1 Dear Editor,

The article by Kendzerska et al. [1] regarding the use of positive airway pressure (PAP) therapy in patients of sleep apnea during COVID-19 pandemic sheds light into the observation of decreased compliance with PAP and the possible underlying reasons for the same. However, there are few important points to ponder and understand in the study.

Only 7.2% (41/570) patients stopped using PAP therapy for their OSA. This makes the data skewed and hence the analysis that PAP was stopped in situations of “someone in household having COVID-19 being statistically significant” may not actually represent any clinical significance. The confidence interval also in this analysis lies from 1 to 9.31 which is a wide range.

Moreover, the risk of spreading COVID to other family members by the patient who is using PAP therapy would probably have been more important as using a PAP device has a theoretical risk of spreading COVID-19 via aerosols. Thus, the analysis of the patient himself suffering from COVID-19 and his compliance with CPAP could have been more beneficial. A physician consult to reaffirm the safety of use of PAP devices in this situation could have been beneficial.

The 41 patients who had stopped using their PAP therapy should have been evaluated in detail for the possible reasons. This could have included not having access to the health care facility for their follow-up, not having access to the technical staff for maintenance of the machines due to lockdowns [2], taking care of family in hospitals, social fear of spread of COVID-19 by the machines, etc.

The analysis of having a poor sleep quality and efficiency in the patients who had stopped using the PAP therapy is obvious and reaffirms the need for continued PAP therapy as it is a physical therapy and the benefits are dependent on the compliance. It would have been interesting to see if these patients consulted their physicians physically or by telemedicine [3] and whether the need to use the PAP therapy was reemphasized to them by their treating physician.

The underlying diagnosis of obstructive sleep apnea (OSA) was also not confirmed as the study was carried out by a survey method. Thus, it is also possible that the patients who discontinued PAP may not actually be having underlying significant symptoms due to OSA. On the other hand, the group that continued the use of PAP may have been having severe symptoms, activity limitation, loud snoring, excessive daytime sleepiness, or severe desaturations in sleep because of which the compliance to the PAP therapy was maintained.

Nevertheless, the study clearly brings to light the need to continue follow up with patients of sleep apnea to ensure their compliance with pap devices even in the COVID pandemic. Telemedicine [3] in this regard can have an increased utility.