Ms and pneumonia. End Stage MS: Understanding Symptoms, Complications, and Advance Care Planning

18.07.202112.07.2023 by alexxlab

What are the symptoms of end stage MS. How can complications arise in advanced multiple sclerosis. Why is advance care planning important for MS patients. What options are available for end-of-life care in multiple sclerosis.

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Recognizing End Stage MS: Key Symptoms and Vulnerabilities

End stage multiple sclerosis (MS) is a critical phase of the disease where individuals may develop severe disabilities that make them more susceptible to life-threatening complications. While it’s uncommon for MS to directly cause death, the progression of symptoms can lead to increased vulnerability. Understanding these symptoms is crucial for patients, caregivers, and healthcare providers.

Common Symptoms of End Stage MS

Severe bladder and bowel problems
Increased susceptibility to respiratory infections
Swallowing difficulties
Feeding challenges
Respiratory muscle weakness
Speech impairment or loss
Pressure sores due to immobility
Risk of blood clots
Elevated pain levels
Mental confusion or disorientation

These symptoms can significantly impact an individual’s quality of life and may require frequent hospitalizations. How do these symptoms differ from those experienced in advanced MS? The main distinction lies in the response to treatment. In end stage MS, patients may no longer show improvement with medical interventions, shifting the focus to comfort and dignity in their final days.

Complications and Life-Threatening Conditions in End Stage MS

As MS progresses to its final stages, patients become increasingly vulnerable to severe complications. These can include:

Sepsis: A Critical Concern

What is sepsis, and why is it a significant risk for MS patients? Sepsis is a potentially life-threatening condition where the body’s immune response to infection becomes dysregulated, attacking its own tissues and organs. For individuals with end stage MS, recurrent infections and compromised immune function can elevate the risk of developing sepsis.

Pneumonia and Respiratory Complications

Why are MS patients particularly susceptible to pneumonia? Weakened respiratory muscles, difficulty swallowing, and reduced mobility can all contribute to an increased risk of aspiration pneumonia and other respiratory infections. These conditions can be particularly dangerous for individuals with advanced MS.

Identifying the Transition to End Stage MS

Distinguishing between advanced MS and end stage MS can be challenging, as many symptoms overlap. However, certain indicators may suggest a transition to the end stage:

Rapid physical decline
Significant weight loss
Multiple comorbidities
Need for 24-hour care
Lack of response to traditional treatments

How can healthcare providers and caregivers recognize this transition? Close monitoring of symptom progression, frequency of hospitalizations, and overall health status can help identify when a patient may be entering the end stage of MS.

The Importance of Advance Care Planning in MS

Advance care planning (ACP) is a crucial process for individuals with MS, particularly as they approach the later stages of the disease. Why is ACP so important for MS patients?

Benefits of Advance Care Planning

Ensures patient wishes are respected
Reduces stress and uncertainty for family members
Improves communication between patients, families, and healthcare providers
Allows for more personalized end-of-life care
Increases the likelihood of receiving care in preferred settings

When should MS patients consider creating an advance care plan? While it’s relevant at all stages of MS, it becomes particularly crucial as the disease progresses. Starting these conversations early can help ensure that patients’ voices are heard, even if they become unable to communicate their wishes later on.

Key Components of an Advance Care Plan for MS Patients

An effective advance care plan for individuals with MS should address several important aspects of end-of-life care. What should be included in an MS patient’s advance care plan?

Essential Elements of an MS Advance Care Plan

Treatment preferences and limitations
Designation of healthcare proxy or decision-maker
Preferred care settings (hospital, hospice, or home)
Pain management and comfort care preferences
Spiritual or religious considerations
Funeral and memorial wishes

How can patients ensure their advance care plan is comprehensive and legally valid? Consulting with healthcare providers, legal professionals, and family members can help create a thorough and enforceable plan that reflects the patient’s wishes.

Palliative Care and End-of-Life Services for MS Patients

As MS progresses to its final stages, palliative care becomes an essential component of patient management. What services are available to support MS patients nearing the end of life?

