Executive Summary Sleep Apnea and Commercial Sept 06 - Sleep Apnea... · Executive Summary Sleep Apnea…

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  • Executive Summary

    Sleep Apnea and Commercial Motor VehicleOperators:Statement From the Joint Task Force of the American College of ChestPhysicians, American College of Occupational and Environmental Medicine,and the National Sleep Foundation

    Natalie Hartenbaum, MD, MPH, FACOEMNancy Collop, MD, FCCPIlene M. Rosen, MD, MSCE, FCCPBarbara Phillips, MD, MSPH, FCCPCharles F. P. George, MD, FRCPCJames A. Rowley, MDNeil Freedman, MD, FCCPTerri E. Weaver, PhD, RN, CS, FAANIndira Gurubhagavatula, MD, MPHKingman Strohl, MDHoward M. Leaman, MDGary L. Moffitt, MDMark R. Rosekind, PhD

    Obstructive sleep apnea (OSA) hasbeen demonstrated to significantly in-crease safety and health risks. Medicalresearch has shown that OSA is asignificant cause of motor vehiclecrashes (resulting in a two- to seven-fold increased risk) and increases thepossibility of an individual developingsignificant health problems such ashypertension, stroke, ischemic heartdisease, and mood disorders. Studiessuggest that commercial motor vehicle(CMV) operators have a higher prev-alence of OSA than the general popu-lation. U.S. federal statute requiresCMV drivers to undergo medical qual-ification examinations at least every 2yearsthe federal medical standardthat deals with OSA is section 49 CFR391.41(b)(5) of the Federal Motor Car-rier Safety Regulations. This sectionstates that the driver must have noestablished medical history or clinicaldiagnosis of respiratory dysfunctionlikely to interfere with the ability tocontrol and drive a commercial motorvehicle safely.

    Recently, the Federal Motor CarrierSafety Administration (FMCSA)changed the medical examination re-porting form to include a question thatasks a driver whether he or she has asleep disorder, pauses in breathingwhile asleep, daytime sleepiness, orloud snoring. So far, the only guidanceavailable from FMCSA on the diagno-sis and treatment of OSA in CMVdrivers was issued in 1991, the result

    From OccuMedix, Inc. (Dr Hartenbaum), Dresher, Pennsylvania; the Department of Medicine,Division of Pulmonary/Critical Care Medicine (Dr Collop), Johns Hopkins University, Baltimore,Maryland; the Department of Medicine, Divisions of Sleep Medicine and Pulmonary, Allergy &Critical Care Medicine (Dr Rosen), University of Pennsylvania School of Medicine, Philadelphia,Pennsylvania; the Division of Pulmonary Critical Care and Sleep Medicine (Dr Phillips), University ofKentucky College of Medicine, Lexington, Kentucky; the Department of Medicine, Division ofRespirology (Dr George), University of Western Ontario, and the Sleep Laboratory, London HealthSciences Centre, South Street Hospital, London, Ontario, Canada; the Department of Medicine,Division of Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine (Dr Rowley),Wayne State University School of Medicine, Harper University Hospital, Detroit, Michigan; The Sleepand Behavior Medicine Institute and Pulmonary Physicians of the North Shore (Dr Freedman),Bannockburn, Illinois; Biobehavioral and Health Sciences Division (Dr Weaver), University ofPennsylvania School of Nursing, Philadelphia, Pennsylvania; the Department of Medicine, Divisions ofSleep, Pulmonary and Critical Care Medicine (Dr Gurubhagavatula), University of PennsylvaniaMedical Center, Philadelphia, Pennsylvania; the Department of Medicine, Director (Dr Strohl), Centerfor Sleep Disorders Research, Case Western Reserve University School of Medicine, Louis StokesDVA Medical Center, Cleveland, Ohio; the IHC Health Services to Business (Dr Leaman),Intermountain WorkMed, Salt Lake City, Utah; and Arkansas Occupational Health (Dr Moffitt),Springdale, Arkansas; Alertness Solutions (Dr Rosekind), Cupertino, CA.

