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To the Editor:
I read the article by Jin et al.1 with interest. I am concerned that the title is misleading and not supported by the authors' data.
The phenomenon of central sleep apnea (CSA) developing after tracheostomy in multiple system atrophy (MSA) has been noted before and is of uncertain prognostic significance.2,3
Jin et al. describe CSA in seven patients following tracheostomy for vocal cord paralysis. In three patients, polysomnography (PSG) was also performed before surgery. However, comparison of the studies showed that obstructive apneas had changed to central apneas in one patient with a lower apnea-hypopnea index while pre-existing central apneas had increased in frequency in the other two.
As pre-tracheostomy PSG was not reported in the other four patients, it is impossible to know whether there was any change in apnea type or severity. The authors do not mention that any of the patients died during the course of the study. Table e-1 on www.neurology.org indicates that the three patients with both pre- and post-tracheostomy studies survived a mean of 11.4 years from disease onset and 5.8 years after tracheostomy (range 4.3–8.0 years). As the mean life expectancy in MSA is 8 to 10 years from onset,4 there is no evidence that tracheostomy resulted in reduced life expectancy by “fatally” exacerbating sleep disordered breathing.
CSA should be distinguished from central neurogenic hypoventilation in MSA. The latter condition can result in hypercapnic respiratory failure and may be a factor causing death even in patients who have undergone tracheostomy. However, the patients described by Jin et al. actually had lower Paco2 levels than before tracheostomy with no evidence for hypoventilation. The presence of laryngeal stridor is associated with reduced survival in MSA5 and there are many reports of sudden death occurring within days to weeks of identification …
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