Antonio Esquinas,1 Ritesh Agarwal21Intensive Care Unit, Hospital Morales Meseguer, Murcia, Spain; 2Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, IndiaWe read with interest the paper by Rawat et al1 related to the role of bilevel positive airway pressure (BiPAP) delivered via endotracheal tube in unconscious patients suffering from acute exacerbations of chronic obstructive pulmonary disease in a real-world situation. Although the authors provide some justification for the use of BiPAP through an endotracheal tube, we believe that this technique is fraught with complications and should not be routinely employed. In fact, three patients failed BiPAP therapy, two patients received conventional invasive ventilation, and one patient failed to respond to BiPAP. Thus, almost 30% of patients either failed or showed no evidence for benefit of BiPAP. Further, the authors provide no data on the amount of leakage that was present while administering BiPAP therapy. The authors also do not provide details on whether the nurses/chest therapist administered intermittent manual bag ventilation. Ideally, the authors should have referred the patients on manual bag ventilation to another public health center where facilities for invasive ventilation are available free of cost.View original paper by Rawat and colleagues.