In patients with motor neurone disease, progressively worsening breathlessness often coincides with deteriorating bulbar function, and this combination may lead to difficulties in swallowing and coughing and a risk of aspiration. Occasionally, chest infections cause life threatening respiratory failure. The progressive nature of motor neurone disease acts as a deterrent to active management, but since its time course varies so much, should patients be denied the treatments that would be considered if they had a different diagnostic label? There is no simple answer to these difficulties. The essential starting point is a detailed analysis of the distribution of the affected respiratory muscles and of the patient's symptoms. The most common way in which the chest wall muscles are affected is weakness of the expiratory muscles leading to a weak cough.1 If there is no bulbar weakness a poor cough does not require any specific treatment unless it is severe enough to cause retention of sputum, at which stage a tracheostomy should be considered. A few …