Missing Sleep Apnea Link May Affect COVID-19 Outcomes

Wide-ranging effects from sleep apnea could undermine recovery for some patients
May 7, 2020 Updated: May 7, 2020

If you’ve been hunkering down and watching the news, you probably know about the emerging developments on the CCP(Chinese Communist Party) virus, revealing many seriously afflicted cases—those in intensive care or dying—suffer from two common medical conditions: hypertension (high blood pressure) or obesity.

While these data are intriguing, we can drill deeper to learn more about these “co-occurring” conditions (or comorbidity in doctor-speak) to find additional links.

First, let’s ask the obvious questions on how high blood pressure and obesity worsen COVID-19. Obesity patients suffer from systemic inflammatory processes burdening their immune systems; maybe the virus finds it easier to overwhelm an already compromised immune system.

High blood pressure, especially when ineffectively treated, damages large and small blood vessels. Specifically, the inner lining of vessels known as the endothelial layer becomes dysfunctional, no longer operating at full capacity to maintain the smooth flow of blood cells traversing the circulatory system. A compromised flow of blood prevents a healthy response to an infection.

Sounds credible, but might we uncover a deeper explanation? At the next level, most health care professionals know obesity causes hypertension, so is excess weight the real culprit? Perhaps, but I would like to examine the relationship between obstructive sleep apnea (OSA) and both obesity and hypertension.

Although these relationships are complex, obesity worsens sleep apnea, and sleep apnea causes and worsens hypertension. Coming full circle, many sleep researchers also think sleep apnea amplifies the negative influences of obesity such as exacerbating diabetes and kidney disease. As OSA is a serious medical condition with critical relationships to obesity and hypertension, the two factors affecting morbidity (severity of illness) and mortality (lethality of illness) in CCP virus, commonly known as novel coronavirus, cases, by extension it makes sense to learn whether these patients are also suffering from undiagnosed and untreated sleep apnea.

OSA damages several major organ systems. Indeed, “obstructive sleep apnea” and “sleep-disordered breathing” are misleading names for this routinely undiagnosed sleep disorder. Yes, the condition blocks your airway and restricts airflow, but if you consider all the downstream mental and physical damage, a more comprehensive name would be “systemic sleep disorder of the brain, heart, lungs, and kidneys,” and, even this name is too short.

There is compelling evidence to suggest OSA is a factor in many COVID-19 cases.

Sleep apnea begins in the upper airway, from the breath you draw in through the nostrils all the way down to the bottom of the throat or pharynx. At any point, restrictions in airflow disrupt breathing patterns. Having a broken nose or deviated septum, enlarged tonsils, excessive tissue in the back of the soft palate, or a large tongue all contribute to OSA. Greater collapsibility inside the throat caused by a large neck circumference is a very strong contributor to OSA in an obese patient.

Sounds like a breathing disorder, doesn’t it? Right, if that’s all there were to OSA. Nonetheless, two more problems occur downstream when you cannot get enough air into your lungs while sleeping, and both could prove deadly over the long run. Health care professionals have only been trained to look at the first and most obvious damage caused by the decrease in oxygen getting into the bloodstream and incorrectly profess OSA is sufficiently treated by oxygen therapy. Supplemental oxygen helps, but if used in isolation, we would be neglecting the second and more common adverse component of OSA, namely, brain damage.

When the central nervous system or brain detects restriction in airflow, it is programmed to react to an anticipated drop in oxygen levels. The brain’s response is so rapidly effective in the majority of OSA cases, oxygen levels fluctuate yet infrequently drop below 90 percent, that is, below the normal range for oxygenation during sleep. The brain achieves this masterful result by activating a part of the nervous system to trigger brief awakenings, commonly for only 10–15 seconds, which is long enough to increase the volume of air. To be clear, you breathe more forcefully awake than asleep. You are unlikely to recall any of these events, because after the arousal you return to sleep and the breathing disruption cycle repeats … usually all night long.

Scientific evidence has proven that this rapid cycling between being awake and asleep causes brain damage, even though you would hold absolutely no memory of the events taking place. Paradoxically, the usual way you gain awareness of brain damage is the degree to which you suffer from daytime sleepiness or fatigue after repeated tumultuous nights of disrupted sleep.

Lamentably, few doctors understand or discuss these disastrous consequences to their patients, and as a result, undiagnosed OSA patients experience progressive brain damage, manifesting as symptomatic deviations in executive function, typically impairment in memory, concentration or attention, and all the while these specific cognitive declines are erroneously attributed to stress, depression, or aging.

Making matters worse for this second process, also known as sleep fragmentation, are the harmful effects on the rest of the body, particularly through direct actions on the inner linings of the blood vessels. This damage to the endothelial layer is how OSA causes and aggravates high blood pressure as well as causing more damage to other blood vessels in the heart, lungs, and kidneys.

OSA acts very much like diabetes as its tentacles reach into and degrade the normal functioning of virtually every cell in the mind and body. Most people struggle to digest these insights about the destruction OSA causes as it plows through their sleep and their health along with it.  Despite the likelihood of OSA damaging health outcomes for COVID-19 patients, few health care professionals are likely to consider OSA as part of the CCP virus equation as these obese or hypertensive patients struggle to recover.

Great sleep is a powerful yet invisible healer. That makes treating OSA important and necessary. Ignoring this affliction is dangerous and unacceptable.

We now know many of the worst CCP virus cases, including the lethal ones, are found among patients suffering from obesity or hypertension. That means we can reasonably propose that a significant number, perhaps even a majority, of these patients are also suffering from sleep apnea.

Obesity or hypertension should serve as red flags to signal an urgent need for OSA testing. A large proportion of these patients will likely benefit from the diagnosis and treatment of their sleep disorder, which could aid in their recovery from the CCP virus. This is a supposition that needs to be affirmed, for the well-being of patents and to ensure effective use of medical resources.

Barry Krakow, MD is a board-certified internist and sleep medicine specialist who has practiced clinical sleep medicine and conducted sleep research for 30 years. He has pioneered innovative treatments for common sleep disorders and hosts the website www.BarryKrakowMD.com.  He lives in Savannah, Ga.