(Kiosk 4) Respiratory Dysfunction in Advanced Multiple Sclerosis with Intrathecal Baclofen Pump: A Case Report

Case Diagnosis: 44-year-old woman with advanced multiple sclerosis (MS), tetraplegia, acute respiratory failure

Case Description or Program Description: A patient with advanced MS tetraplegia on Ocrevus, Intrathecal Baclofen-Bupivacaine pump (ITBB) was admitted to an intensive care unit (ICU) with history of progressive dysphagia, weakness, and shortness of breath for two weeks. Treatment included intravenous steroids (despite no new or enhancing lesions), decreased ITBB, intubation, and ventilator support. Patient was transferred to a Spinal Cord Injury (SCI) Inpatient rehabilitation facility (IRF) for home ventilator management.

Setting: Academic: Academic Inpatient Rehabilitation Hospital

Assessment/Results: At IRF, patient’s ITBB was decreased daily x 4 (from 600 mcg to 347mcg). By week 3, respiratory support requirements improved from average volume-assured pressure support (AVAPS) to bilevel positive airway pressure (BiPAP). Anxiety management was improved. She progressed to room air during the day with BiPAP at night and trialed off respiratory support in week 4. Ultimately, she was discharged on noninvasive respiratory support at night.

Discussion (relevance): Advanced MS can lead to respiratory failure secondary to muscle weakness. Patients with advanced MS and ITBB can have worsened respiratory symptomatology requiring aggressive management, including ventilator support. Treatment requires an interdisciplinary team to optimize ventilator management, exercise regimen, speech, and respiratory therapy to facilitate potential ventilator weaning. In this case, presenting symptoms were unrelated to active MS. Inability to wean ventilation in the acute care setting may be explained by a combination of factors, including advanced MS with severe deconditioning, ITBB dose, and uncontrolled anxiety.

Conclusions: There is a high prevalence of respiratory disorders in advanced MS. Physiatrists must consider all possible risk factors of respiratory failure in advanced MS patients with abnormal ventilatory control, including chronic ITBB. Early intervention can be critical to restoring function.