Does obstructive sleep apnea lead to increased risk of COVID-19 infection and severity?

Artificial Intelligence-guided Total Opacity Scores and Obstructive Sleep Apnea in Adults with COVID-19 Pneumonia

OBJECTIVE

We previously demonstrated that artificial intelligence (AI)-directed chest computed tomography (CT)-based total opacity scores (TOS) are associated with high-risk obstructive sleep apnea (OSA) based on the Berlin Questionnaire. In the current study, we examined the association between TOS severity and OSA severity based on polysomnography (PSG) recordings among participants with a history of Coronavirus disease-2019 (COVID-19) infection.

MATERIAL AND METHODS

This was a post-hoc analysis of 56 patients who underwent CT imaging after being diagnosed with COVID-19 pneumonia as well as overnight PSG for a validation study with a median of 406 days after the initial COVID-19 onset. The AI software quantified the overall opacity scores, which included consolidation and ground-glass opacity regions on CT scans. TOS was defined as the volume of high-opacity regions divided by the volume of the entire lung, and severe TOS was defined as the score ≥15. OSA was defined as an apnea-hypopnea index (AHI) of at least 15 events/h.

RESULTS

In total, 21 participants had OSA and 35 had no OSA. The median TOS was 10.5 [interquartile range (IQR) 1.6-21.2] in the OSA group and 2.8 (IQR 1.4-9.0) in the non-OSA group (P = 0.047). In a multivariate logistic regression analysis, OSA, AHI, and oxygen desaturation index were associated with severe TOS (P < 0.05 for all, respectively) adjusted for age, sex, body mass index, and hypertension.

CONCLUSION

AI-directed CT-based TOS severity in patients with COVID-19 pneumonia was associated with OSA severity based on PSG recordings. These results support our previous findings suggesting an association between questionnaire-based high-risk OSA and worse outcomes in COVID-19 pneumonia.

Assessment of PAP Device Usage and COVID-19 Related Anxiety in Patients with OSAS During COVID-19 Pandemics

OBJECTIVE

In this study, we aimed to determine the positive airway pressure (PAP) device usage and pandemic-related anxiety in obstructive sleep apnea syndrome (OSAS) patients during the pandemic.

MATERIAL AND METHODS

Five hundred twenty-seven OSAS patients were recruited into the study. A questionnaire consisting of 7 questions was filled to find out their Coronavirus disease-2019 (COVID-19)-related anxiety levels and PAP device usage.

RESULTS

The mean age of the patients was 53.3 years (±11.9). One hundred forty-one 141 (27%) of the participants were female and 382 (73%) were male. Two hundred sixteen (41%) patients reported using the PAP device regularly [PAP (+) group); 307 (59%) patients reported not using it at all or using it irregularly (PAP (-) group]. Forty-nine (23%) PAP (+) patients and 91 (29%) PAP (-) patients had COVID-19. The use of a PAP device was not significantly associated with an increased risk of COVID-19 infection (P = 0.077). The most common symptom was myalgia without a between-group difference, (P = 0.967). There was no significant difference between the PAP (+) and PAP (-) groups in the hospitalization rates for COVID-19 (P = 0.252). The presence of apnea was not considered as a cause of a higher level of COVID-19-related anxiety in patients with the PAP (+) group compared to the PAP (-) group (P = 0.095).

CONCLUSION

There was no evidence that the use of PAP devices in OSAS patients influenced the risk of getting COVID-19 and the clinical course of the disease. PAP device usage did not affect the level of anxiety associated with the pandemic in patients.

Association Between Severities of Obstructive Sleep Apnea and COVID-19 Outcomes

Introduction Obstructive sleep apnea (OSA) is characterized by repetitive upper airway collapse resulting in episodes of apnea and hypopnea. Studies have shown worsened coronavirus disease 2019 (COVID-19) severity due to coexisting respiratory conditions and suggest increased severity of COVID-19 in patients with or at high risk of OSA. However, the extent of this correlation is unclear. This retrospective study aimed to evaluate the association between OSA severity and COVID-19 severity and assess the impact of continuous positive airway pressure (CPAP) compliance. Methods This single-center retrospective study was conducted at King Abdulaziz University Hospital (KAUH), a tertiary care center in Jeddah, Saudi Arabia. Data were collected from 62 adult patients with OSA who were diagnosed via polysomnography (PSG) and had a positive documented severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR) test result. COVID-19 severity was categorized into mild, moderate, and severe. Results There was no significant correlation between OSA severity as measured by the apnea-hypopnea index (AHI), low oxyhemoglobin desaturation (LSAT), arousal index (AI), respiratory disturbance index (RDI), or the type of treatment used, including adherence to CPAP, and the outcomes of COVID-19. However, higher arousal with respiratory index (ARI) and a lower percentage of time with SpO2 < 90% (T90) values were linked to moderate COVID-19 severity with significant p-values of 0.046 and 0.007, respectively. Conclusion There was no significant correlation between the severity or types of OSA treatment and the severity of COVID-19. Further research including multicenter studies with bigger populations and extensive sleep study data is warranted. Understanding the OSA-COVID-19 link may improve risk stratification and patient management.

The prevalence of sleep disorders in Iranian adults - an epidemiological study

BACKGROUND

Sleep disorders can be harmful to our health and treating them can also be expensive. Due to the widespread occurrence and impact of sleep disorders, it is valuable to investigate and study them from an epidemiological perspective. Therefore, this study aimed to determine the prevalence of sleep disorders among Iranian adults in 2022.

METHOD

This is a cross-sectional study that examines the prevalence of sleep disorders and problems in Iranian society. The participants were selected using a mixed sampling approach (utilizing virtual space and cluster sampling). A two-part package was used for evaluating participants sleep problems, which included a demographic profile form and the Holland Sleep Disorders Questionnaire. After collecting the data, appropriate statistical tests in SPSS version 25 were utilized for analysis.

RESULTS

A total of 6013 questionnaires were fully filled out for this research, with participants answering the specific questions. The participants' score on sleep disorders was 1.94, which means 44.1% of them suffer from sleep disorders. The results indicated that the prevalence of sleep disorders in this study was as follows: insomnia (35%), parasomnia (35.3%), circadian rhythm sleep disorder (38.4%), hypersomnia and excessive daytime sleepiness (39%), restless leg syndrome and leg movements during sleep (43%), and breathing disorders related to sleep (38.4%). The prevalence of sleep disorders among the study participants demonstrated a significant relationship with most of their demographic variables (P < 0.001). The Pearson correlation coefficient also revealed an inverse and significant relationship between the prevalence of sleep disorders in the study participants and their age, monthly household income, and BMI (P < 0.001).

