MND Factsheet 35 Breathing Matters

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					                                                         MND Factsheet 35
                                                         Breathing Matters
                                                                              Last Updated 25/10/08
While MND does not impair the lungs                  monitor lung function also vary across the
themselves the muscles involved in                   world. Nonetheless, most MND clinical
breathing and coughing may become                    specialists believe regular monitoring
weakened over time. Breathing may be                 promotes early detection of breathing
significantly impaired without complaints            problems, prevention of unnecessary
of breathlessness due to the reduction of            emergencies, and opens the door for you
physically demanding activities imposed              to consider whether or not you want to go
by MND. Impairments to breathing may                 down certain roads.
not be detected until there is a lung
infection, most probably occurring                   THE MECHANICS OF BREATHING
because of limited breathing ability.
                                                     Normal "easy" breathing involves two
This factsheet will explain the breathing            main muscle groups. When you breathe
process and provide overviews of                     in, a large dome-shaped muscle that
symptoms of changes in breathing, tests              separates your heart and lungs from your
that may be used to monitor breathing                stomach, called the diaphragm, moves
function (so you know what to expect),               down; at the same time the muscles
respiratory       infections,      airway            between your ribs contract to pull your rib
management techniques, and options for               cage up and out.
decision you might want to make for the
future.    If your breathing is already
affected by your MND you might also
want to look at factsheet number 40 “The
Use of Ventilation in MND,” after you
have read this one. Number 40 describes
how your breathing can be supported,
particularly overnight, somehting you
might want to think about before it
becomes a necessity.

Poor breathing (respiratory) function
leaves a person with MND fatigued, short
of breath, and more prone to respiratory              These two actions cause a partial
infections and, possibly, respiratory                vacuum in your chest cavity. Fresh air
failure. Therefore, it is a vital part of the        rushes down the windpipe into your
MND disease management plan to                       lungs, inflating them to fill your chest and
monitor breathing function throughout the            at the same time pass fresh oxygen (O2)
course of the disease.                               to the blood. This process is called
However, how and when to address
respiratory issues in MND remains                    When you breathe out, both diaphragm
debatable and is practised differently               and rib muscles relax, and the lung
across the world.   Methods used to                  recoils decreasing the size of your chest
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    funding research and providing care and information for those affected by MND in Scotland.

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                               MND Factsheet 35 Breathing Matters

cavity. Used air that contains waste                       muscles. You may notice shortness of
carbon dioxide from your bloodstream                       breath after rushing upstairs, carrying a
(CO2) is pushed out of your lungs. This                    load, etc. Shortness of breath can also
process is called expiration.                              occur with no particular exertion; you may
                                                           not be able to walk or talk for long without
If   you    are    breathing      heavily,    two          becoming breathless. You should tell
                                                           your doctor about these symptoms.
                                                           When you experience breathlessness,
                                                           stop what you are doing as the symptoms
                                                           will disappear when activity is reduced.

                                                           If you are able, relax in one of the
                                                           following positions and breathe slowly
                                                           and deeply.

                                                               1.   Sit at a table, lean forward with a
                                                                    straight back and rest your head
                                                                    and shoulders on a pillow on the

additional muscle groups come into play:                       2.   Sit on a chair or the edge of your
when you take in a deep breath muscles                              bed, lean forward, keep your back
in the neck that attach to the collarbone                           straight and rest your elbows and
and upper ribs assist in breathing; and                             forearms on your thighs.
when you force a breath out, your
abdominal muscles help to push up the                          3. Lean against a wall with your feet
diaphragm.                                                        about 12 inches from the wall.
                                                                  Rest your lower back against the
Many of the muscles involved in                                   wall and lean your upper back
breathing can be under conscious control                          away from the wall.
and are called “voluntary” muscles. Since
MND is a disease that causes muscle                        Fatigue
atrophy (wasting) and weakness, it is                      Fatigue, or tiredness, is a common
easy to imagine how changes in                             symptom of MND. It is caused by a
breathing can occur, even though your                      number of factors. As MND attacks your
lung tissue may be very healthy. People                    motor neurons, they become increasingly
with pre-existing lung disease may have                    less able to send commands from your
their breathing abilities much more                        brain to the muscles cells that they
affected by the weaknesses MND can                         control. A smaller number of muscle cells
bring.                                                     must then try to perform jobs usually
                                                           done by the full number. The result is
SIGNS  AND    SYMPTOMS    OF                               that your muscles tire before they
WEAKENED BREATHING MUSCLES                                 normally would.
Shortness of Breath with Activity                          When your respiratory muscles are
Shortness of breath may be the first                       affected by MND, you may be less able
symptom of the weakening of breathing                      fill your lungs as you were once able to

The information in this leaflet is believed to be accurate at the time of production. MND Scotland cannot give
      detailed medical advice, this leaflet should be regarded only as general background information.

