Critical illness related pneumonia rather than Ventilator-Associated Pneumonia (VAP).

tubation. During spontaneous breathing without an artificial airway (normal breathing), an open airway is a prerequisite for breathing. This fact is violated in clinical practice. When we evaluate a patient for extubation (a transition to breathing without an artificial airway), we frequently evaluate the breathing pattern first and then decide if the patient can keep the airway open. We believe that this practice is the result of 2 beliefs: the belief that one extra day on the ventilator is more harmful than failed extubation (confirmed by the fact that most physicians in the study were aggressive in extubating patients) and the belief that the available predictors of keeping the airway open are weak (supported by the fact that 21% of the physicians in the study were influenced by mental status and secretions).1 These beliefs might result in the extubation of patients who ultimately required re-intubation because they cannot “protect the airway.” If we perform weaning trials only on patients able to keep the airway open, we will reduce re-intubation from airway related reasons. Before we replace our current practice with computer aided weaning and extubation algorithms, we should better understand the physiology of the upper airway after extubation and determine the strongest predictors of keeping it open. Then we should determine when to incorporate these predictors, before and after breathing trials. At that point we can use the new knowledge to create comprehensive computer aided algorithms. And even then, gut feeling might remain superior to computers, particularly in complex situations.4