CONCLUSION

Overall, the results depicted a relatively high prevalence of sleep disorders in the studied community. These findings emphasize the need for interventions to prevent and treat sleep disorders in society.

Insights into the Overlap of Chronic Obstructive Pulmonary Disease and Sleep Apnea: Experience from the Clinic of Pneumology, Târgu Mureș

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) has a severe impact on patients' health and can lead to multiple complications.

MATERIAL AND METHODS

We analyzed the co-occurrence of obstructive sleep apnea (OSA) in COPD patients hospitalized in the Pneumology Clinic of Târgu Mureș, Romania.

RESULTS

A total of 150 COPD patients were investigated by clinical examination, STOP-BANG and Epworth questionnaires, ventilatory polygraphy (PG), EKG, cardiac ultrasound, blood lipids, and sugar. Sixty-eight patients (45.3%) had OSA associated with COPD. A total of 61.7% were COPD gr. E, and 30.8% were gr. B. Frequently shown symptoms were snoring and nonrestorative sleep (100%), somnolence (73.5%), nocturnal awakenings (41.17%), morning headache (32.3%), and aggravated dyspnea. Types of OSA included obstructive (97.05%), central (2.5%), and associated obesity-hypoventilation (39.7%). A total of 76.4% were recently diagnosed with OSA. Men predominated at 70.5%, 76.4% were smokers, and 61.7% had experienced alcohol abuse. A total of 25% were overweight, and 71% had obesity. A total of 13.2% belonged to the category of 38-50-year-olds, 55.8% were in the 51-65-year-old category, 17.6% were in the 66-70-year-old category, and roughly 13.2% were in the 71-year-old category. Overlap syndrome (OS) comorbidities and complications were frequently present: 41% experienced respiratory failure, 66.1% experienced blood hypertension, 58.8% experienced ischemic cardiac disease, 32.35% experienced diabetes mellitus, 50% experienced dyslipidemia, and 29.4% experienced cor pulmonale.

CONCLUSIONS

OS conferred gravity or directly contributed to cardiovascular, respiratory, and metabolic complications. OS was associated with more severe COPD and obesity. The prevalence of smoking in OS patients was higher than the national/European average.

Association of High-Risk Obstructive Sleep Apnea with Artificial Intelligence-Guided, CT-Based Severity Scores in Patients with COVID-19 Pneumonia

Background: We have previously demonstrated that high-risk obstructive sleep apnea (HR-OSA), based on a modified Berlin Questionnaire (mBQ), is linked to worse clinical outcomes. Chest computed tomography (CT) imaging with the implementation of an artificial intelligence (AI) analysis program has been a valuable tool for the speedy assessment of huge numbers of patients during the COVID-19 epidemic. In the current study, we addressed how the severity of AI-guided, CT-based total opacity ratio (TOR) scores are associated with high-risk OSA and short-term outcomes in the same cohort. Methods: The ratio of the volume of high opacity areas to that of the total lung volume constituted the TOR. We arbitrarily applied thresholds of <5 (no or mild TOR), ≥5 and <15 (moderate TOR), and ≥15 (severe TOR). Results: In total, 221 patients were included. HR-OSA was observed among 11.0% of the no or mild TOR group, 22.2% of the moderate TOR group, and 38.7% of the severe TOR group (p < 0.001). In a logistic regression analysis, HR-OSA was associated with a severe TOR with an adjusted odds ratio of 3.06 (95% confidence interval [CI] 1.27-7.44; p = 0.01). A moderate TOR predicted clinical worsening with an adjusted hazard ratio (HR) of 1.93 (95% CI 1.00-3.72; p = 0.05) and a severe TOR predicted worsening with an HR of 3.06 (95% CI 1.56-5.99; p = 0.001). Conclusions: Our results offer additional radiological proof of the relationship between HR-OSA and worse outcomes in patients with COVID-19 pneumonia. A TOR may also potentially indicate the individuals that are at higher risk of HR-OSA, enabling early intervention and management strategies. The clinical significance of TOR thresholds needs further evaluation in larger samples.

Is Obstructive Sleep Apnea Associated with Higher Covid-19 Severity?

Objective  To investigate the associations between obstructive sleep apnea (OSA) and coronavirus disease 2019 (COVID-19) severity. Methods  Twelve individuals hospitalized in a Brazilian tertiary hospital diagnosed with COVID-19 by reverse transcriptase-polymerase chain reaction (RT-PCR) underwent respiratory polygraphy. Results  Polygraphic records identified seven participants without obstructive sleep apnea (OSA) (OSA-) and five with OSA (OSA + ). The OSA+ group presented worse peripheral oxygen saturation (77.6% ± 7.89%) than the OSA- group (84.4% ± 2.57%) ( p  = 0.041). Additionally, the OSA+ group showed greater COVID-19 severity (100%) than the OSA- group (28.57%) ( p  = 0.013) and required longer oxygen therapy ( p  = 0.038), but without difference in the length of hospitalization. The OSA+ group also presented higher rates of platelets ( p  = 0.008) and D-dimer (1,443 ± 897) than the OSA- group (648 ± 263 ng/mL) ( p  = 0.019). Conclusion  Obstructive sleep apnea in individuals hospitalized due to COVID-19 was associated with higher COVID-19 severity, worse peripheral oxygen saturation, longer oxygen therapy time, and higher platelet and D-dimer rates.

Diagnosing OSA and Insomnia at Home Based Only on an Actigraphy Total Sleep Time and RIP Belts an Algorithm "Nox Body Sleep™"

Purpose

The COVID-19 pandemic has influenced clinical sleep protocols with stricter hospital disinfection requirements. Facing these new rules, we tested if a new artificial intelligence (AI) algorithm: The Nox BodySleep™ (NBS) developed without airflow signals for the analysis of sleep might assess pertinently sleep in patients with Obstructive Sleep Apnea (OSA) and chronic insomnia (CI) as a control group, compared to polysomnography (PSG) manual scoring.

