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Poor adherence to positive airway pressure (PAP) in patients with obstructive sleep apnea was associated with increased rates of COVID-19 infection, a researcher said.

Among a group of about 82,000 patients in southern California, a significantly higher percentage of patients (2.1%) with obstructive sleep apnea and lower adherence to PAP (defined as less than 2 hours per night) had COVID-19 infection compared with 1.3% of obstructive sleep apnea patients who had the best adherence to PAP (more than 4 hours per night), reported Dennis Hwang, MD, of Kaiser Permanente in Fontana, California.

At a presentation at the virtual American Thoracic Society annual meeting, the question came up about why PAP adherence might play a role in risk of COVID-19 infection. Hwang theorized it might be more of a social factor than a biological one, though he noted the retrospective nature of the study, meaning it was not possible to send out surveys to verify specific behaviors.

"I think we can certainly infer that a social-behavioral mechanism is at play here," he said. "Those who are more adherent to PAP may be more adherent to social distancing, masking, and so forth. We can infer that, but we don't know for sure."

Hwang's group set out to examine patients with obstructive sleep apnea, because they share demographic and clinical characteristics, such as age, gender, cardiovascular disease, and obesity, associated with increased COVID-19 severity, but that pathophysiologic factors suggest the direct negative effect of obstructive sleep apnea and protective effect of positive airway pressure is possible.

The team examined data from adults at Kaiser Permanente Southern California and its network of 10 sleep centers. Participants were included if they had available daily PAP data, which was wirelessly transmitted. Hwang's group calculated PAP adherence from March 1 to July 31, 2020.

Overall, 81,932 patients were included in the study. They were a mean age of 54, 60% were men, 40% were white, and 35% were Hispanic. There were 1.8% who had COVID-19 infection, but less than 1% were hospitalized, required ICU care, or died.

Patients were divided into four groups:

• No obstructive sleep apnea

• Obstructive sleep apnea, with PAP less than 2 hours per day

• Obstructive sleep apnea, with PAP at 2 to 3.9 hours per day

• Obstructive sleep apnea, with PAP more than 4 hours per day

Patients with obstructive sleep apnea tended to be older, more likely to be men, more likely to have obesity, and had a greater rate of baseline comorbidities, Hwang said.

As adherence to PAP improved, the rate of infection decreased. However, Hwang noted, there was no relationship between obstructive sleep apnea and PAP therapy and rates of COVID-19 hospitalization, ICU, or death.

An adjusted analysis found that older patients had lower rates of becoming infected, which Hwang characterized as a "surprising" finding, but theorized this was also a "social-behavioral factor," where these patients were more adherent to public health measures and less likely to be engaging in "higher risk social behavior."

Patients with obesity and more comorbidities also had a higher risk of becoming infected, he said. Socioeconomic factors also played a role, with Black race, Hispanic ethnicity, and Medicaid enrollment linked to higher infection rates.

Hwang said his group is in the process of "redoing the numbers" now that more time has passed, including PAP use before and after becoming infected with COVID-19, and finding there was no difference in PAP use between those hospitalized and non-hospitalized.

However, not everything remained the same, with Hwang's group uncovering additional data from November and December 2020.

"The initial analysis did not find a relationship between [obstructive sleep apnea] and severity of illness [but] in the new analysis, [obstructive sleep apnea] might be associated with increased risk of hospitalization," he said.

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