Respiratory outcomes
Following a spinal cord injury (SCI), the neurological level of injury (NLI) often determines both the degree of respiratory muscle impairment. The table below illustrates the direct correlation between a NLI with complete motor impairment (AIS A) and respiratory function outcomes.
However, actual respiratory function outcomes can vary significantly, based on severity of motor impairment and ANS disruption, along with a range of individual predictive factors. Hence, this table provides a general summary only.
The key message is that a person with SCI who has respiratory dysfunction, will have ongoing ventilation and respiratory health needs for community living. Typically this involves a process of comprehensive hospital discharge and/or community planning to secure adequate funding, personal care and health professional supports. It will also involve the trialling and prescription of necessary assistive technology concerning ventilation and respiratory devices.
For more information, refer to Discharge and community planning.
C1-C2
C3
C4-C5
C6-C8
T1-T6
T7-T12
L1 and below
| Respiratory muscle impairment and ANS disruption | Respiratory function outcomes + ventilation support and respiratory health needs |
|---|---|
| No diaphragm muscle activity or function No abdominal and intercostal muscle activity Very limited accessory muscles, with only upper trapezius and partial sternocleidomastoid muscle activity Significant ANS disruption: no sympathetic inputs for regulating cardiovascular and respiratory system | No spontaneous breathing No capacity to generate any lung volume or cough VENTILATION SUPPORT Full-time invasive ventilation support via ventilator + tracheostomy Daily tracheostomy hygiene and regular tracheostomy changes RESPIRATORY HEALTH Lung volume augmentation for deep breathing benefits + pulmonary and chest wall compliance maintenance Cautious use of cardiorespiratory exercise program to monitor any adverse impact related to ANS disruption Secretion management using cough augmentation device and suction unit +/- manual assisted cough Abdominal binder if tolerated for sitting OTHER MANAGEMENT Voice and speech generation needs |
| Respiratory muscle impairment and ANS disruption | Respiratory function outcomes + ventilation support and respiratory health needs |
|---|---|
| Very weak diaphragm muscle activity and significantly impaired function No abdominal and intercostal muscle activity Very limited accessory muscles with only upper trapezius, partial sternocleidomastoid, and weak portion of scalene muscle activity Significant ANS disruption: no sympathetic inputs for regulating cardiovascular and respiratory system | Limited capacity for spontaneous breathing across a 24-hour period Severely reduced lung volumes: vital capacity < ⅓ predicted No capacity to cough voluntarily VENTILATION SUPPORT Full time invasive ventilation support via ventilator + tracheostomy Daily tracheostomy hygiene and regular tracheostomy changes May be able to transition to daytime non-invasive ventilation support (NIV) +/- periods of independent breathing Requires overnight ventilation support to manage respiratory fatigue and significant sleep-disordered breathing Additional ventilation supports when unwell RESPIRATORY HEALTH Lung volume augmentation for deep breathing benefits + pulmonary and chest wall compliance maintenance Cautious use of inspiratory muscle training (IMT) to manage risk of respiratory fatigue Ventilation support during cardiorespiratory exercise program to manage risk of respiratory fatigue and monitor any adverse impact related to ANS disruption Secretion management using cough augmentation device and suction unit +/- manual assisted cough Abdominal binder if tolerated for sitting OTHER MANAGEMENT Voice and speech generation needs Sleep-disordered breathing assessment and management needs |
| Respiratory muscle impairment and ANS disruption | Respiratory function outcomes + ventilation support and respiratory health needs |
|---|---|
| Partial diaphragm muscle activity, but impaired function No abdominal and intercostal muscle activity Limited accessory muscles with only upper trapezius and sternocleidomastoid, partial scalene and weak portion of serratus anterior and pectoralis muscle activity Significant ANS disruption: no sympathetic inputs for regulating cardiovascular and respiratory system | Able to achieve spontaneous breathing across a 24-hour period Severely reduced lung volumes: vital capacity < ⅓ predicted No capacity to cough voluntarily VENTILATION Full time invasive ventilation support via ventilator + tracheostomy likely, at least initially May be slow to wean and benefit from transition to daytime non-invasive ventilation support (NIV) + tracheostomy—especially in sitting; likely to achieve independent breathing + no tracheostomy Requires overnight ventilation supports to manage initial respiratory fatigue and persistent sleep-disordered breathing Additional ventilation supports when unwell RESPIRATORY HEALTH Lung volume augmentation for deep breathing benefits + pulmonary and chest wall compliance maintenance Cautious use of inspiratory muscle training (IMT) and cardiorespiratory exercise program to manage risk of respiratory fatigue and monitor any adverse impact related to ANS disruption Secretion management using cough augmentation device +/- manual assisted cough Abdominal binder if tolerated for sitting OTHER MANAGEMENT Voice and speech generation needs Sleep-disordered breathing assessment and management needs |
| Respiratory muscle impairment and ANS disruption | Respiratory function outcomes + ventilation support and respiratory health needs |
