Problems related to bulbar dysfunction during NIV in ALS and proposed solutions from the literature
| Problems | Proposed solutions |
| NIV | Check effectiveness (built-in software, polygraphy, polysomnography) [12, 17] |
| Obstructive events | Increase EPAP [16, 24, 25] |
| Decrease ventilator support [12, 16, 24, 25] | |
| Reduce inspiratory time [12, 16, 24, 25] | |
| Switch to volume assist/control mode [12, 16, 24, 25] | |
| Orofacial muscle weakness | Switch from nasal or MPV during day to a nasal mask with chin strap, leap-seal MPV or an oronasal mask [18] |
| Sialorrhoea | Anticholinergic drugs [30] |
| Botulinum toxin [30] | |
| Radiotherapy [30] | |
| Respiratory secretions | Assisted coughing techniques [3, 11, 12, 26, 27, 29] |
| MI-E | Optimal adjustments and individualised settings (laryngoscopy or waveforms analysis) [26, 27] |
| Obstruction during insufflation | Decrease insufflation pressure [26, 27] |
| Obstruction during exsufflation | Decrease exsufflation pressure [26, 27] |
NIV: noninvasive ventilation; ALS: amyotrophic lateral sclerosis; EPAP: expiratory positive airway pressure; MI-E: mechanical in-exsufflation; MPV: mouthpiece ventilation.