COVID-19 Response Read More

Do I have a higher risk of getting coronavirus because I have sleep apnea?

There is no evidence linking sleep apnea with coronavirus risk. People who have a higher risk for severe illness from the coronavirus include:

  • Those who are 65 years of age or older
  • Those who have serious underlying medical conditions. These conditions include
    • Chronic lung disease
    • Moderate to severe asthma
    • Serious heart conditions
    • Severe obesity with a body mass index (BMI) of 40 or higher
    • Diabetes
    • Chronic kidney disease
    • Liver disease
  • Those who have a medical disorder, or take a medication, that weakens the immune system.
  • Those who have had close contact with another person who has the coronavirus.

If I have symptoms of the coronavirus, should I continue using my CPAP?

If you have symptoms of the coronavirus, you should isolate yourself in a separate bedroom and use a separate bathroom, if available. In this “recovery room,” you can continue to use CPAP while you sleep alone. Be sure to follow these steps for routine CPAP care:

  • Wash your hands thoroughly with soap and water before and after handling the CPAP device, mask, tubing and filters.
  • Clean your CPAP equipment according to manufacturer’s instructions.
  • Change filters and accessories as directed in your CPAP user guide.
  • Avoid letting anyone smoke in your home, especially around the CPAP machine.
  • Keep pets away from your CPAP machine.
  • Use distilled water in your humidifier to keep the tub clean.

**Get medical attention immediately if you develop emergency warning signs for COVID-19. Emergency warning signs include trouble breathing and persistent pain or pressure in the chest.

After you are free from the coronavirus, replace your CPAP filters and disposable accessories.

If I have symptoms of the coronavirus, will using CPAP spread the virus to others?

Current evidence suggests that the virus that causes COVID-19 spreads between people who are in close contact with one another (within about 6 feet). It is transmitted through respiratory droplets produced when an infected person coughs or sneezes. However, there is some concern that using CPAP could spread the virus through the exhalation port, which allows carbon dioxide to escape from your mask. This port also may release smaller virus-containing particles as an “aerosol,” which can remain suspended in the air for a few hours. It’s possible that your bedpartner could inhale these virus particles. Therefore, it is important to sleep alone by isolating yourself in a separate bedroom. You can continue to use CPAP while sleeping in this recovery room.

The virus also can remain on surfaces for a long time. Others could get the virus by touching an infected surface and then touching their own mouth, nose or eyes. Be sure that you routinely clean “high-touch” surfaces in your recovery room and bathroom. This includes include phones, remote controls, counters, tabletops, doorknobs, bathroom fixtures, toilets, keyboards, tablets, and bedside tables.

Should I use CPAP if I have symptoms of the coronavirus but can’t self-isolate?

If you have symptoms of the coronavirus but are unable to isolate yourself in a separate bedroom, then you should contact your medical provider. Ask your medical provider if there are short-term interventions or alternative treatments for sleep apnea that could help you while you recover from the coronavirus.

If I have the coronavirus, will my CPAP be helpful for my breathing? Or could CPAP cause the coronavirus to get worse?

If you have the coronavirus, you should continue using CPAP while sleeping alone in a separate bedroom. There is no evidence that using CPAP will cause the coronavirus to get worse.

If I have the coronavirus, how should I clean and disinfect my CPAP mask and hose?

The CDC recommends that you should clean and disinfect your medical equipment according to the manufacturer’s instructions.* The directions for CPAP masks and hoses normally include regular cleaning with soap and water.

*Keeping it clean: CPAP hygiene (Philips)

*How to clean your CPAP equipment (ResMed)

The CDC also recommends that you clean and disinfect frequently touched surfaces in your household. This includes door knobs, light switches and handles. Learn more from the CDC about how to clean and disinfect your household.

Is it safe to use CPAP if I don’t have symptoms of the coronavirus?

If you have the coronavirus, you may be able to spread it to others before you have symptoms. Even if you don’t have symptoms of the coronavirus, you may want to sleep and use CPAP in a separate bedroom during this public health emergency.

Distilled water is unavailable in my area. What should I use in my CPAP humidifier?

