key: cord-287281-x30fx97e
authors: Thorpy, Michael; Figuera-Losada, Mariana; Ahmed, Imran; Monderer, Renee; Petrisko, Monica; Martin, Chris; Akhtar, Jamal; Thorpy, Jacqueline; Haines, Carver
title: Management of Sleep Apnea in New York City during the COVID-19 Pandemic
date: 2020-07-18
journal: Sleep Med
DOI: 10.1016/j.sleep.2020.07.013
sha: 
doc_id: 287281
cord_uid: x30fx97e

With the onset of the COVID-19 outbreak there has been concern that patients with obstructive sleep apnea (OSA) who develop COVID-19 may be at risk of greater morbidity and mortality than patients without OSA. COVID-19 is associated with an increased mortality in the elderly and particularly those with obesity, hypertension and diabetes, features which are typically seen in patients with OSA. This article describes the COVID-19 environment in New York City in which patients were evaluated and treated for OSA. A telephone questionnaire survey of 112 OSA patients determined the occurrence of COVID-19 in the sleep apnea population and the patients’ perspective on sleep apnea Positive Airway Pressure (PAP) management during the COVID-19 outbreak. The three main objectives of the survey were as follows: 1) To discover how patients were coping with COVID-19 pandemic in terms of their sleep apnea and PAP use, 2) To determine whether PAP usage changed after the onset of the outbreak in terms of adherence, and 3) To find out if patients were concerned about whether they were at greater risk of contracting COVID-19 because of their sleep apnea and, if they became infected, whether COVID-19 might result in greater complications because of the presence of sleep apnea. The adjustment in clinical management of OSA patients is described both during the peak of the outbreak in NYS, as well as the proposed modifications that will be instituted in order to return to full sleep center activities.

whether PAP usage changed after the onset of the outbreak in terms of adherence, and

3) To find out if patients were concerned about whether they were at greater risk of contracting COVID-19 because of their sleep apnea and, if they became infected, whether COVID-19 might result in greater complications because of the presence of sleep apnea.

The adjustment in clinical management of OSA patients is described both during the peak of the outbreak in NYS, as well as the proposed modifications that will be instituted in order to return to full sleep center activities.

Highlights:

Common OSA comorbidities such as hypertension, diabetes mellitus and obesity, overlap with those of patients who die of COVID-19 complications and the interaction needs further research.

Treating OSA patients with PAP during the COVID-19 pandemic requires careful management to reduce patient concerns and optimize patient care.

Safety measures to minimize exposure and dissemination of COVID-19 by PAP therapy should be instituted by sleep centers during both the peak of the epidemic and at centers reopening.

In December of 2019 a series of viral pneumonia cases were reported in China.

Analysis of patient samples by deep sequencing showed that a novel coronavirus, severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), was the cause of the illness which was later named coronavirus disease [1, 2] .

Clinical features of COVID-19 include fever, cough, shortness of breath or difficulty breathing, chills, shaking, headaches, muscle aches, loss of sense of smell or taste [3] .

As of the end of April 2020, it has been reported that about 80% of people infected by the novel coronavirus had mild flu-like symptoms and recovered without having to seek medical attention [4] . However, severe illness and hospitalization has been reported in patients with comorbidities such as chronic lung disease, diabetes, heart conditions, hypertension, chronic kidney disease, obesity, age 65 years and older, immunocompromised, and liver disease [5, 6, 7] .

Interestingly, many of the COVID-19 severe illness risk factors are also well-known comorbidities of obstructive sleep apnea (OSA), a highly prevalent sleep-related breathing disorder estimated to affect over 29 million people in the U.S. alone. OSA is characterized by reduced breathing and/or breathing cessation during sleep and is more often seen in older obese adults with a prevalence of approximately13% in males and 9% in females [8, 9, 10, 11] . The comorbidities associated with death in patients with COVID-19 commonly occur in patients with OSA, including hypertension, diabetes mellitus, hyperlipidemia and obesity. In addition, OSA patients have compromised breathing. This suggests that OSA patients on PAP may have greater concerns than the general population about being infected with COVID-19.

