Respiratory complications are a significant concern for patients with spinal cord injury (SCI), particularly those with high cervical lesions. These complications arise from impaired respiratory muscle function, leading to decreased lung volumes, ineffective cough, and increased risk of respiratory infections. This chapter explores the pathophysiology of respiratory dysfunction in SCI, the relationship between injury level and respiratory compromise, and the role of the respiratory therapist (RT) in managing these complications. The respiratory therapist details ventilatory assessment techniques, including diaphragmatic function monitoring, spirometry, and maximal inspiratory pressure measurements before the planning of noninvasive ventilation (NIV) strategies and/or invasive ventilation management. The RT’s role extends from the evaluation of the appropriate interface and NIV settings to the use of mechanical and manual cough assistant techniques (respiratory muscle training, cough augmentation, secretion management, and the use of mechanical insufflation-exsufflation devices). By providing comprehensive care and optimizing ventilatory support, intensive RTs probably play a role in improving respiratory outcomes and, therefore, the quality of life for SCI patients. This chapter highlights the importance of timely intervention and continuous monitoring to effectively address the respiratory challenges associated with SCI.