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To the Editor: Patients with chronic obstructive pulmonary disease (COPD) experience sleep-related hypoventilation (1, 2). However, there is controversy as to whether this occurs due to an increase in upper airway resistance or a reduction in neural respiratory drive. Elevated neural respiratory drive in wakefulness is well documented in COPD (3). O’Donoghue and coworkers (4) reported in patients with COPD that a sleep-related hypoventilation was due to increased upper airway resistance, and Ballard and coworkers (5) reported an increase in upper airway resistance moving from wakefulness to sleep, although upper airway resistance was not consistently greater during sleep (see Figure 3 of their article [5]). Moreover, in healthy young adults, a poor correlation was observed between changes in ventilation and upper airway resistance (6). Morrell and coworkers (7) addressed the question directly in tracheotomized subjects, confirming hypoventilation during sleep, thus excluding an obligate contribution from upper airway resistance. To further address the question, we performed diaphragm electromyography (EMGdi) using a multipair esophageal electrode as an index of neural respiratory drive (8–11). Some of the data have been previously reported in abstract form (12). A total of 17 stable patients with moderate to very severe COPD and 14 age-matched normal subjects participated. All subjects were free from obstructive sleep apnea (OSA; apnea–hypopnea index < 5.0 events/h) and snoring confirmed by prior overnight polysomnography, and were free from clinically significant coexisting diseases, including neuromuscular disorders. The study was approved by the Ethics Committee of the Chinese State Key Laboratory of Respiratory Disease, and all patients gave their informed consent to participate. A multipair esophageal electrode catheter (Yinghui Medical Technology Co., Ltd, Guangzhou, China) was used as previously described (8) to record the EMGdi during overnight polysomnography (9–11). Airflow was recorded with a pneumotachograph connected to a full facemask. Maximal EMGdi was recorded from maximal voluntary inspiratory maneuvers. Polysomnography was manually analyzed based on standard criteria (13). The root mean square (RMS) of the EMGdi (RMSEMGdi) was calculated by computer with a time constant of 100 milliseconds. Efficacy of neural respiratory drive was defined as the ratio of minute ventilation to peak RMSEMGdi of each breath. Data were selected during stable breathing without respiratory events. Data collected for 10 minutes before sleep and for at least 15 minutes during non–rapid eye movement (NREM) and REM in the supine position were selected for analysis. Two-way ANOVA was used to test differences between wakefulness, NREM, and REM sleep; data are presented as means (±SD), and statistical significance was determined as a P value of less than 0.05. Some subjects could not tolerate the full facemask, and satisfactory measurements were therefore obtained in 10 male patients with COPD (age, 59.3 ± 11.5 yr; body mass index, 20.8 ± 3.1 kg/m2; FEV1, 34.2 ± 15.8% predicted; FEV1/FVC, 37.8 ± 11.6%; oxygen saturation