Transcript Sleep Apnea and the Commercial Driver

SLEEP APNEA AND THE
COMMERCIAL DRIVER
What’s New?
Kimberly Mebust, M.D.
Executive Medical Director
MultiCare Sleep Disorders Centers
Obstructive Sleep Apnea (OSA)
Sleep Apnea Is a Breathing
Disorder
That Disrupts Sleep
There are Two Primary Types of
Sleep Apnea
Obstructive Sleep Apnea
and Central Sleep Apnea
Related breathing disorders:
Mixed Sleep Apnea
Upper Airway Resistance Syndrome
Obstructive Sleep Apnea (OSA)
Affects Many People—Most
Undiagnosed
• Affects 18 million Americans
• Who is more likely to get OSA:
– Obese people
– Men, those with large necks, are at risk
– Women, in menopause, are at risk
– Those with a physical abnormality of the
upper airway
Prevalence of Obstructive Sleep
Apnea
• 2.4-3.9 million licensed commercial drivers
in the US
• Truck drivers with sleep apnea have up to
a 7 fold increased risk of being involved in
a motor vehicle crash
What are the Symptoms of
Sleep Apnea
• Excessive daytime sleepiness
• Snoring
• Pauses in breathing
Pathophysiology of Apnea
OSA is Associated with
Medical/Psychiatric and Safety
Problems
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Headaches
Depression
Stroke
Cardiovascular disease
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High blood pressure
Heart Attack
Congestive heart failure
Atrial Fibrillation and other arrhythmias
• Diabetes
• Driving drowsy
• Accidents at home and work
Prevalence of Obstructive Sleep
Apnea Amongst Truck Drivers
• Sponsored by the FMCSA and the
American Transportation Research
Institute of the American Trucking
Association
• Among sample of commercial driver’s
license holders:
– 17.6% had mild sleep apnea
– 5.8% had moderate sleep apnea
– 4.7% had severe sleep apnea
OSA Is Diagnosed with an
Overnight Sleep Study
• Measures brain waves, body
movements, blood-oxygen levels,
heart rates, snoring, and breathing
• Done at a sleep center or home
Polysomnography
• Continuous Positive Airway
Pressure (CPAP) is the gold
standard of treatment
Positive Airway Pressure
Nasal-Aire CPAP interface
Lifestyle Changes can Reduce the
Severity of Sleep Apnea
• Lose weight
• Avoid alcohol and nicotine
• Do not use sleeping medications
• Try sleeping on your side
Snore cushion
Dental Appliances and Surgery
May Be Helpful
– Oral devices
– UPPP
– LAUP
Oral Appliance: Mechanics
Uvulopalatopharyngoplasty (UPPP)
Laser-Assisted
Uvulopalatopharyngoplasty (LAUP)
Sleep Apnea
Good Night!
Federal Regulations for Sleep
Apnea Evaluation/Treatment
• US commercial drivers are required to
undergo medical qualification
examinations at least every 2 years
• Initial recommendations regarding
evaluation and treatment of sleep apnea
were introduced in 1991
Federal Regulations for Sleep
Apnea Evaluation/Treatment
• Joint Task Force of the American College
of Chest Physicians, American College of
Occupational and Environmental Medicine
and National Sleep Foundation published
recommendations for Evaluation and
Fitness For Duty for Commercial Drivers
with Sleep Apnea in 2006
2006 Recommendations
• Truck drivers are medically qualified to
drive IF driver meets either of the
following:
– No positive findings suggestive of sleep
apnea or any of the numbered in service
evaluation factors
– Diagnosis of sleep apnea with documentation
of CPAP compliance
2006 Recommendations
In-Service
• In-Service Evaluation (truck driver can drive
while work up in progress for up to 3 months)
• If Driver falls into any one of 5 categories:
– History suggestive of sleep apnea (snoring,
sleepiness, witnessed apnea)
– Two or more of the following:
• BMI of 35 or greater
• Neck circumference of greater than 17 inches n men and 16
inches in women
• Hypertension (new, uncontrolled, or unable to control with
less than 2 medications)
2006 Recommendations
In-Service
• Epworth Sleepiness Scale greater than 10
• Previously diagnosed sleep disorder,
compliance claimed, but no recent medical
visits/compliance data available for immediate
review (must be reviewed with in 3 month
period), if found not compliant, then remove from
service
• Apnea/hypopnea index more than 5 but less
than 30 in a prior sleep study and no excessive
daytime sleepiness (Epworth 10 or less), no
motor vehicle accidents, no HTN requiring 2 or
more agents to control
2006 Recommendations
Out-of-Service
• Immediate evaluation recommended and
removal from service for any one of the
following:
– Observed unexplained excessive daytime sleepiness
(in waiting room or on examination) or confessed
excessive sleepiness