This manuscript documents how the COVID-19 pandemic affected patients with OSA on PAP in the epicenter of the illness as was found in New York City. Information obtained from a survey indicated whether patients with OSA who were on a PAP device, were concerned enough to ensure their OSA was being effectively treated during this time.

The survey also indicated the degree of concern that patients with OSA had that they might be more susceptible to get COVID-19 because of their OSA, and asked whether patients were concerned that by having OSA they might be more likely to have more severe complications of COVID-19 because of their OSA.

Although the American Academy of Sleep Medicine (AASM) has made theoretical recommendations for the management of OSA during the pandemic this manuscript describes the clinical practice that occurred in a sleep center that continued to operate during the COVID-19 pandemic, although in a reduced capacity, and the steps that were taken from a practical aspect to treat patients during this time.

We believe the information obtained from our experience will be found useful by other sleep centers that are in early stages of the pandemic, or may be facing a similar pandemic in the future.

The COVID-19 outbreak pandemic has been particularly devastating to the vulnerable populations that are well represented in New York State (NYS), New York City (NYC) and the Bronx. NYC was the major epicenter of the COVID-19 outbreak in the USA. The first case of COVID-19 was detected in NYC on March 1 st 2020 in a 39 year old female healthcare worker [12] . The outbreak spread rapidly throughout the city and state and by April 25 th there were 288,045 positive cases in NYS. The positivity rate peaked on April 14 th . NYC hospital admissions were at a peak on April 6 th and daily deaths peaked on April 7 th [13] . The NYC death rate affected a higher percentage of Blacks and Hispanics. [13] .

The number of deaths related to COVID-19 in NYS peaked on April 26 th with 59.6% males and 40.3% females, and older age (≥65 years) and the presence of comorbidities were associated with a more severe course. Of those that died due to complications of COVID-19, hypertension, diabetes mellitus, hyperlipidemia, and coronary artery disease were the most common comorbidities [14] . Surprisingly, obesity was not reported as a comorbidity.

Even though the sex distribution for positive cases in NYC was roughly the same for males and females (51.8% males and 47.7% females), nearly 60% of fatalities constitute male patients. Similarly, lower socioeconomic status has been associated with increased mortality. The Bronx population is a lower income working class population [15] .

The (ASV). The SWDC operating modifications are described both during the peak of the outbreak in NYS, and the proposed modifications that will be instituted in order to return to full sleep center activities.

In the Bronx public health insurance is more common (16%) while 12% of patients have Private Health Insurance, 10% Employer-based health Insurance, 9% Medicare, and 10% Medicaid [16] . Soon after the outbreak of COVID-19 in NYC the SWDC altered its procedures accordingly, and moved to telemedicine with video telehealth for new patients so patients did not need to physically visit the SWDC. New patient appointments were mainly done from the physician's home by video televisits, and patient follow-up appointments were mainly by telephone televisits, but a small number also had video televisits. A proprietary video system called, Montefiore First, was established for patient scheduling and appointments by video televisits. The secretarial staff maintained the schedule, and relayed telephone calls to the clinicians for televisits. These patients ranged in age from 43 to 77 years of age, and 100% were overweight or obese, 30% had diabetes mellitus, 80% had cardiovascular diseases, and 20% had asthma. Two patients increased their use of PAP device at least in the early stages of the illness. Six patients reported not using their PAP device because of difficulty breathing.

Of all patients surveyed, 85 (88%) continued to use their PAP device during the COVID-19 outbreak. 11 (11%) of patients surveyed indicated that they had ceased to use their PAP device. 21 (20%) indicated that they were using their PAP device more during the outbreak. Patients were concerned about the presence of OSA if they were to get COVID-19 and believed that using the PAP device more often and/or for a longer time would be of clinical benefit at this time. 41 (38%) patients indicated that they were concerned about getting COVID-19 because they had OSA. 29 (29%) felt that they were at greater risk of getting COVID-19 because they had underlying OSA, even though there is no evidence that they would be more vulnerable to acquire COVID-19. 63 (63%) patients were concerned that the presence of OSA made them more likely to have greater medical complications if they were to get COVID-19.

