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Introduction Patients with motor neurone disease (MND) frequently develop bulbar dysfunction and dysphagia requiring enteral feeding. Gastrostomy insertion is higher risk due to respiratory muscle weakness, and radiologically inserted gastrostomy (RIG) may be poorly tolerated. PEG insertion with non-invasive ventilation (NIV) support offers an alternative to address this unmet need.Methods We performed a retrospective case series of all NIV-assisted pull-through PEG insertions at Aintree University Hospital between April 2024 and December 2025. All cases were discussed in a multidisciplinary setting or specialist clinic. Procedures were undertaken with joint gastroenterology and respiratory input, using continuous NIV delivered via a full-face mask with an access port, rather than nasal NIV interfaces more commonly described, allowing endoscope passage without interruption of ventilatory support. Procedures were performed predominantly in the endoscopy unit, with one undertaken in the respiratory high care unit setting using a disposable Ambu endoscope. Cautious conscious sedation was used. Data collected included patient characteristics, prior RIG attempts, procedural success, sedation, complications, length of stay and mortality.Results Fourteen patients with MND were referred (mean age 69 years). One patient was unable to tolerate NIV and did not proceed. Duration of NIV prior to referral ranged from less than three months to over twelve months. Six patients (42.9%) had a prior attempted RIG. Thirteen PEG insertions were attempted, of which eleven were successful; two were unsuccessful due to the stomach being positioned high within the thorax. All procedures were performed under dual sedation, with a mean fentanyl dose of 38.5 micrograms and mean midazolam dose of 1.2 mg. One patient required a brief jaw thrust post-sedation; no reversal agents were required. All patients received post-procedural tube checks by a specialist nutrition nurse prior to discharge.Among elective admissions, mean length of stay was 2.5 days, with no readmissions. One patient developed hospital-acquired pneumonia four days post-admission. One patient died three days following PEG insertion, with MND recorded as the cause of death. Mortality at 30, 60 and 90 days was 9.1%, 10% and 22.2% respectively.Conclusions NIV-assisted pull-through PEG insertion using full-face mask NIV is feasible and generally safe in patients with MND and respiratory muscle weakness, including those unable to tolerate radiological gastrostomy. This represents a practical variation of NIV-assisted PEG insertion compared with nasal NIV-based techniques used in many centres and may broaden access to enteral feeding in this high-risk population.