Patients-Methods

NBS is a recurrent neural network model that estimates Wake, NREM, and REM states, given features extracted from activity and respiratory inductance plethysmography (RIP) belt signals (Nox A1 PSG). Sleep states from 139 PSG studies (CI N = 72; OSA N = 67) were analyzed by NBS and compared to manually scored PSG using positive percentage agreement, negative percentage agreement, and overall agreement metrics. Similarly, we compared common sleep parameters and OSA severity using sleep states estimated by NBS for each recording and compared to manual scoring using Bland-Altman analysis and intra-class correlation coefficient.

Results

For 127,170 sleep epochs, an overall agreement of 83% was reached for Wake, NREM and REM states (92% for REM states in CI patients) between NBS and manually scored PSG. Overall agreement for estimating OSA severity was 100% for moderate-severe OSA and 91% for minimal OSA. The absolute errors of the apnea-hypopnea index (AHI) and total sleep time (TST) were significantly lower for the NBS compared to no scoring of sleep. The intra-class correlation was higher for AHI and significantly higher for TST using the NBS compared to no scoring of sleep.

Conclusion

NBS gives sleep states, parameters and AHI with a good positive and negative percentage agreement, compared with manually scored PSG.

Identification of biomarkers and pathways for the SARS-CoV-2 infections in obstructive sleep apnea patients based on machine learning and proteomic analysis

BACKGROUND

The prevalence of obstructive sleep apnea (OSA) was found to be higher in individuals following COVID-19 infection. However, the intricate mechanisms that underscore this concomitance remain partially elucidated. The aim of this study was to delve deeper into the molecular mechanisms that underpin this comorbidity.

METHODS

We acquired gene expression profiles for COVID-19 (GSE157103) and OSA (GSE75097) from the Gene Expression Omnibus (GEO) database. Upon identifying shared feature genes between OSA and COVID-19 utilizing LASSO, Random forest and Support vector machines algorithms, we advanced to functional annotation, analysis of protein-protein interaction networks, module construction, and identification of pivotal genes. Furthermore, we established regulatory networks encompassing transcription factor (TF)-gene and TF-miRNA interactions, and searched for promising drug targets. Subsequently, the expression levels of pivotal genes were validated through proteomics data from COVID-19 cases.

RESULTS

Fourteen feature genes shared between OSA and COVID-19 were selected for further investigation. Through functional annotation, it was indicated that metabolic pathways play a role in the pathogenesis of both disorders. Subsequently, employing the cytoHubba plugin, ten hub genes were recognized, namely TP53, CCND1, MDM2, RB1, HIF1A, EP300, STAT3, CDK2, HSP90AA1, and PPARG. The finding of proteomics unveiled a substantial augmentation in the expression level of HSP90AA1 in COVID-19 patient samples, especially in severe conditions.

CONCLUSIONS

Our investigation illuminate a mutual pathogenic mechanism that underlies both OSA and COVID-19, which may provide novel perspectives for future investigations into the underlying mechanisms.

A comparative study of accuracy in major adaptive filters for motion artifact removal in sleep apnea tests

Sleep apnea is probably the most common respiratory disorder; respiration and blood oxygen saturation (SpO2) are major concerns in sleep apnea and are also the two main parameters checked by polysomnography (PSG, the gold standard for diagnosing sleep apnea). In this study, we used a simple, non-invasive monitoring system based on photoplethysmography (PPG) to continuously monitor SpO2 and heart rate (HR) for individuals at home. Various breathing experiments were conducted to investigate the relationship between SpO2, HR, and apnea under different conditions, where two techniques (empirical formula and customized formula) for calculating SpO2 and two methods (resting HR and instantaneous HR) for assessing HR were compared. Various adaptive filters were implemented to compare the effectiveness in removing motion artifacts (MAs) during the tests. This study fills the gap in the literature by comparing the performance of different adaptive filters on estimating SpO2 and HR during apnea. The results showed that up-down finger motion introduced more MA than left-right motion, and the errors in SpO2 estimation were increased as the frequency of movement was increased; due to the low sampling frequency features of these tests, the insertion of adaptive filter increased the noise in the data instead of eliminating the MA for SpO2 estimation; the normal least mean squares (NLMS) filter is more effective in removing MA in HR estimation than other filters.

COVID-19: A Challenge to the Safety of Assisted Reproduction

There is an increased risk of becoming pregnant through fertility treatments using assisted reproductive technology (ART) during the COVID-19 pandemic. The aim of this review is to gather comprehensive data from the existing literature on the potential risks of fertility management during the pandemic period, and outline strategies to mitigate them, with a focus on the hormonal and surgical procedures of ART. A comprehensive search of the scientific literature on COVID-19 in relation to fertility was conducted in the PubMed database using the keywords "coronavirus," "COVID-19," "SARS-CoV-2" and "pregnancy," "fertility," "urogenital system," "vertical transmission," "assisted human reproduction," "controlled ovarian stimulation," "oocyte retrieval," "in vitro fertilization," "hormones," "surgical procedures," "embryos," "oocytes," "sperm," "semen," "ovary," "testis," "ACE-2 receptor," "immunology," "cytokine storm," and "coagulation," from January 2020-July 2022. Published data on pregnancy and COVID-19, and the interaction of the urogenital system and SARS-CoV-2 is reported. The immunologic and prothrombotic profiles of patients with COVID-19, and their increased risks from controlled ovarian stimulation (COS) and ART surgeries, and how these procedures could facilitate COVID-19 and/or contribute to the severity of the disease by enhancing the cytokine storm are summarized. Strategies to prevent complications during COS that could increase the risks of the disease in pre-symptomatic patients are considered. The impact of SARS-CoV-2 on pre-symptomatic infertile patients presents a challenge to find ways to avoid the increased hormonal, immunologic, and prothrombotic risks presented by the use of COS in ART protocols during the COVID-19 outbreak. Safe ART procedures and recommendations are highlighted.

Impact of the early months of the COVID-19 pandemic on the sleep patterns of a Brazilian population sample

Humanitarian and health crisis have drastic effects on the physical and mental well-being of people. The COVID-19 pandemic forced many countries to impose containment measures on its population to halt the spread of the new coronavirus (SARS-CoV-2). This aim of this study was to explore self-reported sleep quality and insomnia symptoms in a sample of the Brazilian population before and during the COVID-19 quarantine period. Our data was collected through online questionnaires, including the Pittsburgh Sleep Quality Index, the Insomnia Severity Index, and the Sleep Hygiene Index. The final sample comprised 1,109 volunteers. Generalized estimating equations (GEE) revealed that during the initial months of the COVID-19 pandemic, alterations in self-reported sleep parameters were observed in the participants. Sleep efficiency and sleep duration increased, but there was a worsening in sleep quality and an increase in symptoms related to insomnia.