Palliative Care Options for End Stage MS

Symptom management and pain control
Emotional and psychological support
Spiritual care
Family support and counseling
Assistance with practical matters (e.g., legal and financial issues)

How does palliative care differ from curative treatment? While curative treatment aims to improve the patient’s medical condition, palliative care focuses on enhancing quality of life and providing comfort in the final stages of illness.

Navigating Difficult Conversations: Discussing End-of-Life Care

Addressing end-of-life care can be emotionally challenging for patients, families, and healthcare providers. How can these conversations be approached sensitively and effectively?

Strategies for Discussing End-of-Life Care

Choose an appropriate time and setting
Use clear, compassionate language
Encourage open expression of emotions
Provide information in manageable portions
Respect cultural and personal beliefs
Offer ongoing support and follow-up

Why is it important to have these conversations early? Early discussions about end-of-life care can reduce anxiety, improve decision-making, and ensure that patients’ wishes are respected throughout their journey with MS.

Resources and Support for MS Patients and Caregivers

Navigating end stage MS can be overwhelming for both patients and their caregivers. What resources are available to provide support and guidance during this challenging time?

Valuable Resources for End Stage MS

MS Trust’s “Thinking Ahead” guide
Dying Matters website
Local MS support groups
Hospice and palliative care organizations
Mental health professionals specializing in chronic illness

How can these resources benefit MS patients and their families? By providing information, emotional support, and practical guidance, these resources can help individuals navigate the complexities of end stage MS with greater confidence and peace of mind.

As we continue to explore the challenges and considerations surrounding end stage MS, it’s crucial to remember that each patient’s journey is unique. By understanding the symptoms, complications, and available support systems, patients and caregivers can make informed decisions that align with their values and wishes. The focus on quality of life, dignity, and personalized care remains paramount throughout the progression of MS, ensuring that individuals receive the support they need during this challenging phase of their illness.

End stage MS | MS Trust

It is rare for someone to die directly from MS itself. However, it is possible to develop disabilities as a result of your MS that make you more vulnerable to serious complications which can lead to death. If you reach the stage where your disabilities result in severe difficulties, which may not respond to treatment and so lead to life-threatening complications, you’re considered to have end stage MS.

Some of the symptoms that can make an individual vulnerable to reaching end stage MS are:

very severe bladder and/or bowel problems – which lead to recurrent infections or regular hospitalisation
increased susceptibility to respiratory infections – which can lead to repeated bouts of pneumonia
swallowing problems – which can cause choking or aspiration pneumonia (where food or fluid enters the lungs)
feeding difficulties – which may require a feeding tube or result in severe weight loss
difficulties breathing due to weakening of the respiratory muscles
difficulty with speech or losing the ability to speak
pressure sores due to immobility – which are at risk of becoming infected
developing blood clots due to lack of mobility
increased levels of pain
mental confusion or disorientation.

All of the above can lead to you needing an increasing number of emergency admissions to hospital. If you experience an infection it can put you at risk of developing sepsis. Sepsis is a potentially life-threatening condition where the body’s immune system overreacts to an infection and begins to attack it’s own organs and tissues. If not treated quickly it can lead to organ failure and death. Sepsis is sometimes referred to as septicaemia or blood poisoning.

Some other signs which might indicate end stage MS include physical decline, weight loss and multiple health conditions (comorbidities). If you have end stage MS you will often require 24 hour care.

Many of these symptoms are similar to those seen in someone with advanced MS, so it can be difficult to determine whether you’ve entered the end stage of MS. However, whilst treatment for advanced MS aims to help you improve medically, in end stage MS you may no longer respond to treatment and so the focus shifts to helping you live to the end of your life with respect, dignity and as comfortably as possible. When you reach the end stage of MS it might be appropriate for you to access end of life palliative care services.

If you don’t already have an advance care plan in place, this is something you might like to consider discussing with a health professional involved in your care. Advance care planning (ACP) is a process through which you can think about how you would like to be cared for in the future, including at the end of life.

Advance care planning is relevant at all stages of MS, as it gives you a chance to talk through what might happen and what your treatment options might be. It’s also a way of making your wishes known if you’re ever in the position where you’re unable to decide for yourself and you need someone else to do it on your behalf. However, it’s especially pertinent to have a plan in place as you near the end of life so you can make your wishes known to your family and friends, and the health professionals involved in your care.