– Motor vehicle accident likely related to sleep
disturbance, unless evaluated for sleep disorder in
the interim
– Epworth Sleepiness Scale of 16+ or FOSQ <18
2006 Recommendations
Out-of-Service
• Previously diagnosed sleep disorder:
– Noncompliant with CPAP
– No recent follow up with in the recommended
time frame
– Any surgical approach with no objective follow
up
– Apnea/hypopnea index of >30
2006 Screening Recommendations
for Commercial Drivers with
Possible Obstructive Sleep Apnea
• Diagnosis should be made by a physician
and confirmed by sleep study, preferably
in an accredited sleep lab or by a certified
sleep specialist
• A full night study should be done unless a
split night study is indicated (for immediate
treatment of severe sleep apnea)
2006 Treatment Recommendations
• First line treatment for CMV drivers with sleep
apnea should be with positive airway pressure
(CPAP or BiPAP or ASV)
• All drivers must use machines that can measure
time on pressure
• A minimum acceptable average use of CPAP is
4 hours with in 24 hour period, but longer time is
more beneficial
• Treatment should be started with in 2 weeks of
study
2006 Treatment Recommendations
• Follow-up by a sleep specialist should be done
after 2-4 weeks of treatment
• After approx 1 week of treatment, there should
be contact between the patient and CPAP
vendor, treating physician/provider (to ask about
mask fit, compliance and to download smart
card
• Ideally have an AHI</= 5 documented with
CPAP with titration study or after surgery or with
use of oral appliance, can have AHI </= 10
depending on clinical findings
2006 Treatment Recommendations
• At a minimum of 2 weeks but within 4
weeks of starting treatment, driver should
be reevaluated by sleep specialist and
compliance and BP measured
• IF driver compliant and BP improving,
driver can return to work but should be
certified for no longer than 3 months
• Older regulations required treatment for 48 weeks before returning to work
2006 Oral Appliance Treatment
Recommendations
• Oral appliances should only be used as a
primary therapy if AHI less than 30
• Before returning to service, must have
follow up sleep study demonstrating AHI
ideally less than 5 but can be 10 or less
while wearing oral appliance
• All reported symptoms of sleepiness must
be resolved and blood pressure must be
improving or controlled
2006 Treatment Recommendations
Using Weight Loss or Surgery
• Follow up sleep study with AHI ideally less
than 5 ( but can be 10 or less) required to
document efficacy
2006 Ongoing Assessment
• After patients have been on CPAP treatment for
3 months, they need to be seen by the physician
to document compliance again
• After this, they must be certified annually
• Retesting may not be required if sleep apnea is
adequately controlled using subjective reports
and compliance data from machine
– Multiple sleep latency testing no longer required
Sleep Apnea Screening Problems
• Talmadge et al. Journal of Occupational
and Environmental Medicine 50:324, 2008
– During screening evaluations with
questionnaires, no one answered yes to the
questions on snoring and witnessed apnea
– Conclusion:
• Cannot rely on any self-reporting for symptoms of
sleep apnea
• An objective, independent method of identifying
patients with sleep apnea is needed
Do Truck Drivers Treat Their Sleep
Apnea?
• Philip Parks, MD, MPH et al published
study in Journal of Occupational and
Environmental Medicine March 2009
• Over 15 months, 456 commercial drivers
were examined from 50 different
employers
– 78 (17%) met screening criteria for suspected
sleep apnea (these drivers tended to be older,
more obese, and have relatively high blood
pressure)
Do Truck Drivers Treat Their Sleep
Apnea?
• Of the 78 drivers, 53 were referred to have
a sleep study
– 33 did not comply with the referral and were
lost to follow-up
– 20 were confirmed to have sleep apnea
– Only ONE with confirmed sleep apnea
complied with treatment recommendations
– Concern: It is possible that many of the 14
million American truck drivers have
undiagnosed or untreated sleep apnea
What is Next?
• Increased risk of motor vehicle crashes for
noncommercial drivers if there is:
– Abnormal Epworth Sleepiness Scale
– Degree of severity of sleep apnea based upon
AHI
– Degree of oxygen desaturations in sleep
– Body Mass Index (BMI)
• BMI independently predicts increase risk of
crashes regardless of whether the person has
sleep apnea or not
What’s Next?
• Can treatment with CPAP improve
daytime sleepiness?