According to ResMed, “*optimal* humidifier performance requires distilled water. That’s because most or all of its minerals have been removed, preventing mineral buildup in the humidifier tub. That said, tap or bottled water may also be used. It will not harm the device or pose a risk to patients. It will, however, require more rigorous humidifier cleaning to prevent excess mineral buildup in the tub.”

PAP (POSITIVE AIRWAY PRESSURE THERAPY) THERAPY IN THE CONTEXT OF COVID-19

Empirical contact, droplet, and airborne precautions are necessary when dealing with PAP therapy in the context of the Covid-19 pandemic. Droplet and aerosol generating procedures such as tracheal intubation, non-invasive ventilation, and cardiopulmonary resuscitation have been associated with Covid-19 transmission. 1   It is imperative to understand that all forms of PAP therapy should be assumed to increase risk of transmission by droplet and aerosolized virus as they are an open circuit.2.3 The COVID-19 virus is also known to be viable for several hours after aerosolization. 4

There are medically prudent recommendations from the American Academy of Sleep Medicine (AASM)*,   as well as from experts in the field through the AASM on the COVID-19 blog post.**

The major points are summarized below, followed by the links for reference.

 

use of pap For the aSymptomatic patient at home:

  • There may be increased risk of transmission of COVID-19 to others in the environment if PAP is continued.
  • Persons at risk for infection from using PAP include co-habitants of the same dwelling.
  • Additionally, whether it is possible for the patient to be re-infected from tubing, filters, and/or mask reuse is not known.
  • The person using PAP should sleep in a separate bedroom; and if possible, a separate bathroom.
  • Continue diligent cleaning of your PAP according to manufacturer’s guidelines below:
  • Keeping it clean: CPAP hygiene(Philips)+
  • How to clean your CPAP equipment(ResMed)++
  • If distilled water is not available for the humidifier, one can substitute in the short-term with purified bottled water, or filtered tap water.  Well water should be avoided. Durable medical equipment companies (DMEs) can provide replacement humidification chambers.  Instructions for making your own distilled water can be found at the link below. +++
  • Completely dry the humidifier, mask and tubing once it is washed.
  • Disinfection of the humidifier chamber is generally with vinegar and water as per manufacturer’s guidelines. Avoid adding chemicals or disinfectants to the humidifier chamber that are not recommended by the manufacturer. This can lead to inhalational lung injury.
  • Avoid leaving the PAP running when not in use.
  • Address significant mask leaks with DME.

 

 

For the Patient suspected/confirmed of having covid-19:

  • If the use of PAP therapy is for the treatment of Obstructive Sleep Apnea (OSA), the risk of stopping PAP for a short period of time until no longer contagious may be reasonable. The patient would need to be counseled regarding increase risks in the short term such as accidents due to sleepiness or cardiovascular events. It would be reasonable to suggest the following in the interim:

-Positional therapy with side sleeping, or head elevated at least 30 degrees.

-Use of dental appliance if the patient already has one.

-Treatment of nasal congestion.

-Avoidance of alcohol and sedating medications.

-Avoidance of sleepy driving.

  • If the patient must use PAP due to the risk of cessation being too great, then the patient should be advised to maintain strict quarantine and consider strategies for protecting household contacts.
  • If it is necessary for the patient to go to the hospital for any reason, encourage them to bring PAP equipment with them.
  • Once the patient is non-infectious, would recommend changing all disposables such as masks and tubing, as well as filters.

