Sleep testing during the pandemic.

BACKGROUND: The COVID-19 pandemic disrupted the U.S. healthcare system, reducing the capacity available for unrelated conditions, such as sleep disordered breathing, and increasing concerns about the safety of in-lab testing. This study characterizes how the pandemic impacted the assessment of sleep disordered breathing and use of associated services. METHODS: Sleep testing claims occurring between January 2019 and June 2021 were extracted from the database of a national healthcare organization. Utilization was trended. Logistic regressions were run to assess the association between quarter of initial testing, whether testing was followed by treatment, and whether testing was followed by a clinical visit with a diagnosis related to sleep apnea, after controlling for patient-related factors. A Cox proportional hazards model assessed factors influencing time to treatment. Finally, a logistic regression assessed factors influencing the finality of home-based testing. RESULTS: In Q2 2021, home-based testing utilization was 134% of its initial level, while in-lab and split night testing were both at 61% of initial levels. Patients receiving initial home-based testing did not significantly differ in their likelihood of treatment, but were significantly less likely to have a clinical visit for sleep apnea (P < 0.01). Patients initially tested in 2021 were treated significantly more quickly than those initially tested in Q1 2019. Home-based testing occurring in Q4 2019 or later was significantly more likely to be definitive than home-based testing occurring Q1 2019. CONCLUSIONS: Home-based sleep testing increased significantly and durably in 2020, and was associated with faster time to treatment than initial in-lab testing.

The Utility of Home Sleep Apnea Testing in the Advanced Heart Failure Populations.

Untreated sleep disorders form a risk of coronary artery disease, hypertension, obesity, and diabetes mellitus. Access to polysomnography is limited, especially during the COVID-19 pandemic, with home sleep apnea testing (HSAT) being a potentially viable alternative. We describe an HSAT protocol in patients with advanced heart failure (HF). In a single-center, observational analysis between 2019 and 2021 in patients with advanced HF and heart transplant (HT), 135 screened positive on the STOP-Bang sleep survey and underwent a validated HSAT (WatchPAT, ZOLL-Itamar). HSAT was successful in 123 patients (97.6%), of whom 112 (91.1%; 84 HF and 28 HT) tested positive for sleep apnea. A total of 91% of sleep apnea cases were obstructive, and 63% were moderate to severe. Multivariable linear regression showed that the apnea hypopnea index was 34% lower in the HT group than in the HF group (p = 0.046) after adjusting for gender, and that this effect persisted in White patients but not among African-Americans. Patient characteristics were similar between groups, with coronary artery disease, diabetes mellitus, and hypertension as the most prevalent co-morbidities. In conclusion, sleep apnea remains prevalent in patients with HF with a high co-morbidity burden. HSAT is a feasible and effective tool for screening and diagnosis in this population.

Influences of sleep and lifestyle factors on the risk for covid-19 infections, from internet survey of 10,000 Japanese business workers.

We conducted an internet survey to assess sociodemographic variables, lifestyle factors, sleep problems, and comorbidities for sleep apnea syndrome (SAS) in COVID-19 and influenza (FLU) infections. Data from 10,323 workers (50.0% male) were analyzed. COVID-19 was diagnosed in 144 subjects (COVID-19+), and 8,693 were classified as not suspected to be infected (COVID-19-). SAS had been diagnosed in 35.4% of the COVID-19+ subjects, but only 231 (2.7%) of the 8,693 COVID-19- subjects. COVID-19+ subjects were more susceptible to FLU (35.4%) compared to COVID-19- subjects (3.0%). A multivariate analysis revealed that higher risks of COVID-19+ were linked to the following factors: going out without a face mask (OR 7.05, 95% CI 4.53-11.00), FLU+ (OR 6.33, 95% CI 3.80-10.54), excessive exercise before going to sleep (OR 2.10, 95% CI 1.63-2.70), SAS+ (OR 5.08, 95% CI 2.88-8.94), younger age (OR 1.05, 95% CI 1.03-1.07), falling sleep while sitting or talking with someone (OR 3.70, 95% CI 2.30-5.95), and use of hypnotics (OR 2.28, 95% CI 1.20-4.30). Since sleep impairment played a relatively small role in COVID-19+/SAS- subjects, we assume that SAS itself was a more significant risk factor for COVID-19 infection rather than sleep impairment. A better understanding of the mechanisms that result in increased susceptibility to COVID-19 in SAS is vital for helping prevent COVID-19.