Validation of the Modified Berlin Questionnaire for the Diagnosis of Obstructive Sleep Apnea in Patients with a History of COVID-19 Infection

(1) Background: The Berlin questionnaire (BQ) is a widely used survey to predict obstructive sleep apnea (OSA). Considering the confounding effect of obesity and hypertension on the clinical course of COVID-19, we have recently developed a modified BQ (mBQ) based on the subscales snoring intensity/frequency, witnessed apneas and morning/daytime tiredness, and demonstrated that patients with high-risk OSA had worse outcomes during the COVID-19 pandemic. In the current study, we aimed to validate the mBQ in adults with a history of COVID-19 infection. (2) Method: All cases who suffered from COVID-19 infection between 10 March and 22 June 2020, and who completed the mBQ in our first study, were invited to participate. Participants refilled the questionnaires, and an attended polysomnography (PSG) was conducted. An apnea-hypopnea index (AHI) of 15 events/h or more was considered as OSA. (3) Results: Out of the 70 participants, 27 (39%) were categorized as having a high risk of OSA based on the mBQ. According to the PSG results, 24 patients with high-risk OSA (89%) and 3 patients with low-risk OSA on the mBQ (7%) had AHI ≥ 15 events/h. The mBQ had a sensitivity of 89%, a specificity of 93%, a positive predictive value of 89%, a negative predictive value of 93%, and an accuracy of 91%. The area under the curve was 0.91 confirming a very good performance of the mBQ in screening for OSA. (4) Conclusions: The mBQ has a good level of diagnostic sensitivity, specificity, and accuracy among adults with a history of COVID-19 infection. Since the confounding effects of obesity and hypertension are eliminated, the mBQ may be used not only as a screening tool for high-risk OSA but also as a prognostic survey in clinical cohorts.

Accuracy and modification of the STOP ‐bang questionnaire for screening patients with obstructive sleep apnea in China

Despite the high sensitivity of the STOP-Bang questionnaire [snoring, tiredness, observed apneas, high blood pressure, body mass index, age, neck size, gender] questionnaire (SBQ), which is widely used to screen individuals at high risk of obstructive sleep apnea (OSA), few studies have evaluated the discrimination related to sex in the SBQ. Therefore, our study aimed to assess whether SBQ performance is gender-related and modified by changing body mass index (BMI) and neck circumference (NC) cut-off values. A total of 470 patients attended the sleep centres. They were divided into moderate-to-severe OSA and non-moderate-to-severe OSA groups based on the apnea-hypopnea index (AHI) and the results of the SBQ screening. The predictive performance of the SBQ screening instrument was evaluated by 2 × 2 contingency tables and discriminatory ability, which was estimated from the area under the curve (AUC) obtained from receiver operating characteristic curve. Our results suggest that when screening for moderate-to-severe OSA, the original SBQ has higher sensitivity and lower specificity for men; however, women have higher specificity and lower sensitivity. The SBQ achieved the maximum AUC of 0.783 for men and 0.634 for women when the BMI cut-off value was established at 30 kg/m² and the NC cut-off value was established at 38 cm in men, and the BMI cut-off value was established at 25 kg/m² and the NC cut-off value at 36 cm in women. Balancing the optimal sensitivity and specificity, the cut-off value of the optimal modified SBQ total scores for men was determined to be ≥4 and ≥3 for women.

From SARS-CoV-2 infection to COVID-19 morbidity: an in silico projection of virion flow rates to the lower airway via nasopharyngeal fluid boluses

Background: While the nasopharynx is initially the dominant upper airway infection site for SARS-CoV-2, the physiologic mechanism launching the infection at the lower airway is still not well-understood. Based on the rapidity of infection progression to the lungs, it has been hypothesized that the nasopharynx may be acting as the primary seeding zone for subsequent contamination of the lower airway via aspiration of virus-laden boluses of nasopharyngeal fluids. Methodology: To examine the plausibility of the aspiration-driven mechanism, we have computationally tracked the inhalation process in three anatomic airway reconstructions and have quantified the nasopharyngeal liquid volume transmitted to the lower airspace during each aspiration. Results: Extending the numerical trends on aspiration volume to earlier records on aspiration frequencies indicates a total aspirated nasopharyngeal liquid volume of 0.3 – 0.76 ml/day. Subsequently, for mean sputum viral load, our modeling projects that the number of virions reaching the lower airway will range over 2.1×106 – 5.3×106 /day; for peak viral load, the corresponding number hovers between 7.1×108 – 1.8×109. Conclusions: The virion transmission findings fill in a key piece of the mechanistic puzzle on the systemic progression of SARS-CoV-2, and subjectively point to health conditions like dysphagia, with proclivity to increased aspiration, as some of the potential underlying risk factors for aggressive lung infections.

Sleep Deprivation, Immune Suppression and SARS-CoV-2 Infection

Sleep health and its adaptation to individual and environmental factors are crucial to promote physical and mental well-being across animal species. In recent years, increasing evidence has been reported regarding the relationship between sleep and the immune system and how sleep disturbances may perturb the delicate balance with severe repercussions on health outcomes. For instance, experimental sleep deprivation studies in vivo have reported several major detrimental effects on immune health, including induced failure of host defense in rats and increased risk for metabolic syndrome (MetS) and immune suppression in humans. In addition, two novel risk factors for dysregulated metabolic physiology have recently been identified: sleep disruption and circadian misalignment. In light of these recent findings about the interplay between sleep and the immune system, in this review, we focus on the relationship between sleep deprivation and immunity against viruses, with a special interest in SARS-CoV-2 infection.

Impact of Metabolic Risk Factors on COVID-19 Clinical Outcomes: An Extensive Review

BACKGROUND

Cardiovascular (CV) risk factors, particularly cardiometabolic, seem to be associated with heightened severity and increased morbimortality in patients infected with the novel Coronavirus disease-2019 (COVID-19).

METHODS

A thorough scoping review was conducted to elucidate and summarize the latest evidence for the effects of adverse cardiac metabolic profiles on the severity, morbidity, and prognosis of COVID-19 infection.

