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The advent of the COVID-19 pandemic has wreaked havoc with the health care system. And, Sleep Medicine is no exception. Interestingly, while there have been many new problems to solve, the majority of the impact has been to accelerate the pace of already established trends.
One of the first changes has been the inability of the brick and mortar sleep labs to continue to function as before. They have faced a daunting series of challenges, including inadequate staffing and PPE, sanitizing equipment, patient cancellations, and reduced referrals. Over the last decade, there has been a sea change in the way patients are tested for obstructive sleep apnea (OSA). Since the approval of home sleep tests (HST) by CMS in 2008, there has been a long-term trend away from sleep labs and toward the use of HSTs for the majority of patients at risk for apnea. While this trend was well established, the rapidity with which COVID-19 struck the U.S. population has created tremendous disruption for patients awaiting diagnosis. Given recent estimates of over fifty million Americans with OSA (1), and the majority still undiagnosed, any disruption in the delivery of diagnostic services is cause for concern.
Similarly, home sleep testing services have faced numerous COVID-19 related challenges. Some providers of HSTs have used a classroom model to educate several patients at a time about OSA and the HST they would be performing. Clearly, the classroom model is no longer feasible. Unfortunately, some of these providers can not adequately staff individual set up sessions and have been forced to discontinue all testing services. For those who provide remote HST services, with no required person to person contact, there remains a significant decontamination challenge. Once again, this difficulty in decontamination plays into a long- term trend to use disposable HSTs. Prior to COVID-19 there has been the need to deal with seasonal flu, HIV, and multi-drug resistant bacteria, to name just a few. Given the higher cost of disposable testing technologies, their appropriate place in the diagnostic armamentarium is still being elucidated. As with in-lab studies, the pace of referrals for HSTs has slowed, given the reduced number of patients being seen in primary care and specialty care settings.
Once a patient has obtained a diagnosis of OSA, there remains the issue of initiating PAP therapy. Again, traditionally this is done during an in-person session with a licensed therapist. Yet another long-term trend is that manufacturers of PAP equipment have made enormous strides in more universally applicable mask designs and intuitive setup instructions. We have been performing “remote” PAP setups for several years. Using various platforms ranging from full audio / visual to a simple phone call to dyssynchronous support, we have been able to successfully initiate PAP therapy with CMS success rates similar to in-person setups. We are scheduled to present our work in Philadelphia this June during the SLEEP 2020 conference. (2) The meeting has not been officially cancelled but they have said it is unlikely to occur as scheduled.
Once a patient is set up on a PAP device, it is important to realize that because PAP circuits are not closed circuits, there is the potential to spread infectious agents through the exhalation of contaminated aerosols. (3) Therefore, the patient and their family need to be educated accordingly. If the PAP device is to be used in an in-patient setting, then all healthcare providers need to be educated about possible disease transmission and use appropriate PPE.
Patient communication has also been a challenge. The longer-term trend of telemedicine is well established but is far from universally available. As a result, there are numerous reports of patients being “seen” via non-HIPAA compliant platforms such as facetime and the like. CMS has moved quickly to ease certain restrictions on telemedicine to allow for the recruitment of healthcare providers from other states as well as waiving the “face to face” requirements in certain situations (4). These changes apply nationwide for the duration of the emergency declaration. While the final deployment of widespread telemedicine will dramatically assist in this need, it does not entirely deal with the centralized nature of much of medical care. Many Americans receive their care in large and small medical centers throughout the country. Uninsured patients without primary care physicians are often forced to use urgent care and emergency care facilities for their healthcare needs. As we have seen in the “hot spots” throughout the U.S., having symptomatic patients congregating in waiting rooms in centralized facilities is quite problematic. This difficulty plays into another long-term trend of decentralized primary care. The ability to see patients in the communities in which they live, or the provision of on-site and near-site care can dramatically reduce congestion in urgent and emergent care facilities and reduce the potential for disease transmission. Decentralized care has also taken the shape of on-demand text-based care. Moving forward, no doubt, many of these approaches will find their appropriate audience.
Lastly, and perhaps most importantly, in this time of pandemic viral infection, we must remember the impact of sleep on our mental health and immune competence. In addition to myriad cardiovascular, cognitive, and endocrine consequences, OSA is associated with an increased incidence of depression. (5) This is particularly important in this time of social isolation and diminished access to mental health services. Sleep is also vitally important in rejuvenating our body’s immune system. Sleep deprivation compromises our ability to fight off a viral infection. Individuals who were sleep-deprived developed flu symptoms more commonly than non-sleep deprived individuals when both had a rhinovirus instilled in their noses. (6) Furthermore, it has been documented that sleep-deprived individuals mount a much weaker response to the flu vaccine that non-sleep deprived individuals. (7) A weaker response means less protection against infection. As we contemplate mass inoculation to protect against COVID- 19, we must recognize the importance of adequate sleep before receiving any vaccine.
Written by: Dominic Munafo, MD, FABSM, Chief Medical Officer for BetterNight
References
(1) Benjafield A, Ayas N, Eastwood P et al. Estimation of the global prevalence and burden of obstructive sleep apnoea: a literature-based analysis. Lancet Respir Med 2019 Aug 7(8):687-698 doi:10.1016/S2213-2600(19)30198-5.
(2) Hevener W, Barnes F, Munafo D. Feasibility Of Observed But Physically Unaided Continuous Positive Airway Pressure Set Ups. Accepted Abstract SLEEP 2020-A-259-APSS
(3) Ferioli M, Cisternino C, Leo V et al. Protecting healthcare workers from SARS-CoV-2 infection: practical indications. European Respiratory Review 2020 29: 200068; doi:10.1183/16000617.0068-2020
(4) https://www.cms.gov/files/document/covid-19-physicians-and-practitioners.pdf
(5) Ejaz S, Khawaja I, Bhatia S et al. Obstructive Sleep Apnea and Depression: A Review. Innov Clin Neurosci. 2011;8(8):17–25
(6) Prather A, Janicki-Deverts D, Martica H et al. Behaviorally Assessed Sleep and Susceptibility to the Common Cold. SLEEP 2015;38(9):1353–1359.
(7) Prather A, Pressman S, Miller G et al. Temporal Links Between Self-Reported Sleep and Antibody Responses to the Influenza Vaccine. Int J Behav Med 2020