Oxygen desaturation occurs during sleep in severe chronic obstructive pulmonary disease (COPD), especially during rapid eye movement (REM) sleep, due to hypoventilation and ventilation-perfusion mismatching, but the possible contribution of airflow limitation is unclear.In a randomised, placebo-controlled, double-blind study of severe, stable COPD patients, the authors compared 4 weeks treatment with a long-acting inhaled anticholinergic agent (tiotropium), taken in the morning (tiotropium-AM), or in the evening (tiotropium-PM), on sleeping arterial oxygen saturation (Sa,O 2 ) and sleep quality. Overnight polysomnography was performed at baseline and after 4 weeks treatment. A total of 95 patients with awake resting arterial oxygen tension f9.98 kPa (75 mmHg) were randomised, with a mean age of 66.4 yrs and mean forced expiratory volume in one second (FEV1) of 32% predicted.A total of 80 patients completed the study, of which 56 fulfilled the polysomnographic criterion of at least 2 h sleep in both sleep study nights and represent the group analysed. Tiotropium significantly improved spirometry compared with placebo. Both tiotropium-AM and tiotropium-PM groups had higher Sa,O 2 during REM than placebo (z2.41% and z2.42%, respectively, and both pooled and tiotropium-PM groups had higher Sa,O 2 during total sleep time (z2.49% and z3.06%, respectively). Sleep can be associated with clinically important adverse effects in patients with chronic obstructive pulmonary disease (COPD), principally disordered gas exchange and disturbances in sleep quality [1]. Sleep-related hypoxaemia and hypercapnia are well recognised in such patients, particularly during rapid eye movement (REM) sleep, and may contribute to cardiac arrhythmias during sleep [2] and predispose to nocturnal death during exacerbations [3]. The principal mechanism of disordered gas exchange during sleep is the physiological hypoventilation that is a normal feature of sleep, which has a disproportionate effect in hypoxaemic patients because of their position on the oxyhaemoglobin dissociation curve [4]. In addition, the physiological reduction in accessory muscle contribution to breathing, particularly during REM sleep, results in a decreased functional residual capacity, which leads to worsening ventilation-to-perfusion relationships, and further aggravates hypoxaemia [5]. Whether the severity of airflow limitation directly contributes to the degree of hypoventilation and/or oxygen desaturation is unclear, but cholinergic mechanisms could play a role in increasing airflow obstruction, since cholinergic tone has a normal circadian rhythm with higher levels during the sleeping hours [6].Hypoxaemia during sleep is easily corrected by supplementary oxygen [7,8], although whether this improves sleep quality is less clear [7][8][9][10]. An alternative approach would be to ameliorate some of the factors contributing to hypoxaemia during sleep described above, and a previous study of ipratropium, a short-acting anticholinergic bronchodilator, has shown im...