I appreciate the letter from Dr Vianello et al about difficulties when extubating patients who are unweanable. Airway protection is, indeed, critical. However, as reported in 1994,1 if the glottis is sufficient to permit assisted cough peak flows (CPFs) of 160 L/min, then aspiration of saliva does not decrease baseline pulse oxyhemoglobin saturation (Spo2) <95% (the only indication for tracheotomy in amyotrophic lateral sclerosis),2 and 98 of 98 such extubations were successful.3 Since this does not occur in other neuromuscular disorders (NMDs) (eg, Duchenne muscular dystrophy [DMD]), tracheotomies are not needed for those patients.2 Oral intake is less of a concern since following extubation a percutaneous gastrostomy under local anesthesia (modified Stamm or radiographically inserted) can be done as the patient uses continuous noninvasive ventilation (NIV) with little risk of respiratory complications.4 The Gilardeau Deglutition Index is a subjective indication of the ability to safely swallow, not a quantifiable indication of glottic integrity or the risk of aspiration to decrease Spo2. The maximum insufflation capacity (MIC), vital capacity (VC), their difference (MIC-VC), and the assisted and unassisted CPF difference are quantifiable and reproducible measures of glottic integrity. When patients are capable of air stacking (MIC-VC >0), their assisted CPFs are almost always >160 L/min, and extubation to NIV/mechanically assisted coughing (MAC) should be successful close to 100% of the time, even in the absence of respiratory muscle function.