Many patients indicated that they were concerned about COVID-19 because of their associated comorbidities. Comorbidities were: obesity 77%, asthma or COPD 31%, diabetes 24%, and cardiovascular disease 83% including hypertension (59%), arrhythmias (8%) or coronary artery disease (11%).

A two-phase plan was devised for return to full SWDC activities as resolution of COVID-19 allows.

The first phase will be the return of clinical and technical staff who are currently redeployed to COVID-19 activities in the hospital. All returning clinical staff will have COVID-19 testing before seeing patients in the SWDC.

Patients with any type of sleep disorder will be evaluated either in the office, or by telehealth. Baseline sleep studies, PAP titrations, PAP-NAP tests, Multiple Sleep Latency Tests (MSLT) and Maintenance of Wakefulness (MWT) tests will resume on a limited basis.

All new patients under aged 70 years at initial sleep evaluation will be seen on the SWDC premises and appointments will be scheduled at 1-2 per hour maximum to allow for social distancing. Clinicians will be on site one day per week on a staggered schedule with only one clinician present at any one time. Patients older than 70 years of age would be evaluated only by Telehealth.

All follow-up appointments will be by telehealth from the clinician's home. If a physical exam or hands-on PAP or PAP mask education is deemed necessary for follow-up patients they will be seen in the SWDC. No patients with COVID-19 would be seen within 3 weeks of onset of symptoms.

The office environment will be modified so that Plexiglass shields would surround all secretarial desks. Masks, hand sanitizers and disinfectant wipes would be fully available to staff and patients. Staff will wear N95 masks and use gloves at all times. All patients seen at the SWDC will be required to wear a mask and gloves. If a patient presents without a mask, a surgical mask will be provided as well as plastic one-time-use gloves.

Patient forehead temperatures would be checked and saliva viral tests performed by the clerical staff. The office waiting room would allow for 6 feet social distancing. If a patient refuses to comply, the patient would be scheduled for a televisit appointment.

For sleep studies in the SWDC, the technicians will be required to use N95 masks, gloves, eye shields and when necessary, gowns when interacting with patients.

Forehead temperature and a COVID-19 test would be taken on all patients arriving for sleep lab evaluation.

Plastic vertical split screens would be placed outside the doors to PAP titration rooms to minimize aerosolization, and a HEPA air purifier installed in each room. Several rooms will have fans installed in the walls to create a negative pressure environment.

The second phase, when the risk of COVID-19 is further reduced, would entail all new patients, including those over the age of 70 years, being physically seen in the SWDC.

Full clinical staff attendance will occur one to two days per week. Patients with a history of COVID-19 would be excluded, unless shown to be cleared by viral testing before attending the SWDC. Appointments will be at intervals of 30 minutes minimum to allow for social distancing. Most patients evaluated by in-lab polysomnography with the remainder having HST as determined by the clinician or health insurance. Masks, gloves and gowns would be discretionary depending upon the consideration of potential risk of COVID-19 from the patient. Telehealth would be utilized for patient follow-up appointments, and initial evaluation of patients especially those who live more than approximately 100 miles from the SWDC.

With the onset of the COVID-19 outbreak there has been concern that patients with OSA who develop COVID-19 may be at risk of greater morbidity and mortality than patients without OSA. COVID-19 is associated with difficulty in breathing and the development of a pneumonia that has led to an increased mortality in the elderly and particularly those with obesity, hypertension and diabetes [17, 18, 19] . There is currently no data on the prevalence of OSA in COVID-19 patients, however the profile of those with greater likelihood of death associated with COVID-19 is similar to our random sample of 112 PAP using OSA patients many of whom have cardiovascular disease, hypertension, obesity and diabetes mellitus.

