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Mr Miller's letter appropriately emphasizes the imperfections of tracheostomy for the treatment of obstructive sleep apnea. Patient and physician dissatisfaction with this intervention has prompted investigation of a number of alternative therapies for this disorder, including nocturnal CPAP.While the therapeutic regimen outlined by Mr Miller, which includes a sleep laboratory CPAP polysomnogram followed by home administration of CPAP and follow-up evaluations at three-month intervals, is appropriate for patients with mild obstructive apnea, it is difficult to apply to the subset of patients described in my article with hypercapnia, respiratory acidosis, hypoxemia, pulmonary hypertension, and corpulmonale often requiring intensive care unit management with intubation and mechanical ventilation. During the period of time necessary to stabilize such severely affected patients, often requiring days to several weeks, it is difficult to manage them safely with CPAP by nasal device or mask. In this group, the severity of cardiopulmonary dysfunction warrants
Hall JB. The Treatment of Sleep Apnea-Reply. JAMA. 1986;256(3):348-349. doi:10.1001/jama.1986.03380030050018