1228 TTO, Nasal CPAP and Nasal 02 in OSA (Famey et a!) Transtracheal Oxygen, Nasal CPAP and Nasal Oxygen in Five Patients with Obstructive Sleep Apnea* Robertj Farney, M.D., F.C.C.P;James M. Walker, Ph.D.; Jeffrey C. Elmer, M.D., F.C.C.P; VincentA. Vscomi, M.D., FC.C.P; and R. Jon Ord, M.D. The effect oftranstracheal oxygen administration by means of a 9-French (2.7 mm) percutaneous catheter was assessed in five patients with severe obstructive sleep apnea. We hypothesized that the delivery of oxygen below the site of airway obstruction should reduce the arterial oxygen de- saturation during apneas and hypopneas, thereby increas- ing respiratory stability. Standard sleep and respiratory measurements were recorded in these subjects with all- night polysomnography on nonconsecutive nights during four experimental conditions: room air (BL), nasal contin- uous positive airway pressure (CPAP), nasal 0 (NC Os), and transtracheal O (TT Os). In three of these subjects, room air was infused (TT BA) at flow rates comparable to TT 0,. Compared with baseline room air measurements, TT 0, not only significantly increased the SaO nadir from 70.4 percent to 89.7 percent (p<O.Ol), but it also reduced the frequency of sleep apnea/hypopnea from 64.6 to 26.2/h sleep (p<O.Ol). NC O ameliorated desaturation during apnea/hypopnea (mean SaO, nadir, 86.2 percent; p<.o1) but did not significantly alter frequency (59.0/h sleep). Nasal CPAP was the most effective means of reducing sleep apnea/hypopnea (13.8/h sleep) but did not abolish desaturations when apneas occurred (mean Sa05 nadir, 80.0 percent). Compared with oxygen, transtracheal infu- sion of room air appeared to be somewhat effective; however, the small number ofstudies with TT BA precluded statistical analysis. We believe that TT O is superior to NC 02 for some patients with obstructive sleep apnea because continuous oxygen flow below the site of airway obstruction more reliably prevents alveolar hypoxia and respiration is stabilized. Infusion of air or oxygen through the tracheal catheter flow may also increase mean airway pressure and reduce obstructive apnea similar to nasal CPAP. We con- dude that TT O may be an effective alternative mode of therapy for some patients with severe sleep apnea/hypopnea when nasal CPAP is not tolerated or when combined oxygen and nasal CPAP are required. (Chest 1992; 1O1:122&35) BLbaseline on room air; etCO,end tidal CO ; NC O, oxygen given via nasal cannula; NREMnonrapiJ eye move- ment; TSTtotal sleep time; TT O,transtracheal oxygen; TT RA= room air administered through catheter T he purpose ofthis study was to evaluate the efficacy of transtracheal oxygen (TT Oa) in patients with severe obstructive sleep apnea. Although therapy with nasal continuous positive airway pressure (CPAP) is highly effective in the majority of these patients, the combined immediate and long-term failure rate meas- ures 25 to 40 percent.”2 Accordingly, some patients may receive a tracheostomy or simply oxygen via nasal cannula. While previous studies have demonstrated that supplemental oxygen given by either face mask or nasal cannula (NC O) attenuates the magnitude of oxygen desaturation, there is generally only a modest reduction in apnea frequency. In addition, some patients require continuous oxygen therapy as well as CPAP during sleep. To our knowledge, the frequency of combined therapy has not been reported, but it is *From the Intermountain Sleep Disorders Center, LDS Hospital, and Department of Medicine, University of Utah and Salt Lake Clinic, Salt Lake City. Supported in part by a grant from the Deseret Foundation, LDS Hospital, Salt Lake City. These data were presented in part at the Annual Meeting, American Thoracic Society, May 10, 1988. Manuscript received June 3; revision accepted September 3. Reprint requests: Dt Izrney, LDS Hospital, Sleep Lab, Salt Lake City 84143 clear that oxygen plus CPAP is not only more complex but also more expensive. We were interested in assessing the short-term effects of administration of oxygen below the site of airway obstruction by means of a 9-French (2.7 mm) transtracheal catheter (TT 02) that was recently de- veloped for patients with chronic lung disease. We hypothesized that alveolar hypoxia would be prevented during apnea ifthe catheter flow rate exceeded oxygen consumption. Although ventilation/perfusion mis- matching and increased venous admixture may accom- pany obstructive apneas, increasing the alveolar Po2 should ameliorate arterial hypoxemia, stabilize respi- ratory control, and reduce the frequency of apnea.” Consequently, both the time spent apneic and hypoxic would be reduced. Using all-night polysomnography, we compared TT 02 with nasal CPAP and NC 02 in its ability to reduce oxygen desaturations and obstructive apnea. In some ofthese patients, we also measured the effects of room air administered through the catheter (FT RA) since infusion of gas beneath the site of airway obstruction could increase the airway pressure and exert a similar effect as CPAP. We report herein the first study in which these three modalities and room air have been Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21644/ on 06/03/2017
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1228 TTO, Nasal CPAP and Nasal 02 in OSA (Famey et a!)
