It remains more important than ever to adequately diagnose and treat conditions that may coexist with and worsen the outcome of COVID-19 infection. Just as it is widely done for other known comorbidities such as high blood pressure. We know that hypertension and components of the metabolic syndrome; a euphemism for having excess body fat around the waist, increased blood pressure, high blood sugar, and abnormal cholesterol are largely exacerbated by obstructive sleep apnea. We also know that treating obstructive sleep apnea can help reduce some of these associated risks. But how can we best help achieve this goal?
Enter positive airway pressure (PAP) therapy. Continuous positive airway pressure also widely known as CPAP remains the first line treatment and yet most effective tool to reduce and potentially reverse the dangerous, life-altering effects of obstructive sleep apnea. It eliminates snoring, frequently eradicates daytime sleepiness and fatigue and has been shown to improve quality of life and help reduce major risk factors for silent but fatal diseases such as hypertension.
Positive Airway Pressure (PAP) Therapy for Sleep Apnea
Since its invention by Dr. Colin Sullivan in 1981, the beneficial effects of treating sleep apnea with continuous positive airway pressure have been clear. Although there are several modes of PAP therapy for sleep related breathing disorders, continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP) therapy are the more commonly prescribed modes of treatment for sleep-disordered breathing. Together, both treatment devices used individually i.e one or the other, constitute the major proven arsenal that can be readily procured and used on a regular basis, without undue difficulty. Although seemingly available for purchase on the open market, both device types and relevant components that represent the PAP apparatus require prescription by certified Sleep Medicine professionals. Interestingly, the broader utility of these machines came to the fore during the worrisome peaks of the COVID-19 pandemic.
Positive Airway Pressure (PAP) Therapy for COVID-19 Infection
For individuals using CPAP or BiPAP for obstructive sleep apnea, much apprehension has lingered since the onset of the pandemic, regarding COVID-19 risk status. Numerous questions have arisen such as;
- Does PAP therapy push the Coronavirus into the lungs?
- Should I keep using my CPAP machine?
- Will CPAP help if I have already contracted COVID-19 infection?
From providers’ perspective, valid questions that have been asked include;
- Does CPAP or BiPAP potentiate the spread of the virus?
- Can CPAP or BiPAP be used to help patients who have difficulty breathing from COVID-19 lung involvement?
- What should I be telling my sleep apnea patients receiving CPAP/BiPAP treatment?
Let’s address these valid concerns.
Much as it may seem intuitive, there are no reports and there is no clear evidence that consistent CPAP or BiPAP use at recommended settings causes or enhances migration of the COVID-19 causative virus (SARS-COV-2) from the upper airways into the lungs. In fact, recent literature suggests that CPAP treatment may be beneficial in the early stages of COVID-19 infection (1). Given the non-invasive nature of the device, PAP and especially BiPAP provides an option frequently sought after for treatment of many hospitalized patients with respiratory failure arising from COVID-19 lung disease. In addition to maintaining an open airway, which is a major benefit for sleep apnea, PAP reduces the work of breathing. Hence, patients with sleep apnea who contract COVID-19 infection may have a serendipitous advantage. Occurrence of the phenomenon of Patient Self-Induced Lung Injury (P-SILI) very commonly observed with COVID-19 lung infection and which increases the risk of progression to respiratory failure, acute respiratory distress syndrome and a need for invasive ventilator support may very well be ameliorated in sleep apnea patients using PAP. Therefore, it is important for sleep apnea patients to use their CPAP machine if and when diagnosed with COVID-19. Furthermore, PAP therapy may help newly diagnosed OSA patients who may have already contracted and may be recovering from COVID-19. By reducing the work of breathing, CPAP and especially BiPAP facilitate improvement of respiratory function.
CPAP therapy has not been shown to significantly potentiate the spread of COVID-19. Aerosolization of viral particles has been a concern with BiPAP use. Fortunately, techniques are available to healthcare providers to help minimize the risk of airborne virus particle spread.
As indicated earlier, CPAP or BiPAP can often be used to help patients who have difficulty breathing from COVID-19 lung involvement. Indeed, reduction of the need for invasive respirator use was a frequent benefit for COVID-19 patients who received and tolerated non-invasive positive airway pressure therapy, where and when readily available.
Clearly, providers should emphasize the many beneficial effects of PAP therapy. The benefits of PAP use outweigh any assumed risks. Obstructive sleep apnea patients receiving CPAP/BiPAP therapy should be encouraged and counseled to do all they can to adhere to the treatment measure. It has been shown that the longer the device is worn for sleep per night, the more the health benefits of treating OSA accrue.
An important caveat is that patients with OSA are advised not to solely rely on their CPAP machine in the face of worsening respiratory symptoms. It is by no means a panacea for all breathing disorders. In the event of breathing difficulty that is usually not attributable to obstructive sleep apnea, immediate attention must be sought from the most appropriate facility.
