Considerations for the practice of sleep medicine during COVID-19

Aug. 27, 2020

During the COVID-19 public health emergency, the American Academy of Sleep Medicine (AASM) advises sleep clinicians to follow the recommendations of the CDC as well as additional policies, guidance and/or mandates from state and local health departments and your local hospital, health system, institution or jurisdictions.

Regulatory agencies, such as the CDC, do not currently have guidance related to COVID-19 that is specific to sleep centers and laboratories. In the interim, members of the AASM are invited to consider the following consensus guidance developed by the AASM COVID-19 Task Force.

  • Stay up-to-date on CDC, state, and local public health recommendations based on community risk, as this is an evolving situation. Consider appointing an individual who will be responsible for remaining up to date on these recommendations.
  • Centers should have a policy and plan that conforms to local/state/national regulations and emergency orders and should update it periodically, as needed.
  • Centers should develop plans to ensure staff and visitor safety when dealing with individuals who resist safety policies and procedures.
  • Utilize alternate care delivery models based on the level of community transmission, availability of appropriate technologies, training of health care providers, and patient acceptance level. For sleep practices, strategies could include telemedicine, remote monitoring, home-based testing, and durable medical equipment (DME) services such as remote fitting of masks using video.
    • If telemedicine visits are available, offer this option to your patients for consults and follow-up visits in a preemptive fashion.
  • Develop clear and specific algorithms for patient flow.
    • Follow institutional and CDC guidelines.
    • Consider use of available advice lines, patient portals, and online self-assessment tools for risk assessment.
    • Consider postponing appointments, or use of telephone or virtual visits, whenever appropriate.
    • Consider the needs of patients working in safety-sensitive professions.
    • Follow institutional protocols and CDC guidelines regarding risk assessment on an ongoing basis after arrival at the facility.
    • Consider how to accommodate medically necessary persons who accompany patients (family, translators, medical personnel).
  • Participate in larger efforts for contact tracing when appropriate.
  • Decide on use based on availability, turnaround time, and local/state regulations.
  • Local transmission/prevalence rates influence interpretation.
  • The possibility of false positives and negatives is a function of pre-test probability (local prevalence, presence of symptoms, recent exposure history, etc.) and test methodology.
    • In regions with high or rising prevalence, a negative test is more likely to be a false negative.
    • In low prevalence areas, a positive test may be more likely to be a false positive than in high prevalence areas.
  • Consider risk stratification based on type of encounter.
    • Titration study risk > diagnostic testing
  • Develop a policy for handling positive tests.

Home sleep apnea testing

  • Some sleep centers are dispensing home sleep apnea test (HSAT) units through mail delivery or using curbside pickup and return, to reduce patient contact.
  • Sleep centers can provide patients with access to instructional brochures, video or telemedicine consultations to ensure proper set-up, as well as safe handling of the package upon arrival.
  • Using single-use, fully disposable devices and/or components is an option to reduce the risk of virus transmission from surface contact.
  • If using reusable devices, the units must be cleaned and disinfected according to manufacturer’s instructions and facility policies. As an extra precaution during this public health emergency, some sleep centers are removing a reusable device from service for at least 72 hours in addition to disinfection before its next use.
  • When cleaning reusable devices, staff should wear a facemask, gloves, and appropriate eye protection.

In-laboratory testing

  • Sleep centers should anticipate that some patients — especially older adults, those who are pregnant, and people of any age who might be at higher risk for severe illness from COVID-19 — may be hesitant to undergo in-lab testing during this public health emergency. Taking patient preferences into consideration, providers may consider postponing in-lab studies for these patients on a case-by-case basis when testing is considered to be non-emergent.
  • Medical providers should consider on a case-by-case basis whether it is preferable to initiate positive airway pressure (PAP) therapy in adults using either auto-titrating positive airway pressure (APAP) at home or in-lab PAP titration, in accordance with the AASM clinical practice guideline.
  • During this public health emergency, Medicare will cover PAP devices based on the clinician’s assessment of the patient without requiring an objective diagnosis by polysomnography (PSG) or HSAT. While there are validated screening and assessment tools, specific criteria to justify the prescription of PAP devices are unavailable. Furthermore, CMS has not clarified what follow-up testing, if any, may be required after this public health emergency is over.

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.

Personnel considerations

  • Educate personnel on appropriate screening procedures, selection and use of PPE, physical distancing and handwashing
  • Not all masks are equal; select the appropriate mask for your clinical situation, background prevalence rate and exposure risk.
  • Encourage ongoing staff self-education and training.
  • Staffing: The AASM Accreditation Standards state, “The AASM recommends a patient-to-technologist ratio of 2:1 under usual circumstances for attended PSG at facilities.” In some situations and circumstances, COVID-19-related concerns may constitute “unusual circumstances,” such that other patient-to-technologist ratios may be necessary to address staff and patient safety issues.
  • Adequate PPE availability and appropriate donning and doffing technique is needed for all technologists conducting attended sleep studies.
  • Technologists/RTs should have adequate rest breaks and recovery time between shifts; if found to have been exposed to a potentially COVID-19-positive patient, they should follow employee health guidance at their center or institution regarding testing, quarantine and safe return to work.
  • Personnel who develop respiratory symptoms (e.g., fever, cough, shortness of breath) should be instructed not to report to work. Ensure that the sick leave policies are flexible to ensure safety and consistent with public health guidance and make certain that employees are aware of these policies.
  • Ensure clear lines of communication on policy changes with all staff.

Facility considerations

  • Promote social distancing including utilization of telemedicine, reducing in-person volumes, avoiding crowding in common spaces and using distance markers.
  • Ensure availability of sanitizer and necessary PPE, including masks, gloves, and face shields.
  • Utilize signage to educate/remind both patients and staff.
  • Evaluate options to improve air quality to reduce potential for exposure including ventilation or filtration systems and/or use of outdoor spaces.
  • Clean and disinfect equipment and rooms, per standard CDC recommendations.

Equipment Considerations

  • Individual facilities are urged to follow CDC, institution, and manufacturer protocols regarding cleaning of facilities and equipment.
  • Upon a patient’s recovery from COVID-19, it may be advisable to replace filters, given the lack of data regarding the possibility of re-infection.

For questions or to provide feedback, please contact the AASM at covid@aasm.org.