OBSTRUCTIVE SLEEP APNEA
evaluation in
Commercial Driver Medical Examination
CRMCA 2013 Fall Program
14 November 2013
Dana Rawl, MD, MPH
darwl@lexhealth.org
Lexington Occupational Health
Lexington 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
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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:
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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
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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