Advance care planning can help you prioritise what’s important to you and make choices that help you maintain control over your life right to the end. It’s a way to get your voice heard if you feel very strongly about something, such as a treatment you know you wouldn’t want to have. You can identify who you want to be consulted about your care and to be there to support you. You could also specify where you’d prefer to be cared for, this might be in hospital, a hospice or at home, and where you’d like to die – this might be the same or different places. You can even include any funeral plans.

Remember, you’ll still be given the best possible care, support and any appropriate medication to control symptoms to make you as comfortable as possible.

If advance care planning is something you’d like to consider but you’re not sure where to start, the MS Trust has a guide to advance care planning called Thinking Ahead where you can find more information. There is also the Dying Matters website which aims to encourage people to talk about dying, death and bereavement with their families and friends and to help people discuss their wishes towards the end of their lives.

These conversations are never easy for anyone and it can lead to some powerful emotions such as sadness and grief, especially towards the end of life. However, it’s helpful to think about the choices you have whilst you are still able to. Having an advance care plan in place means that it’s more likely you’ll receive the care you want, in the place of your choice, for example research has shown that people with MS who have an advance care plan are less likely to die in hospital. Planning ahead can also bring with it peace of mind. You know that your loved ones and the health professionals involved with your care are aware of your wishes and will do their utmost to follow them.

Breathing Problems and MS | National Multiple Sclerosis Society

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Respiration problems from multiple sclerosis

Note: If breathing problems occur suddenly, see a healthcare provider immediately or go to the emergency room. Signs of respiratory distress requiring immediate attention include increased breathing rate, grunting when exhaling, nose flaring, sweating, wheezing, chest retractions (chest appears to sink in with each breath), leaning forward while sitting to help take deeper breaths, or bluish color around the mouth, on the inside of the lips, or on the fingernails.

Respiration — or breathing — is primarily under the control of the autonomic or “automatic” nervous system. This is the part of the central nervous system that controls vital functions such as heartbeat and respiration without conscious thought. It is unusual for multiple sclerosis to affect the autonomic nervous system. For this reason, it’s uncommon for breathing problems to occur in MS as a direct result of loss of autonomic control.

In MS, the most common cause of respiratory problems is loss of muscle strength and endurance. Just as a person can experience muscle weakness in the arms or legs, weakness can occur in the muscles of the chest and abdomen that are involved in breathing. And like weakness in other parts of the body, weakness of the muscles related to proper breathing and lung function can begin to occur early in the disease course and gradually worsen over time. People with weakened breathing muscles have to work harder to inhale and exhale. This extra effort can be quite tiring, particularly for people who already experience a significant amount of MS fatigue.

Respiratory problems can also interfere with speech. It can be much more difficult and tiring for people to carry on a conversation or speak loudly enough to be heard. A speech/language pathologist can recommend exercises and tools to enhance speech and communication. Learn more about MS-related speech symptoms.

Does MS cause shortness of breath?

No. Shortness of breath is not usually a direct symptom of MS. If you are experiencing shortness of breath, go to the emergency room.

Breathing problems that occur with MS present differently than what you might call shortness of breath. People with MS experience a tightening of the chest called an MS hug (dysesthesia). Read more about the symptoms of an MS hug and how to manage it in Momentum Magazine.

Treatment for MS breathing problems

Evaluations of breathing problems are most often done by a healthcare provider with special training in this area. If your respiratory function becomes affected, a therapy program including breathing exercises may be recommended to strengthen the muscles that support your lungs and breathing.

Everyone living with MS can benefit from adding breathing exercises into their regular wellness routine. Once you have consulted with your healthcare provider on what exercise program might be best for you, consider viewing our Breathing Tips for MS video for guided breathing exercises.

Breathing assistance devices

Some studies have determined that respiratory muscle training may help strengthen breathing muscles, improve respiratory function, clear airways, decrease fatigue and increase quality of life. This muscle training may include use of a device, such as a positive expiratory pressure (PEP) device or an acapella device (sometimes called a green pickle), to assist you in clearing your lungs and keeping airways open. Discuss the use of a device with your doctor and your rehabilitation care team.

