Najib T Ayas1, Kristin L Fraser2, Eleni Giannouli3, Patrick J Hanly2, Tetyana Kendzerska4, Sherri Lynne Katz5, Brandy N Lachmann6, Annie Lajoie7, Caroline Minville8, Debra Morrison9, Indra Narang10, Marcus Povitz2, Robert Skomro11, Kathy F Spurr12. 1. Department of Medicine, University of British Columbia, Vancouver, BC, Canada. Electronic address: nayas@providencehealth.bc.ca. 2. Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada. 3. Department of Medicine, University of Manitoba, Winnipeg, MB, Canada. 4. Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada. 5. Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada. 6. Vancouver Coastal Health, Vancouver, BC, Canada. 7. Research Institute, McGill University Health Centre, Montréal, QC, Canada. 8. Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada. 9. Department of Medicine, Dalhousie University, Halifax, NS, Canada. 10. Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada. 11. Division of Respiratory, Critical Care and Sleep Medicine, University of Saskatchewan, Saskatoon, SK, Canada. 12. School of Health Sciences, Dalhousie University, Halifax, NS, Canada.
Sleep Disordered Breathing (SDB) includes diseases such as OSA and central sleep disorders (eg, associated with neuromuscular disease, opioid use, congestive heart failure). This commentary summarizes the Canadian Thoracic Society’s position statement on managing SDB during the COVID-19 pandemic in an easy Frequently Asked Questions format. The full SDB position statement, as well as other valuable tools and resources, can be found on the Canadian Thoracic Society website.
Should Patients Be Tested for SDB During the Pandemic?
No, unless a clinician determines that a case is “extremely urgent.” For example: unstable cardiopulmonary disease in which SDB is a substantial contributor (eg, right heart failure, nocturnal angina, hypercapnia in the setting of neuromuscular disease, or severe nocturnal hypoxemia).If testing is required, it should be done in-home with disposable equipment if possible. Otherwise, patients should be screened for COVID before sleep laboratory testing, and attend alone, if possible (eg, this may not be possible if the patient is a minor). Staff must have proper personal protective equipment, and the equipment and space must be cleaned. Positive airway pressure (PAP) titration studies should be avoided, because PAP is thought to generate aerosols.
What Should Clinicians Do If Patients Cannot Be Tested?
In selected patients, an empiric treatment of auto-titrating PAP, nocturnal oxygen, bilevel positive airway pressure, and so forth could be tried until diagnostic testing can be done. Suitable patients for this include: unstable/severe cardiopulmonary disease, neuromuscular disease and respiratory distress/hypercapnia, severe nocturnal hypoxemia, substantial excessive daytime sleepiness with severe impairment of quality of life/daytime function. However, this should be done with specialist consultation (respiratory, sleep).
Should Patients Attend Routine Clinic Visits?
No, these are to be avoided in favor of telemedicine/telephone visits/consultations.
Should Clinicians Prescribe PAP?
Not if it can be avoided/delayed. Patients who need new PAP prescriptions urgently should avoid rental machines in favor of new machines or masks (eg, auto-titrating devices, remote titration) sent by mail rather than picked up in person.Patients who have or may have COVID-19 should not start PAP until all symptoms have resolved and two consecutive negative COVID tests have been confirmed, if possible.
What About Patients Who Are Already Using PAP?
Patients who do not have COVID-19 should continue to use their PAP at home as normal, and clean the equipment according to the manufacturer’s instructions. Masks and hose can be cleaned more often if symptoms are suspected. Masks and machines should not be shared.Patients who have or may have COVID-19 should follow isolation procedures as recommended by public health agencies. Because PAP devices can aerosolize droplets, patients should discuss the risks and benefits of continuing PAP with their clinician. Patients who live with others should sleep alone in a separate room, use a separate bathroom, practice physical distancing, clean the mask daily with a cleaning wipe, avoid use of a humidifier, and clean the hose with sterilizing solution every other day. Mask, filter, and hose should be replaced once COVID-19 has resolved.Caregivers should take appropriate precautions when applying PAP for others.
Should PAP Be Continued If a Patient With SDB Is Admitted to Hospital for COVID-19?
The need should be weighed against the risks of viral transmission. If PAP is continued, the patient should use their own equipment/mask, if possible, and the hospital should follow its infection control protocols.
Should Newly Diagnosed, Hospitalized SDB Patients Get PAP?
The risks and benefits of immediate therapy need to be weighed carefully. However, if therapy could be life-saving, then it should be started according to the hospital’s infection control protocols.These recommendations are subject to change as information regarding COVID-19 and its effects are further understood. We plan to update this guidance as new epidemiologic and other information become available. This information will help to guide future de-escalation of precautions with respect to sleep disordered breathing-related services. We recommend monitoring the Canadian Thoracic Society website for updates.