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Are People With Sleep Apnea At A Higher Risk of Severe COVID-19?

The answer is not so simple according to otolaryngologist Dr. Maurits Boon and sleep medicine specialist Dr. Karl Doghramji.

It has been nine months since the COVID-19 pandemic forced the United States to go on national lockdown, and the effects of living during a pandemic have been vast and unique for us all. We’ve talked to physicians about complaints of ringing ears and even late or missing periods. With reports that people with sleep apnea could be at a higher risk of severe COVID-19, there’s been an uptick in online searches for correlations and more about this disorder.

To help us understand more about sleep apnea, we spoke with Dr. Maurits Boon, otolaryngologist and co-director of the Voice and Swallowing Center, and Dr. Karl Doghramji, medical director of the Jefferson Sleep Disorders Center.

What Exactly Is Sleep Apnea?

The most common form of sleep apnea is known as “obstructive sleep apnea,” which is basically when a patient’s throat and airways close up and restrict airflow, according to Dr. Boon. This is different than snoring—a risk factor for sleep apnea—which is a partial restriction that basically creates turbulence in the airways, or what we hear as the snoring noise. “Sleep apnea patients, especially severe patients, may or may not snore but will wind up gasping for air because they genuinely aren’t getting an airflow to their lungs.”

Dr. Boon says an easy way to evaluate if you have sleep apnea is to use the mnemonic STOP-Bang and ask yourself the following yes/no questions:

  • Am I snoring loudly?
  • Am I overly and chronically tired?
  • Does my partner observe pauses in my sleep? Or do I notice that I choke or gasp while sleeping?
  • Do I have high blood pressure?
  • Is my age 50 years old or older?
  • Do I have a wide neck circumference?
  • Am I of the male gender and therefore at a higher risk for sleep apnea?

If you answered “yes” to three or more of these questions, you are at moderate or high risk for sleep apnea. Dr. Boon cautions that while there are over-the-counter ways to stop snoring—like nasal bandages or oral appliances—this does not cure sleep apnea, and there are huge health risks associated if sleep apnea is untreated. Sleep apnea significantly increases mortality due to health risks including stroke and high blood pressure, which can lead to heart attack or heart disease. Sleep apnea is also connected to depression and can cause motor vehicle and work-related accidents.

“If you believe you might have sleep apnea, I recommend getting checked out by a professional,” says Dr. Boon. “If you’re being cautious right now and do not want to come in for a sleep study, we can provide at-home sleep tests and can evaluate patients via telehealth.”

At-Home Sleep Tests

At-home sleep tests come with advantages and limitations, says Dr. Doghramji. “Whereas in the lab, where we have wires and electrodes on 14 to 16 different points on the body, an at-home test typically involves four points.” He explains that the patient will wear a belt, a little clip on their finger, and an EKG-type of lead that sticks on their chest. The fourth is a small little sensor that goes under the nose to monitor airflow. A small device, kept on the nightstand or nearby the body, records the data of a night of sleep. That data is then analyzed by the physicians at the sleep lab.

“The downside of an at-home sleep study is that it only assesses respiration or breathing during sleep, but it doesn’t assess other things, like narcolepsy or limb movements like restless leg syndrome,” explains Dr. Doghramji. “It also doesn’t actually measure sleep. Theoretically, you could lie awake all night and not sleep a wink. We wouldn’t know looking at this machine because it does not measure brain waves.”

For these reasons, Dr. Doghramji encourages patients to come in for an in-lab sleep study. “We screen all of our patients who come in for COVID-19 and our technicians are tested and wear maximal protective clothing,” says Doghramji. “The rooms are completely sanitized after each study and before the next study. Plus, the rooms are private. We’ve been very, very careful during the pandemic.”

If you are interested in an at-home sleep study or would like to visit the sleep lab, you can make an appointment via JeffConnect.

Does Sleep Apnea Make You More Vulnerable to COVID-19?

Dr. Boon says the short answer is no. However, obesity is a big risk factor for severe COVID-19 and is also a contributing factor for sleep apnea. “About 85% of people who have sleep apnea are considered medically obese,” says Dr. Boon. “And we know now that obesity can cause more severe COVID-19 complications.”

Dr. Doghramji concurs with Dr. Boon, emphasizing the there isn’t any good data at this point that points to sleep apnea patients being any more at risk to contract severe COVID-19 than those without. “People with sleep apnea tend to have other medical conditions, such as heart disease and cerebral vascular disease or stroke,” he explains. “Plus, many sleep apnea patients are older and frail, which puts them in high-risk categories. It is these underlying comorbidities that predispose people to COVID-19, not the sleep apnea itself.”

It is possible theoretically, but the right answer is we don’t know if there’s an association directly between sleep apnea and COVID-19 at this time. –Dr. Karl Doghramji

That being said, Dr. Doghramji also admits that there is very limited data and research on this. “It could very well be that the oxygen deficits caused by sleep apnea after many, many years of having apnea might, because of its inflammatory effect on one’s vascular system, predispose people to COVID,” he says.

Treatment Options for Sleep Apnea

Once formally diagnosed with sleep apnea, patients rated at moderate to severe symptoms will be given a CPAP machine, which uses a hose and face mask or nosepiece to deliver constant, steady air pressure, says Dr. Boon.

The Jefferson Sleep Center offers a comprehensive CPAP acclimatization program to help patients adjust to using the device, including therapists who are available to meet with patients anytime, without an appointment, every day of the week to teach them how to use the machine and ensure their comfort using it and adjust face masks, free of charge.

Woman sleeping on her side with CPAP machine

“We have advanced care nurse practitioners who also follow up with our patients systemically after they start CPAP approximately a month later and six months later routinely,” explains Dr. Doghramji. “We can adjust settings to make the CPAP machines more comfortable.”

This patient-centered attention is reflected in the 80% compliance rate for CPAP tolerance, which according to Dr. Doghramji, is higher than the rates of programs across the United States.

Other non-surgical treatment options include BiPAP therapy, which is a dual cycle machine that pushes air into the upper airways once when people breathe in and when people breathe out, the air comes out much more passively.

“Some of my patients swear by their CPAP machines while others find them completely intolerable,” explains Dr. Boon. “One alternative treatment for select patients is getting an upper airway stimulation therapy with Inspire, a small implanted device.”

The device works by sensing unique breathing patterns and delivering mild stimulation to key airway muscles, like the tongue, to keep airways open during sleep. “The procedure takes about two hours under general anesthesia and patients are able to go home the same day after surgery,” says Dr. Boon.

On December 11, Dr. Boon and his colleague Dr. Colin Huntley implanted the 300th Inspire sleep apnea device at Thomas Jefferson University Hospital. This is a surgical milestone for Drs. Boon and Huntley, as Jefferson leads with the greatest number of total Inspire implants in the country.

To find out if you qualify for this type of therapy, click here.

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COVID-19, Healthy You