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Moderate to Severe Obstructive Sleep Apnea Is a Risk Factor for Severe COVID-19—A Nationwide Cohort Study

Ljunggren, Mirjam ; Palm, Andreas ; Ekström, Magnus LU orcid ; Sundh, Josefin ; Grote, Ludger ; Li, Huiqi ; Nyberg, Fredrik and Emilsson, Össur Ingi (2025) In Journal of Sleep Research
Abstract

The impact of obstructive sleep apnea (OSA) and positive airway pressure (PAP) treatment on COVID-19 severity is unclear. In this population-based, nationwide study using multi-register data, we aimed to assess if OSA is a risk factor for COVID-19 severity and how adherence to PAP treatment and clinical characteristics affect the risk. Swedish residents with COVID-19 infection January 2020–May 2022 were included. An exposed group of OSA (starting PAP treatment 2015–2019) was identified. COVID-19 severity outcome was defined as mild (non-hospitalised), severe (hospitalised) or critical (intensive care or death). Covariates included comorbidities and sociodemographics. Conditional odds ratios (COR) with 95% confidence intervals (95% CI)... (More)

The impact of obstructive sleep apnea (OSA) and positive airway pressure (PAP) treatment on COVID-19 severity is unclear. In this population-based, nationwide study using multi-register data, we aimed to assess if OSA is a risk factor for COVID-19 severity and how adherence to PAP treatment and clinical characteristics affect the risk. Swedish residents with COVID-19 infection January 2020–May 2022 were included. An exposed group of OSA (starting PAP treatment 2015–2019) was identified. COVID-19 severity outcome was defined as mild (non-hospitalised), severe (hospitalised) or critical (intensive care or death). Covariates included comorbidities and sociodemographics. Conditional odds ratios (COR) with 95% confidence intervals (95% CI) were estimated using multinomial logistic regression. Among 8,894,162 individuals in Sweden, 1,932,081 (21.7%) had registered COVID-19 January 2020–May 2022. OSA was identified in 11,407 (0.6%) and was associated with an increased risk of severe (COR 1.34; 95% CI 1.25–1.43) and critical (1.25; 1.11–1.42) COVID-19 after adjustment for age, sex, education and comorbidities. Stratified by PAP adherence, age and COVID-19 wave, OSA was a risk factor for more severe COVID-19 in PAP-adherent and non-adherent individuals, in people aged 40–60 but not > 60 years and not after June 2021. OSA severity, assessed with the oxygen desaturation index (ODI), was independently associated with COVID-19 severity, with the highest risks for severe (1.23; 1.01–1.52) and critical (1.76; 1.17–2.63) COVID-19 observed in ODI ≥ 30 (vs. ODI < 15). We conclude that patients with moderate to severe OSA have an increased risk of severe COVID-19, also when PAP-treated, with an independent dose–response relationship between the severity of intermittent hypoxia and COVID-19 severity.

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author
; ; ; ; ; ; and
organization
publishing date
type
Contribution to journal
publication status
epub
subject
keywords
CPAP, oxygen desaturation index, SARS-CoV2, sleep disordered breathing
in
Journal of Sleep Research
publisher
Wiley-Blackwell
external identifiers
  • scopus:105004313776
  • pmid:40325794
ISSN
0962-1105
DOI
10.1111/jsr.70082
language
English
LU publication?
yes
id
fa574386-3a17-4286-8dd8-06c84e947784
date added to LUP
2025-09-22 15:57:20
date last changed
2025-10-20 12:26:47
@article{fa574386-3a17-4286-8dd8-06c84e947784,
  abstract     = {{<p>The impact of obstructive sleep apnea (OSA) and positive airway pressure (PAP) treatment on COVID-19 severity is unclear. In this population-based, nationwide study using multi-register data, we aimed to assess if OSA is a risk factor for COVID-19 severity and how adherence to PAP treatment and clinical characteristics affect the risk. Swedish residents with COVID-19 infection January 2020–May 2022 were included. An exposed group of OSA (starting PAP treatment 2015–2019) was identified. COVID-19 severity outcome was defined as mild (non-hospitalised), severe (hospitalised) or critical (intensive care or death). Covariates included comorbidities and sociodemographics. Conditional odds ratios (COR) with 95% confidence intervals (95% CI) were estimated using multinomial logistic regression. Among 8,894,162 individuals in Sweden, 1,932,081 (21.7%) had registered COVID-19 January 2020–May 2022. OSA was identified in 11,407 (0.6%) and was associated with an increased risk of severe (COR 1.34; 95% CI 1.25–1.43) and critical (1.25; 1.11–1.42) COVID-19 after adjustment for age, sex, education and comorbidities. Stratified by PAP adherence, age and COVID-19 wave, OSA was a risk factor for more severe COVID-19 in PAP-adherent and non-adherent individuals, in people aged 40–60 but not &gt; 60 years and not after June 2021. OSA severity, assessed with the oxygen desaturation index (ODI), was independently associated with COVID-19 severity, with the highest risks for severe (1.23; 1.01–1.52) and critical (1.76; 1.17–2.63) COVID-19 observed in ODI ≥ 30 (vs. ODI &lt; 15). We conclude that patients with moderate to severe OSA have an increased risk of severe COVID-19, also when PAP-treated, with an independent dose–response relationship between the severity of intermittent hypoxia and COVID-19 severity.</p>}},
  author       = {{Ljunggren, Mirjam and Palm, Andreas and Ekström, Magnus and Sundh, Josefin and Grote, Ludger and Li, Huiqi and Nyberg, Fredrik and Emilsson, Össur Ingi}},
  issn         = {{0962-1105}},
  keywords     = {{CPAP; oxygen desaturation index; SARS-CoV2; sleep disordered breathing}},
  language     = {{eng}},
  publisher    = {{Wiley-Blackwell}},
  series       = {{Journal of Sleep Research}},
  title        = {{Moderate to Severe Obstructive Sleep Apnea Is a Risk Factor for Severe COVID-19—A Nationwide Cohort Study}},
  url          = {{http://dx.doi.org/10.1111/jsr.70082}},
  doi          = {{10.1111/jsr.70082}},
  year         = {{2025}},
}