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O bstructive sleep apnea syndrome (OSA) affects 2-4% of the general population. 1 Irrespective of the type of sleep apnea (central versus obstructive), epidemiologic studies have indicated its independent association with hypertension 2 and cardiovascular disease. 3 Also, there is emerging evidence suggesting that sleep disordered breathing (SDB) has an association with fasting hyperglycemia, insulin resistance, and type 2 diabetes mellitus. 4,5 The impact of tracheostomy for severe obstructive sleep apnea syndrome on glycemic control has not been previously reported. CASE REPORTRR is a 58-year-old African American male with history of longstanding hypertension, obesity, type 2 diabetes mellitus, chronic kidney disease, congestive heart failure, sinus node dysfunction status post permanent pacemaker placement, coronary artery disease, and severe obstructive sleep apnea. He had a body mass index of 32. His baseline blood pressures were in the range of 140-160 mm Hg systolic and 70-90 mm Hg diastolic.An overnight sleep study prior to admission documented severe OSA, with an apnea-hypopnea index (AHI) of 54/hr and oxygen desaturation to 66%. He failed continuous positive airway pressure titration and was subsequently titrated to a bilevel (BiPAP ® ) setting of 15/9 cms of H 2 0 with 3 liters/minute of oxygen. Despite