Obstructive Sleep Apnea with COVID-19.

The novel coronavirus disease-2019 (COVID-19) and the ensuing pandemic have greatly impacted the global healthcare system due to its high infectiousness, associated high mortality, and a complete lack of immunity in the population. Globally, the COVID-19 pandemic has unleashed a health crisis that has not only seriously disrupted people's lives but also affected their normal sleep, along with physical and mental health; this situation is especially exacerbated in people suffering from pre-existing conditions, such as sleep apnea. A recent meta-analysis of 18 studies by Miller et al. (September 2020) showed that obstructive sleep apnea (OSA) is related to higher mortality and morbidity in patients with COVID-19 and is most likely independent of other risk factors. A recent meta-analysis indicated that COVID-19 patients with OSA are more severely affected than those without OSA, thereby providing further evidence that concurrent OSA may elevate the severity of COVID-19 infection, along with the risk of mortality. The COVID-19 pandemic has significantly impacted the diagnosis and therapeutic management of patients with OSA. Thus, it is necessary to identify and develop new diagnostic and therapeutic avenues in the future. In this context, the current study summarizes known associations between COVID-19 and OSA and the regular diagnostic and therapeutic strategies for OSA in the light of COVID-19 pandemic prevention and control.

Prevalence of sleep apnea in children and adolescents in Colombia according to the national health registry 2017-2021.

OBJECTIVE: To describe the sociodemographic and epidemiological characteristics of diagnosis and treatment of pediatric patients with sleep apnea, both central and obstructive, in Colombia between 2017 and 2021. METHODS: Observational, descriptive, cross-sectional, epidemiological study using the International Classification of Diseases and Related Health Problems as search terms for sleep apnea, based on SISPRO, the Colombian national health registry. Stratification by gender and age groups was performed. We also generated data of the amount of diagnostic and therapeutic procedures performed. A map of prevalence by place of residency was performed. RESULTS: National records report 15200 cases of SA between 2017 and 2021, for an estimated prevalence of 21.1 cases by 100000 inhabitants in 2019 the year with the most cases (4769), being more frequent and in the 6 to 11 age group and in males, with a male to female ratio of 1.54:1. The number of cases declined in 2020 and 2021. The map showed a concentration of cases in the more developed departments of the country. DISCUSSION: This is the first approximation to a nation-wide prevalence of sleep apnea in Colombia which is lower to what is found in the literature worldwide, including studies performed in Latin America and in Colombia, this could reflect sub diagnosis and sub report. The fact that the highest prevalence was found in males and in the 6-11 age group is consistent with reports in literature. The decrease in cases in 2020 and 2021 could be related to the COVID-19 pandemic impact in sleep medicine services.

Did COVID-19 impact Positive Airway Pressure adherence in 2020? A cross-sectional study of 8477 patients with sleep apnea.