                               MND Factsheet 35 Breathing Matters

do. In turn this makes it difficult to clear
CO2 from the bottom of your lungs and O2                   Hypoventilation: The relaxation of nerve
uptake may also be reduced. When                           and muscle functions during sleep may
activity increases, it becomes more                        lead to under-ventilation (hypoventilation)
difficult for the lungs to supply enough                   causing carbon dioxide (CO2) levels to
oxygen to the body causing other                           rise.   For example, when you stand
metabolic changes to take place so                         upright, the diaphragm moves down when
making you feel fatigued.                                  you breathe in.

Besides the physiological changes that                     When you lie down, the organs in your
may cause fatigue, MND can produce                         abdomen press against the diaphragm
many other changes in your life. Change                    pushing it up into your chest, and more
often results in general stress that can                   strength is required for the diaphragm to
also manifest itself as fatigue. Do what                   be pressed down during breathing.
you can to prevent getting tired. Rest
when you begin to feel tired. Try to keep                  To help cope with this problem, you may
your exertions within the limits that your                 want to try to raise your head and
body is now imposing. Pay attention to                     shoulders during sleep. It is best to raise
signals like fatigue. It may be necessary                  the whole torso by using blocks 4" to 6"
for you to change your priorities and                      high under the head of your bed, a wedge
forego less important activities. Plan your                pillow 6-8" at its highest point, or a
day to include regular rest periods.                       motorised adjustable bed. If you do not
                                                           have access to the best solutions, try
Morning Fatigue or Headache                                putting two or more pillows under your
Some people with MND experience                            head and shoulders until you do.
morning fatigue.      You may wake up
feeling tired, sometimes with a headache,                  Obstructive sleep apnoea and under-
and the feeling that you slept poorly. This                ventilation often occur together; therefore
may be caused by what is known as                          a sleep study in which your blood oxygen
obstructive sleep apnoea and/or under-                     levels are measured, (nocturnal oximetry)
ventilation.                                               may be advised (see Monitoring Your
                                                           Breathing Function). Blood that is rich in
Obstructive sleep apnoea: Weakened                         oxygen is bright red whereas blood that is
(bulbar) muscles of the upper throat and                   low in oxygen is dark red. The precise
pharynx may over-relax result in noisy                     colour of your blood is related to the
breathing, snoring, or closing of the upper                amount of oxygen it contains. A device
airway while sleeping. This is what is                     like the one used to measure your pulse
called sleep apnoea and is characterised                   in hospital is clasped to your finger tip
by intermittent reduction or stopping of                   before you go to sleep and it logs the
breathing. A decrease in the oxygen (O2)                   changing colour of your blood at intervals
saturation of the blood can result. Sleep                  throughout the night. The level of oxygen
apnoea can also put strain on your heart                   in your blood is then determined.
as you struggle to take in air through the
closed airway. The body’s reaction to low                  Excess Mucus and Secretions
blood oxygen is to cause you to waken,                     In some people, excess mucus and
resulting in disturbed sleep patterns and                  secretions can build up to the point where
daytime tiredness.                                         they cannot be easily cleared by

The information in this leaflet is believed to be accurate at the time of production. MND Scotland cannot give
      detailed medical advice, this leaflet should be regarded only as general background information.

                               MND Factsheet 35 Breathing Matters

coughing. This is particularly the case                    mentioned later in this section and
first thing in the morning when secretions                 described in more detail on the web site
have built up during the night. If you                     of The Ottawa Rehabilitation Centre at
experience this problem, ask your doctor         
for a referral to a physiotherapist or                     fName=e2r3&slideid=55 . You will need
respiratory therapist to teach you                         to consult with a skilled professional to
methods to loosen secretions and bring                     train you and your family.
them to the mouth to be spat out.

