Experiences of MI‑E provision and use from the perspective of people with NMD and physiotherapists: A qualitative multi-sample study

Background Mechanical insufflation–exsufflation (MI‑E) is recommended to support secretion clearance for people with neuromuscular disorders (NMD) with ineffective cough. Limited research has examined, within one enquiry, how people with NMD and physiotherapists understand MI‑E provision and use, and how this may influence access and outcomes. The study aimed to explore areas of alignment and difference in experiences, priorities, and decision-making to identify service gaps and inform person-centred care. Design A qualitative multi‑sample study, analysed using reflexive thematic analysis. Methods Semi-structured interviews were conducted with people with NMD and physiotherapists, and free-text survey responses were obtained from physiotherapy leaders. Participants included 15 people with NMD (plus 9 supporters), 9 physiotherapists, and 19 physiotherapy leaders. Data were coded inductively, and themes were developed iteratively. Results Three overarching themes were identified. (1) Negotiating safety and responsibility: physiotherapists prioritised responsibility, while people with NMD emphasised survival and timely access; labels such as ‘reliance' and ‘palliative care' influenced when MI‑E was offered and accepted. (2) MI‑E in everyday life: participants highlighted benefits beyond acute illness, including more predictable breathing, home-based routines, and social participation. (3) Building capability: variable service capability and resourcing affected physiotherapist support for MI‑E, while users developed practical expertise through routine MI-E use. Conclusions Differences in how risk, responsibility, and expertise are understood influence MI‑E timing, titration, and perceived purpose. Person‑centred decision‑making, that links physiological indicators with quality‑of‑life and participation goals, supported by clinician training, may improve equitable MI‑E access and outcomes. Contribution of the Paper •People with NMD and physiotherapists prioritise different aspects of MI-E (autonomy and participation versus risk management). •"Reliance" and "palliative" are interpreted differently (early, quality‑of‑life‑oriented support versus deterioration) by people with NMD and physiotherapists, respectively, influencing when MI-E is offered and how it is positioned. •People with NMD described using MI‑E in everyday self-management to support participation; this was not always recognised by physiotherapists. •Uneven service capability contributes to cautious MI‑E provision and variable access; person-centred decision-making and clinician training may improve equity.