Introduction: Sleep apnea (SA)-prevalent in older, obese and minority individuals- increases risk for COVID-19 co-morbidities and may contribute to poor outcomes by exacerbating or causing endothelial dysfunction, inflammation, oxidative stress, micro-aspiration, and lung injury. Given its association with recognized COVID-19 comorbidities and physiological plausibility, we analyzed electronic health record (EHR) data to ask whether SA is an unrecognized risk factor for COVID-19 related death, hospitalization, ventilator use and ICU admission.

Methods: The sample was 4,668 adult non-employee participants with positive COVID-19 RNA polymerase chain reaction diagnostic results who had available demographic data and a minimum level of EHR documentatation. SA controls and cases were defined as those with either zero or two or more International Classification of Disease diagnoses of SA or obstructive sleep apnea on different dates. Natural language processing was used to obtain documentation of continuous positive airway pressure (CPAP) usage.

Results: The 443 participants (9.5%) with SA had an increased all-cause mortality rate (11.7%) compared to SA controls (6.9%), p<0.001. A significant association between with SA and COVID-19 death persisted in analyses adjusted for demographics. Associations were somewhat attenuated after adjusting for BMI class and diagnoses associated with SA. Similar but weaker associations were observed between SA and the composite outcome of ICU admission, mechanical ventilation, or death. In an exploratory analysis, participants with EHR CPAP documentation in the prior year displayed a non-significant trend for attenuated composite outcome results compared to participants without evidence of CPAP documentation.

Discussion: These results identify SA as a risk factor for COVID-19 mortality, highlighting the need for close monitoring of patients with SA who become infected. Research is warranted to understand whether SA-related pathologies contribute to the excessive COVID-19 morbidity and mortality observed in obese, minority and other individuals at risk for SA.