One method of dealing with mucus and                         Quick List           of    Signs and
saliva build-up is suctioning. Suction                       Symptoms             of       Breathing
equipment acts very much like a dentist's                    Problems
suction tube; it consists of a motor, a                          •   Paleness
collection bottle, tubing and a mouthpiece                       •   Bluish colour to finger tips
to gather the saliva. However, some                                  (cyanosis)
healthcare        professionals    believe                       •   Contraction of neck and
suctioning may be counter-productive for                             other muscles to breathe
persons with MND.                                                •   Confusion
                                                                 •   Inappropriate sleepiness
Talk to your MND Care Team Specialist                            •   Inadequate cough
or a respiratory specialist about whether
suctioning may be right for you, and if
there is anything else you can do to                       There are a variety of methods to choose
reduce mucus build-up, such as assisted                    from to monitor the breathing function of a
cough techniques (see Assistive Cough                      person with MND. Physicians vary in
Techniques later in this factsheeet) or                    their approach, so keep that in mind as
the use of medications.                                    you read this section. If you have not had
                                                           your breathing function monitored you
Weak Cough                                                 might want to use this factsheet as the
During a cough, the diaphragm and                          starting point for a discussion with your
additional muscles draw air in to                          doctor.
completely fill the lungs.     Then, the
abdominal muscles and intercostal                          Since MND is a progressive disease, it is
muscles between the ribs contract quickly                  helpful to assess lung function early on in
generating a high pressure against a                       the disease, so that there is a baseline
glottis (larynx) that is kept closed by                    pulmonary function test (PFT) result, or
force.     The glottis is then suddenly                    starting point, with which follow-up
opened and a very high speed flow of air                   assessments can be compared. Without
is pushed from the lungs and up the                        monitoring, a person with MND might
airway. Any mucus or food in one of the                    seemingly experience sudden respiratory
air passages is forced out as well.                        failure without having had the benefit of
                                                           advance planning regarding ventilation
People with MND have normal cough                          options. Plus, with use of appropriate
reflexes, but the muscles involved may be                  airway management strategies, quality of
weakened and unable to produce a                           life can be so much better. Signs and
strong enough cough.            You can                    symptoms of weakness in the breathing
strengthen your cough using techniques

The information in this leaflet is believed to be accurate at the time of production. MND Scotland cannot give
      detailed medical advice, this leaflet should be regarded only as general background information.

                               MND Factsheet 35 Breathing Matters

muscles can be subtle and missed if not                    meter commonly used by people with
specifically looked for.                                   asthma.

Repeating PFTs every three to six                          Normal PCF values would be 360 to 720
months may be advised to assess any                        Litres per minute (L/min). The minimum
decline in the respiratory system and to                   effective PCF is 180 to 200 L/min
guide your doctor about when to discuss                    (recognising that some smaller individuals
certain interventions such as airway                       may manage with lower values). PCF is
management techniques, or non-invasive                     highly dependent on the function of those
ventilation in as timely a manner as                       muscles in the mouth, throat and larynx
possible. The most common breathing                        (bulbar muscles/bulbar function). The
support is known as the BiPap™ .                           greater the loss of function, the lower
                                                           these measures become.
The following are some of the
measurements used to assess lung                           Maximum Inspiratory Force (MIF)/
function.                                                  Maximum Expiratory Force (MEF)
                                                           Maximum inspiratory force (MIF) or
Forced Vital Capacity (FVC)                                maximum inspiratory pressure (MIP) is
FVC is the volume of air that can be                       the greatest force generated by the
maximally, forcefully exhaled following                    muscles of inspiration (breathing in); this
maximal inspiratory effort.      The test                  force comes mainly from the diaphragm,
generally involves having you sit with                     but is contributed to by the other
your trunk elevated to between 30 to 90                    breathing muscles.
degrees, putting a mouthpiece in your
mouth, a nose clip on your nose, and                       A      pressure      measuring       device
breathing into a spirometer that may                       (manometer) is attached to a mouth-piece
either be a simple hand held unit or a                     and the individual is instructed to breathe
computerised machine. After taking as                      in as forcefully as possible without using
deep a breath as you can, you blow out                     the cheeks (the cheek muscles can
quickly and as hard as you can for one-                    falsely indicate a much higher pressure).
to-two seconds. If your lips are weak,
you will be provided a lip seal mouthpiece                 Maximum expiratory force (MEF) or
or mask to promote an accurate                             maximum expiratory pressure (MEP) is
measurement.                                               the greatest force generated by the
                                                           muscles of expiration (breathing out),
Peak Expiratory Flow Rate (PEFR)                           primarily the abdominal muscles. These
PEFR is the highest rate of expiratory                     too may be much weakened in MND.
(out) airflow you can generate (peak                       These muscles and their pressure
expiratory flow) following maximal                         measurement are important in the
inspiratory (in) effort. Flow rate can be                  prediction of an adequate cough.
measured at the same time as FVC using                     Remember, an adequate cough helps to
spirometry with flow volume loops. This                    clear airways. Maximum pressures of
is closely related to Peak Cough Flow                      less than 40 - 50 cm H2O are of some
(PCF) which tends to be slightly greater.                  concern as they may be a sign of less
PCF can also be measured at home                           respiratory reserve and some limitation of
using an inexpensive hand held peak flow                   ventilation or cough ability.

