Association of Sleep-Related Hypoxia With Risk of COVID-19 Hospitalizations and Mortality in a Large Integrated Health System

Abstract

IMPORTANCEThe influence of sleep-disordered breathing (SDB) and sleep-related hypoxemia in SARS-CoV-2 viral infection and COVID-19 outcomes remains unknown. Controversy exists regarding whether to continue treatment for SDB with positive airway pressure given concern for aerosolization with limited data to inform professional society recommendations. OBJECTIVE To investigate the association of SDB (identified via polysomnogram) and sleep-related hypoxia with (1) SARS-CoV-2 positivity and (2) World Health Organization (WHO)-designated COVID-19 clinical outcomes while accounting for confounding including obesity, underlying cardiopulmonary disease, cancer, and smoking history. DESIGN, SETTING, AND PARTICIPANTS This case-control study was conducted within the Cleveland Clinic Health System (Ohio and Florida) and included all patients who were tested for COVID-19 between March 8 and November 30, 2020, and who had an available sleep study record. Sleep indices and SARS-CoV-2 positivity were assessed with overlap propensity score weighting, and COVID-19 clinical outcomes were assessed using the institutional registry. EXPOSURES Sleep study-identified SDB (defined by frequency of apneas and hypopneas using the Apnea-Hypopnea Index [AHI]) and sleep-related hypoxemia (percentage of total sleep time at <90% oxygen saturation [TST <90]). MAIN OUTCOMES AND MEASURES Outcomes were SARS-CoV-2 infection and WHO-designated COVID-19 clinical outcomes (hospitalization, use of supplemental oxygen, noninvasive ventilation, mechanical ventilation or extracorporeal membrane oxygenation, and death). RESULTS Of 350 710 individuals tested for SARS-CoV-2, 5402 (mean [SD] age, 56.4 [14.5] years;3005 women [55.6%]) had a prior sleep study, of whom 1935 (35.8%) tested positive for SARS-CoV-2. Of the 5402 participants, 1696 were Black (31.4%), 3259 were White (60.3%), and 822 were of other race or ethnicity (15.2%). Patients who were positive vs negative for SARS-CoV-2 had a higher AHI score (median, 16.2 events/h [IQR, 6.1-39.5 events/h] vs 13.6 events/h [IQR, 5.5-33.6 events/h]; P < .001) and increased TST <90 (median, 1.8% sleep time [IQR, 0.10%-12.8% sleep time] vs 1.4% sleep time [IQR, 0.10%-10.8% sleep time]; P = .02). After overlap propensity scoreweighted logistic regression, no SDB measures were associated with SARS-CoV-2 positivity. Median TST <90 was associated with the WHO-designated COVID-19 ordinal clinical outcome scale (adjusted odds ratio, 1.39; 95% CI, 1.10-1.74; P = .005). Time-to-event analyses showed sleep-related hypoxia associated with a 31% higher rate of hospitalization and mortality (adjusted hazard ratio, 1.31; 95% CI, 1.08-1.57; P = .005).

Inventory study of an early pandemic COVID-19 cohort in South-Eastern Sweden, focusing on neurological manifestations

“…The frequency of insomnia in our material is not different from the expected prevalence, but OSAS most certainly exceeds than what is expected. Interestingly, in line with our study, a previous American study covering 5400 COVID-19 infected patients found that people with a pre-existing sleep disorders have more severe outcomes from COVID-19 [43]. However, another study conducted by Goldstein et al, on 572 adult patients hospitalized for COVID-19, reported no significant contribution of sleep disorders to outcomes of the illness [44].…”

Mapping One Million COVID-19 Deaths and Unhealthy Lifestyle Behaviors in the United States: Recognizing the Syndemic Pattern and Taking Action

“…15 , 16 , 17 Althoff et al 18 assessed food environment and diet trends in the US, providing several nationwide maps illustrated in Figure 5 . Moreover, sleep-related hypoxia has been associated with a worsening of COVID-19 related outcomes, 19 and the CDC has previously reported the prevalence of low sleep durations (i.e., ≤ 6 hours in a 24-hour period) to be of epidemic proportions 20 . Additionally, stresses related to living with the pandemic has led to sleep dysfunction, changes in sleep-wake cycle disrupted sleep and decreased sleep quality.…”

Association of clinically significant obstructive sleep apnoea with risks of contracting COVID-19 and serious COVID-19 complications: a retrospective population-based study of health administrative data

“…38 The authors suggested that baseline sleep-related hypoxaemia may be associated with hypoxia-related injury due to COVID-19. 38 COVID-19-related hospitalisations or ICU admissions are often driven by hypoxaemia, 42 43 which may be exacerbated by OSA due to lower baseline oxygen saturation, upper airway obstruction and desaturation during sleep, disease-related gas exchange deficits, obesity-related restricted lung volumes and hypoventilation. 44 45 At the same time, it has been hypothesised that COVID-19 exposure in individuals with pre-existing OSA puts them at increased risk of morbidity and mortality through the inflammatory response as they both involve and affect the respiratory system.…”