BACKGROUND: Whether the COVID-19 pandemic impacts Positive Airway Pressure (PAP) adherence over the long-term is unknown and only preliminary short-term data have been reported. METHODS: With the aim of describing the impact of the first and second waves of COVID-19 on PAP adherence during 2020 in France, we designed a cross-sectional study of Sleep-Apnea (SA)-patients under PAP telemonitoring. To examine PAP adherence in adult SA patients, we assessed de-identified data from a non-profit healthcare provider database during the period January 1, 2019 to December 31, 2020. Included patients met the following criteria: (i) PAP-treated for at least 4 months before January 1, 2019 and with continuous PAP during both 2019 and 2020; (ii) ≥ 360 daily PAP telemonitored data per year. For PAP adherence, data were collected using the PAP-software. RESULTS: 8477/10482 patients were finally included in the analysis [72.4% male, median age 70 years (IQ25-75: 61-77], 25.6% < 62 years old, initial Apnea-Hypopnea Index (AHI) of 41 (31-59)/h. Median PAP adherence was 7.21 (6.12-8.10) h/day in 2020 versus 7.12 (6.05-8.02) h/day in 2019, p < 0.001. The median difference in PAP adherence between the first 2020 lockdown and the corresponding 2019 weeks was 9.75 (CI95% 8.75-10.75) min/day, p < 0.001. The median difference in PAP adherence between the second 2020 lockdown and the corresponding 2019 weeks was 5.00 (CI95% 4.00-6.00) min/day, p < 0.001. If we consider the minimal clinically important difference of 30 min for PAP adherence, 30.4% and 26% of the patients increased their PAP adherence by at least 30 min during the first and second lockdowns respectively; 17.6% and 19.3% of the patients lowered their PAP adherence by at least 30 min in the first and second lockdowns, respectively. CONCLUSION: During the first and second lockdowns, the COVID-19 pandemic had a clinically irrelevant effect on PAP adherence for the study population. Future studies are needed to describe COVID-19 pandemic impact on PAP adherence not only for long-term PAP-treated SA patients but also for incident cases. Trial registration The COVADENE study was registered on March 1st, 2021 on ClinicalTrials.gov (Identifier: NCT04775966).

Impacts of the COVID-19 pandemic on sleep center operations and sleep apnea treatment in Korea: A multicenter survey.

ABSTRACT: The coronavirus disease-2019 (COVID-19) pandemic has not only changed the lives of people around the world but also affected all areas of the healthcare system, including sleep medicine. However, no studies in Korea have investigated the status of domestic sleep centers and their challenges during the pandemic.An online survey was performed from December 2020 to January 2021. Hospitals that belonged to sleep-related academic societies and were considered well managed were included in this survey. The questionnaire focused on changes in sleep center operations, infection control policies, and patient treatment since the start of the COVID-19 pandemic. Telemedicine and future directions for sleep medicine services were also investigated.Of the 20 sleep centers that responded, 80% were at university hospitals with more than 500 inpatient beds. During the third wave of the COVID-19 pandemic in Korea (November-December 2020), the routine operating schedule of the sleep study room was reduced in 30% of the sleep centers compared to November-December 2019 (before COVID-19). The number of type 1 polysomnographies performed decreased in 85% of the sleep centers. In contrast, in-lab positive airway pressure (PAP) titrations decreased in 40%, remained unchanged in 35%, and increased in 25%. With respect to prescriptions, 30% of the sleep centers increased the number of prescriptions for auto-titrating continuous PAP. However, 60% of the sleep centers reported no change in the rate of fixed continuous PAP and auto-titrating continuous PAP prescriptions. All sleep centers that participated in this survey agreed that the need for documented infection control regulations will continue after the COVID-19 pandemic. Since the beginning of the pandemic, 30% of the centers have tried telemedicine. However, respondents expressed concern about telemedicine, citing a number of practical issues.Compared to countries where the COVID-19 pandemic was severe, Korea had less impact of COVID-19 on the sleep center operations and sleep apnea treatment. Infection and quality control in the sleep study room are important and inevitable issues, and regulation within each institution is necessary. Further research and discussion are needed regarding telemedicine and home sleep apnea test in Korea.

[Challenges and opportunities of remote diagnosis and treatment management of sleep disordered breathing under the normalization of epidemic situation].

Since the outbreak of coronavirus disease 2019 (COVID-19), the diagnosis and treatment of diseases has been greatly affected. Obstructive sleep apnea hypopnea syndrome (OSAHS) is a common chronic disease, whose diagnosis and treatment methods have changed dramatically during the epidemic period-from traditional outpatient diagnosis and treatment to online remote diagnosis and treatment based on Internet. The diagnostical capability of major sleep centers has increased instead of decreasing. But with the change of diagnosis and treatment mode, privacy, data security, medical insurance policy and other related issues also emerge as the times require. Under the normalization of epidemic situation, telemedicine not only creates new opportunities, but also faces unprecedented challenges.

