Asleep at the Wheel

Lifesavers 4/23/18

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Asleep at the WheelUnderstanding and Preventing Drowsy Driving

aasm.org

EVOLVING SAFETY PRIORITIES AND SOLUTIONS

LIFESAVERS ● April 23, 2018 ● San Antonio, TX

2:15 – 3:45 PM

Room 214 D

Conflict of Interest Disclosures for Speakers

1. I do not have any potential conflicts to disclose.

2. I wish to disclose the following potential conflicts of interest:

Type of Potential Conflict Details of Potential Conflict

Grant/Research Support

Consultant

Speakers’ Bureaus

Financial support

Other

3. The material presented in this lecture has no relationship with any of these potential conflicts, OR

4. This talk presents material that is related to one or more of these potential conflicts, and the following objective references are provided as support for this lecture:

1.

2.

3.

X

Asleep at the Wheel: Understanding and Preventing Drowsy Driving

Healthy sleep, sleepiness and sleep disorders: role in motor vehicle accidents (35 min)

Shift work and crash risk (25 min)

Sleep deprivation and crash risk (25 min)

Sleepiness and Accidents: A Crash Course

Occupational Sleep Health and Wellness

Presidential Committee

Healthy sleep, sleepiness and

sleep disorders: role in motor

vehicle accidents

Sleepiness and Accidents: A Crash Course

Director, Occupational Sleep Medicine

Perelman School of Medicine

University of Pennsylvania

Director, Sleep Disorders Clinic

VA Medical Center

Philadelphia, PA

Indira Gurubhagavatula, MD, MPH

Associate Professor of Clinical Medicine

American Academy of Sleep Medicine

(AASM)

• 11,000 physicians, scientists, allied health professionals, accredited sleep centers

• leader in setting standards and promoting excellence in sleep medicine health care

• 2014 –Sleep and Transportation Safety Awareness Task Force (STSATF)

• 2017 –Occupational Sleep Health and Wellness Presidential Committee

Mission

• Engage occupations and populations at risk for sleep deprivation

• Provide education– Effects of sleep deprivation

– Fatigue management strategies

• Monitor regulatory agencies’ actions related to sleep health and safety risks in employees– safety-sensitive positions, have sleep

disorders

Asleep at the Wheel

Lifesavers 4/23/18

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Some of our activities

Position statement about addressing sleepiness

and accidents in EMS and ride hailing industry

Educational materials on sleep apnea, shift work,

insomnia, sleep hygiene, drowsy driving, fatigue

management

Response to withdrawal of Notice of Proposed

Rulemaking on sleep apnea

Outline

• What is the difference between healthy sleep and disordered sleep?

• What determines alertness?

• What are some sleep disorders that can impact driving safety?

– Obstructive sleep apnea

– Shift work

– Sleep deprivation

Normal sleep architecture

HOURS OF SLEEP

What determines alertness?HOMEOSTATIC DRIVE FOR SLEEP

CIRCADIAN DRIVE FOR WAKEFULNESS

Reducedbehavioral

capability

Increased behavioral

capabilityInternal Factors

• Stress/anxiety

• Urgency

• Motivation

External Factors

• Alcohol, caffeine

• Medications

• Noise

• Physical activity

Disorders that cause sleepiness

Quality of sleepLength of time awake

Time of day

Duration of sleep

Conditions associated with daytime

sleepiness

• Sleep disorders– Obstructive sleep apnea

– Other sleep disorders (e.g., periodic limb movements, restless legs syndrome, narcolepsy)

• Some medical disorders

• Some psychiatric disorders

• Some medications

• Some behaviors (sleep hygiene)

Asleep at the Wheel

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Obstructive Sleep Apnea

• What is obstructive sleep apnea?

• Who is likely to have it?

• How common is it?

• What are the usual symptoms?

• What are the consequences?

• Can we diagnose it quickly and at low cost?

• Can it be treated?– Does treatment help?

– Does treatment make sense economically?

Sleep apnea: what actually happens?

http://content.revolutionhealth.com/contentimages/ n5551303.jpghttp://www.thetmjcenter.com/sleep_a pnea.jpg

AWAKE ASLEEP

www.thoracic.org

sleep architecture during sleep apnea

Sleep fragmentation

No N3, REM

Desaturation

EXAMPLE OF AN APNEA

OSA AND OXYGEN LEVEL DURING

SLEEP

Why are some people at risk for

sleep apnea?

