We read with interest the review by Polkey et al¹ pointing out the need to use all means possible to enable patients with motor neurone disease to achieve the best quality of life.

The authors state that, in order to maintain 24 hour ventilatory support, nasal ventilation must be complemented with alternative strategies during the day that are not suitable for widespread use in district general hospitals. We consider that it is possible to maintain 24 hour non-invasive ventilation in patients with motor neurone disease if nasal ventilation is combined with other non-invasive techniques such as mouth piece ventilation or a pneumobelt, and with manual or mechanical expiratory muscle aids to clear secretions in those patients whose weakness makes spontaneous coughing ineffective.² It is important to provide these techniques because they can delay tracheostomy and additional problems in most patients with motor neurone disease and are the only way for those patients . . . [Full text of this article]