November 04, 2020
When COVID-19 and OSA collide – what happens when a virus meets a sleep disorder?
In the midst of this pandemic, and as we are deep into a second wave, the prospect of ‘catching COVID ’ is more daunting than ever. Unfortunately, for people with underlying or pre-existing medical issues, it’s an even more worrisome prospect. More specifically, for people with pre-existing breathing disorders, the risk is extremely high.
A surge in patients suffering from serious forms of COVID-19 infections has led to a need for rethinking healthcare around the world. As a result of this, with more testing available and more cases reported on a daily basis, along with the high prevalence of sleep-disordered breathing in the general population, we are seeing a large increase in the number of sleep apnea patients who are being adversely affected by the coronavirus.
So how come OSA patients are more susceptible to COVID-19?
There are a number of plausible reasons why this might be the case.
Firstly, let’s remind ourselves that in the US up to 80% of those with obstructive sleep apnea remain undetected. For those who are undiagnosed, the reason for their increased risk to COVID-19 might simply be that they are totally unaware that they even have an underlying medical issue, and so are not taking extra precautions.
In addition, many of the risk factors and comorbidities associated with sleep apnea, such as diabetes, obesity and hypertension, are similar to those associated with poor COVID-19 outcomes. However, some research has found that those diagnosed with obstructive sleep apnea had an additional risk on top of those factors.
We know that obstructive sleep apnea is a condition characterised by complete or partial blockage of the airways during sleep when the muscles in the airways weaken. We know that coronavirus is a virus that travels down to the lower airways, causing the lining to become irritated and inflamed and infecting cells deep in the lungs. Put these two issues together, and the most likely outcome for patients is a constant state of breathing difficulty and a potentially life-threatening response.
Let’s dig a little deeper into the research
Although a limited number of studies on obstructive sleep apnea in COVID-19 have been performed, the evidence therein does suggest that many patients who were admitted to intensive care for coronavirus symptoms, also had obstructive sleep apnea.
A systematic review of studies in the journal Sleep Medicine Reviews highlights the importance of investigating the impact of the COVID-19 virus on those who suffer from OSA, and to better identify those currently diagnosed with it.
One study from the University of Warwick, reported that people who had contracted COVID-19 but who had also previously been diagnosed with OSA, had a 2.8 times greater risk of dying from the virus. Lead author of this study Dr Michelle Miller said “it is likely that COVID-19 increases oxidative stress and inflammation and has effects on the bradykinin pathways, all of which are also observed in obstructive sleep apnea patients. When you have individuals in which these mechanisms are already affected, it wouldn’t be surprising that COVID-19 affects them more strongly.”
Further to this, a study by Medrxiv of coronavirus cases admitted to a hospital in Finland in the early phase of the pandemic, states that OSA was pre-existent in a disproportionately large group of patients, again suggesting that it is a significant risk factor for severe infection.
Ok, so can you treat sleep apnea while COVID-19 is a risk?
A study from the European Annals of Otorhinolaryngology (ORL) highlighted that the COVID-19 pandemic strongly impacted in-person diagnosis and treatment of sleep disorders. The study clearly outlines the dangers of contracting the disease due to exposure from in-person patient visits or overnight sleep center stays.
The researchers recommend that telemedicine consultations and home-based sleep tests are used in every situation where possible, to prevent any unnecessary exposure to the virus. Other studies have highlighted the importance of maintaining proper hygiene and other risk reducing measures during treatment of sleep apnea.
Aspiration is when something enters your airway or lungs by accident. Fluid can be aspirated from the nose and mouth and then will drain down a person’s throat. It’s a completely normal and involuntary process and it happens more often while a person is sleeping. However, any issues with sleep aspiration can put current sufferers of sleep apnea at a disadvantage if they use continuous positive airway pressure (CPAP) as a therapy. Aspirated fluids can carry bacteria and pathogens that can lead to pneumonia, especially in older patients and those with lung damage. Users of CPAP need to be extra vigilant in maintaining proper hygiene and safety measures for their masks to ensure that the pressurized air does not facilitate a pathway for the virus.
Is it all bad news?
No, but we need to understand the risks, and be aware of preventative measures we can take, so we can protect ourselves and our loved ones.
The good news is that we have seen certain ways that sleep apnea therapy improves long-term cardiovascular outcomes in patients with OSA and in turn it has been shown to improve symptoms of COVID-19. Some studies report that CPAP therapy has been shown to have beneficial effects on these mechanisms.
The first thing to do if you have sleep apnea and COVID-19 symptoms is to see a doctor for a consultation and a review of your health. Those diagnosed with obstructive sleep apnea need to be aware of the potential additional risk and take appropriate precautions to reduce their exposure to the virus, such as; wearing a mask, social distancing and getting tested as soon as you notice any symptoms. Now, more than ever is the time to follow your sleep apnea treatment plan as diligently as possible.