    Copyright 2006 by American College of Occupational and Environmental Medicine

    JOEM Volume 48, Number 9, Supplement September 2006 S1

  • of a report from a conference spon-sored by the Federal Highway Admin-istration. However, in the past 15years, there has been a tremendousincrease in the scientific and clinicalknowledge regarding the diagnosis andtreatment of OSA. This new informa-tion is not reflected in the currentFMCSA guidance and has createdchallenging and, at times, conflictingapproaches to managing OSA in com-mercial drivers.

    Because public safety has alwaysbeen of the highest priority when de-termining acceptable risk in relation tomedical conditions in CMV drivers(this differs significantly from theusual approach in clinical medicine), itis well accepted that when assessingrisk of accidents due to a medicalcondition, CMV drivers are held to ahigher medical standard than the gen-eral population.

    Given the public safety risks associ-ated with OSA, its prevalence in the

    CMV driver population, and the factthat the guidance on OSA diagnosisand management is 15 years old, theAmerican College of Chest Physi-cians, the American College of Occu-pational and Environmental Medicine,and the National Sleep Foundationconvened a Task Force to address thisimportant safety and medical risk inCMV drivers. The Task Force pursuedthe following activities: 1) review theexisting scientific literature related tothe diagnosis and management of OSA;2) review the medical standards andguidelines related to OSA from U.S.Department of Transportation agenciesand equivalent international groups; 3)review other relevant reports and recom-mendations from the National Transpor-tation Safety Board, FMCSA, and oth-ers; 4) draft a preliminary document offindings; 5) develop recommendationsrelated to screening, diagnosis, treat-ment, return to work, and follow up; and6) address other relevant topics such as

    compliance, duration of certification, andresearch needs.

    This report of the Task Force providesthe detailed findings of the extensivereviews conducted of documents fromdiverse resources on many relevant top-ics. The detailed reviews address thefollowing areas: 1) definition of sleepapnea; 2) current regulations, recom-mendations, and guidelines; 3) identifi-cation of patients at risk for sleep apneaand diagnosis; 4) objective assessment ofsleepiness and performance; 5) identifi-cation of CMV drivers with sleep apneawho are at high risk for crashes; 6)management of sleep apnea in the CMVdriver; 7) practical considerations; and 8)additional research questions. Findingsformed the foundation for consensus rec-ommendations regarding the diagnosisand management of OSA in commercialdrivers. The information presented in theeight sections are not summarized here,but rather provided in detail with refer-

    Screening Recommendation for Commercial Drivers With Possible or Probable Sleep ApneaMedically Qualified to Drive

    Commercial Vehicles IfDriver Meets Either of the

    Following

    In-Service Evaluation (ISE) RecommendedIf Driver Falls Into Any One of the

    Following Five Major Categories (3 momaximum certification)

    Out-of-Service Immediate EvaluationRecommended If Driver Meets Any

    One of the Following Factors

    1. No positive findings or anyof the numbered in-serviceevaluation factors

    1. Sleep history suggestive of OSA (snoring,excessive daytime sleepiness, witnessedapneas)

    1. Observed unexplained excessivedaytime sleepiness (sleeping in ex-amination or waiting room) or con-fessed excessive sleepiness

    2. Diagnosis of OSA withCPAP compliance docu-mented

    2. Two or more of the following: 2. Motor vehicle accident (run off road,at-fault, rear-end collision) likely re-lated to sleep disturbance, unlessevaluated for sleep disorder in theinterim

    a) BMI 35 kg/m2;b) Neck circumference greater than 17

    inches in men, 16 inches in women;c) Hypertension (new, uncontrolled, or un-

    able to control with less than 2 medica-tions).

    3. ESS 10 3. ESS 16 or FOSQ 184. Previously diagnosed sleep disorder; 4. Previously diagnosed sleep disorder:

    compliance claimed, but no recent medi-cal visits/compliance data available forimmediate review (must be reviewedwithin 3-mo period); if found not to becompliant, should be removed from ser-vice (includes surgical treatment)

    d) Noncompliant (CPAP treatmentnot tolerated);

    e) No recent follow up (within recom-mended time frame);

    f) Any surgical approach with no ob-jective follow up.