The information in this leaflet is believed to be accurate at the time of production. MND Scotland cannot give
      detailed medical advice, this leaflet should be regarded only as general background information.

                               MND Factsheet 35 Breathing Matters

Arterial Blood Oxygen Saturation                           environmental irritants such as cigarette
(SaO2)                                                     smoke, or allergies. In response to the
A non-invasive way to measure oxygen                       inflammation, airways secrete a sticky
saturation is to use an oximeter device                    mucous. If a person is unable to produce
which involves attaching small sensors to                  an effective cough to clear the lungs,
a pulse point on a person's body (e.g.,                    there is a risk of developing pneumonia.
finger tip) to transmit oxygen saturation
readings.     Normal levels of oxygen                      If you do get a fever with thick
saturation are above 95%. Lower than                       discoloured or bloody mucus coughed
expected levels of oxygen saturation in                    from the chest, or if you notice that the
the blood (SaO2) may indicate areas of                     mucus has changed from clear white to
loss of volume in the lungs (atelectasis)                  yellowish, tell your doctor immediately.
or when associated with illness may                        These could be symptoms of a
indicate pneumonia. Less commonly a                        respiratory infection that could worsen if
low saturation can indicate that not                       your breathing is impaired.
enough      CO2     is   being    cleared
(hypoventilation). Hypoventilation often                   Pneumonia
begins, or is worse during sleep.                          Pneumonia can be caused by bacteria or
                                                           viruses, and may be a complication of a
Nocturnal oximetry, is an over-night                       cold, flu, bronchitis, or the aspiration
assessment used as an alternative to a                     (breathing in) of food or liquid.
full sleep study (polysomnogram) when                      Pneumonia causes the very small air
problems associated with night-time                        sacs in the lungs (alveoli) and
(nocturnal) apnoeas (short periods of time                 surrounding     tissues    to   fill with
when breathing stops), or hypoventilation                  inflammatory cells (pus) and mucus which
are evident. Sleep studies, conducted                      prevents the normal exchange of O2 and
over-night in a sleep laboratory, are not                  CO2. When this occurs oxygen is not
commonly       performed      in     MND                   taken up sufficiently by the blood and a
management, but in some cases of                           low oxygen level may result.
suspected obstructive sleep apnoea and
nocturnal hypoventilation they may be                      Aspiration
advised.                                                   Aspiration occurs when liquids or solids
                                                           get into the airways blocking the airflow
COMPLICATIONS OF RESPIRATORY                               and preventing gas exchanges (O2/CO2).
INFECTION                                                  Aspiration can also cause irritation, and
                                                           might carry infection from the mouth and
Common respiratory illnesses can cause                     gums into the lungs. Small amounts of
complications in persons with MND. To                      aspirated material can be coughed out.
reduce your odds of infection, try to avoid
contact with people who have colds or flu                  If aspiration is frequent and involves large
and to practise regular hand-washing.                      amounts of material, an evaluation by a
                                                           speech and language therapist and/or a
Bronchitis                                                 respiratory     consultant    is    advised.
Bronchitis is an inflammation and irritation               Changes in nutrition and swallowing
of the bronchial tubes in the lungs                        techniques may be recommended.
characterised by a cough. This condition
may be caused by viruses, bacteria,

The information in this leaflet is believed to be accurate at the time of production. MND Scotland cannot give
      detailed medical advice, this leaflet should be regarded only as general background information.