• OBESITY

• OBESITY

• OBESITY

• Airway crowding

–Large tonsils

–Large tongue

–Small jaw

• Heredity

• Middle age/older

• Male gender

• Female gender, after menopause

• Nasal congestion

• Alcohol, sedatives, narcotics

Asleep at the Wheel

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As obesity becomes more common, so does sleep apnea

Prevalence of moderate to severe apnea

Men Women

1994 (Young et al)

(state employees, age 30-60 years)

9% 4%

2007-2010 (Peppard et al)

30-49 years 10% 3%

50-70 years 17% 9%

Peppard, Am J Epidemiol, 177 (9):1006-1014; 2013

prevalence data from 1994 was used to model current prevalence rates, based on

recent age, sex, BMI data from NHANES

Studies have linked OSA to crashes

Research studies that were

evaluated

Odds of crash

18 studies in car drivers;

2 in truck drivers

1.21-4.89

http://www.fmcsa.dot.gov/facts-research/research-technology/report/FMCSA-RT-04-008.pdf

Tregear et al, JCSM 2009, Dec 15 5(6); 573-581.

Life with sleep apnea

APNEAS, HYPOPNEAS

(observed by others)

Snoring

Choking, Gasping

Frequent urination

ADRENALINE

LOW OXYGEN

• Sleepiness

• ↑Crash risk

• ↓ mood, memory,

concentration,

attention, decision-

making

• ↑ reaction time

• Morning headache

• Impotence

• ↓producLvity

• Absenteeism

• Hypertension

• Heart disease

• Stroke

• Pre-diabetes

• Death

NIGHTTIME

DAYTIME

LONG-TERM

AROUSALS

worse with weight gain

Costs of crashes due to undiagnosed OSA

(2015, U.S.)

AASM, 2016

In-lab sleep study

• Brain waves

• Eye movement

• Chin, leg muscles

• Chest and abdomen

effort

• Airflow, snoring

• Oxygen level

85% of cases remain undiagnosed

Brain waves

Eye movement

Chin, leg muscles

• Chest and abdomen

effort

• Airflow, snoring

• Oxygen level

http://www.fette-thimm.de/img/embletta400.jpg

Portable sleep study

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Is sleep apnea treatable?

http://amysorrells.files.wordpress.com/2012/06/flat_bicycle_tire.jpg

http://www.everettclinic.com/crs/aha/cpap.jpg

Continuous positive airway pressure (CPAP)

http://www.sleepwise.com.au/images/D912193040.gif

http://www.resmed.com/uk/images/cpap_treatment.jpg

Continuous positive airway pressure

(CPAP)

In addition to improving oxygen level and sleep quality, what are the benefits of CPAP?

� CPAP lowers � crash risk1

� blood pressure2,3

� heart disease, stroke5,6,7

� mortality7,8

� health care costs9,10

� CPAP improves

� alertness1

� performance on

driving

simulator1

� quality of life4

1Tregear, Sleep, 20102Haentjens, Archives Int Med, 20073Bazzano, Hypertension, 20074Sanner, Eur Respir J, 20005Buchner, AJRCCM, 20076Marin, Lancet, 20087Yaggi, NEJM, 20058Martinez-Garcia, AJRCCM, 20099Albarrak, Sleep, 200510Ronald, Sleep Res Online, 1998

How do we know if patients are using

CPAP?

https://www.respshop.com/images/DreamStation-CPAP-Machine-2.jpg

https://sleepright.com.au/wp-content/ uploads/2012/05/Resmed-S10-CPAP-300x226.png

http://www.1800cpap.com/images/ products/detail/iconautoplussensea wakecpa p.jpg

Monitoring therapy

http://www.cpapxchange.com/cpap-machines-bipap-machines/sleepmapper-screens.png

Did they wear it?

Did the mask leak?

Is apnea still present?

http://www.cpaptalk.com/in-house-cpap-news/images/encorepro/ComplianceScreen.jpg

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Sleep apnea

– is common

– causes sleepiness

– is linked to crashes, as well as major economic and health outcomes

– can be diagnosed in the home/berth

Summary

CPAP treatment

• is inexpensive

• is accessible

• lowers crash risk

• improves many health conditions

• lowers health care costs

• can be tracked in real-time

Occupational Sleep Health and

Wellness: Dream Team

Omer Ahmed, MD

Michael Berneking, MD

Jacob Collen, D

Binal Kancherla, MD

Shannon Sullivan, MD

Indira Gurubhagavatula, MD, MPH (Chair)

Questions?