– One study has suggested that CPAP can
reduce crash risk, as marked by a reduction in
the Epworth Sleepiness Scale in
noncommercial drivers
– To date, there have been no other studies
providing data to demonstrate treatment
reduces crash risk
2008-2009
State of Regulations
• Federal Motor Carrier Safety Administration
Medical Advisory Board
– Called upon by congress to develop evidence based
guidelines for criteria for all medical conditions
relevant to commercial drivers
– Established a medical expert panel on sleep apnea
– Developed new standards for physicians doing
physical exams for drivers
– Proposed web-based national registry of commercial
drivers
Issues at stake
• Regulations have come about for public
safety
• Need to strike a balance between the
commercial driver industry and public
safety
– Detection and treatment needed without the
mandate to stop working
– Cannot rely on self reporting as part of
screening
Expert Panel Recommendations For Obstructive Sleep
Apnea and Commercial Motor Vehicle Driver Safety
January 2008
• Lengthy 37 page document outlining
specific guidelines for certification,
evaluation, diagnosis, and treatment
• Changes from 2006:
– Treatment for only 1 week required with
compliance data and improvement of
symptoms as opposed to 2-4 weeks
– Oral appliance not acceptable for treatment
since compliance cannot be measured
Expert Panel Recommendations For Obstructive Sleep
Apnea and Commercial Motor Vehicle Driver Safety
January 2008
• Changes from 2006
– Weight loss surgery acceptable for treatment as long
as CPAP used, weight loss occurs, repeat sleep
study shows AHI >/= 10 and no longer sleepy
– Facial bone and tracheostomy ENT surgeries
acceptable as long as follow-up sleep study done
indicating AHI>/= 10 and patient continues to have
yearly re-evaluations (since high incidence of
reoccurrence of sleep apnea)
Expert Panel Recommendations For Obstructive Sleep
Apnea and Commercial Motor Vehicle Driver Safety
January 2008
• BMI (Body Mass Index) recommended for use
as screening for presence of obstructive sleep
apnea
– Expert panel subgroup voted using BMI of 33 or more
the trigger for evaluation for sleep apnea (24% of
commercial drivers)
– Medical Advisory Board voted to use 30 or more
instead (estimated 42% of commercial drivers)
– For those with BMI 30 or more, driver gets a
conditional certification pending sleep study (max one
month)
Expert Panel 2008
Recommendations
• Old guidelines did not feel home sleep
studies acceptable, but now new
guidelines approve the use as long as
oxygen saturations, nasal pressure, and
sleep/wake time are measured but
concern that drivers would place the
device on someone else and collect false
data
What is Happening NOW?
• The Federal Motor Carrier Safety
Administration has taken NO action on the
recommendations for sleep apnea
evaluation
NEW REGULATION CONCERNS
2009
– Owners of transportation companies are
frightened because of liability (one company
in US successfully sued because driver with
OSA not on CPAP)
– Drivers are frightened about losing job
• “Don’t ask, don’t tell appears to be the current
policy
– Need to strike a balance to protect the driver
and to protect the public
What Will Regulation of
Commercial Drivers With Sleep
Apnea Look Like in the Future?
• Proposal to establish a National Registry of
Certified Medical Examiners to ensure that
physical qualification exams of commercial
drivers are standardized
• The Medical Examiner would electronically
submit name and numerical identification for
each driver examined so that drivers will not
“doctor shop” in order to get certified to drive
Summary
• Obstructive sleep apnea is a common problem
• Obstructive sleep apnea may result in driving
drowsy and put the commercial driver and
others at risk
• Efforts should be made to evaluate drivers for
the presence of sleep disorders, especially
obstructive sleep apnea
• Barriers for diagnosis, treatment, and
certification need to be further evaluated
Summary--Problems
• Currently many certifying physicians do not know the
guidelines so need education to perform certification
properly at the least
• Commercial drivers may avoid relating symptoms to their
physicians because of the fear that they will be pulled off
of the job for weeks to months, or longer
– So need to allow an acceptable way for drivers to relate
symptoms in order for work up to be done
– Work up and return to work path must be easy and quick
• Documentation of compliance with treatment using smart
machines and web-based databases is needed for
oversight of treatment
The Ultimate Question
• Will the federal government (Federal
Motor Safety Administration) ultimately
mandate sleep apnea screening
• Or
• Will there be other methods put into place
to provide the necessary screening and
oversight of the transportation industry in
sleep apnea evaluation, treatment and
compliance with therapy?
For More Information Contact:
National Sleep Foundation
1522 K Street, NW, Suite 500
Washington, DC 20009
(202) 347-3471
or visit
www.sleepfoundation.org
Resources
• Philips Respironics website
– http://www.trucking.respironics.com/FMCSA
– Contains the link to the Summary of Proposed
Federal Motor Safety Administration
Guidelines and other resources
– www.fmcsa.dot.gov/rulesregulations/TOPICS/mep/report/Sleep-