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Published on: May 15, 2013
Mechanical ventilation and tracheostomy in multiple sclerosis
S J Pittock1, B G Weinshenker, E F M Wijdicks
1Department of Neurology, Mayo Clinic, W8B, 200 First Street SW, Rochester, MN 55905, USA.
Abstract:
Decisions on ventilatory support (VS) in multiple sclerosis (MS) are complex. All patients with MS requiring mechanical ventilation or tracheostomy since 1969 (22) at Mayo Clinic were reviewed. Seventeen had progressive (PMS; 11 secondary and six primary progressive) and one had relapsing remitting MS (RRMS). Four had neuromyelitis optica (NMO). Of those with PMS, all but two required a wheelchair or were bedbound before VS and survived a median of 22 months; 14 were mechanically ventilated and seven underwent subsequent lifelong tracheostomy; three had tracheostomy only. The indications (usually multiple) for VS in PMS patients were aspiration pneumonia, poor ventilation because of mucous plugging, mechanical failure, and airway control/protection for seizures and coma. The RRMS patient required mechanical ventilation for 10 days, with subsequent short-term tracheostomy during a brainstem exacerbation. Of the four patients with NMO one made a dramatic recovery after plasmapheresis. Compared with PMS, the NMO group had a shorter time from disease onset to VS, a longer duration of ventilation, and the three patients not treated with plasma exchange or steroids did worse. The prognosis for independent ventilation (+/- tracheostomy) was worst for patients with NMO, except for one patient who received plasma exchange, and better then expected for PMS, despite poor preventilation functional status.
Insights
Ventilatory support decisions in multiple sclerosis (MS) are complex. Progressive MS patients showed better-than-expected survival with support, while Neuromyelitis Optica (NMO) patients had varied outcomes.
Area of Science:
- Neurology
- Critical Care Medicine
Background:
- Decisions regarding ventilatory support (VS) for patients with multiple sclerosis (MS) present significant complexity.
- Historically, MS management has not extensively detailed outcomes for patients requiring mechanical ventilation or tracheostomy.
Purpose of the Study:
- To review the outcomes of patients with multiple sclerosis (MS) who required mechanical ventilation or tracheostomy.
- To compare the prognostic implications of ventilatory support in different subtypes of MS, including progressive MS (PMS) and relapsing-remitting MS (RRMS), as well as Neuromyelitis Optica (NMO).
Main Methods:
- Retrospective review of all MS patients who underwent mechanical ventilation or tracheostomy at Mayo Clinic since 1969.
- Categorization of patients into progressive MS (PMS), relapsing-remitting MS (RRMS), and Neuromyelitis Optica (NMO) groups.
- Analysis of survival, duration of ventilation, need for tracheostomy, and outcomes based on treatment modalities.
Main Results:
- Seventeen patients with PMS (11 secondary, 6 primary progressive) and one with RRMS required ventilatory support. Four patients had NMO.
- PMS patients, despite pre-existing severe disability, had a median survival of 22 months with VS; 14 required mechanical ventilation and 7 had lifelong tracheostomy.
- NMO patients experienced a shorter time to VS and longer ventilation duration; outcomes were poorer without plasma exchange or steroids, with the worst prognosis for independent ventilation, except for one treated patient.
Conclusions:
- Ventilatory support in progressive MS patients, despite poor pre-support functional status, yielded a better prognosis than anticipated.
- Neuromyelitis Optica patients requiring ventilatory support had a complex prognosis, with outcomes significantly influenced by treatments like plasma exchange and steroids.
- The study highlights the critical role of early and appropriate interventions in managing respiratory failure in MS and NMO patients.
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