What alternative, low-effort airway clearance strategies do you use in frail neuromuscular patients who are unable to tolerate or fail manual chest physiotherapy (e.g., oscillating PEP devices, high-frequency chest wall oscillation vests, or mechanical insufflation-exsufflation/cough assist)?

Airway clearance is key to quality of life and prolonged survival in frail NMD patients, sometimes adding decades, depending on the particular NMD and other factors (luck and prayers don't hurt). Most tolerate manual techniques (i.e., quad coughing) reasonably well, so I wouldn't wait for them to not tolerate or fail them: a multipronged approach is best. As a step up, some use stacked breaths with the patient closing the glottis after each insufflation, using either the ventilator or an AMBU ba...