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Community-acquired pneumonia (not caused by Covid-19) – Diagnostic approach

During a pandemic, all patients with cough, fever or other suspicious symptoms should be considered as having COVID-19 until proven otherwise.

The patient’s history and physical examination are important components of the diagnosis and may indicate symptoms that are consistent with CAP, immune dysfunction, and/or potential exposure to specific pathogens. However, a definitive diagnosis of pneumonia requires confirmation of the presence of a new infiltrate on a chest x-ray.

History

The purpose of the history is to identify symptoms consistent with CAP, immune dysfunction, and possible exposure to specific pathogens.

Risk factors include age over 65 years, institutionalization, COPD, HIV infection, exposure to cigarette smoke, alcohol abuse, poor oral hygiene, contact with children, and use of certain drugs (eg, acid-lowering drugs, inhaled corticosteroids, antipsychotics, antidiabetic drugs, opioids). Diabetes mellitus and chronic liver or kidney disease are also associated with PFS.

Typically present with clinical signs and symptoms of infection (fever or chills and leukocytosis) and respiratory symptoms (including cough, often with increased sputum production, dyspnea, pleural pain, and hemoptysis). There may be complaints of non-specific symptoms such as myalgia and arthralgia. In elderly, chronically ill, and immunocompromised patients, the signs and symptoms of a lung infection may be less severe, and pneumonia may not be recognized due to the presence of non-respiratory symptoms.

Some causes of pneumonia (eg, legionellosis) may have a specific history. Legionellosis may present with headache, confusion, digestive disturbances such as diarrhea, and clinical manifestations of hyponatremia.

Mycoplasma pneumoniae infection is most common in younger patients and patients treated with antibiotics prior to current presentation for pneumonia. It can present with extrapulmonary manifestations such as myringitis, encephalitis, uveitis, iritis, and myocarditis.[20]Torres A, Barberán J, Falguera M, et al. Multidisciplinary guidelines for the management of community-acquired pneumonia [in Spanish]. Med Clin (Barc). 2013 Mar 2;140(5):223.e1-223.e19.
http://www.ncbi.nlm.nih.gov/pubmed/23276610?tool=bestpractice.com

CVD is more severe in men than in women, resulting in higher mortality among men in general and especially among older men.[71]Barbagelata E, Cillóniz C, Dominedò C, et al. Gender differences in community-acquired pneumonia. Minerva Med. 2020 Apr;111(2):153-65.
http://www.ncbi.nlm.nih.gov/pubmed/32166931?tool=bestpractice.com

Physical examination

Perform a physical examination. The patient may have fever, tachycardia, and dyspnea at rest. Auscultation of the chest may reveal moist rales, rales or bronchial breathing, dullness of percussion sound or weakening of voice trembling may be determined.

Imaging methods

Chest x-rays should be ordered as soon as possible in all patients hospitalized with suspected NGP to confirm or rule out the diagnosis. In general, a chest x-ray is not mandatory for outpatients with suspected NGP. Direct and oblique lateral projections increase the likelihood of diagnosing pneumonia and are useful in establishing the severity of the disease.

The benefit of chest x-ray in the diagnosis of CAP has been questioned by studies using lung ultrasound and computed tomography (CT) of the chest. Lung ultrasonography should be considered if the chest x-ray is negative and the patient is elderly and frail, or clinical suspicion is uncertain.[72] Niederman MS. Imaging for the management of community-acquired pneumonia: what to do if the chest radiograph is clear. Chest. 2018 Mar;153(3):583-5.
http://www.ncbi.nlm.nih.gov/pubmed/29519296?tool=bestpractice.com
The American College of Physicians recommends bedside ultrasound in patients with acute dyspnea in case of diagnostic uncertainty.[73]Qaseem A, Etxeandia-Ikobaltzeta I, Mustafa RA, et al. Appropriate use of point-of-careultrasonography in patients with acute dyspnea in emergency department or inpatientsettings: a clinical guideline from the American College of Physicians. Ann Intern Med. 2021Jul;174(7):985-93.
https://www.doi.org/10.7326/M20-7844

http://www.ncbi.nlm.nih.gov/pubmed/33

2?tool=bestpractice.com
Chest CT scan should be considered in patients with an indeterminate diagnosis after chest x-ray and ultrasonography.[72]Niederman MS. Imaging for the management of community-acquired pneumonia: what to do if the chest radiograph is clear. Chest. 2018 Mar;153(3):583-5.
http://www.ncbi.nlm.nih.gov/pubmed/29519296?tool=bestpractice.com

