| Summary: | <strong>Background:</strong> The safety of percutaneous endoscopic gastrostomy (PEG) insertion in amyotrophic lateral sclerosis (ALS) patients with significant respiratory compromise has been questioned. <strong>Objectives:</strong> To review the characteristics of an ALS clinic patient cohort undergoing PEG, and the introduction of a risk stratification tool with procedural adaptations for higher-risk individuals. <strong>Methods:</strong> Patients undergoing PEG insertion were analysed (n=107). Cases stratified as higher-risk underwent insertion in a semi-recumbent position, minimising sedation, with the option of nasal non-invasive ventilation. <strong>Results:</strong> All underwent successful PEG. One third had pre-procedure FVC≤50% (mean 64±22%). Of those who underwent PEG insertion after introduction of risk stratification (n=58), 39 (67%) met criteria for being higher-risk, 16 (41%) of whom had FVC≤50% (p=0.005). High-risk patients received lower sedative doses versus the low-risk group (midazolam 2.1±1.1 versus 2.8±0.95mg, p = 0.021; fentanyl 42±16 versus 60±21μg, p = 0.015). Four deaths occurred within one month of insertion (attributable to the natural disease course). <strong>Conclusions:</strong> Risk stratification identified a greater number of patients with evidence of respiratory compromise than using the sole criterion of FVC ≤50%. A modified PEG procedure enabled safe insertion despite respiratory compromise, in those who might not have tolerated attempted insertion by alternative means such as radiologically-inserted gastrostomy.
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