Transtracheal Oxygen, Nasal CPAP andNasal Oxygen in Five Patients withObstructive Sleep Apnea*Robertj Farney, M.D., F.C.C.P;James M. Walker, Ph.D.;
Jeffrey C. Elmer, M.D., F.C.C.P; VincentA. V�scomi, M.D., FC.C.P;
and R. Jon Ord, M.D.
The effect oftranstracheal oxygen administration by meansof a 9-French (2.7 mm) percutaneous catheter was assessed
in five patients with severe obstructive sleep apnea. Wehypothesized that the delivery of oxygen below the site ofairway obstruction should reduce the arterial oxygen de-saturation during apneas and hypopneas, thereby increas-ing respiratory stability. Standard sleep and respiratory
measurements were recorded in these subjects with all-night polysomnography on nonconsecutive nights during
four experimental conditions: room air (BL), nasal contin-uous positive airway pressure (CPAP), nasal 0 (NC Os),
and transtracheal O� (TT Os). In three of these subjects,room air was infused (TT BA) at flow rates comparable toTT 0,. Compared with baseline room air measurements,
TT 0, not only significantly increased the SaO nadir from70.4 percent to 89.7 percent (p<O.Ol), but it also reducedthe frequency of sleep apnea/hypopnea from 64.6 to26.2/h sleep (p<O.Ol). NC O� ameliorated desaturation
during apnea/hypopnea (mean SaO, nadir, 86.2 percent;
p<.o1) but did not significantly alter frequency (59.0/h
sleep). Nasal CPAP was the most effective means of reducing
sleep apnea/hypopnea (13.8/h sleep) but did not abolish
desaturations when apneas occurred (mean Sa05 nadir,80.0 percent). Compared with oxygen, transtracheal infu-
sion of room air appeared to be somewhat effective;
however, the small number ofstudies with TT BA precludedstatistical analysis. We believe that TT O� is superior to NC02 for some patients with obstructive sleep apnea becausecontinuous oxygen flow below the site of airway obstruction
more reliably prevents alveolar hypoxia and respiration isstabilized. Infusion of air or oxygen through the trachealcatheter flow may also increase mean airway pressure andreduce obstructive apnea similar to nasal CPAP. We con-dude that TT O� may be an effective alternative mode oftherapy for some patients with severe sleep apnea/hypopnea
when nasal CPAP is not tolerated or when combined oxygen
and nasal CPAP are required. (Chest 1992; 1O1:122&35)
BLbaseline on room air; etCO,end tidal CO ; NC O,oxygen given via nasal cannula; NREMnonrapiJ eye move-ment; TSTtotal sleep time; TT O,transtracheal oxygen;TT RA= room air administered through catheter
T he purpose ofthis study was to evaluate the efficacy
of transtracheal oxygen (TT O�a) in patients with
severe obstructive sleep apnea. Although therapy with
nasal continuous positive airway pressure (CPAP) is
highly effective in the majority of these patients, the
combined immediate and long-term failure rate meas-
ures 25 to 40 percent.”2 Accordingly, some patients
may receive a tracheostomy or simply oxygen via nasal
cannula. While previous studies have demonstrated
that supplemental oxygen given by either face mask
or nasal cannula (NC O��) attenuates the magnitude of
oxygen desaturation, there is generally only a modest
reduction in apnea frequency.� In addition, some
patients require continuous oxygen therapy as well as
CPAP during sleep. To our knowledge, the frequency
of combined therapy has not been reported, but it is
*From the Intermountain Sleep Disorders Center, LDS Hospital,
and Department of Medicine, University of Utah and Salt LakeClinic, Salt Lake City.Supported in part by a grant from the Deseret Foundation, LDSHospital, Salt Lake City.These data were presented in part at the Annual Meeting,American Thoracic Society, May 10, 1988.
