Amyotrophic lateral sclerosis is a neuromuscular disease characterized by progressive motor neuron degeneration. The poor prognosis of this disease means that integrated patient management, including early introduction of non-invasive mechanical ventilation, is essential for improving survival and quality of life.1

We read with interest the original article by Sanjuán-López et al.,2 discussing the importance of integrated pulmonary care and the detection of possible shortcomings. In our opinion, however, some points mentioned in the study need to be addressed:

• 1.

  Exclusion of outpatients from the study limits the extrapolation of clinical course and survival outcomes, since by including only patients who needed hospitalization, the authors have selected a subgroup of patients who are probably in a more serious clinical situation than those treated at home. Accordingly, it would have been interesting to include a subgroup of subjects treated on an outpatient basis, specifying the criteria used for initiating non-invasive mechanical ventilation (NIMV) and the progress of these patients.

• 2.

  According to the authors, NIMV was initiated in the patients in this study on the basis of respiratory failure criteria, without taking into account the current recommendation for indicating NIMV in patients with ALS on the basis of clinical criteria and lung function tests.3 Indeed, only 30 of the 43 patients who started NIMV during admission had previous lung function test results, suggesting that in many of the cases, NIMV was introduced at a late stage, with possible repercussions on the clinical course and survival of patients described in the article. This issue is of importance since there are two advantages to initiating NIMV on the basis of an early pulmonary assessment: on the one hand, patients have a better chance of being managed in outpatient clinics, with close collaboration between the home and the hospital4; and on the other, it improves quality of life and survival. Thus, hospital admission would be limited to more complex situations, such as NIMV maladjustment or complications derived from disease progression.

In our opinion, the role of the pulmonologists and the involvement of a multidisciplinary team are essential for reaching an integrated evaluation and an early pulmonary assessment. This in turn optimizes patient management and improves both quality of life and survival.5