyspnoea and vital capacity are explained by worsening dyscoordination in this position. To our knowledge this is the first case of impairment of respiratory muscle control in a patient with early-stage MS presenting with dyspnoea and diagnosed by oesophageal manometry.


  • Support Statement

    S.H. Loring was supported by a grant from the National Institutes of Health (HL-52586).

  • Statement of Interest

    None declared.

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Invisible illnesses are conditions patients have that are not obvious when looking at them. Often people with an invisible illness face a lot of prejudice; others accuse them of faking, lying or exaggerating their illness. People just don’t fully understand what patients with invisible illnesses are going through.

Just because you cannot see a person’s illness doesn’t mean they don’t have one. Just because a person looks OK doesn’t mean that they’re feeling OK. Invisible illnesses often have no cure and patients need to take medication for the rest of their lives to help control and manage the symptoms.

Here are some of the invisible illnesses that could be affecting your friends and colleagues that you wouldn’t know about unless they told you (based on information from

Cancer comes in many different forms and certainly for most cases you wouldn’t know a person was being treated for cancer unless they told you. While chemotherapy can often make cancer patients lose their hair, other forms of cancer treatment leave no visible outward signs.

Did you know that there are some less common signs of MS you might not know about?

Scleroderma is an autoimmune disease that causes an over-production of collagen. This can lead to problems with skin thickening, joint pain, and internal organ complications. While many scleroderma patients suffer from obvious facial and body changes, other scleroderma patients will not have any visible signs of the disease or signs that are hard for an untrained eye to spot.

MS patients with spasticity needed for a study of extended-release Baclofen capsules. Find out more.

Cystic fibrosis is a disease where patients have an increased level of mucus in their vital organs. This primarily affects the lungs and pancreas and is life-threatening. Cystic fibrosis leaves patients susceptible to serious and sometimes fatal lung infections and their pancreas is unable to produce enzymes needed to extract nutrients from food.

Here are six quick facts about MS that might interest you.

Pulmonary fibrosis is a serious lung disease where scarring of the lung tissue leads to chronic shortness of breath and fatigue. Patients may have pulmonary fibrosis as a secondary illness to an autoimmune disease such as scleroderma or lupus.

To help you live better with MS, here are seven useful tips you should take a look at.

Another serious lung disease which can develop as a result of an autoimmune disease or on its own is pulmonary hypertension. An increase in blood pressure in the lungs leads to the right side of the heart having to work harder to pump oxygenated blood back into the lungs, which can cause heart failure.

Resilience in MS patients linked to social satisfaction and quality of life and not physical function in MS. Find out more.

Fibromyalgia is a musculoskeletal condition where patients experience extreme pain in various trigger points in their muscles and joints, exhaustion and problems with memory and concentration. The condition usually affects women between the ages of 25 and 60.

Read our list of 10 MS support organizations you should know about.

Lupus is another autoimmune disease where the immune system begins to attack the body rather than defend it. Lupus can present a variety of symptoms, some of which may be apparent (like a butterfly rash), but others (like flu-like fevers, chronic fatigue, and internal organ complications) are not visible.

How can MS be treated? Here are nine approved MS therapies you should know about.

Mostly affecting men over the age of 50, benign prostatic hyperplasia (BPH) or enlarged prostate causes men to experience problems with urination. The prostate grows until it begins to squeeze the urethra causing pain and other symptoms involved in urination.

Did you know that drinking problems among MS patients can be linked to anxiety and family history?

Chronic obstructive pulmonary disease (COPD) is a very common disease in the U.S. Visible signs of the disease include a persistent cough and shortness of breath. Like most lung diseases, there is no cure for COPD, but lifestyle changes and medical treatments can help to slow the progression of the disease.

Can lifestyle choices affect the severity of MS? Find out more.

This chronic lung disease is usually due to either a childhood infection that has compromised the lungs or another serious lung disease like COPD or cystic fibrosis. Scarring of the bronchi (branches in the lungs) makes breathing difficult and often results in a chronic cough, chest pain, wheezing, and shortness of breath.

Learn more about the importance of early treatment in multiple sclerosis.

Not to be confused with irritable bowel disease, this serious autoimmune disease manifests itself as either Crohn’s disease or ulcerative colitis. Patients with IBD suffer painful ulcers in their digestive tract leading to many symptoms such as internal bleeding, diarrhea and constipation, abdomen pain, fatigue and weight loss. Many patients will need to have part of their colon removed.

Should MS patients get the flu shot? Read our columnist Laura Kolaczkowski’s opinion on influenza vaccination.

There are outwardly visible symptoms of multiple sclerosis but not all patients will be physically handicapped and need a wheelchair. MS presents a variety of symptoms and no two patients experience the disease in the same way. MS is an autoimmune disease which attacks the central nervous system and tampers with the flow of information between the brain and the rest of the body.

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Alzheimer’s disease is a progressive neurological condition that affects a person’s memory and brain function. People suffering from Alzheimer’s disease may be hard to detect during the early years, they may just appear a little forgetful. As the disease progresses, it will become more apparent–patients’ confusion and lack of memory becomes more obvious, as well as the physical symptoms of the disease.

Learn more about the at-home study of bacteria’s benefits on bladder health in MS patients.

Many people will suffer from chronic fatigue syndrome as a standalone disease, but some have it as a secondary illness. Many patients will experience the same level of fatigue as those with other invisible illnesses such as MS, scleroderma, and lupus but without the physical complications of these diseases.

To help you live better with MS, here are seven useful tips you should take a look at.

Multiple Sclerosis News Today is strictly a news and information website about the disease. It does not provide medical advice, diagnosis or treatment. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or another qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website.

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