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OBSTRUCTIVE SLEEP APNEA evaluation in Commercial Driver Medical Examination

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OBSTRUCTIVE SLEEP APNEA evaluation in Commercial Driver Medical Examination CRMCA 2013 Fall Program 14 November 2013 Dana Rawl, MD, MPH darwl_at_lexhealth.org – PowerPoint PPT presentation

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Title: OBSTRUCTIVE SLEEP APNEA evaluation in Commercial Driver Medical Examination


1
OBSTRUCTIVE SLEEP APNEA evaluation in
Commercial Driver Medical Examination
  • CRMCA 2013 Fall Program
  • 14 November 2013
  • Dana Rawl, MD, MPH
  • darwl_at_lexhealth.org
  • Lexington Occupational Health
  • Lexington Medical Center, Lexington, South
    Carolina

2
Commercial Driver Medical Examination
  • Purpose to determine a drivers 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

3
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.

4
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)

5
OSA
  • Sleep disorder, a medical condition
  • Blockage of the airway from relaxed soft tissue
  • Sucking against a closed airway

6
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

7
OSA Co-morbidity
  • Hypertension
  • Diabetes
  • Congestive heart failure
  • Coronary artery disease
  • Renal disease
  • Stroke
  • Erectile dysfunction

8
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

9
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

10
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

11
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12
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13
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

14
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

15
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 youre asleep?
  • Subjective responses may not be reliable
  • Incentive not to admit to daytime sleepiness

16
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

17
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

18
Body Mass Index
  • A function of weight and height
  • Use as a screening tool to identify drivers at
    risk for having OSA
  • BMI gt 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

19
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 workers compensation costs
  • Reduce fatigue, improve focus, increase
    productivity
  • Promote healthier culture, use as a benefit or
    recruiting and retention tool

20
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

21
Sleep Study Request
  • Use gt 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

22
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

23
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

24
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25
Whats 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

26
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

27
References
  • Medical Examiner Handbook
  • http//nrcme.fmcsa.dot.gov/mehandbook/MEhandbook.a
    spx
  • 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/DS001
    48
  • Dr. Jeffrey Durmer, Fusion Health Chief Medical
    Officer at 2012 American Trucking Association
    ITLC/NAFC Annual Conference
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