RESULTS

The pathophysiology of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is complex, being characterized by viral-induced immune dysregulation and hypercytokinemia, particularly in patients with critical disease, evolving with profound endothelial dysfunction, systemic inflammation, and prothrombotic state. Moreover, cardiovascular comorbidities such as diabetes are the most prevalent amongst individuals requiring hospitalization, raising concerns towards the clinical evolution and prognosis of these patients. The chronic proinflammatory state observed in patients with cardiovascular risk factors may contribute to the immune dysregulation mediated by SARS-CoV-2, favoring more adverse clinical outcomes and increased severity. Cardiometabolism is defined as a combination of interrelated risk factors and metabolic dysfunctions such as dyslipidemia, insulin resistance, impaired glucose tolerance, and central adiposity, which increase the likelihood of vascular events, being imperative to specifically analyze its clinical association with COVID-19 outcomes.

CONCLUSION

DM and obesity appears to be important risk factors for severe COVID-19. The chronic proinflammatory state observed in patients with excess visceral adipose tissue (VAT) possibly augments COVID-19 immune hyperactivity leading to more adverse clinical outcomes in these patients.

Effects of Obstructive Sleep Apnea on SARS-CoV-2 Antibody Response After Vaccination Against COVID-19 in Older Adults

INTRODUCTION

Previous studies have linked sleep disturbances (including sleep deprivation and obstructive sleep apnea) to an impairment in immune response after vaccination for several diseases, although it has not yet been tested for COVID-19. This study sought to evaluate the effects of obstructive sleep apnea on anti-SARS-CoV-2 IgG levels after vaccination against COVID-19 among older adults.

METHODS

The study was based on a convenience sample of inpatients who underwent full night type-I polysomnography. Inclusion criteria included being ≥60 years with full COVID-19 vaccination schedule. Exclusion criteria included previous COVID-19 diagnosis (assessed via self-report), less than 15 days between last dose and IgG testing, self-report of continuous positive air pressure (CPAP) use in the last three months, having undergone CPAP or split-night polysomnography, or incomplete/invalid data.

RESULTS

Out of 122 included patients (no/mild OSA: 35; moderate: 31; severe: 56), 9.8% were considered seronegative for the IgG anti-SARS-CoV-2 test (IgG count<50.0 AU/mL), and the median IgG levels for the whole sample was 273 AU/mL (IQR: 744), with no statistically significant differences among OSA severity groups. There was neither association between OSA severity and IgG serostatus nor correlation between IgG levels and apnea-hypopnea index. A linear regression model to predict IgG levels was built, produced an R² value of 0.066 and the only significant predictor was time from vaccination to testing; while OSA severity was considered non-significant.

DISCUSSION

Our results demonstrate that the severity of OSA is not correlated with a decrease in anti-SARS-CoV-2 IgG levels among older adults, and that the efficiency of COVID-19 vaccinations are not reduced from mild to severe OSA.

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.

The Association Between Sleep Disturbances and Erectile Dysfunction During the COVID-19 Pandemic

INTRODUCTION

There is increasing concern about the impact of the SARS-CoV-2 pandemic on mental and physical health. Among the many possible outcomes of COVID-19, reports of sleep disturbances, and erectile dysfunction are becoming prevalent worldwide.

OBJECTIVES

We sought to evaluate the recent literature on this subject to produce a narrative review of the topic.

METHODS

We performed an extensive literature search to identify recent scientific findings on this subject.

RESULTS

To date, the precise mechanisms that trigger pandemic related sexual dysfunction are not completely understood, although it has been suggested that psychogenic effects play an important role, in addition to the direct effects of the disease itself on those infected. There is evidence that the stress induced by the pandemic has had a significant impact on sleep, and sleep disturbances are known to induce erectile dysfunction. Other mechanisms which trigger this phenomenon, such as hormonal changes and previous health conditions, have been suggested to be associated with SARS-CoV-2 infection, and these factors may have a potential link to sleep disturbance.

CONCLUSION

The combined effect of COVID-19 and the psychogenic disorders triggered by isolation, grief, and anxiety might be associated with the increased prevalence of erectile dysfunction. This feature might be worsened by the onset of pre-existing or pandemic-induced sleep disorders. However, few studies explored this subject. Understanding this phenomenon is important for the strategic planning of treatments that could improve the quality of life of the population. Andersen ML, Tufik S. The Association Between Sleep Disturbances and Erectile Dysfunction During the COVID-19 Pandemic. Sex Med Rev 2021;XX:XXX-XXX.

Obstructive sleep apnea and COVID-19 clinical outcomes during hospitalization: a cohort study

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is an extremely common sleep disorder. A potential association between OSA and coronavirus disease 2019 (COVID-19) severity has been proposed on the basis of similar comorbid medical conditions associated with both OSA and COVID-19.

METHODS

We performed a retrospective review of 1,738 patients who were hospitalized with COVID-19 between March and October of 2020. Patients were classified based on the presence or absence of OSA diagnosis based upon the International Classification of Diseases (ICD; codes G47.33 and U07.1 for OSA and COVID-19, respectively). Other data were collected, including demographics, body mass index, and comorbid conditions. COVID-19 severity was compared between groups using the quick COVID-19 severity index.

RESULTS

Quick COVID-19 severity index scores were higher in patients with OSA compared with those without OSA. However, the prevalence rates of type 2 diabetes (P < .0001), coronary artery disease (P < .0001), congestive heart failure (P < .0001), and chronic obstructive pulmonary diseases (P < .0001) were also significantly greater in the OSA group. Unadjusted models revealed higher risk of intensive care unit admission in patients with COVID-19 and OSA. However, such an association was attenuated and became nonsignificant after adjusting for age, sex, body mass index, and comorbid disease.

CONCLUSIONS

In our study, OSA does not appear to be an independent risk factor for worse COVID-19 outcomes in hospitalized patients. Further studies with larger sample sizes are needed to delineate the potential role of OSA in determining outcomes in hospitalized patients with COVID-19.

CITATION

Mashaqi S, Lee-Iannotti J, Rangan P, et al. Obstructive sleep apnea and COVID-19 clinical outcomes during hospitalization: a cohort study. J Clin Sleep Med. 2021;17(11):2197-2204.