Manuscript received June 3; revision accepted September 3.Reprint requests: Dt� I�zrney, LDS Hospital, Sleep Lab, Salt LakeCity 84143
clear that oxygen plus CPAP is not only more complex
but also more expensive.
We were interested in assessing the short-term
effects of administration of oxygen below the site of
airway obstruction by means of a 9-French (2.7 mm)
transtracheal catheter (TT 02) that was recently de-veloped for patients with chronic lung disease.� We
hypothesized that alveolar hypoxia would be prevented
during apnea ifthe catheter flow rate exceeded oxygen
consumption. Although ventilation/perfusion mis-
matching and increased venous admixture may accom-
pany obstructive apneas, increasing the alveolar Po2
should ameliorate arterial hypoxemia, stabilize respi-
ratory control, and reduce the frequency of apnea.�”
Consequently, both the time spent apneic and hypoxic
would be reduced.
Using all-night polysomnography, we compared TT
02 with nasal CPAP and NC 02 in its ability to reduce
oxygen desaturations and obstructive apnea. In some
ofthese patients, we also measured the effects of room
air administered through the catheter (FT RA) since
infusion of gas beneath the site of airway obstruction
could increase the airway pressure and exert a similar
effect as CPAP. We report herein the first study in
which these three modalities and room air have been
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21644/ on 06/03/2017
Table 1-Study Population
CHEST I 101 I 5 I MAY, 1992 1229
Patient/Sex/Age, yr
Height,
cm
\�ight,
kg
PaO,,
mm HgSaO,,
%
HB,
g/dlPaCO2,
mm Hg pH SAHI
Additional
Diagnoses
1/Fi�l0 157 106 90 14 � 37 7.47 35
21M157 183 135 62 93 17 31 7.50 50 CB
a’M/48 183 147 71 93 15 40 7.41 74 CB
431/47 167 116 58 88 16 43 7.43 78
5fM/37 188 206 49 82 15 45 7.43 86
*SAHI = sleep apnea plus hypopnea index competed as total apneas and hypopneas/total sleep time in hours; CB chronic bronchitis
compared in sleep apnea patients with polysomnog-
raphy using one therapeutic condition across the night.
Rd� Ib�on
METHODS
Five patients with severe obstructive sleep apnea were selected
to participate in this study because they were either noncompliantwith nasal CPAP or also required supplemental oxygen 24 K/day.
All had been previously tested by means of all-night polysomnog-
raphy with and without nasal CPAP The anthropometric and
baseline arterial blood gas data for the patient population arepresented in Thble 1. Male subjects predominated (4’S) and two
subjects had chronic bronchitis secondary to cigarette smoking.
Study Protocol
The research protocol was approved by the Institutional ReviewBoard and informed consent was Obtained. Following selection from
patients with previously documented sleep apnea, subjects wererestudied with polysomnography on nonconsecutive nights using
the following experimental conditions: baseline on room air (BL),
nasal CPA1� NC 0, TT 0,,, and Tf BA (three patients only). The
sequence oftests, intervals between studies, and ultimate therapeu-tic levels used in each case are shown in lhble 2. An unusually long
interval occurred in one subject (No. 3) who had been tested onCPAP three months before his repeated baseline polysomnogram.
This person� testing was delayed because he temporarily movedout of state. Not only was he completely intolerant of nasal CPAP,
but he also had severe sleep apnea on baseline testing subsequent
to the CPAP trial (sleep apnea plus hypopnea index 74/h sleep).A transtrachealeatheter(SCOOP)was placed using the technique
described by Christopher et al. Ifpossible, one week was allowed
for the subjects to become accommodated to the catheter beforerestudying with TT O�. Since experimental data were also beingused for clinical decision making, maximal levels ofnasal CPAP andoxygen were arbitrarily set that would be practical to continue afterthe study. Nasal CPAP was adjusted in approximate increments of
2.5 cm H,O pressure up to a maximum of 15 cm H,O. Oxygen flow
rates were adjusted in approximate increments of 1 IJmin using a
pediatric flowmeter up to a total flow of 6 IJmin. Oxygen or nasal
CPAP was titrated as quickly as possible, generally within the first
hour following the initiation ofsleep to a target Sa02 of9O percent,
after which therapeutic levels remained constant. If desaturationsdeveloped after the initial titration period, fur example, with rapid
eye movement (REM) sleep, no changes in therapy were made so
that the experimental condition would remain constant throughout
the night.
