man sleeping and snoring in bedMany of the common risk factors and comorbidities associated with OSA, such as diabetes, obesity, male sex, upper airway structure anomalies and hypertension are similar to those associated with poor COVID-19 outcomes. Researchers have started to investigate whether being diagnosed with Obstructive Sleep Apnea conferred an additional risk on top of those factors.

Since OSA affects nearly 8% of the population and has a higher prevalence of over 20% in individuals above 60 years, its association with the risk of severe COVID-19 infection leading to hospitalization is worrying.  Results of recent studies are showing that OSA patients with COVID-19 were at 5 times more risk of developing complications and being hospitalized. OSA is an independent risk factor for severe COVID-19 that requires hospitalization. 

Is there a link between OSA and COVID-19?

While the mechanisms potentially linking OSA to COVID-19 have not been concretely identified, there are a number of studies being performed all over the world to gain more knowledge and allow physicians and hospitals to treat patients accordingly. Identifying risk factors for coronavirus 2019 (COVID-19) infection and severe disease course facilitates personalizing preventative measures, targeting surveillance and diagnostic testing, and managing active infections.

One area that warrants special attention in future research is the role of the immune system in OSA. There is a need for additional investigation regarding the benefits of OSA treatment from the standpoint of respiratory infection. Separating the causes and effects are what makes this research challenging. 
Patients with previously diagnosed OSA experience a risk that is approximately 8 times higher for COVID-19 infection.  

Does having OSA increase my risk of Covid-19 hospitalization?

Among patients with COVID-19 infection, OSA was associated with increased risk of hospitalization and approximately double the risk of developing respiratory failure. 
In 2 small recent studies of individuals admitted to the ICU with confirmed COVID-19, OSA was present in approximately 25% of patients. Such findings suggest that OSA “could potentially contribute to worsening hypoxemia and the cytokine storm that occurs in COVID patients,” wrote the authors of an article published in the Journal of Clinical Sleep Medicine (JCSM).2
(References 1&2).

Similar questions have begun to emerge in the medical literature. So, what do we know so far:
covid 19 deaths by state

  • The first confirmed case of coronavirus disease 2019 (COVID-19) in the US was reported from Washington State on January 31, 2020
  • Cases in the US have now exceeded total cases reported in both Italy and China
  • The rate of infections in New York, with its high population density, has exceeded every other state, and, as of April 20, 2020, it has more than 30% of all of the US cases
  • Common morbidities between OSA and Covid-19 include obesity, asthma, diabetes, hypertension, cardiovascular disease, and pulmonary disease
  • OSA is related to hypoxemia, which can be an aggravating factor in Covid-19 pneumonia
  • Sleep deprivation causes increased inflammatory processes and decreased immune systems

The role of physicians since the emergence of the pandemic has changed drastically.  The sleep medicine community, in particular, must collaborate with multiple other specialists, assuring what comorbidities are preexisting.

In order to have a strategy for therapies and treatments, we need research with a greater number of individuals to determine the possible effect of OSA on patients with COVID-19. Screening with simple instruments like the four question STOP-Bang Questionnaire may be helpful in guiding management decisions in COVID-19 patients.

It is difficult to estimate whether OSA may be overrepresented or underrepresented in COVID-19 cases due to selection bias for testing and healthcare avoidance behaviors during the pandemic.  Not to mention that OSA is underdiagnosed in the first place. 

Can I still use my CPAP machine if I have Covid-19?

In terms of treatment for OSA, keep in mind that there are different treatment options available depending on the type, cause and severity of your sleep apnea.  For patients who are currently under treatment for OSA with a CPAP, cleaning methods should be taken with the utmost seriousness. 
Poor maintenance not only lessens the effectiveness of your CPAP, but it can damage the actual equipment.  If you have been sick, it is imperative to wash your mask, tube, and humidifier (if applicable) daily.

Even when not feeling sick, during this pandemic it is recommended that you increase the cleaning of the machine to weekly, instead of biweekly as previously recommended.  Masks should be replaced every 90 days.

For those who choose an alternative method of treatment, such as an oral appliance, there are multiple options. At Michigan Head & Neck Institute, we exclusively offer treatment for obstructive sleep apnea that consists of creating a custom-fit oral appliance (mouthpiece) which is comfortable and can be adjusted to meet the requirements of each patient. Each patient that chooses an oral appliance (OA) as their treatment, will receive follow up sleep studies (either at-home or in a sleep lab) which will ensure the OA is positioned accordingly. There are over 100 different types of oral appliances that are made for OSA. Dr. Klein works with each patient to provide the best options for their specific treatment.
oral appliances
Please visit our website for further information. 
References:

  1. Tufik S, Gozal D, Ishikura IA, Pires GN, Andersen ML. Does obstructive sleep apnea lead to increased risk of COVID-19 infection and severity? J Clin Sleep Med. Published online May 22, 2020. doi:10.5664/jcsm.8596
  2. McSharry D, Malhotra A. Potential influences of obstructive sleep apnea and obesity on COVID-19 severity. J Clin Sleep Med. Published online May 1, 2020. doi:10.5664/jcsm.8538
  3. Bhatraju PK, Ghassemieh BJ, Nichols M, et al. COVID-19 in critically ill patients in the Seattle region – case series. N Engl J Med. 2020;382(21):2012-2022.
  4. Arentz M, Yim E, Klaff L, et al. Characteristics and outcomes of 21 critically ill patients with COVID-19 in Washington State. JAMA. 2020;323(16):1612-1614.
  5. Taylor DJ, Kelly K, Kohut ML, Song KS. Is insomnia a risk factor for decreased influenza vaccine response? Behav Sleep Med. 2017;15(4):270-287.
  6. Salles C, Barbosa HM. COVID-19 and obstructive sleep apnea. J Clin Sleep Med. Published online June 2, 2020. doi:10.5664/jcsm.8606
  7. Maas MB, Kim M, Malkani RG, Abbott SM, Zee PC. Obstructive Sleep Apnea and Risk of COVID-19 Infection, Hospitalization and Respiratory Failure [published online ahead of print, 2020 Sep 29]. Sleep Breath. 2020;1-3. doi:10.1007/s11325-020-02203-0
  8. Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW, and the Northwell COVID-19 Research Consortium. Barnaby DP, Becker LB, Chelico JD, Cohen SL, Cookingham J, Coppa K, Diefenbach MA, Dominello AJ, Duer-Hefele J, Falzon L, Gitlin J, Hajizadeh N, Harvin TG, Hirschwerk DA, Kim EJ, Kozel ZM, Marrast LM, Mogavero JN, Osorio GA, Qiu M, Zanos TP. Presenting Characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area. JAMA. 2020;323:2052–2059. doi: 10.1001/jama.2020.6775
  9. University of Warwick. (2020, September 14). COVID-19 patients with sleep apnea could be at additional risk. ScienceDaily. Retrieved November 23, 2020 from www.sciencedaily.com/releases/2020/09/200914112218.htm