Truckers & Sleep Apnea

8/6/2019 Truckers & Sleep Apnea

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The Link BetweenTruck Drivers, Crashes

& Obstructive Sleep

Apnea

Tom Lamphere BS, RRT, RPFTExecutive Director, PSRCAdjunct Instructor, Gwynedd Mercy College

Objectives1. Define Obstructive Sleep Apnea and

review the incidence of it among the truckdriver population.

2. Review the most current NSTHA DriverFitness Medical Guidelines

3. Discuss the recommendations of the 2008Expert Panel on OSA and CommercialMotor Vehicle (CMV) driver safety.


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Definitions

Apnea

Interruption of normal ventilatoryexchange for at least 10 seconds or thecessation of airflow ( at the level of thenostrils and the mouth).

Inspiration of less than 25% of a normalbreath.

May also be defined as at least a 4% dropin SaO2 when breathing stops.

DefinitionsHypopnea

A decrease in breathing that is not as severe as an

apnea.

Can be defined as 69% to 26% of a normal breath.

Apnea-Hypopnea Index (AHI)

Calculated by dividing the # of apneas and

hypopneas by the number of hours of sleep. AHI

values are typically categorized as 5-15 Mild, 15-

30 Moderate, and above 30 listed as Severe.


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Definitions

Central Sleep Apnea

Cessation of airflow resulting from the

absence of ventilatory effort

Obstructive Sleep Apnea (OSA)

Lack of ventilatory exchange due topharyngeal occlusion

Incidence / Prevalence According to National Institute of Health

(NIH), estimated 18 million Americans

have some type of sleep disorder (1:15

people)

An estimated 12 million Americans have

OSA (1:22 people)

An estimated 10 million Americans have

undiagnosed OSA (1:27 people)


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Other Definitions

CDL: Commercial Driver License

Other Definitions

Traditional Truck Driver:

One who drives a truck!!!

Non-Traditional Truck Driver:

One who drives a truck!!!


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Other Definitions

Commercial Motor Vehicle

(CMV)

Commercial Motor Vehicle

(CMV)

Little Known Facts Of all occupations in

the U.S., workers intrucking industryexperience the 3rdhighest fatality rate ofall worker deaths

About 2/3 of truckerdeaths are related tohighway crashes.


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Little Known Facts

In 2005, there were 4,932 fatal crashesinvolving trucks and 5,212 fatalities

In 2005, there were 137,144 nonfatal crashesof which 59,405 had an injury to at least oneperson (89,681 total injuries)

A 2006 report by the Fed. Motor CarrierSafety Admin. estimated the cost of eachcrash involving a large truck was $91,112while the average cost of a fatal crash was$3,604,518.

Another Cost. 5,212 fatalities x $3,604,518 =

$18,786,747,816(thats almost $19 billion a year)


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So What Does This Have

To Do With Sleep???

Incidence of OSA In Truck

Drivers Multiple studies have been

completed but results vary.

Nearly all studies indicatea higher rate forcommercial truck driversthan the general

population. Overall prevalence is

somewhere between 17% -28%.


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Incidence of OSA In Truck Drivers

There are approximately14 million commercial driverslicensed in the U.S.

Approximately 2.4 to 3.9million of these individuals are

predicted to suffer from OSA

U.S. National TransportationSafety Board estimates 31% of

fatal-to-the-driver commercialtruck crashes and 17% of ALLfatal crashes are caused bydriver fatigue

What Do Truckers Think?

Not Me!


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Bottom Line.

Even if truckers have same prevalence asthe rest of the population (1:27)

14,000,000 licensed CMV drivers

=

518, 500 licensed CMV drivers with OSA

How Does One Obtain A

Commercial Driver License (CDL)?

There is a federal requirement that each statehave minimum standards for the licensing ofcommercial drivers.

Requirements include:

1. Knowledge tests

2. Skills tests

3. At least 21 years of age to driver interstate(18 years to drive intrastate)

4. Completed Medical Examiners Certificate


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Medical Examiners Certificate

Department of Transportation Physical

Required by the Federal Motor Carrier Safety

Regulations (FMCSR)

Includes SOME information gathering on sleep

related issues..but not much!

Medical Examiners Certificate


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Interpretation of Medical Standards

The FMCSA has published recommendationscalled Advisory Criteria to help medicalexaminers in determining whether a drivermeets the physical qualifications forcommercial driving.

Many conditions interfere with oxygenexchange and may result in incapacitation

including emphysema, chronic asthma,carcinoma, tuberculosis, chronic bronchitisandsleep apnea.

Interpretation of Medical Standards If the medical examiner detects a respiratory

dysfunction, that in any way is likely to

interfere with the driver's ability to safely

control and drive a commercial motor vehicle,

the driver must be referred to a specialist for

further evaluation and therapy.

Just one problem.


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How Do They Diagnosis Sleep

Problems???

What if Sleep Apnea is Suspected?

It is recommended that operators with

suspected sleep apnea (symptoms of snoring

and hypersomnolence), or with proven but

untreated sleep apnea, not be medically

qualified for commercial motor vehicle

operation until the diagnosis has been

eliminated or adequately treated.


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What if Sleep Apnea is Known?

individuals with known OSA be allowed toobtain certification to drive only after successfultherapy has resulted in multiple sleep latencytesting values within the normal range or repeatsleep study during treatment that showsresolution of apneas.

.. subjects obtaining medical qualificationshould agree, as a condition of continuingqualification, that their sleep apnea therapycontinue in an uninterrupted fashion while theymaintain the operator certification.