In our laboratory, independent simultaneous recording of the
SaO, at slow paper speed (20 cm/li) has been a convenient method
of titrating CPAP When respiratory disturbances occur at our
elevation, desaturations or oscillations of the SaC), almost alwaysresult.”The Sa02 pattern thereby provides a reproducible endpointthat may be less subject to observer error and artifactual changes
compared with the detection of hypopneas, for example. Further-
more, since a major therapeutic objective was to maintain the Sa01
at a physiologic level, the SaC)1 of9O percent was chosen as the end
point (for both CPAP and 0,, trials). Consequently, therapy was not
specifically adjusted to eradicate apneas and hypopneas. In three
subjects, room air (IT BA) was administered through the catheter
and compared with TT 0, at identical flow rates (3 L/min). Patient
5, who was restudied seven months after his original TT O� test,
underwent a second night of testing with TT 0, with a resultantdecrease in his 0, requirements to 3 Iimin.
Sleep and Respiratonj Measurements
Fblysomnographic recordings included standard placements forcontinuous monitoring of central and occipital electroencephalo-
gram (C3/C4 and 0IA�2), horizontal electro-oculogram, and sub-mental and anterior tibialis electromyogram. Mrflow at the nose
and mouth was sensed by measurement of end tidal CO2 (etCO,)
*BLBL�jff�� from baseline p<O.05 and p<O.Ol, respectively; � differs from NC 0, p<O.05 and p<O.Ol, respectively; �!i=differs
from U 0, p<O.OS and p<O.Ol, respectively.
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21644/ on 06/03/2017
60
40�
66.9 85.9
80
60
40
I00
::T�T�0�frf�r :�5.5 20.0 40
100 N-CPAP(I5cm)
� 00
80
60
40
� 00
80
60
40#{149}
55.7 67.9
80
60
40
80
60
40
SAl SAHI
4.3 8.9
- 100
. 80
- 60
- 40
80
60
40
SAl
I 4.2
SAHI
49.5
l00
80
60
40
I00
80
60
40
SAl SAHI
3.9 0.7
I I I I I I I I
2 3 4
TIME (hours)
FIGURE 1. Oximetric recordings from patient 5. The SaO, recorded from the second to fourth hour of eachexperimental condition are shown. The more severe desaturations in each panel are related to REM sleep.
PATIENT 5 00
1232 1-To. Nasal CPAP and Nasal O� k� OSA (Fameyetal)
2
0
I-
(I,
2
u-i>-
0
ment conditions may have led to artifactual changes
in respiratory scoring. However, the concordance
between measurements of etCO2, VT, chest wall
excursion, and abdominal excursion in association with
electrophysiologic arousals at the termination of res-
piratory events indicates that their frequency and
duration were not underestimated. Note that the
changes in the arousal index paralleled changes in
apnea plus hypopnea index (Tables 3 and 6).
Duration of Apnea/Hypopnea: None of the treat-
ments resulted in a significant increase in duration of
apnea compared with the baseline room air condition.
However, there was a significant difference in the
hypopnea duration (p’(0.01) between the CPAP and
02 conditions as a result of decreased duration during
CPAP.
Transtracheal Room Air Studies: The effects of
administering room air via the transtracheal catheter
on apneas, hypopneas, and oxygen desaturation are
shown in Figures 2 and 3. Since apneas and hypopneas
did not result in consistent differences in desaturation,
mean SaO2 values for all respiratory events are plotted.
Compared with baseline studies, TT BA resulted in a
slight increase in the Sa02 nadir and a mild reduction
in frequency of apneas and hypopneas (apnea plus
hypopnea index: BL, 79.5; TT BA, 66.7; TT 02, 39.9).In one case (No. 5), the apnea index was markedly
decreased with TT BA but there were frequent
hypopneas associated with substantial oxygen desatu-
rations (Figs 1 through 3). In two subjects, frequent
hypopneas were also observed with TT 02, but the
overall Sa02 was about 90 percent (mean nadir, 88.7
percent).
