Intubated ventilator-dependent patients with high-level spinal cord injury can be managed without tracheostomy tubes provided that they have sufficient cognition to cooperate and that any required surgical procedures are completed and they are medically stable. Intubation for a month or more than extubation to continuous noninvasive ventilatory support (NVS) can be safer long term than resort to tracheotomy. Noninvasive ventilation (NIV) is not conventionally being used for ventilatory support. Noninvasive interfaces include mouthpieces, nasal and oronasal interfaces, and intermittent abdominal pressure ventilators. NIV/NVS should never been used without consideration of mechanical insufflation-exsufflation for airway secretion clearance.