The impact of the COVID-19 pandemic on positive airway pressure usage in children with sleep-disordered breathing.

PURPOSE: To evaluate the impact of the COVID-19 pandemic on non-invasive positive airway pressure (PAP) usage among children with sleep-disordered breathing (SDB). METHODS: PAP usage data in children with SDB aged 1 to 18 years old at The Hospital for Sick Children, Canada, were analyzed. The PAP usage data were recorded for 3 months prior to and 3 months following the COVID-19 lockdown in Ontario, Canada. The primary outcomes of interest were (i) percentage of days that PAP was used for ≥ 4 h and (ii) average daily usage of PAP based on days when PAP was used. RESULTS: A total of 151 children were included. The mean (± SD) age and BMI were 12.6 ± 4.1 years and 28.7 ± 12.4 kg/m2, respectively. The median (IQR) percentage of days of PAP usage for ≥ 4 h and average nightly PAP usage was significantly higher during compared with prior to the pandemic (76.7 [19.0-94.0] vs 62.0 [15.5-89.0]%, p = 0.02, and 406.0 [244.0-525.0] vs 367.0 [218.0-496.0] min, p = 0.006, respectively). Within this cohort, 95/151 (63%) children with SDB showed increased PAP usage and 56/151 (37%) either decreased the amount of time they used PAP or stopped PAP use altogether. CONCLUSIONS: COVID-19 pandemic has provided opportunities for increased PAP usage in a significant number of children with SDB. A subset of children with prior evidence for suboptimal PAP usage showed further decreases in PAP usage during the pandemic. This information is critical for clinicians to provide anticipatory guidance to encourage PAP usage both during the pandemic and beyond.

Prevalence of Sleep Disordered Breathing in Children With Myelomeningocele.

BACKGROUND: Retrospective studies have shown high rates of sleep disordered breathing in children with myelomeningocele. However, most patients included in those studies underwent polysomnography because of symptoms, so the prevalence of sleep disordered breathing in this population is unknown. OBJECTIVE: To determine the prevalence of sleep disordered breathing in children with myelomeningocele using screening polysomnography. METHODS: In this cross-sectional study, all children with myelomeningocele seen in a multi-disciplinary spina bifida clinic between 2016 and 2020 were referred for polysomnography regardless of clinical symptoms. Included children had not previously undergone polysomnography. The primary outcome for this study was presence of sleep disordered breathing, defined as Apnea-Hypopnea Index (AHI, number of apnea or hypopnea events per hour of sleep) greater than 2.5. Clinical and demographic variables relevant to myelomeningocele were also prospectively collected and tested for association with presence of sleep apnea. RESULTS: A total of 117 participants underwent polysomnography (age 1 mo to 21 yr, 49% male). The majority were white, non-Hispanic. Median AHI was 1.9 (interquartile range 0.6-4.2). A total of 49 children had AHI 2.5 or greater, yielding a sleep disordered breathing prevalence of 42% (95% CI 33%-51%). In multivariable logistic regression analysis, children with more rostral neurological lesion levels had higher odds of sleep disordered breathing (OR for thoracic, mid-lumbar, and low-lumbar: 7.34, 3.70, 4.04, respectively, compared to sacral level, P = .043). CONCLUSION: Over 40% of a sample of children with myelomeningocele, who underwent screening polysomnography, had significant sleep disordered breathing. Routine screening polysomnography may be indicated in this population.

Reduction in Hospitalizations for Respiratory Diseases during the First COVID-19 Wave in Greece.

