Sleep apnea is a condition that leads to short pauses in breathing during sleep. It falls into the larger category of sleep-disordered breathing (SDB).1
The causes of sleep apnea can be subdivided into:
- Obstructive: The throat narrows or closes, effectively ‘obstructing’ the airway and causing the breathing pauses
- Central: The ‘central’ brain signal that should be telling the body to breathe does not do so, causing the pauses.
Obstructive sleep apnea (OSA) leads to sleep interruptions and poor-quality sleep, and it may also have serious health consequences if severe and/or if not treated. Common symptoms during daytime hours include excessive sleepiness and headaches in the morning. Common symptoms while asleep during the nighttime (which most commonly is observed by a bed partner) includes gasping, choking, and snoring. Getting up to urinate (nocturia) during the night is also common. OSA is by far the most common form in the population1 and is therefore the focus of this blog.
How is sleep apnea diagnosed?
Sleep apnea is diagnosed with a ‘sleep test’ (or sleep apnea test), which can either be performed at home or in a formal laboratory setting.2 The choice of setting would depend on a variety of factors, including not only access considerations (local access/wait times to these labs) but also on how ‘complicated’ your case might be. For example, if you also have any chronic heart, lung or neurologic conditions, a formal lab sleep study would likely be more appropriate.2
Are testing facilities closed because of the COVID-19 pandemic?
The majority of these sleep lab facilities were initially forced to close during the COVID-19 pandemic. This was a very important step to prevent the spread of infection.
The decision to close sleep labs and other facilities like it (including, for example, pulmonary function testing labs and in-person pulmonary rehabilitation programs) continues to be a careful and ongoing assessment based on the evolving available information and COVID-19 infection rates.3 The overall risks and benefits must be weighed whenever closing or opening these facilities, and must factor:
- The well-being of patients by providing access to these important clinical services (which would favour reopening)
- Minimizing infection exposure to the patients and to the the healthcare workers (which would favour keeping them closed)
- The net benefit to society as a whole.
The Canadian Thoracic Society has provided important guidance on this exact dilemma throughout the pandemic.1,4 While in April all sleep lab and home testing was strongly discouraged except under extremely urgent cases1, in July an update was released which outlined the steps and conditions for resuming sleep testing.4 These include:
- Proper equipment handling and sterilization practices (and/or using disposable equipment)
- Appropriate personal protective equipment (PPE) availability for healthcare workers involved in testing
- Screening everyone for COVID-19 infection (by questionnaire and/or temperature checks/COVID-19 tests) before coming to the facility.
As has always been the case, ongoing changes to the recommendations are not only possible but probable.
What is the treatment for Obstructive Sleep Apnea?
Since the problem in obstructive sleep apnea or OSA is the partial (or full) collapse of the upper airway during sleep, the treatment involves applying a constant positive pressure to the inside of the airway to help keep it open.
This is the concept behind your CPAP machine (CPAP stands for ‘Continuous Positive Airway Pressure’), a sleep apnea machine which ‘splints’ the airways open throughout the night.
Lifestyle adjustments including diet, exercise and weight optimization are also very important.
If I already have sleep apnea, how does this affect me and my care during the COVID-19 pandemic?
It is important to understand how the COVID-19 pandemic may affect you as a patient, if you are currently living with sleep apnea. Let’s explore this question together.
Increased use of CPAP machines at home
Many people living with sleep apnea find it difficult to use their machine all night and every night. A recent report from France showed that home CPAP machine use in patients with sleep apnea actually went up during the lockdown measures as compared to beforehand.5
Is Sleep Apnea a risk factor for severe COVID-19 infection?
Many patients with sleep apnea may also have high blood pressure (hypertension), elevated weight, diabetes, and/or other heart or lung disorders. This is important, because some of these same conditions have been shown to increase the risk of more serious COVID-19 infection. For example, hypertension is a well-known risk factor for severe COVID-19 infection6-8 which is also known to be better controlled when sleep apnea itself is properly treated.9
A very recent report looked at the risk of sleep apnea on COVID-19 severity: although there was a trend showing sleep apnea may be a risk factor for bad COVID-19 outcomes, this finding was much weaker when also factoring in for the effects of hypertension, diabetes and being overweight on COVID-19 outcomes that were observed in those same study participants.10
In this sense, it may be important to optimize all chronic conditions (including sleep apnea) as much as possible, to keep as healthy as possible overall.
Reduction of in-person interactions in the healthcare system
The healthcare system as a whole is trying to limit the amount of in-person interactions in order to limit the spread of infection, including sleep clinics.1,4
Fortunately, many CPAP machines nowadays can collect clinical information that can be sent remotely to your care provider. This, combined with ‘virtual’ telephone or video clinic visits, can help to minimize interruptions to your care.
Does using my Continuous Positive Airway Pressure (CPAP) machine affect the spread of COVID-19?
As a general rule, using positive pressure machines like CPAP machines are felt to be aerosol-generating. Therefore, a reasonable concern that you may have is whether using your CPAP machine might promote the spread of COVID-19 infection.
Should I continue my CPAP treatment during the pandemic?
If you do not have any symptoms of COVID-19 infection, the recommendation of the Canadian Thoracic Society is to continue using your CPAP machine as usual.1 Of course, it remains very important to:
- Clean your equipment (hose and mask)
- Not share any of your personal equipment with others.
What should I do if I live with sleep apnea and develop symptoms of COVID-19?
If you do develop symptoms of COVID-19 infection and already live with sleep apnea, then you should discuss whether or not to continue using your machine with your treating team. In this case, the choice balances the risks and benefits of stopping or not stopping treatment for you and for those around you.
For example, if you do live with others and develop symptoms of COVID-19, and it is decided that it still is best for you to continue using your CPAP machine, it would be prudent for you to sleep alone in a separate room. Extra recommendations from the Canadian Thoracic Society guidelines which may be worth discussing with your treating team include1:
- Increasing how often you clean your equipment (every other day)
- Possibly not using humidification
- Possibly using a full face mask
What you need to remember
If you are currently living with obstructive sleep apnea:
- Continue using your CPAP machine if you do not have symptoms of COVID-19
- Continue to optimize your diet, exercise, and weight control
- Continue to optimize any other health conditions you may also have
- If you develop symptoms of COVID-19, talk to your treating team about the best plan moving forward. The solution here should maximize your sleep apnea control while minimizing possible infection spread.
About the author
Bryan completed his medical school and Internal Medicine residency at the University of Toronto, and his Respirology fellowship at the University of Alberta. Most recently, he completed an additional fellowship at the Montreal Chest Institute (McGill University Health Centre) in pulmonary rehabilitation and chronic disease management. Prior to his medical training he completed his undergraduate degree at Queen’s University and his master’s degree in Physiology at McGill University. He has had a longstanding clinical and research interest in respiratory and cardiac physiology and applied exercise science, in pulmonary rehabilitation, and in the management of chronic respiratory disease.