What About Narcolepsy? The guidelines recommend disqualifying a

CMV driver with a diagnosis of Narcolepsy,

regardless of treatment because of the

likelihood of excessive daytime somnolence.


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Statistics Dont Lie.

Although the scope of the problem can beargued, the fact that OSA exists in the

population of CDL holders cannot be denied.

Fatigue is also a well known cause of highwaycrashes and is estimated to be the cause of 17%of all fatal crashes.

What should be done to improve the statistics?


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What IS This Report?

A two day conference was held with a five memberexpert panel, ECRI, Manila Consulting and the U.S.Department of Transportations Federal MotorCarrier Safety Administration (FMCSA) in August,2007. The goal of the conference was to:

1. Review existing FMCSA guidelines for medicalexaminers which pertain to individuals with orsuspected of having OSA.

2. Discuss available evidence pertaining to theconsequences to public safety of certifying peoplewith OSA.

3. Recommend changes to FMCSA guidelines deemednecessary based on the available evidence.

Summary of Recommendations

Guideline 1: General Guideline

1. A dx of OSA should preclude an individualfrom obtaining unconditional certification todrive a CMV for the purpose of interstatecommerce.

2. Individuals with an OSA diagnosis MAY becertified to drive a CMV if the individual:

Has untreated OSA with an AHI < 20 AND

Has no daytime sleepiness OR

Has OSA that is being effectively treated


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Guideline 2: Immediate Disqualification

1. Certain populations should not be certified or recertifiedto drive a CMV. These include individuals who:

Report excessive sleepiness while driving OR

Have had a crash associated with falling asleep OR

Have an AHI that is > 20, until they are adherent toPAP OR

Have undergone surgery & who are pending thefindings of a 3 months post-op evaluation OR

Have been found to be non-compliant with their tx OR

Have a BMI or > 33 kg/m2 (pending sleep study eval)

Guideline 3: Conditional Certification

1. The following groups of individuals with OSA beallowed to conditionally drive a CMV :

Individuals with a BMI > 33 kg/m2 be certified for onemonth pending the findings of a sleep study (pref. 1 week)

Individuals recently diagnosed with OSA be certified forone month during which time they will be started onCPAP. At the end of the month, conditional certificationcan be granted for 3 months if there is documentedcompliance of CPAP use for the previous 2 weeks. After3 months (with documented compliance) conditionalcertification can be extended to 1 year. After 1 year, re-evaluation and re-certification should occur andcompliance with CPAP evaluated (> 4hr/night; 70% days).


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Guideline 4: Confirmation of Dx and/or

Stratification of Severity

1. The following groups of individuals should berequired to undergo evaluation & if necessary,stratify severity of OSA:

Individuals categorized as high risk for OSAaccording to Berlin Questionnaire OR

Those with BMI > 33 kg/m2 OR

Those judged to be at risk for OSA based onclinical evaluation


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Guideline 5: Clinical Evaluation-Identification

of Individuals w/ Undiagnosed OSA

1. The Medical Examiners role should includeidentifying undiagnosed OSA by:

Actively screening for OSA in all individuals who areapplying for certification for CMV

Looking for symptoms of OSA including: Chronicloud snoring; Witnessed apneas during sleep;Daytime sleepiness

Risk factors for OSA including: Advancing age; BMI> 28 kg/m2; Small jaw; Lg neck; Small airway; Familyhx; Hx of hypertension; Type 2 diabetes;Hypotyroidism


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Guideline 6: Method of Diagnosis & Severity

1. The preferred method of diagnosis & assessmentof disease severity is overnight polysomnography

2. Acceptable alternative methods for assessment ofrisk in CMV drivers include objective recordingdevices, validated against PSG that include atleast 5 hrs of measurement of:

Oxygen saturation AND Nasal Pressure ANDsleep/wake time

Guideline 7: Treatment of OSA

1. Positive Airway Pressure (PAP) is preferredmethod of therapy. Adequate PAP should bedetermined by either an in-laboratory titrationstudy or an auto-titration system w/o in-laboratorytitration.

2. Optimal treatment efficacy ocurs with 7 hrs ormore of use during sleep. However, an acceptable

CPAP use is at least 4 hours of use per night on atleast 70% of nights.


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Guideline 8: Alternative Treatment of OSA

1. Dental appliances & surgery are consideredpotential alternatives to PAP therapy.

2. There is no method of measuring compliance inindividuals treated with dental appliances.Therefore, the use of dental appliances cannot beconsidered an acceptable alternative to PAP inindividuals who require certification to drive aCMV.

Guideline 9: Bariatric Surgery

1. Obese individuals who have moderate to severeOSA and who undergo bariatric surgery may becertified if:

They are compliant with PAP OR

Are 6 months post-surgery (allows time for wt loss)AND

Are cleared by their treating clinician AND

Have a sleep exam indicating their AHI is < 10 AND They are no longer excessively sleepy

(Re-evaluate within 2 yrs OR if> 5% weight gain)


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Guidelines 10 - 12: Oropharyngeal or FacialBone Surgery or Tracheostomy

1. Individuals who have moderate to severe OSAand who undergo either oropharyngeal or facial

bone surgery or tracheostomy may be certified if:

They are > 1 month post surgery AND

Are cleared by their treating clinician AND

Have a sleep exam indicating their AHI is < 10 AND

They are no longer excessively sleepy

**ANNUAL Recertification is required to ensure AHI

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Truckers & Sleep Apnea