                               MND Factsheet 35 Breathing Matters

STAYING HEALTHY: PREVENTATIVE                              the breath for a few seconds, and then
AIRWAY MANAGEMENT STRATEGIES                               exhale.

Preventative      airway      management                   3. Repeat several times.
measures initiated at an early stage can
prevent unnecessary hospital emergency                     Some doctors believe that patients who
visits and intensive care unit admissions.                 do deep breathing exercises are less
Airway management strategies are used                      prone to lung infections and partial lung
to either improve your ability to take air                 collapse. Ask your physiotherapist to
into your lungs or cough effectively.                      demonstrate an exercise routine and
Strategies     range     from      self-care               advise you about the use of exercise
techniques to the use of assistive                         devices.
devices.     Using airway management
strategies can give better lung function for               Assisted Cough Techniques Without
longer, and so promote quality of life.                    Devices
                                                           Assisted coughing is a technique where a
Lung Volume Recruitment (LVR) and                          carer applies forceful pressure to the
Assisted Coughing Strategies                               abdomen and occasionally the chest wall,
                                                           timed to the effort of coughing. This
Before trying any assistive breathing and                  action assists the weakened muscles
coughing techniques, make sure to                          responsible for an effective cough. These
discuss them with your healthcare                          techniques are very helpful, effective and
professionals.     Some exercises and                      easily learned.         They are very
techniques are more complex than others                    empowering and relieving for carers who,
and require training and practice                          without them, feel powerless to assist
                                                           their loved ones in their respiratory
For more information about many of                         distress.
these techniques talk to a respiratory
therapist, respirologist, or physiotherapist.              1.   Abdominal thrust: Immediately prior
Baseline pulmonary function and a                               to a timed cough the carer applies
respiratory         assessment           are                    rapid and forceful pressure to the
recommended if these haven’t already                            upper abdomen in an inward and
been carried out.                                               upward fashion between the bottom of
                                                                the breast bone and the navel (see 4).
Deep Breathing Exercise
Exercises to use full lung capacity can                    2. Lateral      costal     compression:
compensate for weakened muscles. This                         Sometimes      combined      with   the
can be achieved with the following deep                       abdominal thrust, or used alone when
breathing exercise:                                           a PEG tube has recently been
                                                              introduced. Firm but not too forceful
1. Sit at a table, hunched over slightly                      pressure is applied by each hand on
with your weight supported on your hands                      the lower rib cage below the breasts
or elbows. This position expands the rib                      or at the sides of the chest timed to a
cage for larger breaths by allowing your                      cough effort.
shoulder and neck muscles to assist your
breathing.                                                 3. Self-assist: This is most appropriate
                                                              for paraplegic patients and would
2. Breathe in as deeply as possible, hold                     rarely be used by MND patients. The

The information in this leaflet is believed to be accurate at the time of production. MND Scotland cannot give
      detailed medical advice, this leaflet should be regarded only as general background information.

