It is important to note that despite the evidence presented in this chapter, less than ten percent of all studies to date in acute SCI are RCTs. As such, most evidence in this field has been determined retrospectively.

Most of the research in acute respiratory management for people with SCI is centered on re-establishing ventilation (e.g., tracheostomy, intubation, extubation, or secretion removal techniques) and preventing and treating pulmonary complications. It is of vital importance to maintain an open airway and diaphragm functioning while preventing respiratory failure, atelectasis, and pneumonia. This is a delicate balance for medical personnel as the process of ventilation itself (despite assisting breathing) can directly lead to these pulmonary complications.

There is some evidence that tracheostomies can reduce the number of pulmonary complications in people with acute SCI compared to those not receiving this procedure (Leelapattana et al. 2012). There is also some consensus that early tracheostomies provide fewer ICU, hospital, and ventilation days in comparison with late tracheostomies; however, more evidence is still needed to elucidate if early tracheostomies may decrease the rates of mortality and other complications in patients with acute SCI (Anand et al. 2020; Beom & Seo 2018; Choi et al. 2013; Flanagan et al. 2018; Romero-Ganuza et al. 2011b; Holscher et al. 2014; Kornblith et al. 2014; Romero et al. 2009; Wang et al. 2020; Wang et al. 2021). Predictors of early tracheostomy in people with SCI include: higher injury level, more severe AIS score, cervical spine fractures at C4 or above, and lower mean AIS motor impairment score at the time of injury (Beom & Seo 2018; Flanagan et al. 2018; Binder et al. 2016).

The inability to clear bronchial secretions is a major cause of pulmonary complications in patients with acute SCI; unfortunately, only a few high-quality studies show that techniques such as mechanical insufflation/exsufflation and oscillated positive expiratory pressure breathing (OPEP) plus oscillated incentive spirometry (OIS) facilitate secretion removal in the acute phase of SCI (Pillastrini et al. 2006; Kluaythomthong et al. 2019).

There is good evidence to show that non-pharmacological interventions, such as respiratory muscle training, have positive effects on lung function in people with acute SCI, regardless of AIS status (Boswell-Ruys et al. 2020; Sikka et al. 2021; Mueller et al. 2012 & 2013; Postma et al. 2014; Liaw et al. 2000; Derrickson et al. 1992; Raab et al. 2019; Raab et al. 2018; Shin et al. 2019; McDonald & Stiller 2019).

Some evidence suggests that diaphragmatic pacing system (DPS) implantation and/or phrenic nerve stimulation can produce significant improvements in ventilation, reduce hospital LOS, and be an alternative to mechanical ventilation for people with acute SCI (Kerwin et al. 2018; Kerwin et al. 2020a; Kerwin et al. 2020b; Posluszny et al. 2013; Elefteriades et al. 2002; Nakajima & Sharkey 1990).

Two RCTs have demonstrated that adding medications such as salbutamol or high-dose ambroxol to bronchodilator therapy or post-surgery can improve pulmonary function and minimize post-operative complications in people with acute SCI (Barratt et al. 2012; Li et al. 2012).

Further, evidence suggests that specialized respiratory management programs delivered in the hospital, implementation of a clinical care pathway, and/or early admission to a level 1 trauma center can result in better respiratory outcomes and higher rate of discharge to the community Wong et al. 2012; Cameron et al. 2009; Vitaz et al. 2001; Richard-Denis et al. 2018; Romero-Ganuza et al. 2015).

Sleep disordered breathing (SDB), more specifically obstructive sleep apnea (OSA), is common in people with SCI. Though there are few studies in this area, in an RCT, Berlowitz et al. (2019) found that continuous positive airway pressure (CPAP) therapy was effective in treating OSA in people with acute SCI.