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Sleep apnea: Risks and worsening due to COVID-19

February 24, 2021

Studies have linked obstructive sleep apnea with risks of infection, hospitalization and mortality of patients with COVID-19

Analyses made in Chicago and New England present similarities related to sleep apnea and the possible worsening due to COVID-19. According to these
searches, obstructive sleep apnea (OSA) may contribute to poor outcomes by exacerbating or causing endothelial dysfunction, inflammation, oxidative stress, micro aspiration, and lung injury, increasing risk for comorbidities, hospitalization, and respiratory failure.

Researchers from the American Thoracic Society (ATS), point out that older age and diagnoses of obesity, hypertension, pulmonary or cardiovascular diseases are well-known risk factors indicated by the World Health Organization for COVID-19. However, mortality and hospitalization are not always explained by those aspects.
Apnea has not yet been determined to worsen due to COVID-19, but research like this can open the spectrum a little bit more and help save lives.

The article developed by Dr. Matthew Maas and Dr. Phyllis Zee, and released through the International Journal of Science and Practice of Sleep Medicine, shows that OSA was more prevalent among patients requiring hospitalization and among those who progressed to respiratory failure. Conducted in the Chicago area, the research studied data obtained by an electronic medical record system integrated in ten hospitals. The risk for COVID-19 is eight times greater in hospitalized patients. OSA was also associated with increased risk of hospitalization and patients double the risk of developing respiratory failure.

Dr. Miller (University of Warwick) warns that it is clear the pandemic has had a major effect on the treatment, management, and diagnosis of OSA and moving forward it may be necessary to explore new diagnosis and treatment pathways for these individuals.

The hypothesis presented by these American studies also appears in the research led by Dr. Michelle Miller, from the University of Warwick, United Kingdom. According to the study, people with OSA tend to suffer complications caused by COVID-19. She suggests that could be related to the sleep hormone, melatonin, that may be beneficial for the treatment of COVID-19.

Dr. Miller reminds us that comorbidities such as hypertension, diabetes mellitus, and obesity are common in individuals with OSA and also in severe cases of COVID-19. However, they would like to determine whether sleep apnea was an additional risk in itself, regardless of other factors.
The fact is that there are higher rates of chronic obstructive pulmonary disease, diabetes, and hypertension in patients who were admitted to intensive care units and required mechanical ventilation or died.

Released by ATS and obtained through data from a large health care system in New England, the research carried out by doctors of Harvard Medical School in Boston, Massachusetts correlates sleep apnea as a risk factor for COVID-19 mortality. The sample of 4,668 patients with positive COVID-19 RNA PCR diagnostics demonstrates that individuals with sleep apnea had an 11.7% all-cause mortality rate, while for those with controlled sleep apnea the rate remains at 6.9%. Therefore, doctors highlight the need for close monitoring of patients with sleep apnea who are infected with the coronavirus.

Diagnosis and Treatment

The articles are unanimous regarding the relevance of the apnea prognosis. It is extremely important to provide information about sleep syndromes in patients regarding the severity of COVID-19.
North American research led by Dr. Maas and Dr. Zee in Chicago explains the necessity of an OSA screening to guide treatment decisions in patients with COVID-19, either with simple instruments like the four-question STOP-Bang questionnaire, as suggested by Dr. Maas, or with diagnostic devices. Neurovirtual’s equipment, BWIII PSG PLUS, which diagnoses sleep syndromes, can be a useful ally in this regard.


Dr. Miller (University of Warwick) warns that it is clear the pandemic has had a major effect on the treatment, management, and diagnosis of OSA and moving forward it may be necessary to explore new diagnosis and treatment pathways for these individuals. As it is still an underdiagnosed syndrome, is it potentially common and equally risky. Dr. Miller highlights that patients who have already been diagnosed but are awaiting treatment may need to be prioritized at this time to mitigate any potential increase in risk.


Cade, B. E., Dashti, H. S., Hassan, S. M., Redline, S., & Karlson, E. W. (2020). Sleep Apnea and COVID-19 Mortality and Hospitalization. American journal of respiratory and critical care medicine, 202(10), 1462–1464.

Maas, M.B., Kim, M., Malkani, R.G. et al. Obstructive Sleep Apnea and Risk of COVID-19 Infection, Hospitalization and Respiratory Failure. Sleep Breath (2020).

Miller, Michelle A., Cappuccio, Francesco P. (2020). A systematic review of COVID-19 and obstructive sleep apnea, Sleep Medicine Reviews, Volume 55, 2021, 101382, ISSN 1087-0792.

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