Ultrasound of the lungs is a simple and affordable method for diagnosing CAP. It does not involve radiation and its use is especially valuable if chest x-ray is not available. Diagnosis of CAP by bedside ultrasound of the lungs mainly depends on the detection of induration. However, densification is not always seen in CAP, as the pneumonia may be interstitial or present as diffuse lung infiltration.[74] Reissig A, Gramegna A, Aliberti S. pneumonia. Eur J Intern Med. 2012 Jul;23(5):391-7.
http://www.ncbi.nlm.nih.gov/pubmed/22726366?tool=bestpractice.com
Evidence demonstrates that lung ultrasonography can accurately diagnose pneumonia in adults, including in the emergency department.[75]Llamas-Álvarez AM, Tenza-Lozano EM, Latour-Pérez J. the diagnosis of pneumonia in adults: systematic review and meta-analysis. Chest. 2017 Feb;151(2):374-82.
http://www.ncbi.nlm.nih.gov/pubmed/27818332?tool=bestpractice.com
[76] Orso D, Guglielmo N, Copetti R. Lung ultrasound in diagnosing pneumonia in the emergency department: a systematic review and meta-analysis. Eur J Emerg Med. 2018 Oct;25(5):312-21.
http://www.ncbi.nlm.nih.gov/pubmed/29189351?tool=bestpractice.com
[77] Gartlehner G, Wagner G, Affengruber L, et al. Point-of-care ultrasonography in patients with acute dyspnea: an evidence report for a clinical practice guideline by the American College of Physicians. Ann Intern Med. 2021 Jul;174(7):967-76.
https://www.doi.org/10.7326/M20-5504

http://www.ncbi.nlm.nih.gov/pubmed/33

8?tool=bestpractice.com

Chest CT may improve the diagnosis of NGP because chest x-ray can lead to a misdiagnosis. Chest CT provides detailed information about the condition of the parenchyma and lungs, as well as the mediastinum. However, major limitations include exposure to radiation, high cost, and the inability to perform bedside examinations. One study showed that in patients presenting to emergency departments with suspected NGP, early CT scan results, if CT is used as an adjunct to chest x-ray, significantly affect both diagnosis and clinical management.[ 78] Claessens YE, Debray MP, Tubach F, et al. Early chest computed tomography scan to assist diagnosis and guide treatment decision for suspected community-acquired pneumonia. Am J Respir Crit Care Med. 2015 Oct 15;192(8):974-82.
http://www.ncbi.nlm.nih.gov/pubmed/26168322?tool=bestpractice.com

These alternative imaging modalities may prove useful in diagnosing CAP as the availability of CT in emergency and emergency departments increases in parallel with the ability to perform scans as quickly as chest x-rays with equivalent radiation dose.[30] Wunderink RG, Waterer G. Advances in the causes and management of community acquired pneumonia in adults. BMJ. 2017 Jul 10;358:j2471.
http://www.ncbi.nlm.nih.gov/pubmed/28694251?tool=bestpractice.com

Microbiology

Initial antibiotic treatment is empiric in most cases. Determination of microbial etiology reduces the wastage of broad-spectrum antibiotics and helps ensure appropriate antibiotic therapy, which is an important factor in reducing mortality. It also identifies resistant pathogens and pathogens that may have public health implications (eg Legionella).

