What has been improved in the conventional approach to the treatment of ALS patients? Farrero et al explain in their report how they managed a patient satisfactorily in 1997, when some hospitals were introducing changes in some apparently inflexible treatment procedures4–5 but that did not become widespread until the present time. After diagnosis, they saw their patients for a staging of the target RPs and to plan how to manage them. Physicians assessed the patients functionally (with hindsight one feels they should have given the same relevance to maximum insufflation capacity [MIC] and peak cough flow [PCF] as they gave to FVC),6 they evaluated night pulse oximetric saturation, they assisted in coughing (even though only with manual aids), they used volumetric ventilators, and they gave information for requesting advanced directives. If they alternated between interfaces in NIV (which was still not usual at that time), they did not refer to how many patients used mouthpieces when nasal masks failed, so there is not a sufficiently detailed description of the steps taken before they pronounced the occurrence of NIV intolerance and, consequently, NIV failure.