How Sleep Specialists Can Support Patients During the COVID-19 Pandemic

The viral pandemic has affected how sleep centers and clinicians treat and care for their patients and has changed many expectations and obligations related to professional engagements in sleep medicine. 

There has been a decline in referrals for sleep evaluation and many providers are seeing a decrease in the number of sleep patients. Some sleep centers have temporarily halted in-laboratory operations altogether, opting for home sleep apnea testing instead. (Read more about options for home sleep testing and how to bill properly for it.) Fear of viral transmission can also influence a patient’s decision regarding sleep testing. And many sleep physicians, who are also pulmonary clinicians as well as respiratory therapists may be redeployed to manage patients with respiratory illnesses within their medical systems. 

Sleep and Immune Function

Sleep is essential to health and now more than ever, it is important for sleep specialists to ensure that they are providing the appropriate treatment and that patients continue to adhere to therapy.

Sleep and the immune system are bidirectionally linked and both have important roles in the body’s response to infections. Sleep disturbance and lack of sleep can increase our susceptibility to infections and weaken our response to them. Click here to read the full study.

• Study Objectives: Short sleep duration and poor sleep continuity have been implicated in the susceptibility to infectious illness. However, prior research has relied on subjective measures of sleep, which are subject to recall bias. The aim of this study was to determine whether sleep, measured behaviorally using wrist actigraphy, predicted cold incidence following experimental viral exposure.
• Design, Measurements, and Results: A total of 164 healthy men and women (ages 18 to 55) volunteered for this study. Wrist actigraphy and sleep diaries assessed sleep duration and sleep continuity over seven consecutive days. Participants were then quarantined and administered nasal drops containing the rhinovirus, and monitored over five days for the development of a clinical cold (defined by infection in the presence of objective signs of illness). Logistic regression analysis revealed that actigraphy-assessed shorter sleep duration was associated with an increased likelihood of development of a clinical cold. Specifically, those sleeping <5 hours (odds ratio [OR] = 4.50, 95% confidence interval [CI], 1.08–18.69) or sleeping between 5 hours to 6 hours (OR = 4.24, 95% CI, 1.08–16.71) were at greater risk of developing the cold compared to those sleeping > 7 hours per night; those sleeping 6.01 hours to 7 hours were at no greater risk (OR = 1.66; 95% CI 0.40–6.95). This association was independent of prechallenge antibody levels, demographics, season of the year, body mass index, psychological variables, and health practices. Sleep fragmentation was unrelated to cold susceptibility. Other sleep variables obtained using diary and actigraphy were not strong predictors of cold susceptibility.
• Conclusions: Shorter sleep duration, measured behaviorally using actigraphy prior to viral exposure, was associated with increased susceptibility to the common cold.
• Citation: Prather AA, Janicki-Deverts D, Hall MH, Cohen S. Behaviorally assessed sleep and susceptibility to the common cold. SLEEP 2015;38(9):1353–1359.
• Keywords: common cold, immunity, rhinovirus, sleep continuity, sleep duration,immune components, such as lymphocytes, cytokines and receptors, that are critical to host resistance. Sleep patterns are also altered directly by the infectious pathogen itself or secondarily by the immune response to it. Sleep disturbance, poor sleep quality, daytime sleepiness and fatigue may develop during an illness.

Ways to Navigate the Risks of COVID-19

As sleep laboratories and other sleep providers plan to reopen, it is important to ensure staff and patient safety. Protocols should be developed in order to reduce any adverse consequences as well as to mitigate any regulatory-legal exposures from perceived inaction or lack of transparency.

Taking Precautions

During the pandemic, sleep labs and other sleep professionals should be taking increased precautions to ensure the health and safety of their patients and staff. Some examples include:

• Screen patients for COVID-19 prior to polysomnography (PSG) testing.
• Create and use a tracking system to follow patients for new COVID-19 signs and symptoms in the days after PSG.
• Defer PSG testing for high-risk patients, such as older adults or those that are immunocompromised.
• Temporarily halt any onsite mask fitting services.
• Monitor all members of the team daily for any signs and symptoms of COVID-19.
• Ensure proper safety and hygiene protocols are adhered to by the staff at all times. 

Shifting to Remote Care

Increasing access to therapy in a time of social distancing can be accomplished by broader used of telemedicine and remote patient monitoring.  

• Assess new solutions that allow for limited personal contact or even remote patient mask fittings using the latest technology, such as Philips’ digital mask selector. Cloud-based sleep coaching programs are available to help facilitate PAP use and motivate patients to increase adherence to therapy.
• Provide home sleep testing for patients suffering from sleep issues and looking for a clinical diagnosis. 
• Enlist the support of providers who offer remote patient management services that can help motivate and coach your patients to remain adherent and engaged from home. 
• Consider telehealth as a means to consult with patients as permitted by providers. Work with your patients to help them better understand and navigate telehealth coverage options and hold consultations remotely. Pairing telehealth solutions with patient management services could truly help to strengthen patient engagement.
• Understand the limitations of telehealth. Done improperly, telehealth can be perceived to worsen social injustices by enabling greater access to technologically advantaged groups rather than serving economically marginalized populations. 
• Establish home delivery and remote setup services with your partners to make it easy to get patients up and running on therapy remotely.

Optimizing Therapy 

The risks and benefits of continuing PAP therapy for sleep disordered breathing during a COVID-19 illness should be assessed for each individual by their physician. Being effective is important, but not causing harm is vital.

• Advise patients to use recommended cleaning and disinfecting solutions to decontaminate their PAP device. Ask them to refer to the device’s manual for additional cleaning instructions.
• Suggest using a separate bedroom when using PAP therapy; keep the door closed; and clean and sanitize all surfaces after PAP use.
• Consider other solutions for obstructive sleep apnea (OSA), such as sleep position therapy, if appropriate.

Joining a Learning Community

Clinical consensus requires either extensive research or broad experience, none of which are readily available at this time to guide management of OSA patients with suspected COVID-19 infection. Current recommendations on diagnosing and treating patients with OSA will likely change as we learn new information regarding the infection.  

• Listen to your patients. Understand each patient’s unique needs and challenges. 
• Join or create an ongoing learning community among your peers. Share your experiences regarding best practices. 
• Talk to your local durable medical equipment and medical industry representatives to learn about new technology or services.
• Participate in the activities of your professional societies and help develop new guidelines.  

It is essential to help our patients optimize their sleep during an illness. Along with proper nutrition, adequate rest, and emotional well-being, healthy sleep can help the body recover.