OBSTRUCTIVE SLEEP APNEA

evaluation in Commercial Driver Medical Examination

CRMCA 2013 Fall Program

14 November 2013Dana Rawl, MD, MPHdarwl@lexhealth.org

Lexington Occupational HealthLexington Medical Center, Lexington, South Carolina

Commercial Driver Medical Examination

• Purpose – to determine a driver’s physical qualification to operate a commercial motor vehicle according to federal regulation, 49 CFR 391.41-49

• Requirements and guidelines developed by the Federal Motor Carrier Safety Administration

• Fit-for-duty determination

Advisory Criteria

• FMCSA published recommendations to assist in determining driver qualifications

• Respiratory Dysfunction – 391.41(b)(5)– A person is physically qualified if that person:

Has no established medical history or clinical diagnosis of a respiratory dysfunction likely to interfere with the ability to control and drive a commercial vehicle safely.

Respiratory Dysfunction

• A factor of reduced oxygen exchange that may reduce driving performance and be detrimental to safety

• Conditions that can interfere with oxygen exchange include; emphysema, chronic asthma, carcinoma, tuberculosis, chronic bronchitis, obstructive sleep apnea (OSA)

OSA

• Sleep disorder, a medical condition

• Blockage of the airway from relaxed soft tissue

• Sucking against a closed airway

OSA

• Decreased oxygen - hypoxia• Provokes a brain response

– Frequent brain activation• Frequent awakenings• Prevents restful sleep phases

– Flight or fight response• Reflex air gasp • Reopens airway to breath

– Increased co-morbid disease • Increased cortisol

OSA Co-morbidity

• Hypertension

• Diabetes

• Congestive heart failure

• Coronary artery disease

• Renal disease

• Stroke

• Erectile dysfunction

OSA Prevalence

• General population– 1 in 5 with mild OSA

– 1 in 15 with moderate to severe OSA

• Prevalence in truckers is about 33%

• Similar prevalence in NFL offensive linemen!

• 80-90% of those truckers having OSA go undiagnosed

OSA - Symptoms

• Excessive daytime sleepiness (EDS)

• Loud snoring

• Episodes of breathing cessation while sleeping

• Abrupt gasp of air while sleeping

• Morning headache

• Attention, focus difficulty

• Mood changes, anxiety, irritability

Risk• Driving can be repetitive and monotonous

– Demands alertness and focus at all times • OSA

– Interferes with ability to remain attentive– Excessive daytime drowsiness, chronic fatigue– Detrimental for safe driving when fatigued; response worse when faced with

emergencies– Not to mention increase co-morbid diseases and added risk of sudden

incapacitating event• Reluctance to stop when drowsy

– Desire to complete job, “get-home-itis”– Pressure to meet time schedule

• Crash or accident risk

OSA and Risk of Motor Vehicle Crash: Systemic Review and Meta-Analysis

– Clearly an increased risk of crash; crash-rate ratio in the range 1.21 to 4.89 (other studies as high as a 7 fold increase in crash risk)

– Predicable crash characteristics in those with OSA included:

• Body Mass Index (BMI)

• Apnea plus hypopnea index

• Oxygen saturation

• Possibly daytime sleepiness

– Crash rate increased with BMI alone

FMCSA Guidance

• Input from Medical Review Boards, advisory committees, Medical Evaluation Panels– Evidence based studies

• Untreated significant OSA not medically certifiable

• No current regulation for OSA

• Recommendations vary on who to test, what is positive, and driver disposition

Risk Evaluation for OSA

• Medical Examination Report for Commercial Driver Fitness Determination– Sleep disorders, pauses in breathing while asleep,

daytime sleepiness, loud snoring• Unless previously evaluated for a sleep disorder, how

do you know if you’re asleep?

• Subjective responses may not be reliable

• Incentive not to admit to daytime sleepiness

Risk Evaluation for OSA

• Epworth Sleepiness Scale; subjective test

• Admission of EDS

• History of motor vehicle crash

• Medication use; alcohol, sedatives

• Smokers; 3 times more likely to have OSA

• Family history

• Age, sex and race

Risk Evaluation for OSA

• Objective findings – risk factors – Obvious sleepiness

– Obesity

– Increased neck circumference (17 inches in men and 16 inches in women)

– Visibly narrow airway

– Craniofacial abnormalities

Body Mass Index

• A function of weight and height

• Use as a screening tool to identify drivers at risk for having OSA

• BMI > or = to 35 shown to be associated with an increased risk of OSA severity– 80-90% found to have OSA when tested

• Will not find all drivers with OSA, 20-30% may have normal BMI

Why evaluate for OSA?

• Satisfy intent of FMCSA – reduce risk to driver and public

• Drive a better outcome– Reduce co-morbidity, improve health, reduce overall health

costs

– Improve safety, reduce accidents, reduce insurance and worker’s compensation costs

– Reduce fatigue, improve focus, increase productivity

– Promote healthier culture, use as a benefit or recruiting and retention tool

Lexington Occupational Health

• Identify those commercial drivers at higher risk for OSA, be as consistent as possible among multiple providers while being within current FMCSA guidelines

• Educate employers and drivers about OSA

• Provide employers and drivers with– understandable objective parameters that may trigger a

request for further testing for OSA

– disposition of status after testing +/- for OSA

Sleep Study Request

• Use > or = to 35 BMI as a trigger

• May use neck measurement to reinforce objective parameter

• May use subjective questions to help reinforce request for sleep study

• Consider co-morbid diseases in determining request for sleep study

• Clinical discretion is applicable in determination

R/O OSA

• Send for sleep study – May be conditionally certified for 3 months

– May be disqualified if symptoms/findings severe

– Sleep lab certification, must monitor brain activity (home testing not adequate)

• If no significant OSA– May medically certify for up to 2 years if no other chronic

diseases noted

R/O OSA

• If positive for significant OSA, needs treatment– Will need minimum of 30 days treatment and re-eval to

prove compliance and effectiveness of treatment

– Should not drive commercially until treatment proven to be effective and driver is compliant

– May certify for up to one year, but needs to prove compliance and effective treatment annually

• Documentation form must be completed by treating physician

What’s coming?

• National Registry of Certified Medical Examiners by May 21, 2014

• Advancing technology may improve testing and monitoring, more user and employer friendly– A-PAP (auto-PAP), real-time monitoring – Web based soft ware, work place testing

• More complete recommendations and guidelines on evaluation, treatment and disposition of OSA in commercial drivers that (hopefully) will be in the form of regulation

• Recent legislation to require formal rulemaking process to implement regulation

Bottom Line

• Significant untreated OSA is disqualifying for commercial driver medical certificate

• 80-90% of commercial drivers who have OSA are untreated• OSA is a medical condition that can be effectively treated if

driver is compliant• Focus is on health, safety of driver and public• Employer and driver benefits• “the only incorrect approach for examiners is to do nothing.” –

Hartenbaum, MD, MPH

References

• Medical Examiner Handbook– http://nrcme.fmcsa.dot.gov/mehandbook/MEhandbook.aspx

• The DOT Medical Examination; Hartenbaum, Natalie P., 5th Edition, OEM Press, 2010.

• Obstructive Sleep Apnea and Risk of Motor Vehicle Crash: Systemic Review and Meta-Analysis; Tregear, Stephen, et al, Journal of Clinical Sleep Medicine. 2009 December 15; 5(6): 573-581.

• Sleep Apnea– http://www.mayoclinic.com/health/sleep-apnea/DS00148

• Dr. Jeffrey Durmer, Fusion Health Chief Medical Officer at 2012 American Trucking Association ITLC/NAFC Annual Conference