INTRODUCTION: During the first COVID-19 wave, a considerable decline in hospital admissions was observed worldwide. AIM: This retrospective cohort study aimed to assess if there were any changes in the number of patients hospitalized for respiratory diseases in Greece during the first CO-VID-19 wave. METHODS: In the present study, we evaluated respiratory disease hospitalization rates across 9 tertiary hospitals in Greece during the study period (March-April 2020) and the corresponding period of the 2 previous years (2018-2019) that served as the control periods. Demographic data and discharge diagnosis were documented for every patient. RESULTS: Of the 1,307 patients who were hospitalized during the study period, 444 (35.5%) were males with a mean (±SD) age of 66.1 ± 16.6 years. There was a 47 and 46% reduction in all-cause respiratory morbidity compared to the corresponding periods of 2018 and 2019, respectively. The mean incidence rate for respiratory diseases during the study period was 21.4 admissions per day, and this rate was significantly lower than the rate during the same period in 2018 (40.8 admissions per day; incidence rate ratio [IRR], 0.525; 95% confidence interval [CI], 0.491-0.562; p < 0.001) or the rate during 2019 (39.9 admissions per day; IRR, 0.537; 95% CI, 0.502-0.574; p < 0.001). The greatest reductions (%) in the number of daily admissions in 2020 were observed for sleep apnoea (87% vs. 2018 and 84% vs. 2019) followed by admissions for asthma (76% vs. 2018 and 79% vs. 2019) and chronic obstructive pulmonary disease (60% vs. 2018 and 51% vs. 2019), while the lowest reductions were detected in hospitalizations for pulmonary embolism (6% vs. 2018 and 23% vs. 2019) followed by tuberculosis (25% vs. both 2018 and 2019). DISCUSSION/CONCLUSION: The significant reduction in respiratory admissions in 2020 raises the reasonable question of whether some patients may have avoided seeking medical attention during the COVID-19 pandemic and suggests an urgent need for transformation of healthcare systems during the pandemic to offer appropriate management of respiratory diseases other than COVID-19.

Undiagnosed sleep disorder breathing as a risk factor for critical COVID-19 and pulmonary consequences at the midterm follow-up.

INTRODUCTION: Patients with severe COVID-19 develops an acute respiratory distress syndrome (ARDS), requiring admission to the intensive care unit. COVID-19 also reports an increased prevalence of comorbidities, similar to patients with Sleep disorder breathing (SDB). OBJECTIVES: To evaluate the association between undiagnosed SDB and the risk of ARDS and pulmonary abnormalities in a cohort of patients' survivors of COVID-19 between 3 and 6 months after diagnosis. METHODS: Prospective cohort study of patients who developed ARDS during hospitalization due to COVID-19 compared with a control group of patients who had COVID-19 with mild to moderate symptoms. All patients were evaluated between the 12th and 24th week after SARS-CoV-2 infection. The evaluation includes persistent symptoms, lung diffusing capacity of carbon monoxide (DLCO), chest CT scan and home sleep apnea test. SDB was diagnosed by the respiratory disturbance index ≥5 ev/h. The association between SDB and ARDS, the hazards of lung impairment and the hazard ratios (HR) were analyzed. RESULTS: A total of 60 patients were included (ARDS: 34 patients, Control: 26 patients). The mean follow-up was 16 weeks (range 12-24). ARDS reported a high prevalence of SDB (79% vs. 38% in control group). A total of 35% reported DLCO impairment, and 67.6% abnormal chest CT. SDB was independently associated to ARDS, OR 6.72 (CI, 1.56-28.93), p < 0.01, and abnormal Chest CT, HR 17.2 (CI, 1.68-177.4, p = 0.01). Besides, ARDS, days in mechanical ventilation, male gender were also associated with an increased risk of abnormal chest CT. CONCLUSION: Undiagnosed SDB is prevalent and independently associated with ARDS. In addition, undiagnosed SDB increased the hazard of abnormal Chest CT in the midterm. STUDY REGISTER: ISRCTN16865246.

Clinical characteristics of and outcomes for patients with COVID-19 and comorbid lung diseases primarily hospitalized in a conventional pulmonology unit: A retrospective study.

