Inclusion Criteria:  Age 21 and above, Probable or definite ALS diagnosis, Peak Cough Flow of <160L/min or complain of issues clearing airway secretions Caregiver must also consent to participate  Exclusion Criteria:  Current use of HFCWO or MIE Tracheostomy Congestive heart failure All contraindications for the HFCWO Head and/or neck injury that has not been stabilized; Active hemorrhage with hemodynamic instability; Uncontrolled hypertension; Active or recent gross hemoptysis; and All contraindications for the MIE History of bullous emphysema; Known susceptibility to pneumothorax; Pneumomediastinum; and Recent barotrauma Frontal Temporal Dementia (FTD) - suspected or diagnosed . FTD is a form of dementia found in about 20% of Familial ALS. This dementia interferes with the ability to follow commands and follow through with therapies due to forgetfulness. Patients not able to provide informed consent.