Endotracheal tubes and imposed work of breathing: what should we do about it, if anything?

Concerns about the work of breathing imposed by the endotracheal tube have led clinicians to routinely use pressure support to overcome this resistive component. More recently, ventilator manufacturers have introduced systems to automatically overcome endotracheal tube resistance, regardless of tube diameter or patient demand for flow. Despite the theoretical advantages, neither method appears to provide superior performance. Stepping back, the real question may be, is overcoming endotracheal tube resistance really important?