Sputum and blood culture:

Prior to treatment, Gram stain and culture of lower respiratory secretions and blood culture should be performed in the following patients in a hospital setting:[19]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019Oct 1;200(7):e45-e67.
https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST
http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
- Patients with severe CAP as defined by the American Thoracic Society (ATS) or the Infectious Diseases Society of America (IDSA) criteria for severe CAP (see Diagnostic Criteria section), especially if these patients are intubated
- Patients receiving empiric treatment for methicillin-resistant Staphylococcus aureus (MRSA) or Pseudomonas aeruginosa
- Patients previously infected with MRSA or P. aeruginosa, especially those who have had respiratory tract infections
- Patients with hospitalization and parenteral antibiotic therapy within the last 90 days.
These studies are generally not recommended for other inpatients, nor are they recommended for outpatient use. Consideration should be given to local protocols for rational antimicrobial therapy, local etiological factors, and the clinical picture when deciding whether to conduct these studies.[19]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-e67.
https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST
http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Sputum Gram stain is a sensitive and highly specific method for the detection of pathogens in patients with NGP. In a meta-analysis, this study was found to be highly specific for Streptococcus pneumoniae, Haemophilus influenzae, S. aureus, and Gram-negative bacilli. However, the false negative rate ranged from 22% (for H. influenzae) to 44% (for S. pneumoniae), indicating that a negative result is not definitive confirmation of the absence of causative pathogens, and antibiotic therapy should not necessarily be stopped. based on a negative sputum Gram stain.[79]Del Rio-Pertuz G, Gutierrez JF, Triana AJ, et al. Usefulness of sputum gram stain for etiologic diagnosis in community-acquired pneumonia: a systematic review and meta-analysis. BMC Infect Dis. 2019 May 10;19(1):403.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6509769
http://www.ncbi.nlm.nih.gov/pubmed/31077143?tool=bestpractice.com

Urinalysis for pneumococcal and Legionella antigens:

Patients with severe LPH should have a urine test for pneumococcal antigen. Urinalysis for Legionella antigen should be performed in patients with epidemiological factors (eg, association with a Legionella outbreak or recent travel) or in patients with severe NGP. In patients with severe NGP, lower respiratory secretions should be sampled simultaneously for bacteriological examination for Legionella or nucleic acid amplification. In large observational studies, urinalysis for antigens has been associated with a reduction in mortality and should be considered in settings where Legionella infections are on the rise, especially in critically ill patients.[19]]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-e67.
https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST
http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com

Influenza testing:

Rapid molecular testing (as opposed to antigen-based tests) for influenza virus testing should be performed while influenza viruses are circulating in the community. Studies during periods of low influenza activity are also being considered.[19] Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019Oct 1;200(7):e45-e67.
https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST
http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com

Laboratory tests

In hospitalized patients, complete blood count, blood glucose, serum electrolytes, urea, and liver function tests should be ordered. An elevated white blood cell count indicates infection Chronic kidney and liver disease are risk factors for death and complications in patients hospitalized with CAP.

Arterial blood gases should be measured in critically ill or hospitalized patients. Oximetry is non-invasive and can be used continuously.

Biomarker tests such as C-reactive protein (CRP) and procalcitonin should be considered. These biomarkers are useful in predicting a deficient host response. High levels of CRP or procalcitonin at first visit are risk factors for poor host response,[80] Menéndez R, Cavalcanti M, Reyes S, et al. Markers of treatment failure in hospitalized community acquired pneumonia. Thorax. 2008 May;63(5):447-52.
http://thorax.bmj.com/content/63/5/447.long

http://www.ncbi.nlm.nih.gov/pubmed/18245147?tool=bestpractice.com
while low levels are protective. In patients with suspected pneumonia, a CRP level >100 mg/l suggests the possibility of pneumonia.[81] Woodhead M. New guidelines for the management of adult lower respiratory tract infections. Eur Respir J. 2011 Dec;38(6):1250-1.
http://erj.ersjournals.com/content/38/6/1250.long

http://www.ncbi.nlm.nih.gov/pubmed/22130759?tool=bestpractice.com
Increased PCT values correlate with bacterial pneumonia, while low values correlate with viral and SARS. PCT is especially elevated in cases of pneumococcal pneumonia.[82] Menéndez R, Sahuquillo-Arce JM, Reyes S, et al. Cytokine activation patterns and biomarkers are influenced by microorganisms in community-acquired pneumonia. Chest. 2012 Jun;141(6):1537-45.
http://www.ncbi.nlm.nih.gov/pubmed/22194589?tool=bestpractice.com
[83] Ugajin M, Yamaki K, Hirasawa N, et al. Predictive values of semi-quantitative procalcitonin test and common biomarkers for the clinical outcomes of community-acquired pneumonia. Respiratory care. 2014 Apr;59(4):564-73.
http://rc.rcjournal.com/content/59/4/564.full

