ABSTRACT
(1) Background: The Berlin questionnaire (BQ) is a widely used survey to predict obstructive sleep apnea (OSA). Considering the confounding effect of obesity and hypertension on the clinical course of COVID-19, we have recently developed a modified BQ (mBQ) based on the subscales snoring intensity/frequency, witnessed apneas and morning/daytime tiredness, and demonstrated that patients with high-risk OSA had worse outcomes during the COVID-19 pandemic. In the current study, we aimed to validate the mBQ in adults with a history of COVID-19 infection. (2) Method: All cases who suffered from COVID-19 infection between 10 March and 22 June 2020, and who completed the mBQ in our first study, were invited to participate. Participants refilled the questionnaires, and an attended polysomnography (PSG) was conducted. An apnea-hypopnea index (AHI) of 15 events/h or more was considered as OSA. (3) Results: Out of the 70 participants, 27 (39%) were categorized as having a high risk of OSA based on the mBQ. According to the PSG results, 24 patients with high-risk OSA (89%) and 3 patients with low-risk OSA on the mBQ (7%) had AHI ≥ 15 events/h. The mBQ had a sensitivity of 89%, a specificity of 93%, a positive predictive value of 89%, a negative predictive value of 93%, and an accuracy of 91%. The area under the curve was 0.91 confirming a very good performance of the mBQ in screening for OSA. (4) Conclusions: The mBQ has a good level of diagnostic sensitivity, specificity, and accuracy among adults with a history of COVID-19 infection. Since the confounding effects of obesity and hypertension are eliminated, the mBQ may be used not only as a screening tool for high-risk OSA but also as a prognostic survey in clinical cohorts.
ABSTRACT
Rationale: Coronavirus disease (COVID-19) is an ongoing pandemic, in which obesity, hypertension, and diabetes have been linked to poor outcomes. Obstructive sleep apnea (OSA) is associated with these conditions and may influence the prognosis of adults with COVID-19. Objectives: To determine the effect of OSA on clinical outcomes in patients with COVID-19. Methods: The current prospective observational study was conducted in three hospitals in Istanbul, Turkey from March 10 to June 22, 2020. The participants were categorized as high-risk or low-risk OSA according to the Berlin questionnaire that was administered in the out-patient clinic, in hospital, or shortly after discharge from hospital blinded to the clinical outcomes. A modified high-risk (mHR)-OSA score based on the snoring patterns (intensity and/or frequency), breathing pauses, and morning/daytime sleepiness, without taking obesity and hypertension into account, were used in the regression models. Results: The primary outcome was the clinical improvement defined as a decline of two categories from admission on a 7-category ordinal scale that ranges from 1 (discharged with normal activity) to 7 (death) on Days 7, 14, 21, and 28, respectively. Secondary outcomes included clinical worsening (an increase of 1 category), need for hospitalization, supplemental oxygen, and intensive care. In total, 320 eligible patients (median [interquartile range] age, 53.2 [41.3-63.0] yr; 45.9% female) were enrolled. In all, 121 (37.8%) were categorized as known (n = 3) or high-risk OSA (n = 118). According to the modified scoring, 70 (21.9%) had mHR-OSA. Among 242 patients requiring hospitalization, clinical improvement within 2 weeks occurred in 75.4% of the mHR-OSA group compared with 88.4% of the modified low-risk-OSA group (P = 0.014). In multivariate regression analyses, mHR-OSA (adjusted odds ratio [OR], 0.42; 95% confidence interval [CI], 0.19-0.92) and male sex (OR, 0.39; 95% CI, 0.17-0.86) predicted the delayed clinical improvement. In the entire study population (n = 320), including the nonhospitalized patients, mHR-OSA was associated with clinical worsening (adjusted hazard ratio, 1.55; 95% CI, 1.00-2.39) and with the need for supplemental oxygen (OR, 1.95; 95% CI, 1.06-3.59). Snoring patterns, especially louder snoring, significantly predicted delayed clinical improvement, worsening, need for hospitalization, supplemental oxygen, and intensive care. Conclusions: Adults with mHR-OSA in our COVID-19 cohort had poorer clinical outcomes than those with modified low-risk OSA independent of age, sex, and comorbidities. Clinical trial registered with www.clinicaltrials.gov (NCT04363333).