|---|---|
| Full diaphragm muscle activity, but impaired function Full abdominal and intercostal muscle paralysis More accessory muscles available, including serratus anterior, pectorals and latissimus dorsi muscle activity Significant ANS disruption: no sympathetic inputs for regulating cardiovascular and respiratory system Significantly reduced lung volumes: vital capacity between No ability to cough voluntarily | Able to achieve spontaneous breathing across a 24-hour period Severely reduced lung volumes: vital capacity ⅓ to 1⁄2 of predicted, but may be able to utilise accessory muscles to improve No capacity to cough voluntarily VENTILATION Full time invasive ventilation support via ventilator + tracheostomy likely, at least initially May be slow to wean and benefit from transition to daytime non-invasive ventilation support (NIV) + tracheostomy—especially in sitting; will achieve independent breathing + no tracheostomy Requires overnight ventilation support to manage initial respiratory fatigue and persistent sleep-disordered breathing Additional ventilation supports when unwell RESPIRATORY HEALTH Lung volume augmentation for deep breathing benefits + pulmonary and chest wall compliance maintenance Use of inspiratory muscle training (IMT) and cardiorespiratory exercise program to improve respiratory capacity: monitor any adverse impact related to ANS disruption Secretion management using cough augmentation device +/- manual assisted cough Abdominal binder if tolerated for sitting OTHER MANAGEMENT Voice and speech generation needs Sleep-disordered breathing assessment and management needs |
| Respiratory muscle impairment and ANS disruption | Respiratory function outcomes + ventilation support and respiratory health needs |
|---|---|
| Full diaphragm muscle activity, but impaired function Some upper intercostal muscle activity No abdominal muscle activity Full accessory muscles availability, except for some deep thoracic and paraspinal muscle activity Significant ANS dysfunction: almost no sympathetic inputs for regulating cardiovascular and respiratory system | Able to achieve spontaneous breathing across a 24-hour period Reduced lung volumes: vital capacity 1⁄2 of predicted, but able to utilise accessory muscles to improve No capacity to cough voluntarily VENTILATION Full time invasive ventilation support via ventilator + tracheostomy may be necessary, at least initially May benefit from daytime non-invasive ventilation support (NIV) + tracheostomy—especially in sitting; will achieve independent breathing + no tracheostomy Requires overnight ventilation support to manage initial respiratory fatigue and remains high risk of sleep-disordered breathing May need additional ventilation supports when unwell LUNG VOLUME and COUGH MANAGEMENT Lung volume augmentation for deep breathing benefits + pulmonary and chest wall compliance maintenance Use of inspiratory muscle training (IMT) and cardiorespiratory exercise program to respiratory capacity: monitor any adverse impact related to ANS disruption Secretion management Cough augmentation device may be required +/- manual assisted cough Abdominal binder if tolerated for sitting Cautious cardiorespiratory exercise program to avoid respiratory fatigue during early rehabilitation OTHER MANAGEMENT Voice and speech generation needs Sleep-disordered breathing assessment and management needs |
| Respiratory muscle impairment and ANS disruption | Respiratory function outcomes + ventilation support and respiratory health needs |
|---|---|
| Full diaphragm muscle activity and improving function Full upper and some lower intercostal muscle activity Some abdominal muscle activity Full accessory muscles availability and improving deep thoracic and paraspinal muscle activity Normal ANS function for regulating cardiovascular and respiratory system | Able to achieve spontaneous breathing across a 24-hour period Reduced lung volumes: vital capacity functional Improving capacity to cough voluntarily RESPIRATORY HEALTH Cardiorespiratory exercise program needs Secretion management needs when unwell; manual assisted cough is typically adequate Abdominal binder if tolerated for sitting Voice and speech generation normalising Reducing risk of SCI related sleep-disordered breathing, but assessment and management if indicated |
| Respiratory muscle impairment and ANS disruption | Respiratory function outcomes + ventilation support and respiratory health needs |
|---|---|
| Full respiratory muscle activity and function Normal ANS function for regulating cardiovascular and respiratory system | Independent breathing, normal lung volumes and effective cough Nil respiratory function changes except for loss of pelvic floor control assisting intra-abdominal pressure generation for cough Cardiorespiratory exercise program needs Voice and speech generation normal Nil SCI related sleep-disordered breathing risk |
Relationship between NLI and respiratory outcomes following SCI
Adapted from Berlowitz et al. (2016).
eLearn SCI— physiotherapists—respiratory: assessing and treating module
eLearn SCI.org
Guidance of the support needs of adults with a spinal cord injury
Insurance and Care (iCare) New South Wales)
Berlowitz, D. J., Wadsworth, B., & Ross, J. (2016). Respiratory problems and management in people with spinal cord injury. Breathe, 12(4), 328–340. https://doi.org/10.1183/20734735.012616
Denton, M., & McKinlay, J. (2009). Cervical cord injury and critical care. Continuing Education in Anaesthesia, Critical Care & Pain, 9(3), 82–86. https://doi.org/10.1093/bjaceaccp/mkp013
Harvey, L. A. (2008). Management of spinal cord injuries: A guide for physiotherapists. Churchill Livingstone Elsevier.