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Introduction Neuromuscular diseases (NMD) are often complicated by bulbar dysfunction, limiting nutritional intake, and ventilatory failure requiring non-invasive ventilation (NIV). Although percutaneous endoscopic gastrostomy (PEG) can facilitate nutritional supplementation, challenges include respiratory complications. Our study reports the change in practice at a tertiary centre over a ten-year period with the Introduction of the endoscopy elbow (EE), an adjunct device enabling simultaneous use of NIV during PEG.Methods This retrospective cohort study of 91 NIV-dependent patients with NMD who underwent PEG at our NHS tertiary centre, from 2014-2024, analysed time from referral, length of hospital stay, critical care admission, respiratory complications and six-month survival. Fishers exact test was used for statistical analysis.PEG insertion practices in our centre evolved over time with data divided into three methods to represent this.Method 1: PEG with non-EE-assisted ventilation techniques including pre-existing tracheostomy, nasal mask, PEG with high flow nasal oxygen and radiologically inserted gastrostomy.Method 2: EE-assisted NIV with PEG under sedation in the operating theatre.Method 3: EE-assisted ventilation with PEG under sedation in endoscopy.Figure 1 represents the change in practice from general anaesthesia (GA) to EE-assisted PEG. The EE shown was sourced from Philips Healthcare, Netherlands.Results 83.3% of patients who underwent PEG in Method 1 required admission to critical care compared to 54.2% in Method 2 and 12.0% in Method 3. The was a significant reduction in critical care admission in Method 3 compared to Method 1, and Method 3 compared to Method 2, p<0.05.22.5% of patients who had PEGs with non-EE assisted ventilation experienced respiratory complications (aspiration pneumonia, lobar collapse, respiratory failure, pneumothorax and respiratory infections leading to critical care admission and death). 6.1% of patients who had PEGs with EE-assisted ventilation experienced a respiratory complication (hospital acquired pneumonia), p=0.02. The use of EE showed no difference in length of time from referral to PEG insertion or hospital stay. 61.5% of patients had motor neurone disease (MND). Six-month survival for patients with MND was 40% in Method 1, 65% in Method 2 and 72% in Method 3.Conclusions The method of sedation and respiratory support used during PEG has changed over time in this tertiary centre. The use of NIV with an EE adjunct is a novel approach, appears safe and results in reduced critical care utilisation and respiratory complications. Given the improved outcomes with the use of the EE adjunct, this technique may be applicable to other centres caring for similar patient cohorts, although local protocols and resources should be considered.Abstract P348 Figure 1