key: cord-0911429-iswxlbhb
authors: Bastier, P L; Aisenberg, N; Durand, F; Lestang, P; Abedipour, D; de Santerre, O Gallet; Couloigner, V; Bequignon, E
title: Treatment of sleep apnea by ENT specialists during the COVID-19 pandemic
date: 2020-05-11
journal: Eur Ann Otorhinolaryngol Head Neck Dis
DOI: 10.1016/j.anorl.2020.05.001
sha: f2974ee82d1b9e0a3ac235d981f8bed9cb579576
doc_id: 911429
cord_uid: iswxlbhb

Abstract The treatment of sleep disorders has been strongly impacted by the COVID-19 pandemic. When the lockdown is over, resumption of usual patient care will require precautions to limit the risk of contamination for patients and caregivers. In this document, the French Association of Otorhinolaryngology and Sleep disorders (AFSORL) and the French Society of Otorhinolaryngology (SFORL) put forward a summary of the measures for continuing the treatment of sleep apnoea syndrome in these new practice conditions. Emphasis is placed on teleconsultation, methods of nocturnal sleep studies, the conditions for treatment by continuous positive airway pressure (CPAP) ventilation, and the postponement of more invasive treatments.

The implementation of lockdown measures and the massive surge in patients suffering from serious forms of COVID-19 infections has led to a reorganisation of healthcare in many countries around the world. The focus has shifted to emergency treatment and the postponement of non-priority treatments. If Obstructive Sleep Apnea syndrome (OSAS) is not considered to be an immediately lifethreatening pathology, its consequences can be serious, especially in the presence of specific comorbidities or high-risk occupations. Considering the high prevalence of sleep-disordered breathing in the general population, the structures dedicated to the care of patients with OSAS are likely to be rapidly overwhelmed once the lockdown measures are lifted.

In their latest recommendations regarding this period of the pandemic, the French Regional Health Agencies (ARS) have advocated for a progressive resumption of screening and diagnosis activities in order to avoid any delay in treatment. These recommendations apply to sleep apnoea syndrome, among others. AFSORL and SFORL created this document to provide a practical framework for ENT specialists to allow them to continue treating patients suffering from sleep disorders after the end of the lockdown. The principles on which it is based are the continuation of treatment, prioritising treatment according to severity criteria, and the protection of patients and caregivers from possible viral transmission. These recommendations may change depending on the health situation.

Teleconsultation by phone or dedicated video platform is preferred for an initial consultation concerning sleep disorders. The patient can prepare for this consultation by filling out online or paper questionnaires sent to them beforehand. The clinical examination can be conducted after the sleep recording, except where the consultation raises suspicion of a differential diagnosis whose treatment would require a rapid management (tumour of the upper airways). In this case, prevention measures must be applied: appropriate personal protective equipment, fitting out the practice and waiting room, disinfection after every patient. The initiation of a CPAP treatment without having carried out a recording beforehand can be discussed in the event of a significant clinical probability of OSAS with severe symptoms (https://aasm.org/covid-19-resources/covid-19-mitigation-strategies-sleep-clinics-labs). A Request for Treatment form with a motivation letter can be sent to the social security institution. The conduct of the clinical examination before the initiation of treatment of a patient suffering from OSA must be delayed in the absence of severe symptoms. If the treatment must be implemented rapidly, this examination will be conducted with the strengthened protection measures laid out in the recommendations issued by the French Society of Otorhinolaryngology (SFORL) [1] .

There is no indication to treat patients suffering from simple snoring during the COVID-19 pandemic.

Sleep endoscopy under sedation is not advised during the COVID-19 pandemic as it generally applies to patients presenting with mild to moderate OSAS and asking for surgery. It is possible to implement treatment with a mandibular advancement device (MAD) during the COVID-19 pandemic. The caregiver protection rules put forward by SFORL [2] . The patient's COVID status must be determined before the procedure. If surgery was eventually avoided, the benefit/risk ratio between the initiation of symptomatic treatment with CPAP, with possible risks of domestic contaminations, and no therapy, is to be discussed on a case by case basis.