Sleep Variables: Table 6 shows means and SDs for
standard sleep parameters across experimental con-
ditions. In general, sleep architecture was more nor-
mal during CPAP The percentage of REM and stage
3/4 sleep increased, whereas the percentage of stage 2
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21644/ on 06/03/2017
APNEA + HYPOPNEA INDEX
-----APNEA INDEX
5
43
5”
3a�----��
0�UiUi-JU)
=
U)I-.zUi>Ui
0I-
a.U)Ui
00-
90
80
70
60
50
40
30
20
0
0-
4 �
BASELINE TTRA
STUDY CONDITIONS
3
4
5
90-
c,%J0c� 80-
z
2 70-F-.�
� 60-
U)
� 50-
0 40--i
tr 30-UiI-
I I I
BASELINE TTRA ITO2
STUDY CONDITIONS
Ficuax 3. Mean Sa02 nadir during apneas and hypopneas of three
subjects while receiving either room air or oxygen via transtrachealcatheter at comparable flow rates.
CHEST/lOl /5/MAY, 1992 1233
Ficuns 2. Apnea and hypopnea indices of three subjects while
receiving either room air or oxygen via transtracheal catheter at
comparable flow rates. Subjects 4 and 5 were tested nine and seven
months, respectively, after their original evaluations.
NREM sleep decreased in the CPAP condition as
compared with other conditions. There was a corre-
spondence between the effectiveness of respiratory
therapy and changes in sleep parameters. The number
of arousals decreased significantly with both CPAP
and TT 02 administration as compared with the
baseline study. Treatment with TT 02 resulted in the
next greatest reduction in apnea plus hypopnea index
to 26.2 (± 20.7) with a corresponding reduction in the
arousal index to 41 .5(± 28. 1). Treatment with NC 02
had the least impact on both respiratory parameters
and frequency of arousals. Stage 1 NREM sleep was
reduced (p<O.05) in all treatment modalities. There
were no significant increases in sleep efficiency be-
tween baseline and treatment conditions, possibly due
to the relatively high sleep efficiency (88.6 percent)
on the baseline condition.
DIScUSsIoN
The most important observation from this study is
that transtracheal oxygen maintained a physiologically
adequate Sa02 and reduced the frequency of sleep-
disordered breathing in these patients with severe
sleep apnea. In this study, a pragmatic end point (SaO2
of 90 percent) was selected because of previous
experience.’2 Greater reductions in apnea and hypo-
pnea frequency may have been demonstrated if the
measurement of airflow, tidal volume signal, and/or
electrophysiologic arousals had been used. Our results
are consistent with other more limited studies showing
marked reductions in the apnea/hypopnea index with
TT 02 � Because TT 02 was effective
and well tolerated, the need for tracheostomy was
eliminated. Oxygen via nasal cannula was found to be
the least effective form oftherapy in the present study.
As expected, the frequency of periodic breathing was
most effectively reduced by CPAP. Except when there
was significant hypoxia during wakefulness, CPAP also
resulted in desirable SaO2 levels.
One of the most intriguing questions raised by this
study concerns the mechanism of TT 02 on reducing
respiratory instability, and in particular the s!et�p
apnea index. In some cases, the reduction in bothapneas and hypopneas was dramatic (Fig 1). In other
cases, there were residual respiratory events that were
predominantly hypopneas but without significant de-
saturation. Thus, even when respiratory disturbipces
were not completely eliminated by TT 02, the more
severe grades of obstruction appear to have been
reduced which ameliorated oxygen desaturation.TI 02 Information concerning the effect of either nasal or
transtracheal oxygen therapy in patients with sleep
apnea is ljmjted.3-5,15-’7 Various mechanisms have been
proposed for the salutary effect ofoxygen on eliminat.
ing or reducing periodic breathing#{176}”#{176}that include the
following: (1) a direct stimulation ofthe central nervous
system; (2) reduction of upper airway resistance; and
(3) stabilization of chemical feedback by reduction of
peripheral chemoreceptor activity. According to mod-
els of the respiratory control system that incorporate
negative feedback, ventilatory instability is directly
I00-,
20-
10-
0-
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21644/ on 06/03/2017
1234 TTO, Nasal CPAP and Nasal 02 in OSA (Fameyetal)
correlated with hypoxia, hypercapnia, reduced lung
02 and CO2 storage volumes, and increased gain of
the peripheral chemoreceptors.”
An additional mechanism may be operative with TT
02. As a result of continuous oxygen flow through the
catheter, an increase in the mean airway pressure
might develop sufficient to maintain airway patency
similar to the effect of nasal CPAP Increased airway
pressure may also increase functional residual capacity,
which has been shown to enlarge pharyngeal cross-
sectional area in patients with obstructive sleep ap-
18 Transtracheal room air at comparable flow rates
to TT 02 resulted in slight improvement in both apnea/
hypopnea index and Sa02 nadir compared with base-
line data. The transtracheal room air studies were
interesting but unfortunately inconclusive because of
the small number and because the infusion of room
air still provides oxygen, albeit at a lower concentration
than TT 02. Thus, the effect of oxygen could not be
completely separated from increased airway pressure.