In many instances, PAP machines were reported to be less readily available in many hospitals and healthcare facilities overwhelmed with providing care for COVID-19 patients. For those who already have a CPAP machine for treating their sleep apnea, being able to use their device as a form of non-invasive ventilation may have been a boon to their overall improvement and recovery. In addition, considering that increased CPAP adherence is associated with better clinical outcomes both from obstructive sleep apnea and COVID-19 lung involvement, CPAP-treated OSA patients may have been inadvertently “killing two birds with a stone”, as the proverbial saying goes.
It is crucial to bear in mind that being aware of the existence of obstructive sleep apnea is the first step to possibly receiving CPAP therapy outside of its use for COVID-19 patients. As such, it is important to pay attention to the warning signs of obstructive sleep apnea including snoring, restless sleep, non-refreshing sleep, chronic unexplained fatigue or excessive daytime sleepiness. Equally relevant is seeking evaluation by a readily available sleep medicine provider through an easily accessible platform such as Ognomy. Prior awareness, diagnosis of sleep apnea, prompt CPAP treatment where applicable, coupled with excellent adherence to CPAP therapy could make all the difference in early non-invasive treatment and a better outcome in the event of COVID-19 infection, if obstructive sleep apnea exists.
Positive airway pressure (PAP) therapy for other conditions
Beside obstructive sleep apnea and respiratory failure due to COVID-19, positive airway therapy has been used for years for treatment of numerous medical conditions.
In the acute setting, these include sudden elevation of blood carbon dioxide level as observed in persons with emphysema, chronic bronchitis and other breathing disorders. BiPAP has also been of tremendous utility when blood carbon dioxide levels rise in the setting of respiratory depression due to a variety of causes. Acute heart failure, referred to as pulmonary edema in medical parlance often responds very well to PAP therapy.
On a long-term basis, breathing disorders due to abnormalities of the brain such as birth defects affecting the breathing centers in some children’s brains are often amenable to PAP therapy. Some severe but thankfully relatively rare nerve abnormalities such as Lou Gherig’s disease in adults are commonly treated with PAP. Bony and muscular abnormalities of the chest wall, both congenital and acquired, that make breathing quite difficult for certain individuals, respond well to positive airway pressure therapy.
Last but by no means the least, positive airway pressure therapy provides a major treatment option for treatment of obesity hypoventilation syndrome, which is associated with up to as many as 8 to 20% of obstructive sleep apnea cases. Beside significant weight loss, PAP treatment is the cornerstone of therapy for obesity hypoventilation. Obesity hypoventilation patients literally get the value of treatment of two serious conditions for the price of one, when they receive PAP therapy.
Some may ask, with such myriad benefits, why then is CPAP/BiPAP use not so popular?
Challenges with Positive Airway Pressure therapy
Undoubtedly, acclimatizing to CPAP or BiPAP or the interface for their use can be a task for some patients. For the most part, both modalities of PAP therapy are very well received. Each one offers a great tool to alleviate the suffering of many patients with sleep-disordered breathing. However, PAP therapy does not always suit everyone. Despite advanced technological machine adaptations and interface adjustments to simplify or ease their use, PAP machines may not be a panacea for some.
Numerous alternative approaches have been studied for sleep apnea treatment. A lot of work continues to explore potential options beside Positive airway Pressure therapy. Yet, it remains the most effective treatment modality for obstructive sleep apnea and a very useful tool for several related and unrelated disease conditions that we all often have to contend with acutely and chronically.
Your sleep apnea professionals are always willing to work with our patients’ PAP machine providers to make any necessary adjustment, customize the device as best possible and make its use suitable for every patient with obstructive sleep apnea. We strive to make it a long-term therapeutic relationship rather than a transactional experience, guiding our patients through the diagnostic and treatment maze that obstructive sleep apnea often poses.
So, what do I do if have a diagnosis of Obstructive Sleep Apnea or think I could benefit from positive airway pressure therapy?
If you think you may have OSA, you should contact a sleep doctor and schedule an appointment now. Ognomy is essentially a sleep apnea doctor’s practice in the palm of your hand, or on your screen, where we diagnose and treat sleep apnea all from the comfort of your home.
If left untreated, Obstructive Sleep Apnea can have devastating effects. Fortunately, it has never been easier to receive the sleep medicine care that you deserve. All you have to do is register as an Ognomy patient through our web portal and schedule an immediate appointment. Soon, you will be on your way to a better night’s sleep and, most importantly, a better way of life for you and your family.
- Ashish A, Unsworth A, Martindale J et al.CPAP management of COVID-19 respiratory failure: a first quantitative analysis from an inpatient service evaluation. BMJ Open Respir Res.2020; 7e000692