BACKGROUND: Scant data are currently available about a potential link between comorbid chronic lung diseases (CLD) and the risk and severity of the coronavirus disease 2019 (COVID-19) infection. METHODS: To describe the clinical characteristics of and outcomes for patients with COVID-19 infection, including patients with comorbid respiratory diseases, who have been primarily hospitalized in the pulmonology department of Strasbourg University Hospital, France. In this retrospective, single-center study, we included all confirmed cases of COVID-19 from March 3 to April 15, 2020. We then compared the symptoms, biological and radiological findings, and outcomes for patients with and without CLD. RESULTS: Of the 124 patients that were enrolled, the median age was 62 years, and 75 patients (60%) were male. Overall, 40% of patients (n=50) had preexisting CLD, including chronic obstructive pulmonary disease (COPD) (n=15, 12%) and asthma (n=19, 15%). Twenty-eight patients were transferred to the intensive care unit (ICU), and six patients died in our unit. CLD were not predictive of ICU hospitalization, but a significantly higher total mortality was observed (17.6% vs. 5.5%, P<0.05) in these patients. CONCLUSIONS: Our results suggest the lack of an over-representation of CLD in COVID-19, representing 40% of patients in this cohort and even within a pulmonology department. CLD were not a risk factor for ICU management. However, a tendency to higher global mortality was observed in COVID-19 patients with CLD. Further studies are warranted to determine the risk of COVID-19 for patients with comorbid CLD.

Sleep quality in times of Covid-19 pandemic.

BACKGROUND: Due to the 2019 novel coronavirus (COVID-19) disease outbreak, social distancing measures were imposed to control the spread of the pandemic. However, isolation may affect negatively the psychological well-being and impair sleep quality. Our aim was to evaluate the sleep quality of respiratory patients during the COVID-19 pandemic lockdown. METHODS: All patients who underwent a telemedicine appointment from March 30 to April 30 of 2020 were asked to participate in the survey. Sleep difficulties were measured using Jenkins Sleep Scale. RESULTS: The study population consisted of 365 patients (mean age 63.9 years, 55.6% male, 50.1% with sleep-disordered breathing [SDB]). During the lockdown, 78.9% of participants were confined at home without working. Most patients (69.6%) reported at least one sleep difficulty and frequent awakenings was the most prevalent problem. Reporting at least one sleep difficulty was associated with home confinement without working, female gender and diagnosed or suspected SDB, after adjustment for cohabitation status and use of anxiolytics. Home confinement without working was associated with difficulties falling asleep and waking up too early in the morning. Older age was a protective factor for difficulties falling asleep, waking up too early and non-restorative sleep. Notably, SDB patients with good compliance to positive airway pressure therapy were less likely to report sleep difficulties. CONCLUSIONS: Home confinement without working, female gender and SDB may predict a higher risk of reporting sleep difficulties. Medical support during major disasters should be strengthened and potentially delivered through telemedicine, as this comprehensive approach could reduce psychological distress and improve sleep quality.

Sleep medicine and COVID-19. Has a new era begun?

Since late December 2019, COVID-19, the disease caused by the novel coronavirus, SARS-CoV-2, has spread rapidly around the world, causing unprecedented changes in provided health care services. Patients diagnosed with sleep-disordered breathing (SDB) are subject to a higher risk of worse outcomes from COVID-19, due to the high prevalence of coexistent comorbidities. Additionally, treatment with positive airway treatment devices (PAP) can be challenging because of PAP-induced droplets and aerosol. In this context, sleep medicine practices are entering a new era and need to adapt rapidly to these circumstances, so as to provide the best care for patients with SDB. Novel approaches, such as telemedicine, may play an important role in the management of patients with SDB during the COVID-19 pandemic.

Management of sleep apnea in New York City during the COVID-19 pandemic.

BACKGROUND: 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. METHODS: 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. RESULTS/CONCLUSIONS: The adjustment in clinical management of OSA patients is described both during the peak of the outbreak in New York State (NYS), as well as the proposed modifications that will be instituted in order to return to full sleep center activities.