FIG. 42:  The assumption underlying all of the proposed mechanisms outlined above is that PAP therapy is the culprit.  However we do not know whether PAP is the direct cause of TE-CSA or whether elimination of OSA is the cause.  For example, Guilleminault et al. described a case in which a patient who received tracheostomy, but not PAP therapy, for treatment of OSA, went on to develop CSA.^[38]