Sleep Apnea and Risk of Influenza-Associated Severe Acute Respiratory Infection: Real-World Evidence

Obstructive Sleep Apnea and Acute Lower Respiratory Tract Infections: A Narrative Literature Review

Both obstructive sleep apnea (OSA) and acute lower respiratory tract infections (LRTIs) are important global health issues. The pathophysiological links between OSA and LRTIs include altered immune responses due to chronic intermittent hypoxia and sleep fragmentation, increased aspiration risk, and a high burden of comorbidities. In this narrative review, we evaluated the current evidence on the association between OSA and the incidence and outcomes of acute LRTIs in adults, specifically community-acquired pneumonia and viral pneumonia caused by influenza and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Studies have demonstrated that OSA patients are more likely to develop bacterial pneumonia and exhibit a higher risk of invasive pneumococcal disease. The risk intensifies with the severity of OSA, influencing hospitalization rates and the need for intensive care. OSA is also associated with an increased risk of contracting influenza and suffering more severe disease, potentially necessitating hospitalization. Similarly, OSA contributes to increased COVID-19 disease severity, reflected by higher rates of hospitalization, longer hospital stays, and a higher incidence of acute respiratory failure. The effect of OSA on mortality rates from these infections is, however, somewhat ambiguous. Finally, we explored antibiotic therapy for OSA patients with LRTIs, addressing care settings, empirical regimens, risks, and pharmacokinetic considerations. Given the substantial burden of OSA and its significant interplay with acute LRTIs, enhanced screening, targeted vaccinations, and optimized management strategies for OSA patients should be prioritized.

Impact of obstructive sleep apnea on clinical outcomes of hospitalization due to influenza in children: A propensity score-matched analysis of the US Nationwide Inpatient Sample 2005-2018

BACKGROUND

Previous studies have explored the association between obstructive sleep apnea (OSA) and clinical outcomes of influenza in adults, whereas limited research examined this relationship in pediatric populations. This study aimed to evaluate the clinical impact of OSA on the outcomes of pediatric influenza hospitalizations.

METHODS

This was a population-based, retrospective study. Data of children aged 1-19 years hospitalized for influenza infection were extracted from the United States (US) Nationwide Inpatient Sample Database 2005-2018. Univariable and multivariable regression analyses determined associations between OSA, length of stay (LOS), total hospital costs, pneumonia, and life-threatening events.

RESULTS

After propensity-score matching, a total of 2100 children were analyzed. The logistic analysis revealed that children with OSA had a significantly increased LOS (β = 2.29 days; 95% confidence interval, CI: 1.01-3.57, p < .001) and total hospital costs (β = 26.06 thousand dollars; 95% CI: 6.62-45.51, p = .009), and higher odds of pneumonia (aged 6-10 years: odds ratio [OR] = 1.52; 95% CI: 1.01-2.27, p = .043; aged ≥ 11 years: OR = 1.83; 95% CI: 1.33-2.53, p < .001).

CONCLUSIONS

During influenza admissions, children with OSA had longer LOS, higher hospital costs, and an increased risk of pneumonia compared to those without OSA. These findings underscore the importance of recognizing and managing OSA in influenza-related infections among children.

Effects of Obstructive Sleep Apnea on Airway Immunity and Susceptibility to Respiratory Infections

Obstructive sleep apnea is a prevalent sleep disorder characterized by recurrent episodes of partial or complete upper airway collapse during sleep, leading to disrupted breathing patterns and intermittent hypoxia. OSA results in systemic inflammation but also directly affects the upper and lower airways leading to upregulation of inflammatory pathways and alterations of the local microbiome. These changes result in increased susceptibility to respiratory infections such as influenza, COVID-19, and bacterial pneumonia. This relationship is more complex and bidirectional in individuals with chronic lung disease such as chronic obstructive lung disease, interstitial lung disease and bronchiectasis.

Study on the correlation between lifestyle and negative conversion time in patients diagnosed with coronavirus disease (COVID-19): a retrospective cohort study

BACKGROUND

As of early December 2022, China eased the coronavirus disease (COVID-19) restriction, affecting over 80% of the country's population and posing a severe threat to public health. Previous studies mostly focused factors on the severity/mortality rate of hospitalized COVID-19 patients, but limited studies explored factors associated with virus-negative conversion, particularly lifestyles. Therefore, the aim of our study was to analyze the correlation between lifestyle factors and the negative conversion time in COVID-19 patients.

METHODS

We recruited individuals aged 18 years or older who had a clear time record for both the diagnosis and negative conversion of COVID-19 and completed the electronic questionnaire with no missing data. Dietary data collected from the questionnaire was analyzed using exploratory factor analysis to establish dietary patterns. Age segmentation was performed using restricted cubic spline (RCS) plots. The association between lifestyle factors and the time to negative conversion in different age groups, was assessed using Kaplan-Meier plots and Cox regression analysis.

