Dysphagia and respiratory muscle weakness are the two most potentially dangerous findings in patients with neuromuscular disease because they predispose to aspiration pneumonia and respiratory failure. Myasthenia gravis is unique among the neuromuscular disorders for the variety of exacerbating factors that may lead to such clinical deterioration. While the major cause of ventilatory failure remains intensification of the underlying autoimmune process, well intentioned therapy may also lead to situations that necessitate ventilatory support. This report describes a patient with myasthenia gravis and respiratory failure and reviews the various etiologies of pulmonary dysfunction that are associated with the natural course of this disease and its treatment.