http://www.ncbi.nlm.nih.gov/pubmed/24170911?tool=bestpractice.com
Initial empiric antibiotic therapy should be initiated in patients with clinical suspicion and radiological confirmation of CAP, regardless of initial procalcitonin levels.[19] Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019Oct 1;200(7):e45-e67.
https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST

http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com

In all patients with pleural effusion, aspiration and culture of the pleural fluid should be considered. Parapneumonic effusions – exudates; positive Gram staining of the pleural fluid indicates empyema.

Bronchoscopy

Bronchoscopy should be considered in immunosuppressed patients, in patients with severe AHP, and in cases of treatment failure. The most common sampling methods are bronchoalveolar lavage (BAL) and brush biopsy. A threshold value of 10⁴ colony forming units (CFU)/ml in BAL samples indicates the presence of infection. For brush biopsy, a threshold of 10³ cfu/mL is recommended to distinguish colonization from infection.[84]Sirvent JM, Vidaur L, Gonzalez S, et al. Microscopic examination of intracellular organisms in protected bronchoalveolar mini-lavage fluid for the diagnosis of ventilator-associated pneumonia. Chest. 2003 Feb;123(2):518-23.
http://www.ncbi.nlm.nih.gov/pubmed/12576375?tool=bestpractice.com

Molecular Techniques

Conventional plating is too time consuming and not feasible from a treatment perspective. Nucleic acid amplification techniques such as polymerase chain reaction have improved diagnostic accuracy in NGP. Molecular methods provide high sensitivity and specificity in the diagnosis of mono- or polymicrobial infections and can help detect antimicrobial resistance (as may occur in the presence of Staphylococcus aureus, non-fermenting gram-negative rods, and enterobacteria) associated with severe AHP.[85] Murdoch D.R. How recent advances in molecular tests could impact the diagnosis of pneumonia. Expert Rev Mol Diagn. 2016;16(5):533-40.
http://www.ncbi.nlm.nih.gov/pubmed/26891612?tool=bestpractice.com

The American Thoracic Society recommends that nucleic acid tests be used to analyze respiratory specimens for viral pathogens other than influenza only in hospitalized patients with suspected AHP who have either severe AHP or are immunocompromised.

Ms and pneumonia. End Stage MS: Understanding Symptoms, Complications, and Advance Care Planning

Recognizing End Stage MS: Key Symptoms and Vulnerabilities

Common Symptoms of End Stage MS

Complications and Life-Threatening Conditions in End Stage MS

Sepsis: A Critical Concern

Pneumonia and Respiratory Complications

Identifying the Transition to End Stage MS

The Importance of Advance Care Planning in MS

Benefits of Advance Care Planning

Key Components of an Advance Care Plan for MS Patients

Essential Elements of an MS Advance Care Plan

Palliative Care and End-of-Life Services for MS Patients

Palliative Care Options for End Stage MS

Navigating Difficult Conversations: Discussing End-of-Life Care

Strategies for Discussing End-of-Life Care

Resources and Support for MS Patients and Caregivers

Valuable Resources for End Stage MS

End stage MS | MS Trust

Breathing Problems and MS | National Multiple Sclerosis Society

Respiration problems from multiple sclerosis

Does MS cause shortness of breath?

Other causes of breathing problems

Treatment for MS breathing problems

Breathing assistance devices

Discover More

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So You Have Progressive MS (.pdf)

Respiratory Weakness and MS (video)

How I Cope with Progressive MS

Caring for Loved Ones with Advanced MS – A Guide for Families (.

Joint Conference on Primary-Progressive MS Focuses on Unmet Needs (.pdf)

Less Common Symptoms (video)

Respiratory Weakness and MS (video)

So You Have Progressive MS (.pdf)

Hiring Help at Home (.pdf)

At Home with MS — Adapting Your Environment (.pdf)

A Guide for Support Partners (.pdf)

Seeking Services: Questions to Ask

Osteoporosis

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Advanced Care Needs

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