Obstructive sleep apnea is an independent risk factor for severe COVID-19: a population-based study

Abstract

Study Objectives Obstructive sleep apnea (OSA) has been proposed as a risk factor for severe COVID-19. Confounding is an important consideration as OSA is associated with several known risk factors for severe COVID-19. Our aim was to assess the association of OSA with hospitalization due to COVID-19 using a population-based cohort with detailed information on OSA and comorbidities. Methods Included were all community-dwelling Icelandic citizens 18 years of age and older diagnosed with SARS-CoV-2 infection in 2020. Data on demographics, comorbidities, and outcomes of COVID-19 was obtained from centralized national registries. Diagnosis of OSA was retrieved from the centralized Sleep Department Registry at Landspitali–The National University Hospital. Severe COVID-19 was defined as the composite outcome of hospitalization and death. The associations between OSA and the outcome were expressed as odds ratios (OR) with 95% confidence intervals (95% CI), calculated using logistic regression models and inverse probability weighting. Results A total of 4,756 individuals diagnosed with SARS-CoV-2 infection in Iceland were included in the study (1.3% of the Icelandic population), of whom 185 had a diagnosis of OSA. In total, 238 were hospitalized or died, 38 of whom had OSA. Adjusted for age, sex, and BMI, OSA was associated with poor outcome (OR 2.2, 95% CI 1.4 -3.5). This association was slightly attenuated (OR 2.0, 95% CI 2.0, 1.2-3.2) when adjusted for demographic characteristics and various comorbidities. Conclusions OSA was associated with twofold increase in risk of severe COVID-19, and the association was not explained by obesity or other comorbidities.

Associations Between Obstructive Sleep Apnea (OSA) and COVID-19 Infection and Hospitalization Among U.S. Adults <strong> </strong>

“…The principal finding in our study was that OSA is associated with COVID-19 infection and hospitalization after adjustment for multiple medical comorbidities including BMI. Our results are consistent with many other studies demonstrating that OSA appears to be a risk factor for COVID-19 infection or hospitalization [5][6][7][8]10,12,[14][15][16][17]31,32 as for influenza. 33 However, these prior studies utilized hospital records or other databases to identify COVID-19 cases with or without OSA and in some cases were susceptible to collider bias.…”

“…2,3 For example, among approximately 10,000 COVID-19 decedents during mid-February through mid-May 2020, nearly three-quarters had one or more underlying medical conditions (76.4%) or were aged ≥65 years (74.8%). 4 While these risk factors garnered considerable attention, in many, [5][6][7][8][9][10][11][12][13][14][15][16][17] but not all studies, [18][19][20] obstructive sleep apnea (OSA) was identified as a risk factor as well. The degree to which OSA represents an independent risk factor for adverse COVID-19 outcomes is uncertain; in several investigations, the impact of OSA was observed to be partially or completely explained by the presence of obesity and/or other comorbidities.…”

Lessons for sleep medicine learned from the COVID-19 pandemic

“…The overlap of risk factors for severe COVID-19 and OSA, namely Initially, data on the influence of OSA on COVID-19 outcomes were contradictory when confounders like obesity were added in the analysis models [8]. However, recent large studies and meta-analyses suggest that OSA is a mild-to-moderate risk factor for adverse outcomes in COVID-19, including increased rates of hospitalisation and need for intensive care, as well as mortality [3,[11][12][13]. One of the most comprehensive analyses, to date, on factors predicting adverse COVID-19 outcomes was published by BELLOU et al [3].…”

“…Two recent papers have addressed this question. A large Icelandic cohort of PCR-verified COVID-19 patients (n=4756) was linked with the clinical cohort of known OSA patients to identify OSA patients with COVID-19 (n=185) [12]. Severe COVID-19, defined as hospitalisation and/or death, was fivefold more common in OSA patients compared with the remaining Icelandic inhabitants (odds ratio 5.6), but after adjustment for confounders like age, sex, body mass index and comorbidities, the odds ratio was reduced to 2.0 (95% CI 1.1-3.6).…”

Sleep alterations following COVID-19 are associated with both neuroinflammation and psychological disorders, although at different times

“…In addition, obesity constitutes an important common risk factor for both conditions. It is probably on this basis that patients with OSA were found with higher rates of hospitalization, intensive care admission, and mortality ( 26 – 29 ). Moreover, patients with OSA overexpress the angiotensin-converting enzyme 2 (ACE2) receptor in response to hypoxemia, which can explain the higher infection rate observed in this population ( 28 , 30 ).…”