Considerations for the practice of sleep medicine during COVID-19

Aerosol-generating procedures

• Per the CDC, some procedures performed on patients are more likely to generate higher concentrations of infectious respiratory aerosols than coughing, sneezing, talking, or breathing. These aerosol generating procedures (AGPs) potentially put health care personnel and others at an increased risk for pathogen exposure and infection.
• Commonly performed medical procedures that are often considered AGPs, or that create uncontrolled respiratory secretions, include:
  • open suctioning of airways
  • sputum induction
  • cardiopulmonary resuscitation
  • endotracheal intubation and extubation
  • non-invasive ventilation (e.g., bilevel positive airway pressure [BPAP], continuous positive airway pressure [CPAP])
  • bronchoscopy
  • manual ventilation
• Data regarding relative safety of specific styles of PAP masks are insufficient.
• In general, when the possibility of increased risk of infecting others exists, PAP therapy delivered via mask should be based on a thorough risk-benefit analysis if a patient has COVID-19. Some data to use in your analysis includes:
  • “Noninvasive ventilation (NIV) is a potential aerosol-generating device. In this regard, the deliberate leakage via the exhalation ports may generate droplet nuclei and disperse infective aerosols through the evaporation of the water content of respiratory droplets resulting in a superspreading event.”
    • Source: Singh A, Singh J. Noninvasive ventilation in acute respiratory failure due to H1N1 influenza: A word of caution. Lung India. 2011 Apr;28(2):151. https://doi.org/10.4103/0970-2113.80340
    • Also see: Tang JW, Li Y, Eames I, Chan PK, Ridgway GL. Factors involved in the aerosol transmission of infection and control of ventilation in healthcare premises. J Hosp Infect. 2006;64:100–14. https://doi.org/10.1016/j.jhin.2006.05.022
  • “Until further data become available, it should be assumed that [noninvasive ventilation] is aerosol generating…Transmission of COVID-19 is primarily through droplet spread. These droplets are affected by gravity and may cause direct transmission from close contact or contribute to surface contamination (where the virus may remain active for hours to days). However, positive pressure ventilation is thought to generate aerosols composed of smaller virus containing particles suspended in air. These airborne particles may travel greater distances and be inhaled, increasing the risk of transmission.”
    • Source: Brewster DJ, Chrimes NC, Do TBT, et al. Consensus statement: Safe Airway Society principles of airway management and tracheal intubation specific to the COVID-19 adult patient group. Med J Aust 2020; 212 (10): 472-481. https://doi.org/10.5694/mja2.50598
  • During the outbreak of SARS-CoV in Toronto, half of all SARS-CoV cases were in health care workers, three of whom died, despite existing safety protocols. The greatest risk of becoming infected was experienced by those involved in manipulating the airway or those who were exposed to aerosolized pathogens via nebulizers, positive airway pressure therapy, or high flow nasal oxygen therapy.

Home PAP use in patients with suspected or confirmed COVID-19 infection

• While dispersion of the virus with PAP is theoretically greater with than without PAP, the specific risk to others because of PAP therapy is not known.
• The decision of whether to continue or stop PAP therapy should be based on a risk:benefit assessment.
• If a patient is suspected or confirmed to have COVID-19, we suggest assessing risks and benefits of continuing to use a PAP (CPAP/BPAP/APAP) device at home.
  • The risks of continuing PAP therapy include:
    • Potential risk of transmission of COVID-19 to others in the environment if PAP is continued.
      • Consider proximity of others to the patient (i.e., multi-unit apartment building with shared ventilation, shared rooms, multiple bedroom apartment with shared common space)
      • Consider severity of infection
    • Viral particles may persist for some time depending on the type of surface and environmental factors including room temperature, air exchange rates, filtration, humidity, and air currents.
    • Whether it is possible for the patient to be re-infected from tubing, filters, and/or mask reuse is not known.
  • The risks of discontinuing PAP therapy include:
    • OSA is a chronic disorder, and the risk of stopping PAP for a limited time until the patient is no longer contagious may be manageable, depending on the severity of the disorder and symptoms. Without PAP, however, some patients may experience an increase in unacceptable health risks in the short term, such as accidents, safety incidents, falls, or cardiovascular events.
    • If acute, unacceptable risks to health or safety are identified, risk-mitigation strategies may be appropriate, such as advising the patient to stop driving, adhering to fall precautions, and consulting with their treating physician to optimize medical management of background medical conditions.
  • Using positional therapy or an oral appliance (if the patient already has one or one can be obtained safely), limiting the use of alcohol and sedating medications, and addressing nasal congestion may also be effective for some patients. The risk of transmission using an oral appliance is unknown.
  • If these short-term risk mitigation strategies are insufficient, and a decision is made to continue PAP in a patient who has confirmed COVID-19, or is suspected of having COVID-19, the patient should be advised to maintain strict quarantine and self-isolation when possible and consider strategies for protecting household contacts.

In-patient PAP use for patients with suspected or confirmed COVID-19 infection

• For patients with OSA who are currently hospitalized and waiting for the COVID-19 test results, the AASM recommends using guidance issued by local health centers or hospitals to decide on CPAP/BPAP use, due to regional variation in prevalence and resources. At a minimum, AASM suggests following CDC recommendations regarding aerosolizing procedures.
• If COVID-19 status is suspected or positive, recognize that PAP/NIV may increase aerosolization, and therefore, potential transmission of virus. Therefore, NIV/PAP should be avoided as much as possible, particularly in the absence of proper ventilation, access to PPE, and other strategies to limit viral dispersion to others.
• Among individuals in whom COVID-19 testing is negative, any decision to use PAP/NIV should take into careful consideration the following:
  • Estimated background prevalence rates; under conditions of high background prevalence, the likelihood of false negative (unrecognized cases) is expected to be higher. Therefore, even patients whose COVID-19 testing is negative should be treated with caution. Note that reported rates of false negative rates have varied.
  • Whether PAP is absolutely necessary, based on assessment of acute/short-term health or safety risks of temporary withdrawal of therapy. In typical settings, we expect such need to be infrequent.
  • The ability to properly protect health care professionals and other patients, through access to properly-ventilated rooms, PPE, and other strategies to limit viral dispersion to others.
• Alternatively, for short-term treatment of OSA while hospitalized, we highly recommend conservative measures such as elevating the head of the bed when oxygenation status permits, and or using positional therapy including prone positioning. If appropriate, consider the use of low-flow oxygen via nasal cannula. Limit airway manipulation or procedures that may increase risk of spread of the virus.