Sleep in Older Adults and Its Possible Relations With COVID-19

Since the beginning of the COVID-19 pandemic, older adults have been found to be a highly vulnerable group, with a higher prevalence of severe cases and negative outcomes. Research has focused on the reasons why older adults are at greater risk; Sleep-related factors have been suggested as one possible explanation for this. An individual's sleep pattern undergoes significant changes over the course of their life. In older adults a specific sleep profile can be observed, one characterized by advanced sleep timing, a morningness preference, longer sleep-onset latency, shorter overall sleep duration, increased sleep fragmentation, reduced slow-wave sleep and, increased wake time after sleep onset. Additionally, an increased prevalence of sleep disorders can be observed, such as obstructive sleep apnea and insomnia. Previous research has already linked sleep disorders (especially sleep apnea) with COVID-19, but few studies have focused specifically on the older population. We believe that the intrinsic sleep patterns of older adults, and the prevalence of sleep disorders in this population, may be important factors that could explain why they are at a greater risk of negative COVID-19 outcomes. In this review, we discuss the relationship between sleep and COVID-19 among older adults, focusing on three different aspects: (1) Sleep-related issues that might increase the likelihood of getting infected by SARS-COV-2; (2) Sleep disturbances that might increase the predisposition to worse COVID-19 prognosis and outcomes; and (3) COVID-19-related aspects affecting community-dwelling older adults, such as social isolation, quarantine, and home confinement, among others, that might impact sleep.

[Novel coronavirus disease (COVID-19) and obstructive sleep apnea: age aspects of comorbidity]

In connection with the spread of the novel coronavirus infection (COVID-19) pandemic and the increase in the development of severe acute respiratory syndrome, works are published around the world that determined the risk factors for complications and poor outcomes in this disease. Among the main comorbidities in COVID-19, scientists distinguish hypertension, diabetes, obesity, etc. Recently, more and more physicians and researchers are concerned about the high frequency of severe and critical complications of COVID-19 in patients with obstructive sleep apnea (OSA). In this review, we present some data on COVID-19 and OSA in the age aspect, show the general pathophysiological pathways leading to increased systemic inflammation and adverse consequences in the comorbid course of these diseases. Special attention is paid to such studies in the pediatric population, but only a few works of foreign scientists were found that did not reveal the essence of the problem under discussion, which requires further research in this area.

Severity of Sleep Apnea and COVID-19 Illness

Objective

To characterize the relationship between severity of sleep apnea and coronavirus disease 2019 (COVID-19) hospitalization and severe illness.

Study Design

Retrospective cohort study.

Setting

Montefiore Health System in the Bronx, New York.

Methods

The data set consisted of adult patients with an active diagnosis of obstructive sleep apnea in the past 2 years and a positive severe acute respiratory syndrome coronavirus 2 quantitative polymerase chain reaction test at our institution between March 16, 2020, and May 26, 2020. Sleep apnea severity and continuous positive airway pressure compliance data were abstracted from the electronic medical record. The International Classification of Diseases, 10th Revision was used to classify comorbidities.

Results

A total of 461 patients with sleep apnea tested positive for COVID-19, of whom 149 were excluded for missing data in the electronic medical record. Patients with moderate and severe sleep apnea had higher rates of COVID-19 hospitalization compared to those with mild sleep apnea (P = .003). This association was reduced when accounting for confounders, most notably the Charlson Comorbidity Index, a measure of comorbid illness burden. Moderate and severe sleep apnea were associated with increased Charlson Comorbidity Indices, compared to mild sleep apnea (P = .01). Sleep apnea severity was not associated with a composite outcome of mechanical ventilation, intensive care unit admission, and death.

Conclusion

Sleep apnea severity was associated with the Charlson Comorbidity Index and may be a risk factor for COVID-19 hospitalization. We found no evidence that sleep apnea severity among hospitalized patients was associated with a composite outcome of mechanical ventilation, intensive care unit admission, and death.

Obesity and sleep apnea as a significant comorbidities in COVID-19 - A case report

In our paper we aimed to increase the awareness among physicians, concerning coronavirus disease 2019 (COVID-19) severity, especially in patients with specific underlying comorbidities. Obesity is the second most common condition in hospitalized COVID-19 patients. Furthermore it has a major role in the development of obstructive sleep apnoea (OSA), which is highly involved in a severe COVID-19 development and its serious outcomes. Even though obese OSA patients had an increased pulmonary embolism (PE) risk, there is no enough evidence to support the interaction between obesity and OSA regarding PE development in the setting of COVID-19. Our patient is a 45-year-old obese male with COVID-19, who was admitted to the intensive care unit (ICU) with acute respiratory failure requiring high-flow nasal oxygenation. Clinical, laboratory and diagnostic findings pointed on severe COVID-19 form, complicated with PE. After recovery, the diagnosis of OSA was established. With this case, we wanted to alert the physicians on comorbidities, such as obesity and OSA, while those conditions, to some extent, may contribute to worse COVID-19 clinical presentation.

Previously diagnosed obstructive sleep apnea is not associated with increased risk of SARS-CoV-2 infection in community-dwelling older adults living in a highly endemic setting

OBJECTIVE

In view of the high prevalence of obstructive sleep apnea (OSA) and the increasing global pandemic of SARS-CoV-2 infection, it is likely that many patients with OSA get exposed to this virus. Besides theoretical assumptions, there is no evidence that OSA may favor SARS-CoV-2 acquisition or may lead to a more severe disease. Taking the opportunity of the Atahualpa Project cohort, we aimed to assess the relationship between previously diagnosed OSA and SARS-CoV-2 infection in older adults living in rural Ecuador.

PATIENTS AND METHODS

SARS-CoV-2 antibodies were determined in 180 individuals aged > 60 years that underwent polysomnography previously to this novel pandemic. Those with OSA remained untreated due to income limitations. Exposure-effect models were fitted with OSA as the exposure, SARS-CoV-2 seropositivity and symptomatology as the outcomes, and confounders - age, gender, obesity, arterial hypertension, diabetes mellitus, hypercholesterolemia, individuals per house, home confinement - as independent variables.

RESULTS

A total of 87 (48%) individuals were seropositive to SARS-CoV-2, 77% of whom were symptomatic. The mean apnea/hypopnea index was 11.1 ± 11.7 episodes per hour, with 83 (46%) individuals having mild, and 38 (21%) moderate-to-severe OSA. Exposure-effect models demonstrated lack of relationship between OSA and SARS-CoV-2 seropositivity and symptomatology.

CONCLUSIONS

This study shows no relationship between history of OSA and SARS-CoV-2 seropositivity or symptomatology, opposing previous suggestions that persons with OSA are more prone to acquire the infection and have a more severe disease.

