Ventilator withdrawal and artificial airway removal are important issues, as unnecessarily prolonged respiratory support and/or artificial airway use increases the risk of ventilator-associated pneumonia, exposes the lung to potentially injurious airway pressures, increases the need for sedation, and drives up costs. The reverse, however, is also true: premature ventilator withdrawal and artificial airway removal can precipitate ventilatory muscle fatigue, worsen gas exchange, expose the lungs to aspiration risks, and even result in the loss of a functioning airway. We have made particular progress in understanding factors related to the continued need for positive pressure ventilation and these new data from Frutos-Vivar and colleagues3 add to this understanding, especially in demonstrating how extubation failure can often be a result of an imperfect assessment of the need for continued ventilatory support. We also need, however, a better understanding of the factors related to the continued need of an artificial airway after a patient has been determined to no longer need positive pressure respiratory support. Much like earlier studies using specific protocols to determine the assessment tools appropriate for removing mechanical ventilatory support, carefully designed prospective studies using explicit rules for guiding artificial airway removal are clearly needed to improve the decision process for managing the artificial airway.