RESULT

Out of 514 participants, all achieved viral negative conversion within a median time of 11 days. Based on nutrient intake, we identified four dietary patterns. The relationship between age and negative conversion rate, as depicted by RCS plots, exhibited an inverted "U" shape. We categorized age into three segments: <35 years, 35-45 years, and ≥ 45 years. For individuals under 35, our study indicated that a higher protein intake was linked to a faster recovery among COVID-19 patients, while medical staff or those receiving prescription treatments exhibited a slower recovery rate (P < 0.05). The 35 ~ 45 age group showed that adequate sleep and physical exercise were associated with a shorter time to negative conversion, whereas southern regions and a higher intake of carbohydrates were related with a longer conversion time (P < 0.05). Among individuals aged ≥ 45 years, the negative conversion time was primarily associated with physical exercise and being a medical staff member(P < 0.05).

CONCLUSION

Our research suggests that adequate sleep, physical exercise and a higher protein intake can help alleviate COVID-19 symptoms, while a higher level of carbohydrates intake may hinder recovery from COVID-19.

Lower respiratory tract infections among newly diagnosed sleep apnea patients

BACKGROUND

Sleep apnea is associated with chronic comorbidities and acute complications. Existing data suggest that sleep apnea may predispose to an increased risk and severity of respiratory tract infections.

METHODS

We investigated the incidence of lower respiratory tract infections in the first and second year before and after diagnosis of sleep apnea in a Finnish nationwide, population-based, retrospective case-control study based on linking data from the national health care registers for primary and secondary care from 2015-2019. Controls were matched for age, sex, hospital district, and multimorbidity status. We furthermore analysed the independent effect of comorbidities and other patient characteristics on the risk of lower respiratory tract infections, and their recurrence.

RESULTS

Sleep apnea patients had a higher incidence of lower respiratory tract infections than their matched controls within one year before (hazard ratio 1.35, 95% confidence interval 1.16-1.57) and one year after (hazard ratio1.39, 95% confidence interval1.22-1.58) diagnosis of sleep apnea. However, we found no difference in the incidence of lower respiratory tract infections within the second year before or after diagnosis of sleep apnea in comparison with matched controls. In sleep apnea, history of lower respiratory tract infection prior to sleep apnea, multimorbidity, COPD, asthma, and age greater than 65 years increased the risk of incident and recurrent lower respiratory tract infections.

CONCLUSIONS

Sleep apnea patients are at increased risk of being diagnosed with a lower respiratory tract infection within but not beyond one year before and after diagnosis of sleep apnea. Among sleep apnea patients, chronic comorbidities had a significant impact on the risk of lower respiratory tract infections and their recurrence.

Associations between obstructive sleep apnea and COVID-19 infection and hospitalization among US adults

STUDY OBJECTIVES

Medical comorbidities increase the risk of severe COVID-19 infection. In some studies, obstructive sleep apnea (OSA) has been identified as a comorbid condition that is associated with an increased prevalence of COVID-19 infection and hospitalization, but few have investigated this association in a general population. This study aimed to answer the following research question: In a general population, is OSA associated with increased odds of COVID-19 infection and hospitalization and are these altered with COVID-19 vaccination?

METHODS

This was a cross-sectional survey of a diverse sample of 15,057 US adults.

RESULTS

COVID-19 infection and hospitalization rates in the cohort were 38.9% and 2.9%, respectively. OSA or OSA symptoms were reported in 19.4%. In logistic regression models adjusted for demographic, socioeconomic, and comorbid medical conditions, OSA was positively associated with COVID-19 infection (adjusted odds ratio: 1.58, 95% CI: 1.39-1.79) and COVID-19 hospitalization (adjusted odds ratio: 1.55, 95% CI: 1.17-2.05). In fully adjusted models, boosted vaccination status was protective against both infection and hospitalization. Boosted vaccination status attenuated the association between OSA and COVID-19 related hospitalization but not infection. Participants with untreated or symptomatic OSA were at greater risk for COVID-19 infection; those with untreated but not symptomatic OSA were more likely to be hospitalized.

CONCLUSIONS

In a general population sample, OSA is associated with a greater likelihood of having had a COVID-19 infection and a COVID-19 hospitalization with the greatest impact observed among persons experiencing OSA symptoms or who were untreated for their OSA. Boosted vaccination status attenuated the association between OSA and COVID-19-related hospitalization.

CITATION

Quan SF, Weaver MD, Czeisler MÉ, et al. Associations between obstructive sleep apnea and COVID-19 infection and hospitalization among U.S. adults. J Clin Sleep Med. 2023;19(7):1303-1311.