Old age, hypertension, obesity and diabetes are the major risk factors for severe disease with COVID 19. However, snoring and obstructive sleep apnoea (OSA), unrecognised, or under reported [1], occurs in over 50% of these comorbidities [2], and is a known risk factor for pneumonia. Preliminary reports confirm an association between OSA and severe COVID 19 disease [3]. Aspiration during sleep is among several pathways by which snoring, and sleep apnoea increases vulnerability to pneumonia [4]. The propensity for aspiration increases with age related deterioration in pharyngeal competence. Apnoeic events, and the vibrating pharyngeal airway of snoring, coupled with strong inspiratory efforts, are powerful mechanisms capable of sucking large amount of viral loaded saliva and mucus from the nasopharyngeal airway into the lower airways and lungs. The early reports of patchy non-uniform pneumonic changes in COVID 19 is highly suggestive of aspiration. In an elegant study, Hou et al. [5] provide evidence for aspiration as a major mechanism leading to viral pneumonia. While some have recommended suspending the use of nasal positive pressure therapy (CPAP) and non-invasive positive pressure ventilation (NIV) because of the risk of viral spread [6], CPAP with oxygen via a face mask or helmet has become a major part of the management of the COVID respiratory failure, with reports suggesting that many pneumonia patients avoid full intubation [7, 8]. In those who already have developed pneumonia, the benefit of the positive pressure is in its role in maintaining alveolar air spaces for gas exchange, helping to prevent airway closure and alveolar loss. However, another, perhaps more important benefit of CPAP use in sleep, is preventing aspiration, by stopping snoring and apnoea. In the time window between the initial viral infection in the nasopharynx and the onset of the lung disease, unrecognised snoring and sleep apnoea may be significant mechanisms increasing aspiration during sleep and exposing the lungs to high levels of viral inoculates. Rather than waiting for the patient to develop lung changes, early use of nasal CPAP in sleep might offer a safe method of helping to reduce the progression to potentially fatal COVID 19 pneumonia. The report by Oranger et al. [8] supports this idea, as CPAP was used continuously only during the night, and thus during presumed sleep. The problem of viral spread can be minimized with the use of appropriate circuit filters [8, 9, 10], good mask fit [11, 2] including the use of adapted surgical masks over a nasal CPAP interface [13, 14], and usual barrier nursing. Given that mask CPAP is being used to help slow the progress of the worsening pneumonia once respiratory failure has developed, introducing it earlier to the sleeping patient with COVID 19 does not require a major change in clinical protocols.

中文翻译：

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打鼾和阻塞性睡眠呼吸暂停是 SARS-Cov-2 的危险因素：睡眠期间经鼻 CPAP 可以降低肺炎风险吗？

高龄、高血压、肥胖和糖尿病是 COVID 19 重症的主要危险因素。然而，打鼾和阻塞性睡眠呼吸暂停 (OSA) 未被识别或报告不足 [1]，发生在超过 50% 的这些合并症中 [2 ]，并且是已知的肺炎危险因素。初步报告证实 OSA 与严重的 COVID 19 疾病之间存在关联 [3]。睡眠期间的吸入是打鼾和睡眠呼吸暂停增加患肺炎易感性的几种途径之一 [4]。误吸的倾向随着年龄相关的咽部功能退化而增加。呼吸暂停事件和打鼾引起的咽部气道振动，加上强烈的吸气努力，是能够将大量载有病毒的唾液和粘液从鼻咽气道吸入下呼吸道和肺部的强大机制。COVID 19 中出现斑片状、不均匀的肺炎变化的早期报告高度提示误吸。在一项优雅的研究中，Hou 等人。[5] 为吸入作为导致病毒性肺炎的主要机制提供了证据。虽然由于存在病毒传播的风险，一些人建议暂停使用经鼻正压通气 (CPAP) 和无创正压通气 (NIV) [6]，但通过面罩或头盔吸氧的 CPAP 已成为主要部分COVID 呼吸衰竭的管理，有报告表明许多肺炎患者避免完全插管 [7、8]。对于已经患上肺炎的患者，正压的好处在于它可以维持用于气体交换的肺泡空气空间，有助于防止气道闭合和肺泡丢失。然而，另一个，也许在睡眠中使用 CPAP 更重要的好处是通过停止打鼾和呼吸暂停来防止误吸。在鼻咽部最初的病毒感染和肺部疾病发作之间的时间窗口中，未被识别的打鼾和睡眠呼吸暂停可能是增加睡眠期间吸入和使肺部暴露于高水平病毒接种物的重要机制。与其等待患者出现肺部变化，不如在睡眠中尽早使用经鼻 CPAP 可能提供一种安全的方法来帮助减少可能致命的 COVID 19 肺炎的进展。Oranger 等人的报告。[8] 支持这个想法，因为 CPAP 只在夜间连续使用，因此在假定的睡眠期间。通过使用合适的电路过滤器 [8、9、10]、合适的面罩 [11, 2] 包括在经鼻 CPAP 接口上使用改装的外科口罩 [13、14]，以及常规的屏障护理。鉴于一旦发生呼吸衰竭，面罩 CPAP 被用于帮助减缓肺炎恶化的进展，因此将其更早地引入睡眠中的 COVID 19 患者不需要对临床方案进行重大改变。