Understanding neuro–pulmonary dysfunction in children with neurodisability

Children with neurodisability experience a high burden of respiratory morbidity, which remains a leading cause of hospitalisation, long-term lung disease and reduced quality of life. Respiratory problems in this population often reflect shared underlying neuro-pulmonary pathophysiology that evolves across a child's development. In this narrative review, we describe how respiratory vulnerability arises from three interacting domains: dysregulated central control of breathing; impaired neuromuscular activation and coordination; and altered respiratory mechanics related to abnormal tone, weakness, posture and chest wall restriction. Early functional impairment in these systems compromises ventilation, airway protection and airway clearance, establishing baseline respiratory vulnerability. Over time, secondary clinical features such as sleep disordered breathing, pulmonary aspiration, secretion retention and recurrent infection may come to dominate the respiratory phenotype and contribute to progressive lung injury, including restrictive lung disease and bronchiectasis. We synthesised evidence linking neuro-pulmonary mechanisms to clinical presentations and highlight challenges in assessment where standard investigations are limited. By integrating mechanistic understanding with history-led clinical reasoning, we identify opportunities for proactive, anticipatory respiratory care across childhood and during the transition to adult services. This review aims to support earlier recognition of respiratory risk factors and to promote pathophysiology-informed strategies to preserve long-term respiratory health in children with neurodisability.