Sleep laboratories reopening and COVID-19: a European perspective

Clinical activities regarding sleep disordered breathing (SDB) have been sharply interrupted during the initial phase of the coronavirus disease 2019 (COVID-19) epidemic throughout Europe. In the past months, activities have gradually restarted, according to epidemiological phase of COVID-19 and national recommendations. The recent increase in cases throughout Europe demands a reconsideration of management strategies of SDB accordingly. Diagnosis of SDB and initiation of treatment pose some specific problems to be addressed to preserve the safety of patients and health personnel. This perspective document by a group of European sleep experts aims to summarise some different approaches followed in Europe and United States, which reflect national recommendations according to the epidemiological phase of the COVID-19 infection. Respiratory sleep medicine is likely to change in the near future, and use of telemedicine will grow to avoid unnecessary risks and continue to provide optimal care to patients. In addition, the document covers paediatric sleep studies and indications for titration of noninvasive ventilation, as well as precautions to be followed by patients who are already on positive airway pressure treatment. A single consensus document developed by the European Respiratory Society and national societies would be desirable to harmonise SDB management throughout Europe.

Specific precautions should be applied for starting activities in respiratory sleep centres during the COVID-19 epidemichttps://bit.ly/3keRjii

Effect of High-Risk Obstructive Sleep Apnea on Clinical Outcomes in Adults with Coronavirus Disease 2019: A Multicenter, Prospective, Observational Cohort Study

Rationale: Coronavirus disease (COVID-19) is an ongoing pandemic, in which obesity, hypertension, and diabetes have been linked to poor outcomes. Obstructive sleep apnea (OSA) is associated with these conditions and may influence the prognosis of adults with COVID-19.

Objectives: To determine the effect of OSA on clinical outcomes in patients with COVID-19.

Methods: The current prospective observational study was conducted in three hospitals in Istanbul, Turkey from March 10 to June 22, 2020. The participants were categorized as high-risk or low-risk OSA according to the Berlin questionnaire that was administered in the out-patient clinic, in hospital, or shortly after discharge from hospital blinded to the clinical outcomes. A modified high-risk (mHR)–OSA score based on the snoring patterns (intensity and/or frequency), breathing pauses, and morning/daytime sleepiness, without taking obesity and hypertension into account, were used in the regression models.

Results: The primary outcome was the clinical improvement defined as a decline of two categories from admission on a 7-category ordinal scale that ranges from 1 (discharged with normal activity) to 7 (death) on Days 7, 14, 21, and 28, respectively. Secondary outcomes included clinical worsening (an increase of 1 category), need for hospitalization, supplemental oxygen, and intensive care. In total, 320 eligible patients (median [interquartile range] age, 53.2 [41.3–63.0] yr; 45.9% female) were enrolled. In all, 121 (37.8%) were categorized as known (n = 3) or high-risk OSA (n = 118). According to the modified scoring, 70 (21.9%) had mHR-OSA. Among 242 patients requiring hospitalization, clinical improvement within 2 weeks occurred in 75.4% of the mHR-OSA group compared with 88.4% of the modified low-risk–OSA group (P = 0.014). In multivariate regression analyses, mHR-OSA (adjusted odds ratio [OR], 0.42; 95% confidence interval [CI], 0.19–0.92) and male sex (OR, 0.39; 95% CI, 0.17–0.86) predicted the delayed clinical improvement. In the entire study population (n = 320), including the nonhospitalized patients, mHR-OSA was associated with clinical worsening (adjusted hazard ratio, 1.55; 95% CI, 1.00–2.39) and with the need for supplemental oxygen (OR, 1.95; 95% CI, 1.06–3.59). Snoring patterns, especially louder snoring, significantly predicted delayed clinical improvement, worsening, need for hospitalization, supplemental oxygen, and intensive care.

Conclusions: Adults with mHR-OSA in our COVID-19 cohort had poorer clinical outcomes than those with modified low-risk OSA independent of age, sex, and comorbidities. Clinical trial registered with www.clinicaltrials.gov (NCT04363333).

Sleep apnoea is a risk factor for severe COVID-19

Background

Obstructive sleep apnoea (OSA) is associated with higher body mass index (BMI), diabetes, older age and male gender, which are all risk factors for severe COVID-19.

We aimed to study if OSA is an independent risk factor for COVID-19 infection or for severe COVID-19.

Methods

OSA diagnosis and COVID-19 infection were extracted from the hospital discharge, causes of death and infectious diseases registries in individuals who participated in the FinnGen study (n=260 405). Severe COVID-19 was defined as COVID-19 requiring hospitalisation. Multivariate logistic regression model was used to examine association. Comorbidities for either COVID-19 or OSA were selected as covariates. We performed a meta-analysis with previous studies.

Results

We identified 445 individuals with COVID-19, and 38 (8.5%) of them with OSA of whom 19 out of 91 (20.9%) were hospitalised. OSA associated with COVID-19 hospitalisation independent from age, sex, BMI and comorbidities (p-unadjusted=5.13×10⁻⁵, OR-adjusted=2.93 (95% CI 1.02 to 8.39), p-adjusted=0.045). OSA was not associated with the risk of contracting COVID-19 (p=0.25). A meta-analysis of OSA and severe COVID-19 showed association across 15 835 COVID-19 positive controls, and n=1294 patients with OSA with severe COVID-19 (OR=2.37 (95% 1.14 to 4.95), p=0.021).

Conclusion

Risk for contracting COVID-19 was the same for patients with OSA and those without OSA. In contrast, among COVID-19 positive patients, OSA was associated with higher risk for hospitalisation. Our findings are in line with earlier works and suggest OSA as an independent risk factor for severe COVID-19.

Is there a link between COVID-19 and obstructive sleep apnea?

Although obstructive sleep apnea syndrome (OSAS) is not considered a risk factor for COVID-19, studies have observed that these two conditions have comorbidities in common such as diabetes, cardiovascular diseases, asthma, obesity, hypertension, and chronic obstructive pulmonary disease. Thus, one may question the possible contribution of OSAS to the worsening of hypoxemia in patients with COVID-19 since OSAS and obesity (hypoventilation) are associated with hypoxemia, which can be a worsening factor in the hypoxemia of COVID-19 pneumonia. Moreover, one may question whether sleep deprivation would negatively interfere with the pulmonary condition caused by COVID-19. Another question would be whether sleep deprivation resulting from OSAS would be a favorable condition for the pulmonary inflammatory process in patients with COVID-19. Studies with a more significant number of participants are needed to assess the possible impact of OSAS on the outcomes of patients with SARS-CoV-2 infection, providing a more solid basis for making therapeutic decisions. An important advance in understanding the influence of OSAS on COVID-19 is represented by careful identification of comorbidities and potential pathophysiological mechanisms that may contribute to the favorable outcome of these patients.

