Key Points

Evidence of Pharmaceutical Interventions

• The use of bronchodilators should be considered in people with tetraplegia who demonstrate an element of obstructive airway impairment.
• The effects of other medications commonly used in the management of SCI, such as baclofen and oxybutynin, should be considered when reviewing airway hyperreactivity in people with tetraplegia.
• The short-term use of oxandrolone can be considered to improve pulmonary function in people with tetraplegia.

Evidence of Mechanical Ventilation (MV) and Weaning Protocols

• Progressive ventilator free breathing (PVFB) protocol should be considered for ventilator dependent people with tetraplegia who are appropriate for ventilator weaning.
• Resistive and endurance training should be considered in people who are candidates for ventilator weaning.

Evidence of Tracheostomy (TOT) Decannulation

• There is some evidence that the implementation of an invasive acute phase respiratory management for patients with cervical SCI receiving tracheostomy (TOT) or endotracheal intubation provides successful in TOT removal.
• There is some evidence that a specific protocol; which consists of decannulating patients whose assisted peak cough flow (APCF) without an external control device substituting for glottic function was <160L/min and their APCF with the device was measured as ≥160L/min; is beneficial for determining TOT decannulation in patient s with neuromuscular diseases, including patients with SCI.
• Until more evidence is available, case by case consideration should be given to TOT decannulation in people with SCI. The indications and criteria for TOT decannulation have not yet been well established in SCI.

Evidence of Exercise Training of the Upper and Lower Limbs

• For exercise training to improve respiratory function the training intensity must be relatively high (70-80% of maximum heart rate) and performed three times per week for six weeks.
• Ideal training regimes have not been identified.

Evidence of Respiratory Muscle Training

• Respiratory muscle training (RMT) (including IMT, IMT + EMT, and different combinations of other breathing training exercises) generally improves respiratory muscle strength and endurance, pulmonary function, and functionality in people with SCI.
• Dosage of RMT should be defined as there are multiple types, duration, and protocols that have been tested in the literature.

Evidence of Assistive Devices and Other Treatments

• Abdominal binding (AB) can be used to achieve immediate improvements in respiratory function, but long-term effects can be sustained during its application.
• Chest wall vibration may improve pulmonary function while the vibration is applied, but carry-over effects when the vibration is not in use have not been evaluated.
• There is limited evidence that immersion to shoulder-deep 33-34° C water can improve pulmonary function immediately, but carry-over effects following immersion have not been evaluated.

Evidence of Sleep Disordered Breathing (SDB)

• Patients with SCI have a high prevalence of obstructive sleep apnea (OSA), and therapy may improve quality of life (QOL) and other outcomes. Therefore, we recommend vigilance for suggestive signs and symptoms (e.g., snoring, obesity, witnessed apneas, daytime sleepiness) and further testing in patients with suggestive symptoms/signs (with overnight oximetry or polysomnography [PSG]).

Evidence of Cough Assist and Secretion Removal

• There is limited evidence that suggests that improving inspiratory and expiratory muscle force is important to maximize expiratory flow during cough.
• Cough effectiveness can be enhanced by a variety of methods including manual assistance by a caregiver, RMT, glossopharyngeal breathing (GPB), spinal cord stimulation (SCS), and/or electrical stimulation (ES) triggered by the person with SCI.
• Hand-held expiratory pressure devices may enhance secretion removal in people with SCI.
• Lung volume recruitment (or ‘breathstacking’) including mechanical insufflation-exsufflation (MIE) coupled with chest wall therapy has been shown to improve peak cough flow (PCF) and respiratory system compliance.

Evidence of Electrical Stimulation (ES)

• There is some evidence that suggests a higher survival rate in phrenic paced participants compared to mechanically ventilated participants.
• Phrenic nerve or diaphragmatic stimulation may be used as a long-term alternative to MV for people with injuries at C2 or above.
• Diaphragm pacing system (DPS) can help patients with SCI to breathe without a mechanical ventilator, specifically at long term follow-up; with the period of acclimatation recommended to be individualized and gradually incremented, particularly in those patients who have been mechanically ventilated for long periods.
• There is some evidence that restoration of diaphragm innervation through nerve transfer (using intercostal or inferior laryngeal nerve) into the phrenic nerve is feasible and successful in reinnervation of the diaphragm in patients with SCI, but the evidence regarding achieving ventilator independence is still contradictory.