Diaphragmatic ultrasound to guide ventilator weaning and early tracheostomy in high cervical spinal cord injury: A case report

CONTEXT: Ventilator dependence is a major cause of morbidity and mortality in patients with high cervical spinal cord injury (CSCI), largely due to diaphragmatic dysfunction. Conventional assessment of inspiratory muscle strength, such as maximal inspiratory pressure (MIP), is often unreliable in this population because it requires adequate patient cooperation. Objective bedside tools to evaluate diaphragmatic function are therefore essential to guide ventilator weaning and clinical decision-making. FINDINGS: We report the case of a 29-year-old man with high CSCI who developed acute respiratory failure and repeated weaning failure after cervical spine surgery. Serial MIP measurements could not be obtained despite initial spontaneous breathing, limiting volitional assessment of diaphragmatic function. Bedside diaphragmatic ultrasound was performed serially to assess diaphragmatic thickness, thickening fraction (TF), and excursion. Ultrasound demonstrated absent diaphragmatic excursion during unsupported breathing and progressively reduced TF despite ventilatory support, consistent with severe diaphragmatic dysfunction. These findings supported the decision to proceed with early percutaneous tracheostomy after failed extubation attempts. CONCLUSION/CLINICAL RELEVANCE: Diaphragmatic ultrasound provided an objective, noninvasive assessment of diaphragmatic function when volitional measures were unreliable, directly informing ventilatory management in a patient with high CSCI (C5 AIS B). This case highlights the clinical value of serial diaphragmatic ultrasound in complex weaning scenarios, suggesting its potential role in respiratory and rehabilitation care to guide timely decisions such as early tracheostomy.