Risk for COVID-19 and Related Complications Greater in Those With Recent OSA

Greater risk for adverse COVID-19 outcomes was found in those with OSA with comorbid airway disease but not with comorbid cardiometabolic conditions.

Patients have a greater risk for contracting COVID-19 and experiencing serious complications from COVID-19 if they have been recently diagnosed with obstructive sleep apnea (OSA), according to study findings published in Thorax.

Research suggests there is a link between OSA and COVID-19. Investigators therefore examined the association between OSA and the risk for COVID-19 infection or serious COVID-19-related complications through a retrospective, population-based study using provincial health administrative data from Ontario, Canada.

The study involved adults who were alive at the beginning of the pandemic (ie, before March 17, 2020) and were living in Ontario in the previous 5 years (March 2015 to March 2020). Individuals were followed up until March 31, 2021, or death, whichever came first. Patients who purchased a positive airway pressure (PAP) device from the Assistive Devices Program in the 5 years before the COVID-19 pandemic were regarded as having physician-diagnosed OSA requiring PAP treatment (PAP group). An algorithm was used to identify individuals who had at least 50% probability of having moderate to severe OSA in the 5 years before the pandemic (moderate/severe OSA group). A non-OSA group included individuals in the general adult population with a presumably low risk of OSA. The 2 major outcomes were contracting COVID-19 and serious complications from COVID-19.

The 3 study cohorts were populated as follows: the PAP group included 324,029 individuals (median age, 58 years; 65% male); the moderate/severe OSA group included 191,447 individuals (median age, 57 years; 68% male); and the non-OSA general population group included 4,588,200 individuals (median age, 47 years; 52% male). Given the varying cohort sizes, researchers weighted the samples in making cohort comparisons.

The investigators found participants in the PAP group vs non-OSA group had a greater hazard for a positive COVID-19 test (cause-specific HR [csHR] 1.17; 95% CI, 1.13-1.21), COVID-19-related emergency department (ED) visit (csHR 1.62; 95% CI, 1.51-1.73), COVID-19-related hospitalizations (csHR 1.50; 95% CI, 1.37-1.65), and COVID-19-related intensive care unit (ICU) admissions (csHR 1.53; 95% CI, 1.27-1.84), but not COVID-19-related 30-day mortality (csHR 0.98; 95% CI, 0.82-1.16). The moderate/severe OSA group vs the non-OSA group also had a greater risk of a positive COVID-19 test and COVID-19-related ED visits, hospitalizations, or ICU admissions, but not COVID-19-related 30-day mortality.

These findings support consideration of OSA as a high-risk condition for adverse COVID-19 outcomes and warrant higher prioritization of patients with OSA for public health protection..

Patients in the PAP group with comorbid chronic airways disease had a greater hazard of COVID-19-related outcomes, including mortality, vs those who did not have comorbid chronic lung conditions. PAP group individuals with comorbid cardiometabolic conditions had a lower hazard of COVID-19-related outcomes, compared with those without comorbid cardiometabolic conditions.

Study limitations include unmeasured residual confounding, misclassification bias, selection bias (including referral bias), and lack of information on PAP use. Other limitations include the use of PAP as a surrogate marker to identify individuals with clinically significant OSA and researchers’ inability to differentiate between death caused by COVID-19 vs death with COVID-19.

“These findings support consideration of OSA as a high-risk condition for adverse COVID-19 outcomes and warrant higher prioritization of patients with OSA for public health protection,” stated the researchers. “Furthermore, screening for undiagnosed OSA and subsequent treatment should be made a priority — not halted during periods of high COVID-19 in the community — to reduce this risk.”

Disclosure: Some of the study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Kendzerska T, Povitz M, Gershon AS, et al. Association of clinically significant obstructive sleep apnoea with risks of contracting COVID-19 and serious COVID-19 complications: a retrospective population-based study of health administrative data. Thorax. Published online January 30, 2023. doi:10.1136/thorax-2022-219574