It is not advised to initiate a myofunctional therapy for OSAS in the current context of COVID-19 pandemic. Thus, the International Society of Oral, Facial and Lingual Physical Therapy has recommended the closure of physical therapy practices and stated that this type of treatments is not a priority during the current epidemic, as they generally apply to mild forms of OSAS (https://siklomf.fr/). However, a decree issued by the French government on April, 16, 2020, allows for rehabilitation exercises via teleconsultation, including those for the rehabilitation of respiratory diseases (obstructive, restrictive or mixed) and of maxillofacial disorders apart from facial paralysis (https://www.service-public.fr/particuliers/actualites/A14018).

In all cases and particularly for patients presenting with a mild or moderate OSAS whose treatment by surgery, MAD or CPAP must be postponed until after the pandemic, additional non-invasive treatments may be proposed, and individual health practices should be recommended, such as positional therapy in the event of positional OSAS, weight loss, limiting the consumption of alcohol and the use of sedatives, medical treatment of nasal obstruction (https://aasm.org/covid-19resources/covid-19-mitigation-strategies-sleep-clinics-labs). Patients with daytime sleepiness should also be advised to avoid high-risk activities such as car-driving or activities with significant risks of accident.

There is currently no scientific data regarding the dangers of CPAP therapy in the current context of COVID-19 pandemic. However, the intentional air leaks around the mask and the high positive air flows delivered by the machine may contribute to spreading SARS-CoV-2 in the patient's environment and exposing those close to them. Opinions regarding indications and modalities of CPAP therapy during the current pandemic were not consensual [3, 4] . Therefore, on March, 19, 2020, the French Language Respiratory Society (SPLF) issued national recommendations on this subject (http://splf.fr/wp-content/uploads/2020/03/Apnee-du-sommeil-COVID_19-190320.pdf). According to those, CPAP treatment should be limited to severe forms of OSAS in the current context of COVID-19 pandemic. This treatment should be done at home as often as possible through a service provider in compliance with the protective rules. Any patient, even asymptomatic, should be considered as possibly infected with SARS-CoV-2 and contagious. Additionally, even in the rare cases where a patient had a negative PCR testing just before the initiation of CPAP therapy, there is no guarantee that he will not become infected while he or she is still on this treatment. Thus, the same precautions should apply to all patients. Due to the risk of aerosolization, in-laboratory, initiation of CPAP or split-night study are not advised. Explanations for putting on and adjusting the mask can be given while staying at a distance of at least one meter from the patient, or through explanatory videos if necessary.

Telemonitoring is preferred for the initial set-up, with additional equipment sent by post and explanations given by phone or video after it has been received. The CPAP machine should not be used near the patient's family or friends. If possible, he or she should remain alone in the bedroom where the CPAP treatment is performed. If it impossible for the spouse or partner to sleep in a separate room Page 8 of 9 J o u r n a l P r e -p r o o f 8 and especially if he or she suffers from comorbidities at risk of severe complications from COVID-19, a temporary discontinuation of the treatment might be discussed with the physician in charge of the OSAS treatment. The equipment must be cleaned as per the standard procedures laid out by the manufacturers. The bedroom's surfaces must be cleaned and ventilated by opening windows regularly.

The patient must wash their hands before and after handling the equipment, and every time they return to and leave their bedroom. In patients infected with SARS-CoV-2, coughing can make the CPAP machine difficult to tolerate. Additionally, once their symptoms have disappeared, the CPAP machine must be sealed in a plastic bag for 3 days before being reused. The machine must be carefully cleaned to ensure the absence of any live virus and a new tubing and new mask must be used (request these from the service provider). A recent study demonstrated the persistence of the virus on plastic up to 72 hours after its application [5] . In the event of a confirmed or suspected COVID-19 infection in a hospitalised patient, CPAP therapy should be discontinued while awaiting the COVID-19 diagnostic test results. If the infection is confirmed, before resuming the treatment, the CPAP mask and tubing should be modified following the recommendations issued by the "Ventilation and oxygen therapy" (GAV) task force of SPLF (http://splf.fr/wp-content/uploads/2020/04/LES-PROCEDURES-DU-GAVO2-ProtectionVirale2020-MAJ02avril2020.pdf). If it is impossible to follow these recommendations, discontinuing the treatment during the epidemic might be necessary.

Teleconsultation monitoring is advised for all modes of treatment, facilitated by service provider and/or manufacturer websites for CPAP treatment. Sleep studies to control the efficiency of newly installed MAD must be delayed until the end of the pandemic. Monitoring will focused primarily on clinical symptoms during this period (day-time sleepiness, sleep quality, snoring, arousals).

The authors declare that they have no competing interest.

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