Whether bulbar weakness is present or not in patients with ALS is often a major difference at the initiation of NIV. Bulbar-affected patients often have problems with sialorrhea and swallowing. When initiating NIV in patients with sialorrhea, it is important to reduce the amount of salivary secretions. Medication, such as oxybutynin and amitriptyline, and botulinum toxin injections can help patients in the management of their saliva. Speech therapists can provide useful information on effective swallowing. During nocturnal NIV, however, the possibility of aspiration of saliva remains, certainly during use of oronasal interfaces.

The choice of mask is an important issue at initiation of NIV. Oronasal interfaces can be a solution when mouth leakages are persistent (even after the use of nasal mask plus chin strap), however, oronasal interfaces can increase the chance of aspiration. Furthermore, oronasal masks can induce obstructive events by causing backward movement of the tongue during inspiration [3].

One of the new modalities in the recently developed devices is target-volume ventilation. Research on this topic has been performed in patients with chronic obstructive pulmonary disease, obesity hypoventilation syndrome, and kyphoscoliosis. To our knowledge, this research has not been performed in ALS patients. Theoretically, target-volume ventilation could be an addition to pressure support ventilation as it could change its pressure during different sleep stages or even in the further rapid progression of the disease. By increasing pressure, though, the chance of causing leaks increases, especially in the occurrence of bulbar progression.