MANCHESTER, NH — Millions of Americans with obstructive sleep apnea use continuous positive airway pressure, or CPAP, machines.
All these OSA patients should consult their sleep physicians to explore an alternative treatment plan during the new coronavirus pandemic, according to Haitham S. Al Ashry, M.D. at Elliot Pulmonary and Sleep Medicine in Manchester.
Why would these patients need a new plan? Because CPAP machines can increase the aerosolization of COVID-19, the disease caused by the coronavirus, Al Ashry explained. He added this is “probably true for other viruses and bacteria, not only COVID-19.”
“The reason is the current CPAP masks are vented to allow some air leak. We call such leak: intentional leak and its purpose is to prevent the patient from re-breathing his/her own carbon dioxide, which can sometimes be dangerous,” Al Ashry wrote in an email. “As such the American Academy of Sleep Medicine recommends that patients with symptoms of respiratory infections contact their sleep physician to come up with a treatment plan. The treatment plan will depend on how severe OSA is at baseline. In very mild cases of OSA, it may be reasonable to stop using CPAP temporarily and use conservative measures to treat OSA until the patient recovers from the respiratory infection. In moderate to severe cases of OSA, the sleep physician will discuss with the patient whether CPAP can be continued in a safe manner. This may entail having the patient sleep alone in one bedroom that is strictly isolated and meticulously disinfected. If this strict isolation can’t be achieved, then based on the phenotype of OSA, the sleep physician may suggest stopping CPAP treatment and using other temporary measures for treatment until the patient recovers from the respiratory infection.”
Al Ashry wrote this guidance is based on “expert opinion,” adding, “COVID-19 is a new virus and it has not been extensively studied in sleep-disordered breathing.”
The CPAP machine and the similar BiPAP (bilevel positive airway pressure) machine are recommended mainly for patients with OSA.
“There are other disorders in which these machines are used including conditions like obesity hypoventilation syndrome (under breathing during sleep due to obesity), chronic obstructive pulmonary disease, and neuromuscular disorders,” Al Ashry wrote. “In clinical practice, OSA is the most common clinical condition we use these machines for. OSA is highly prevalent and some studies show 70% of the population 60 years or older have some degree of OSA. It is really important to screen and treat for OSA because if left untreated it can increase the risk for heart attacks, abnormal heart rhythm, strokes, early dementia, and blood clots. In fact, patients with any of these conditions should get a screening sleep study even if they don’t have symptoms of OSA.”
During the COVID-19 public health emergency, the American Academy of Sleep Medicine has recommended a temporary stop to lab sleep studies to reduce risk of patients’ exposure to healthcare facilities, Al Ashry wrote. But it has recommended continuing home sleep testing.
“The rationale behind such recommendation is that leaving OSA untreated can actually increase risk of hospital admissions due to associated complications,” he wrote. “Currently at our Elliot Hospital Sleep Division, we implemented a process in place in which patients can pick up these home sleep testing devices through Elliot’s pharmacy drive-thru and drop off the device the next day for interpretation. Through this process, and in combination with tele-health sleep consultation services, we are able to evaluate and treat patients from a distance.”
While COVID-19 has not been extensively studied in patients with OSA, it is believed patients with untreated OSA are at high risk for pneumonias and respiratory infections in general, he wrote.
“There are actually studies showing that OSA is associated with airway inflammation, which makes it easier to contract respiratory infections. In fact, an elegant study published in the European Respiratory Journal a few years ago showed that treating OSA with CPAP resulted in reduction of biomarkers of airway inflammation,” Al Ashry wrote.
The American Academy of Sleep Medicine (AASM) website (https://aasm.org) is continuing to gather and post information and resources for patients and the public about sleep, obstructive sleep apnea, CPAP therapy, and the novel coronavirus.
The AASM site states those with sleep apnea do not have a higher risk of getting coronavirus. However, those who are 65 years of age or older with serious underlying medical conditions do have a higher risk. The at-risk medical conditions include chronic lung disease, moderate to severe asthma, serious heart conditions, severe obesity with a body mass index (BMI) of 40 or higher, diabetes and chronic kidney or liver disease. The AASM advises those with symptoms of the coronavirus to isolate themselves in a separate bedroom and use a separate bathroom, if available.
“Even if you don’t have symptoms of the coronavirus, you may want to sleep and use CPAP in a separate bedroom during this public health emergency,” the AASM states.
In this “recovery room,” a CPAP machine can continue to be used but the following rules are recommended:
- Wash your hands thoroughly with soap and water before and after handling the CPAP device, mask, tubing and filters.
- Clean your CPAP equipment according to manufacturer’s instructions.
- Change filters and accessories as directed in your CPAP user guide.
- Avoid letting anyone smoke in your home, especially around the CPAP machine.
- Keep pets away from your CPAP machine.
- Use distilled water in your humidifier to keep the tube clean.
“If you have symptoms of the coronavirus but are unable to isolate yourself in a separate bedroom, then you should contact your medical provider. Ask your medical provider if there are short-term interventions or alternative treatments for sleep apnea that could help you while you recover from the coronavirus,” the AASM website states. “If you have the coronavirus, you should continue using CPAP while sleeping alone in a separate bedroom. There is no evidence that using CPAP will cause the coronavirus to get worse.”
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