Addressing Obstructive Sleep Apnea (OSA) Among Commercial Motor Vehicle Drivers
by Richard Bunch, January 17, 2018
Obstructive sleep apnea (OSA), also referred to as obstructive sleep apnea-hypopnea (OSAH), is a sleep disorder that involves cessation or significant decrease in airflow in the presence of breathing effort. It is the most common type of sleep-disordered breathing and is characterized by recurrent episodes of upper airway collapse during sleep.
OSA that is associated with excessive daytime sleepiness is commonly called obstructive sleep apnea syndrome. Apnea may occur hundreds of times nightly, 1-2 times per minute, in patients with severe OSA, and it is often accompanied by wide swings in heart rate, a precipitous decrease in oxygen saturation, and brief electroencephalographic (EEG) arousals concomitant with noisy and gasping (stertorous) breathing sounds.
The cardinal symptoms of sleep apnea include the “3 S ’s”: S noring, S leepiness, and S ignificant-other report of sleep apnea episodes. OSA is a very important diagnosis for physicians to consider because of its strong association with debilitating medical conditions such as hypertension, cardiovascular disease, coronary artery disease, insulin-resistance diabetes, depression, and sleepiness-related accidents.
OSA affects about 22 million people in the United States, according to the American Sleep Apnea Association, and 80 percent of moderate to severe obstructive sleep apnea cases are undiagnosed. OSA is caused when the airway is blocked and normal breathing is interrupted. Because OSA can lead to drivers being less alert and reactive due to drowsiness, OSA remains a big concern for motor carrier and railroad industries.
A recent study from researchers at the University of California, San Francisco concluded that 41 percent of commercial motor vehicle (CMV) drivers could have OSA. In addition, a University of Minnesota, Morris study published in March 2016 determined that CMV drivers with OSA who did not stick to their prescribed treatment were five times more likely to experience a crash than drivers without OSA.
The 2016 study “emphasizes that untreated OSA is a pervasive threat to transportation safety,” American Academy of Sleep Medicine President Dr. Nathaniel Watson said in a press release issued shortly after the study’s release: “It is critical for transportation companies to implement comprehensive sleep apnea screening and treatment programs to ensure that truck drivers stay awake at the wheel.”
The OSA screenings, however, proved expensive for drivers, according to a survey conducted from March to May 2016 by the American Transportation Research Institute (ATRI). Fifty-three percent (53%) of CMV operators who were part of a sleep study paid an average of $1,220 in out-of-pocket costs.
Continuous positive airway pressure (CPAP) is a mode of respiratory ventilation used in the treatment of sleep apnea. CPAP treatment can be highly effective in treatment of obstructive sleep apnea. For some patients, the improvement in the quality of sleep and quality of life due to CPAP treatment will be noticed after a single night’s use. Often, the patient’s sleep partner also benefits from markedly improved sleep quality, due to the amelioration of the patient’s loud snoring. The results of the ATRI survey also showed that 84 percent of drivers who used a CPAP machine experienced better sleep, 75 percent said they had lower blood pressure, and 71 percent reported feeling better when they awoke.
Based on the potential severity of OSA-related transportation incidents and crashes/accidents, and the varied, non-regulatory, OSA-related actions the Department’s Operating Administrations have taken to date, the Agencies issued a joint advance notice of proposed rule-making (ANPRM) to consider regulatory action to ensure consistency in addressing the risk of OSA among transportation workers with safety sensitive duties (81 FR 12642, March 10, 2016). The agencies sought to gather data and information on moderate to severe sleep apnea among workers in safety-sensitive positions in highway and rail transportation. They also wanted to look at the benefits and costs of any regulations, such as requiring drivers with multiple OSA risk factors to go through evaluation and treatment by a sleep disorders medical expert.
However, the Federal Motor Carrier Safety Administration (FMCSA) and Federal Railroad Administration (FRA) (collectively, the Agencies) withdrew the ANPRM concerning the prevalence of moderate-to-severe OSA on March 10, 2016. With that action, the Agencies essentially made a decision not to issue a notice of proposed rulemaking. The agencies believed that current safety programs and FRA’s rulemaking addressing fatigue risk management were sufficient avenues to address OSA. FMCSA indicated that it will continue to endorse the voluntary North American Fatigue Management Program (NAFMP) to commercial motor vehicle drivers and employers. The NAFMP is a collaborative initiative to develop a comprehensive, integrated fatigue management program for the commercial motor carrier industry, operating under various regulatory jurisdictions of North America. The elements of the fatigue management program will address corporate culture, education and training, sleep disorder screening and treatment, scheduling and tools, and fatigue monitoring and management technologies.