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.

Obstructive Sleep Apnea and Risk of COVID-19 Infection, Hospitalization and Respiratory Failure

Purpose

To study the relationship between OSA and risk of COVID-19 infection and disease severity, identified by the need for hospitalization and progression to respiratory failure.

Methods

We queried the electronic medical record system for an integrated health system of 10 hospitals in the Chicago metropolitan area to identify cases of COVID-19. Comorbidities and outcomes were ascertained by ICD-10-CM coding and medical record data. We evaluated the risk for COVID-19 diagnosis, hospitalization, and respiratory failure associated with OSA by univariate tests and logistic regression, adjusting for diabetes, hypertension, and BMI to account for potential confounding in the association between OSA, COVID-19 hospitalization, and progression to respiratory failure.

Results

We identified 9405 COVID-19 infections, among which 3185 (34%) were hospitalized and 1779 (19%) were diagnosed with respiratory failure. OSA was more prevalent among patients requiring hospitalization than those who did not (15.3% versus 3.4%, p < 0.0001; OR 5.20, 95% CI (4.43, 6.12)), and among those who progressed to respiratory failure (19.4% versus 4.5%, p < 0.0001; OR 5.16, 95% CI (4.41, 6.03)). After adjustment for diabetes, hypertension, and BMI, OSA was associated with increased risk for hospitalization (OR 1.65; 95% CI (1.36, 2.02)) and respiratory failure (OR 1.98; 95% CI (1.65, 2.37)).

Conclusions

Patients with OSA experienced approximately 8-fold greater risk for COVID-19 infection compared to a similar age population receiving care in a large, racially, and socioeconomically diverse healthcare system. Among patients with COVID-19 infection, OSA was associated with increased risk of hospitalization and approximately double the risk of developing respiratory failure.

Symptomless multi-variable apnea prediction index assesses adverse outcomes in patients with Corona Virus Disease 2019

Purpose

To explore the relationship between symptomless multi-Variable apnea prediction (sMVAP) index and adverse outcomes of patients with Corona Virus Disease 2019 (COVID-19).

Methods

According to the sMVAP quartiles, we divided all patients into four groups. The clinical electronic medical records, nursing records, laboratory findings, and radiological examinations for all patients with laboratory confirmed Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection were reviewed. Cox proportional hazard ratio (HR) models were used to determine the risk factors associated with in hospital death.

Results

A total of 97 patients were included in this study. The “Quartile 4” group 's ICU transfer rate was significantly higher than the “Quartile 1” group. Coronary heart disease, high d-dimer and sMVAP at admission were associated with increased odds of death.

Conclusions

Using the sMVAP index for obstructive sleep apnea hypopnea syndrome (OSAHS) risk assessment, and then predicting the adverse outcomes of COVID-19 patients, is an effective method. Therefore, the use of sMVAP index for OSAHS screening for inpatients with COVID-19 should be vigorously promoted, and high-risk patients should be effectively managed.

•

This is the first study to explore the association between sMVAP index and COVID-19.

•

OSAHS might be an independent risk factor for death in patients with COVID-19.

•

These findings highlight the critical role of the OSAHS screening for inpatients with COVID-19.

Sleep and COVID-19: considerations about immunity, pathophysiology, and treatment

The fear and uncertainty caused by the coronavirus disease 2019 (COVID-19) pandemic, threats to survival are one of the main problems of everyday life; however, mental health care must also be considered a priority. During social isolation also called self-quarantine, the restricted mobility and social contact, concern about financial resources and availability of supplies, fear of infection, questions about the duration of self-quarantine, cause anxiety, depression, stress, insomnia and reduced the quality and quantity of sleep, that may present a greater risk to the health of the general population. Sleep disorders are increasingly becoming a major health issue in modern society, and are influenced by retinal stimulation by electronic devices, as well extended and/or night shift-work, which may aggravate the systemic and lung inflammation during viral infections. Sleep disorders can induce pro-inflammatory states and be harmful during the COVID-19 pandemic. The possible interactions between many drugs used to treat COVID-19, and those used to treat sleep disorders are unknown, mostly due to the lack of a standard protocol to treat these patients. Insufficient sleep or irregular sleep-wake cycles may impair health, immune system, induce pro-inflammation state, and may lead to increased vulnerability to viral infections, involving inflammatory and oxidative/antioxidant imbalance. In this sense, obstructive sleep apnea has been associated with recognized COVID-19 risk comorbidities and considered a risk factor for COVID-19. During the COVID-19 pandemic, health care cannot stop, and telemedicine has presented itself as an alternative method of delivering services. When a face-to-face visit is mandatory, or in locations with minimal community transmission where sleep centers have resumed activities, it is important that the sleep center facilities are properly prepared to receive the patients during the COVID-19 pandemic, and follow all relevant safety rules. In this work we gathered a group of researchers, specialists in aspects related to chronobiology, sleep, sleep disorders, and the immune system. Thus, we conducted a narrative review in order to address the relationship between COVID-19 and sleep, as well as its immunological aspects and strategies that may be applied in order to mitigate the harmful effects on health that affects everyone during the pandemic.

The Impact of Obesity and Lifestyle on the Immune System and Susceptibility to Infections Such as COVID-19

Background: COVID-19 is a global challenge to healthcare. Obesity is common in patients with COVID-19 and seems to aggravate disease prognosis. In this review we explore the link between obesity, chronic disease, lifestyle factors and the immune system, and propose societal interventions to enhance global immunity. Search Strategy and Selection Criteria: We performed three literature searches using the keywords (1) coronavirus AND comorbidities, (2) comorbidities AND immune system, and (3) lifestyle factors AND immune system. Results were screened for relevance by the main author and a total of 215 articles were thoroughly analyzed. Results: The relationship between obesity and unfavorable COVID-19 prognosis is discussed in light of the impact of chronic disease and lifestyle on the immune system. Several modifiable lifestyle factors render us susceptible to viral infections. In this context, we make a case for fostering a healthy lifestyle on a global scale. Conclusions: Obesity, additional chronic disease and an unhealthy lifestyle interactively impair immune function and increase the risk of severe infectious disease. In adverse metabolic and endocrine conditions, the immune system is geared toward inflammation. Collective effort is needed to ameliorate modifiable risk factors for obesity and chronic disease on a global scale and increase resistance to viruses like SARS-CoV-2.