Use of Portable Sleep Testing to Diagnose Obstructive Sleep Apnea in a Patient with Severe COVID-19 Pneumonia and Worsening Nocturnal Hypoxemia, an Individualized Approach

IntroductionHigh-flow nasal cannula (HFNC) is the mainstay of therapy for acute hypoxic respiratory failure (AHRF) in severe COVID-19 pneumonia when conventional oxygen therapy is inadequate. Untreated obstructive sleep apnea (OSA) can worsen AHRF, and the use of positive airway pressure (PAP) leads to improvement in these selected patients. Obtaining inpatient sleep testing for qualification of ambulatory PAP therapy is challenging. We report the successful use of home sleep testing (i.e. WatchPAT™) in the hospital setting for a patient with severe COVID-19 pneumonia and undiagnosed severe OSA. Case A 32-year-old woman with medical history of morbid obesity (BMI 51) presented with hypoxia secondary to COVID-19 pneumonia. Initial oxygen saturation was 88% on room air, and chest radiograph showed bilateral patchy infiltrates and consolidations. On admission, she was treated with IV remdesivir, dexamethasone, azithromycin, and IV ceftriaxone. Overnight, supplemental oxygen requirements escalated to 10 liters per minute via nasal pendent, and she was transferred to the ICU. Given her body habitus and nocturnal desaturations, co-existing OSA was suspected, and the patient was empirically started on auto-titrating continuous positive airway pressure (CPAP) with inline oxygen supplementation. This resulted in improvement in her oxygen desaturations, and she was transferred out of the ICU the next day. Subsequently, a portable home sleep apnea test (i.e. WatchPAT™) was performed, showing an elevated AHI of 31.4/hour, and confirming a severe OSA diagnosis. The patient was prescribed home-going CPAP and discharged home without supplemental oxygen. At her two-month follow-up visit, the patient had a residual AHI of 0.3. Discussion In our patient with increased risk for sleep-disordered breathing, CPAP use with inline oxygen supplementation before trial of HFNC stabilized her respiratory status and shortened her intensive care stay. Performing a portable sleep study in the hospital expedited this patient's workup and facilitated the immediate ambulatory treatment of her underlying sleep-disordered breathing. Without initiation of this treatment in the hospital and during her recovery at home, this patient's severe untreated OSA would likely have prolonged her hospital course and negatively influenced her recovery. Portable sleep studies are an accurate tool to diagnose sleep apnea in selected hospitalized patients and lead to earlier treatment initiation compared to outpatient in-lab polysomnography, especially for COVID-19 patients where safety regulations might prohibit their presence in the lab. Utilizing a portable sleep study in the hospital setting for COVID-19 positive patients can be an efficient and effective intervention, as shown in our unique case.