                               MND Factsheet 35 Breathing Matters

    individual in a stable wheelchair takes                    effective device for those who
    a full breath in, folds their arms across                  maintain sufficient bulbar function but
    their abdomen and forcefully pitches                       have a weak cough. It is a vacuum
    their torso forward over their crossed                     that allows attachment through a face
    arms. Once a significant pressure has                      mask to both the positive pressure
    been generated in the abdomen and                          side (to help inflate the lungs) and the
    chest they release the glottis and                         negative pressure side of the vacuum
    cough.                                                     (to fill up the lungs and then forcefully
                                                               empty them to mimic an effective
4. Phlegm management: With reduced                             cough). The high speed expiratory
   respiratory muscle strength the normal                      flow is effective in clearing airway
   movement of phlegm out of the lungs                         secretions. Considerable experience
   is reduced and this appears to be                           is required in the assessment and
   made worse by a lack of mobility. An                        introduction of this device and it is
   inability to clear phlegm is distressing                    quite costly.
   and increases the risk of chest
   infection. Advice for patients and                      3. Volume ventilator: For people who
   carers on the technique of an assisted                     are already using a volume ventilator
   cough to help bring up phlegm can be                       for mouth-piece ventilation, the
   sought from the physiotherapist.                           volume of an assisted breath can be
   Treatment of chest infections with                         held by the glottis and added to the
   antibiotics may be appropriate.                            next    machine     delivered breath
                                                              achieving a breath-stacking effect.
Assistive     Cough       Techniques        With              This improves both the volume (range
Devices                                                       of motion) of the lungs (and thorax)
                                                              and the effectiveness of the cough.
1. Modified resuscitation bag: A                              Again this is most effective with
   special hand-held bag is usually used                      maintained bulbar function.
   to maintain breath movements in a
   respiratory or cardiac arrest. This                     Lifestyle Strategies
   useful tool can be modified with the
   addition of one-way valve tubing and a                  Do not smoke
   mouth-piece (or mask) to allow the                      In addition to all of the other problems
   passive introduction (by yourself or a                  smoking can cause, it can reduce lung
   carer) of volumes of air into the lungs.                capacity and decrease the oxygen
   This helps you regain breath sizes                      carrying capacity of the blood. A first
   which have previously been lost due                     cigarette of the day reduces the oxygen
   to muscle weakness. Its effectiveness                   carrying capacity of the blood as carbon
   is directly dependent on bulbar                         monoxide from the cigarette locks on to
   function. Once a larger volume has                      the same places where oxygen should
   been taken in then an abdominal                         be. However, carbon monoxide locks on
   thrust (as above) can be added to                       tighter than oxygen and stays there for
   enhance the effectiveness of the                        hours, so every cigarette you take
   cough.                                                  thereafter further reduces your blood’s
                                                           capacity to carry Oxygen even further.
2. "CoughAssist"    (Mechanical      in-                   Smoking can also cause increased
   exsufflation machine): This is a very

The information in this leaflet is believed to be accurate at the time of production. MND Scotland cannot give
      detailed medical advice, this leaflet should be regarded only as general background information.

                               MND Factsheet 35 Breathing Matters

phlegm that some patients can have                         (breathing) muscles have been affected
difficulty clearing from their airways.                    by MND. If these muscles continue to
                                                           deteriorate breathing may become
Be cautious with alcohol and                               increasingly difficult, particularly while
sedatives                                                  sleeping.
Alcohol     and   sedatives    such      as
tranquilisers,   anti-depressants       and                It is worthwhile emphasising that people
sleeping pills taken together can have                     with MND who waken with a headache,
what is called a “Synergistic effect” i.e. if              are tired during the day, have difficulty
alcohol has an effect of “2 units” and a                   concentrating, are often confused or are
sedative has an effect of “2 units,” when                  difficult to rouse from sleep could well be
they are taken together they might have                    suffering from breathing difficulties while
an effect of “8 units” rather than the                     asleep.
expected “4 units” and may consequently
increase the risk of aspiration or                         However, these symptoms could also be
hypoventilation during sleep.                              due to medications being taken to
                                                           alleviate other symptoms of MND, so it is
Avoid allergens                                            worthwhile discussing these symptoms
If you are allergic to fur, feathers or dust               and your medications with your MND
mites, make sure your home is free of                      Care Team Specialist or GP to try to get
pets that cause you problems and is                        to the root of the cause. If the cause is
regularly dusted. You might find hard                      weakened breathing muscles you might
surfaces such as laminate flooring or                      want to consider the use of overnight
linoleum both reduce the number of                         breathing support, which is very effective
allergens in a room and make it easier to                  in curing morning headaches and the
negotiate if you are using a wheelchair                    related symptoms of insufficient breathing
when compared to fitted carpets.                           while asleep.

Investing in an air purifier with a HEPA                   After you decide you might like to try
filter can help keep the air free of particles             overnight breathing support (night-time
that irritate your airways.                                ventilation) to see if it cures the
                                                           headaches, makes you more alert and
Where to now?                                              less confused, you need to consider the
                                                           stage after that, which is where do you go
This factsheet has been concerned with                     when your day time breathing is affected?
maintaining, and hopefully improving,                      Please consult factsheet 40 for more
breathing    when     the   respiratory                    information about these questions.

Further Information

Factsheet 40            Ventilation in MND
Factsheet 6             Feeding Tubes
Factsheet 8             Care Planning and End of Life Issues
Factsheet 24            Powers of Attorney

The information in this leaflet is believed to be accurate at the time of production. MND Scotland cannot give
      detailed medical advice, this leaflet should be regarded only as general background information.