Patients with COVID-19 who have modified high-risk (mHR) obstructive sleep apnea (OSA) are at increased risk for delayed clinical improvement, clinical worsening, and the need for supplemental oxygen compared with patients who have modified low-risk (mLR) OSA. Researchers conducted a multicenter, prospective, observational cohort study ( Identifier: NCT04363333) in 3 hospitals in Istanbul, Turkey, between March 10, 2020, and June 22, 2020. Results of the analysis were published in Annals of the American Thoracic Society.

Recognizing that obesity, hypertension, and diabetes have been linked to poor outcomes in patients with COVID-19, the researchers sought to establish the effect of OSA — which is known to be associated with these conditions as well — on prognosis and clinical outcomes in this population. All of the participants were classified as high-risk OSA or low-risk OSA, based on the Berlin questionnaire (BQ), which was administered either in an outpatient clinic or in the hospital, or shortly after hospital discharge. The mHR-OSA score was based on snoring patterns (ie, frequency and/or intensity), breathing pauses, and morning and/or daytime sleepiness. Patients were classified as mHR-OSA if they scored positive on 2 or more subcategories whereas the patients who did not score positive in any or only 1 subcategory were classified as mLR-OSA.

The primary study outcome was clinical improvement, which was defined as a decline of 2 categories from admission on a 7-category ordinal scale ranging from 1 (discharged with normal activity) to 7 (death) on days 7, 14, 21, and 28, respectively. Secondary study outcomes included clinical worsening, need for hospitalization, use of supplemental oxygen, and intensive care admission.

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A total of 320 patients participated in the study. The median participant age was 53.2 years (range, 41.3-63.0 years); 45.9% of the participants were women. Based on BQ scores, 37.8% (121 of 320) of the participants were categorized as known OSA (n=3) or high-risk OSA (n=118).

Based on modified scoring, 21.9% (70 of 320) of the participants had mHR-OSA. Of 242 participants who were hospitalized, clinical improvement within 2 weeks was reported among 75.4% of those in the mHR-OSA group vs 88.4% of those in the mLR-OSA group (P =.014).

Per adjusted logistic regression models, mHR-OSA and male sex were predictive of significantly delayed clinical improvement within 2 weeks (odds ratio [OR], 0.42;

95% CI, 0.19-0.92; P =.030 and OR, 0.39; 95% CI, 0.17-0.86; P =.020, respectively), after adjusting for age, body mass index (BMI), and hypertension. Louder snoring was also significantly associated with delayed clinical improvement (OR, 0.33; 95% CI, 0.15-0.75; P = .008), when adjusted for age, sex, BMI, and hypertension.

In the overall study population of 320 individuals, including those who were not hospitalized, mHR-OSA was associated with clinical worsening (adjusted hazard ratio, 1.55; 95% CI, 1.00-2.39; P =.048) and with the need for supplemental oxygen (OR, 1.95; 95% CI, 1.06-3.59; P =.032).

The researchers concluded that additional follow-up of the current sample with the use of clinical, laboratory, and radiologic studies, along with objective sleep recordings, is warranted to provide further insights into the clinical utility of the modified BQ as a screening tool during COVID-19 onset, as well as into the relationship between OSA and long-term outcomes among patients with COVID-19.


Peker Y, Celik Y, Arbatli S, et al; on behalf of The OSACOVID-19 Study Collaborators. Effect of high-risk obstructive sleep apnea on clinical outcomes in adults with coronavirus disease 2019: a multicenter, prospective, observational cohort study. Ann Am Thorac Soc. Published online February 17, 2021. doi:10.1513/AnnalsATS.202011-1409OC