Based on the present study and consistent findings
by other investigators, we believe that TT 02 exerts
its major effect by stabilizing chemoreceptor activity
and by reducing the central component of apnea,
although increased airway pressure may play a role.
The superiority of TT 02 over NC 02 most likely
stems from the more reliable delivery of oxygen to
the alveolar gas compartment when upper airway
occlusion is present.
Previous investigators have demonstrated that oxy-
gen via nasal prongs or face mask consistently reduces
both the severity of oxygen desaturation and the
frequency of apnea in patients with obstructive sleep
apnea syndrome.35 Because ofdifferent study designs,
it is difficult to compare our results.
We were concerned that oxygen therapy would
prolong the duration ofrespiratory events and increase
accumulated apnea time.3’5”5”9’�#{176} However, our data
and those of Chauncey and Aldrich’6 did not indicate
that oxygen therapy by transtracheal catheter or nasal
cannula significantly increased the duration of apneic
events. In contrast to some studies,�9m our subjects
were examined using one steady-state treatment mo-
dality throughout the entire sleep period, which we
believe may provide more realistic data.
It is conceivable that the order of the studies or
intervals between tests may have biased these results.
Long-term use ofCPAP has been shown to change the
ventilatory response to C02,2’ which could possibly
also modify the extent of obstructive sleep apnea. It
is unlikely that the prior use ofCPAP was a confound-
ing factor in this study because these patients were
selected on the basis of being poorly compliant with
CPAP and none was using this therapy regularly.
Transtracheal oxygen studies were delayed in several
patients because of scheduling conflicts and one pa-
tient (No. 1) received oxygen via nasal cannula. Gold
et al� have demonstrated that long-term oxygen ther-
apy has no effect on apnea frequency beyond the
period ofadministration. Therefore, the use of oxygen
before TT 02 studies would not likely skew the results.
Finally, the order oftests preceding TT 02 studies was
randomized so that there would be no consistent effect
from any therapy.
Nasal CPAP is the optimal therapy for immediately
eliminating obstructive apneas and normalizing sleep
architecture in the majority of patients. However,
some will be intolerant of nasal CPAP and others may
require concomitant and continuous use of oxygen.
This study suggests that TT 02 may be a viable
therapeutic alternative. When supplemental oxygen
was required in addition to CPAP, transtracheal oxygen
was successfully used as a single modality, thus reduc-
ing complexity and treatment expense.
We did not address potential long-term complica-
lions of transtracheal catheter therapy nor did we
evaluate other catheter systems. Chronic therapy with
TT 02 could be complicated by mucosal ulcerations
and infection. Transtracheal oxygen therapy requires
frequent cleaning and the catheter can be easily
occluded by mucus in patients with heavy secretions.
Some of the subjects in this study may not be
representative of the majority of patients with severe
sleep apnea. All were more difficult to treat than usual
which, in fact, was the specific reason for considering
them for an experimental treatment. Two had chronic
bronchitis and all were studied at moderately high
elevation. Nevertheless, we do not believe that these
considerations seriously detract from the main thrust
ofthis article, which is that TT 02 may be useful when
other modalities of therapy are not successful or are
impractical. Given the success of TT 02 in these
patients, transtracheal oxygen therapy may also be
beneficial in less severe cases, although additional
subjects should be studied before such conclusions
can be drawn. In some subjects, hypopneas may still
be present but perhaps the single most significant
physiologic consequence, hypoxia, can be prevented.
The frequency of arousals was also reduced with
transtracheal oxygen but further studies are necessary
to determine the long-term effects on sleep architec-
ture and daytime symptoms as well as to better define
the role ofairway pressure.
ACKNOWLEDGMENTS: The authors wish to thank Kathy Bradleyfor her invaluable assistance and patience in the preparation of thismanuscript, William Clark and Jan Kramer for their technicalexpertise with polysomnography, Julian Maack for medical illustra-lions, Alan Abdulla, M.D. , for his contributions in the initialstudies, and Alan H. Moms, M.D. , Robert 0. Crapo, M.D., andArthur S . Slutsky, M . D. , for their critical reviews and suggestions.
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