    5. AHI 5 but 30 in a prior sleep study orpolysomnogram and no excessive daytimesomnolence (ESS 11), no motor vehicleaccidents, no hypertension requiring 2 ormore agents to control

    5. AHI 30

    AHI indicates apneahypopnea index; BMI, body mass index; CPAP, continuous positive airway pressure; ESS, Epworth Sleepiness Scale;FOSQ, Functional Outcomes of Sleep Questionnaire; OSA, obstructive sleep apnea.

    S2 Sleep Apnea and Commercial Motor Vehicle Operators Hartenbaum et al

  • ences in the report. The recommendationcategories focus on the following:

    Screening; Diagnosis; Treatment; Compliance and efficacy; Return to work after treatment for

    OSA; and Follow up.

    The tables included in this articleprovide an overview of these rec-ommendations. However, the TaskForce recommends that the com-mercial driver medical examiner(CDME) evaluate each driver indi-vidually and make a judgmentabout his or her fitness for dutybased on specific criteria, including

    those listed in the tables in thisarticle. These criteria cannot pre-dict every situation faced by theexaminer, and the final judgmentbelongs to the CDME. Additionaltesting is optional, based on clini-cal judgment, to document absenceof excessive somnolence. ( J OccupEnviron Med. 2006;48:S1S3)

    Recommendation Regarding the Evaluation for Fitness-for-Duty for Commercial Drivers With Possible or Probable Sleep ApneaCategory Recommendation

    Diagnosis 1. Diagnosis should be determined by a physician and confirmed by polysomnography,preferably in an accredited sleep laboratory or by a certified sleep specialist

    2. A full-night study should be done unless a split-night study is indicated (severe OSAidentified after at least 2 hours of sleep)

    Treatment 1. First-line treatment for CMV drivers with OSA should be delivered by positive airwaypressure (CPAP, Bilevel PAP)

    2. All CMV drivers on PAP must use a machine that is able to measure time on pressure3. A minimum acceptable average use of CPAP is 4 hours within a 24-hour period, but

    drivers should be advised that longer treatment would be more beneficial4. Treatment should be started as soon as possible but within 2 weeks of the sleep study5. Follow up by a sleep specialist should be done after 2-4 weeks of treatment

    Return to work after treat-ment

    1. After approximately 1 week of treatment, contact between the patient and personnelfrom the durable medical equipment supplier, treating provider, or sleep specialist

    Treatment with PAP 2. AHI 5 documented with CPAP at initial titration (full night or split night) or after sur-gery or with use of oral appliance; AHI 10 depending on clinical findings

    3. Query driver about mask fit and compliance and remind to bring card (if used) or ma-chine to next session

    4. At a minimum of 2 weeks after initiating therapy, but within 4 weeks, the driver shouldbe reevaluated by the sleep specialist and compliance and blood pressure assessed

    5. If driver is compliant and blood pressure is improving (must meet FMCSA criteria), thedriver can return to work but should be certified for no longer than 3 months

    Return to work after treat-ment

    1. Oral appliances should only be used as a primary therapy if AHI 30

    Treatment with oral appli-ances

    2. Before returning to service, must have follow-up sleep study demonstrating AHI ide-ally 5, but 10 while wearing oral appliance

    3. All reported symptoms of sleepiness must be resolved and blood pressure must becontrolled or improving (must meet FMCSA criteria)

    Return to work after treat-ment

    Follow-up sleep studyAHI ideally 5 but 10 required to document efficacy

    Treatment with surgery orweight loss

    AHI indicates apneahypopnea index; CPAP, continuous positive airway pressure; FMCSA, Federal Motor Carrier Safety Administration;PAP, positive airway pressure; OSA, obstructive sleep apnea; CMV, commercial motor vehicle.

    JOEM Volume 48, Number 9, Supplement September 2006 S3

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