 

SLEEP CLINICS AND SLEEP LABORATORY ACTIVITIES:

Current recommendations from the American Academy of Sleep Medicine with regards to sleep laboratory testing and Sleep Clinic visits once there is substantial community spread are summarized here.***

  • Postpone in laboratory sleep studies for all patients. At the Cleveland Clinic we are evaluating potential urgent requests on a case by case basis.
  • Postpone HSAT services unless using only disposable HSAT devices. At the Cleveland Clinic we use disposable parts, and disinfect the non-disposable components.
  • Keep the sleep clinic open for phone calls, telemedicine visits, and emergency in-person visits only.
  • Prepare to communicate with patients and other stakeholders (e.g., payors, DME companies, trucking companies) about the need to extend deadlines that may have been set for the completion of sleep study evaluation and follow-up visits.
  • The AASM is advocating for the relaxation of payor requirements during this national emergency.  Currently CMS is relaxing the required face-to-face or in-person encounters for evaluations, assessments and certifications.  In addition, CMS is allowing coverage of CPAP based on clinician’s assessment during the pandemic.  Telehealth modalities that include audio and video two-way communications between patient and provider are accepted. Penalties are being waived for HIPAA violations for the use of FaceTime or Skype.

 

  • USE OF PAP DEVICES IN EMERGENCIES SITUATION AS A SUBSTITUTE FOR VENTILATION:

 

 

Basic CPAP (continuous positive airway pressure) and bilevel PAP are not designed to function as ventilators.  ASV (adaptive servo ventilation) is a device specifically used to treat central sleep apnea, and is also not meant to function as a ventilator in the scenario of respiratory failure.  There are PAP therapy device with Non-Invasive Ventilation (NIV) capacity.  These devices include bilevel PAP ST, AVAPS (average volume assured pressure support), iVAPS (intelligent volume assure pressure support). These devices are not a substitute for the use of a ventilator in the setting of acute respiratory failure. Also, important to note is that they are open circuits with the same risk of droplet and aerosolized particle spread of virus as other PAP devices.  There is recent history of using NIV in critically ill patients due to MERS in a retrospective cohort study. Results were that NIV failure was high, and not associated with improved outcomes. 5

Should there arise a need to use PAP/NIV device to assist with mild hypoxemia and hypercarbia pending endotracheal intubation, adaptations will need to be made to the masks and filtration systems.  In these scenarios, it is best to use an oro-nasal mask that is well fit, and avoid nasal or nasal pillows type of masks.  New information is emerging daily in this area, and would recommend monitoring the manufacturer’s websites, as well as the following medical societies:

 

American Academy of Sleep Medicine (AASM)

American Society of Anesthesiologists (ASA)

American College of Chest Physicians (CHEST)

American Thoracic Society (ATS)

 

 

*https://aasm.org/covid-19-resources/covid-19-faq

**https://aasm.org/covid-19-information-for-sleep-medicine-clinicians/

+https://www.usa.philips.com/c-e/hs/better-sleep-breathing-blog/better-sleep/keeping-it-clean-cpap.html

++https://www.resmed.com/en-us/sleep-apnea/cpap-parts-support/cleaning-cpap-equipment/

+++wikihow.com/Make-Distilled-Water

***https://aasm.org/covid-19-resources/covid-19-mitigation-strategies-sleep-clinics-labs

+++https://www.philips.com/a-w/about/news/archive/blogs/innovation-matters/2020/20200325-covid-19-how-to-safely-optimize-niv-therapy.html

 

  1. 1. Hui, D. S. (2017) “Epidemic and Emerging Coronaviruses (Severe Acute Respiratory Syndrome and Middle East Respiratory Syndrome),” Clinics in Chest Medicine. W.B. Saunders, pp. 71–86. doi: 10.1016/j.ccm.2016.11.007.
  2. Singh, A. and Singh, J. (2011) “Noninvasive ventilation in acute respiratory failure due to H1N1 influenza: A word of caution,” Lung India, p. 151. doi: 10.4103/0970-2113.80340.
  3. Tang, J. W. et al. (2006) “Factors involved in the aerosol transmission of infection and control of ventilation in healthcare premises,” Journal of Hospital Infection, pp. 100–114. doi: 10.1016/j.jhin.2006.05.022.
  4. van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. N Engl J Med. March 2020. doi:10.1056/NEJMc2004973
  5. Alraddadi, B. M. et al. (2019) “Noninvasive ventilation in critically ill patients with the Middle East respiratory syndrome,” Influenza and other Respiratory Viruses. Blackwell Publishing Ltd, 13(4), pp. 382–390. doi: 10.1111/irv.12635.

 

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