OSA is a risk to negative outcomes (such as ICU admission, assisted ventilation or death) in COVID-19 patients and could act as a facilitator of COVID-19 infection [20] .

OSA in patients with COVID-19 could produce a higher incidence of cardiovascular complications, such as arrhythmias, cardiac ischemia, and hypercoagulability states, leading to an unfavorable clinical progression. Sleep deprivation has also been suggested as adding to the severity of the pulmonary inflammatory process of COVID-19. [21] .

Untreated OSA patients are at risk of under-aeration of the lungs and associated hypoxemia which could exacerbate the clinical course of COVID-19. Contamination fears from using nasal positive airway pressure may also be a contributing factor to deterioration in some OSA patients [22] . PAP therapy in the early stages of COVID-19 was reported by some of our patients to be helpful prior to hospitalization, and positive end expiratory pressure has been shown to be helpful for COVID-19 patients on admission to hospital.

Our patients reported concern for complications due to COVID-19 because of their OSA and most were adherent to treatment during the time of the COVID-19 outbreak. 9% of our OSA patients had been infected with COVID-19 and some of these patients reported to have increased their use of PAP, at least in the early stages of their COVID-19 illness. Many patients believed they were not at increased risk of contracting COVID-19 because of the OSA, however they did believe that they could have a more complicated medical course if they were to get COVID-19.

Whether a PAP would be helpful to prevent complications of COVID-19 is unknown.

However it would seem reasonable to suspect that the use of a PAP device may help alleviate some of the breathing difficulty associated with sleep apnea and COVID-19, at least initially in the course of the illness. Some patients with COVID-19 increased their use of PAP while infected and one patient indicated he used it 24 hours a day as he believed it helped his breathing Because of concern regarding COVID-19 cross infection, patients typically have not been studied for OSA either in the laboratory or by HST during the COVID-19 outbreak.

In fact, there has been concern about studying OSA patients with PAP devices because of the potential for aerosolization of the COVID-19 virus. Partly for these reasons many sleep laboratories ceased sleep evaluation activities during the COVID-19 outbreak.

However, PAP machines were sometimes modified for use in hospitalized patients to help prevent the need for, or in the absence of a standard ventilators [23, 24] .

Management of OSA patients during the COVID-19 pandemic has been complicated by the closing of sleep centers due to concern over COVID-19 infection of staff or patients, and the need for clinical staff to attend to COVID-19 patients in other settings. The ability to telehealth patients during the outbreak was reassuring to many OSA patients and the ability to perform HST and place patients on autoCPAP were measures that greatly increased the ease of access to therapy for OSA patients.

The lack of appropriate physical measures to prevent the spread of COVID-19 was a factor in preventing many labs form evaluating and treating patients with OSA. Noninvasive ventilation (NIV), including CPAP, is a high-risk aerosol-generating procedure that could put healthcare workers and family members at increased risk. [2, 3, 25] . There has been reported comparable viral load detection in nasal and throat swabs of symptomatic and asymptomatic patients, suggesting NPAP-induced aerosolization from asymptomatic patients may pose risks for viral transmission to family members or clinical staff [6] .

It has been recommended that patients with OSA cease to use home PAP during the COVID-19 pandemic [26] , while others have recommended that PAP therapy be continued [27] . Many patients in our survey felt greater health security when using PAP therapy. One patient with COVID-19 was concerned that he was advised not to use CPAP on admission to hospital, whereas he found it helpful at home before hospital admission.

Failure to use PAP at home would lead to a return of symptoms of sleepiness that would affect quality of life and predispose the patient to accidents, and possible increased risk of cardiovascular or cerebrovascular events. A return of snoring could affect the sleep of family members' sleep at a time of high anxiety over the COVID-19

pandemic. In addition, positive end expiratory pressure (PEEP) during pulmonary edema, atelectasis, or pneumonia has been demonstrated to improve arterial oxygenation by increasing functional residual capacity, and reducing both the work of breathing [28] .

