In their well-written paper, the authors provide a cogent argumentl that it is time to abandon the practice of empiric tracheostomy in patients with spinal cord injury. They note that the majority of patients with spinal injuries were able to be liberated from the ventilator prior to discharge from the hospital. What they fail to do is truly elucidate the stated goal of deteirnining the predictors of ventilator dependence at discharge in acute spinal cord injury. The authors.state that the only significant predictor of ventilator dependence at the time of discharge was the presence of a tracheostomy. Isn't this at least somewhat a which "came first the chicken or the egg argument"? Did the inability to be liberated from the ventilator lead to placement of a tracheostomy or did placement of a tracheostomy lead to inability to be liberated from the ventilator? Were the clinicians just really adept at predicting which patients would need long-term mechanical ventilation or did placement of a tracheostomy lead to abandoning weaning attempts?
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