Ms and pneumonia: Multiple cause of death analysis in multiple sclerosis

13.07.202112.07.2023 by alexxlab

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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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Why Multiple Sclerosis Can Affect Your Breathing

Multiple sclerosis can negatively affect multiple processes that control or modulate breathing. Here’s what you can do to improve your respiratory function.

By Madeline R. Vann, MPHMedically Reviewed by Jason Paul Chua, MD, PhD

Reviewed: May 24, 2021

Medically Reviewed

MS can make it difficult to cough effectively, which can lead to a higher risk of respiratory infections like pneumonia. Alamy

Among the many possible complications of multiple sclerosis (MS) is a reduction in your ability to exhale fully and to cough effectively enough to clear secretions or food from your airway, says Anthony Reder, MD, a multiple sclerosis specialist and professor of neurology at the University of Chicago. A serious consequence of these changes is a higher risk of respiratory infections like pneumonia. Changes in breathing function can also cause fatigue, as you work harder to breathe and supply your body with the oxygen it needs.

How MS Can Affect Your Breathing

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 respiratory function, says Zulma Hernandez-Peraza, MD, a 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, notes Dr. Reder. 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, adds Reder. Obstructive sleep apnea is associated with snoring and obesity.

Spinal Lesions

These can cause weakness of the breathing muscles and 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. “Weakness can affect breathing,” says Dr. Brod. Spasticity in the muscles that help with inhaling and exhaling could also contribute to the problem.

“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.”

Medication

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

In 2019, the U.S. Food and Drug Administration (FDA) issued a warning that serious breathing difficulties may occur in people who have respiratory risk factors who are taking gabapentin (Neurontin, Gralise, Horizant) or pregabalin (Lyrica, Lyrica CR). According to the National Multiple Sclerosis Society, these pain medications (known as gabapentinoids) are sometimes prescribed for people who have multiple sclerosis. Talk to your doctor if you have respiratory risk factors including (but not limited to) chronic obstructive pulmonary disease (COPD) or older age and you have been prescribed these medications, especially at high doses, notes Reder.

What You Can Do When MS Attacks Your Breathing Function

If you’re unable to cough normally or you’re feeling short of breath, dizzy, or even faint, don’t just write off these symptoms as an expected part of life with MS. Taking the following steps can help you manage the problem and prevent it from getting worse, says Reder.

See your doctor. Your doctor will ask you about your symptoms and do a physical exam to look for the cause of the problem. They may conduct tests of your lung function or refer you to a pulmonologist for pulmonary function tests. Lung function tests are painless and noninvasive, and they allow your doctor to see how much air is moving in and out of your lungs, how forcefully you can exhale after inhaling, and how quickly you can force air out of your lungs.

Go to pulmonary rehabilitation. Depending on the cause of your breathing problems, your doctor may refer you for pulmonary rehabilitation, where you’ll learn exercises and techniques to improve your breathing. You may be instructed to spend several minutes a day using a handheld device to build your breathing muscles and increase your lung volume. You may also work with a physical therapist or pulmonary rehabilitation specialist on exercises to strengthen your upper body.

A study published in October 2020 in Multiple Sclerosis and Related Disorders found that 12 weeks of inspiratory muscle training with low resistance (like breathing in and out through a wide straw) was more effective than conventional respiratory exercises to improve respiratory strength and labored breathing in people who have MS.

Additionally, a review published in December 2017 in the Cochrane Library found some evidence that inspiratory muscle training with a resistive device is moderately effective at improving respiratory muscle strength in people who have mild to moderate MS.

Aim for a healthy weight. Being overweight and having a thick neck can lead to sleep apnea, says Brod. To maintain a healthy weight, you may have to battle the fatigue that often comes with MS, notes Reder. “Many patients with MS are tired, fatigued, and weak from deconditioning and the MS,” he says, adding that it’s important to “fight” these symptoms and try your best to exercise regularly and eat a healthy diet.

Stop smoking. “It is known that smoking is bad for a person with MS,” points out Brod. It’s also bad for your lungs. If you smoke and have multiple sclerosis, you’re increasing the burden on your lungs.

Use oxygen if it’s prescribed. Supplemental oxygen is rarely needed for MS unless you have another medical condition that affects your lungs, such as COPD. But if oxygen is prescribed, it can help you feel better and function better.

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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. The routine use of nucleic acid-based tests in outpatients with suspected NGP is not recommended.[86]Evans SE, Jennerich AL, Azar MM, et al. Nucleic acid-based testing for noninfluenza viral pathogens in adults with suspected community-acquired pneumonia. An official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2021 May 1;203(9):1070-87.
https://www.doi.org/10.1164/rccm.202102-0498ST

http://www.ncbi.nlm.nih.gov/pubmed/33929301?tool=bestpractice.com

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Ms and pneumonia: Multiple cause of death analysis in multiple sclerosis

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

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