In order to continue to treat OSA patients during the COVID-19 pandemic sleep laboratories need to undertake modifications to their usual routine, such as we outlined above, in order to safeguard the staff and patients from infection or reinfection.

In summary, sleep apnea is associated with risk factors that are similar to those associated with morbidity and mortality of hospitalized COVID-19 patients. Patients using PAP devices reported comfort in using their device during the pandemic and believed that they were at greater risk of complications from COVID-19 because of their sleep apnea.

Sleep centers are recommended to develop appropriate procedures to continue to diagnose and treat sleep apnea patients during the COVID-19 pandemic. Those that were unable to operate during the pandemic should try to establish procedures to recommence sleep apnea management after the COVID-19 peak as quickly as feasible, depending upon local COVID-19 conditions. Telehealth is a very efficient way to streamline patient care and to avoid unnecessary patient travel, especially for those that are at a higher medical risk of getting COVID-19 due to comorbidities. Additionally, even with the pandemic improvements in the NYC area, it is possible that an outbreak reoccurrence could occur and the presence of telehealth systems will help prevent interruption of patient care. Highlights:

Common OSA comorbidities such as hypertension, diabetes mellitus and obesity, overlap with those of patients who die of COVID-19 complications and the interaction needs further research.

Treating OSA patients with PAP during the COVID-19 pandemic requires careful management to reduce patient concerns and optimize patient care.

Safety measures to minimize exposure and dissemination of COVID-19 by PAP therapy should be instituted by sleep centers during both the peak of the epidemic and at centers reopening.

Coronaviridae Study Group of the International Committee on Taxonomy of, V. The species Severe acute respiratory syndrome-related coronavirus: classifying 2019-nCoV and naming it SARS-CoV-2

Clinical features of patients infected with 2019 novel coronavirus in Wuhan

Novel Coronavirus Pneumonia Emergency Response Epidemiology, T. [The epidemiological characteristics of an outbreak of

Groups at Higher Risk for Severe Illness

Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the

Prevalence of comorbidities and its effects in coronavirus disease 2019 patients: A systematic review and meta-analysis

Obstructive sleep apnea is a common disorder in the population-a review on the epidemiology of sleep apnea

Epidemiological aspects of obstructive sleep apnea

Underdiagnosing and Undertreating Obstructive Sleep Apnea Draining Healthcare System

Increased prevalence of sleep-disordered breathing in adults

Coronavirus in NY: Manhattan woman is first confirmed case in state. The New York Times

New Yrk Department of Health

Factors associated with hospitalization and critical illness among 4,103 patients with COVID-19 disease

NY Health Insurer Data. Vista health Solutions

Obesity a Risk Factor for Severe COVID-19 Infection: Multiple Potential Mechanisms. Naveed Sattar, MD1; Iain B. McInnes, MD2

Lille Intensive Care COVID-19 and Obesity study group. High prevalence of obesity in severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) requiring invasive mechanical ventilation. Obesity (Silver Spring)

Obesity in patients younger than 60 years is a risk factor for COVID-19 hospital admission

Does obstructive sleep apnea lead to increased risk of COVID-19 infection and severity?

COVID-19 and obstructive sleep apnea

Potential influences of obstructive sleep apnea and obesity on COVID-19 severity

Home PAP devices in COVID-19 infected patients

Helmet CPAP to Treat Acute Hypoxemic Respiratory Failure in Patients with COVID-19: A Management Strategy Proposal

Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review

Guidance regarding coronavirus (COVID-19) and obstructive sleep apnoea (OSA): for people who routinely use continuous positive airway pressure (CPAP), their families and health care workers

Case for continuing community NIV and CPAP during the COVID-19 epidemic

Intermittent hypoxemia and OSA: implications for comorbidities