A more thorough screening and evaluation process, modified criteria for returning to work after treatment, and provision for follow-up and recertification recommendations are among recent recommendations for screening and management of sleep apnea among truck drivers.
The recommendations come from a joint task force of the American College of Chest Physicians (ACCP), American College of Occupational and Environmental Medicine (ACOEM), and the National Sleep Foundation (NSF). "Sleepiness and inattention contribute to a significant number of CMV (commercial motor vehicle) crashes each year, and OSA (sleep apnea) has been shown to significantly increase a driver's risk of driving drowsy," according to information from the task force. "Yet, current CMV screening and treatment procedures for OSA are ambiguous and not reflective of the latest advancements in the diagnosis and management of OSA.
"Conflicting approaches to screening and management of OSA have left drivers undiagnosed, which puts the driver and general public at risk. We hope our joint recommendations will assist the Federal Motor Carrier Safety Administration and states to update screening and treatment guidelines for sleep apnea, which, in turn, may help identify and treat more CMV drivers who suffer from this serious condition."
Guidelines for the diagnosis and treatment of sleep apnea from the Federal Motor Carrier Safety Administration (FMCSA) are based on a 1991 report sponsored by the Federal Highway Administration. Current FMCSA guidance for certification cites that drivers must have "no established medical history or clinical diagnosis of respiratory dysfunction likely to interfere with the ability to control and drive a commercial motor vehicle."
New recommendations are based on an extensive review of the latest sleep apnea research and existing medical guidelines related to OSA from the US Department of Transportation agencies. Recommendations provide an updated description of sleep apnea, based on how sleep apnea is currently defined by professional organizations and other federal agencies. Patients with sleep apnea include those with repetitive partial or complete obstruction of upper airway tissues during sleep, resulting in sleep disruption, gas exchange abnormalities, and cardiovascular changes. In addition, sleep experts advise that the diagnosis and severity of sleep apnea be established using the apnea-hypopnea index.
The joint task force also suggests a screening process that bases driver certification on severity of sleep apnea. These recommendations suggest certifying a driver at lower risk for sleep apnea for a maximum of three months, pending a medical evaluation (in-service evaluations), while drivers with more severe risk factors or a motor vehicle crash likely related to sleep disturbances should be prohibited from returning to work until they receive a medical evaluation (out-of-service evaluations).
Furthermore, the task force suggests expanding the screening process to include a more extensive medical and physical history, flagging such risk factors as body mass index, neck circumference, family history of OSA, and history of comorbidities (the simultaneous appearance of two or more illnesses).
"Difficulty in identifying those drivers at highest risk of OSA and accidents due to OSA has been a significant challenge for the commercial driver medical examiner," according to the information. "In addition, outdated guidance from the FMCSA has left medical examiners in conflict with current sleep guidelines. With recommendations based on current literature, and accepted by both occupational medicine and sleep medical organizations, a more consistent process for medical certification of these drivers can occur, decreasing the risk of accidents."
Although the task force recommends more thorough screening, their recommendations suggest a shorter return-to-work time. Under current FMCSA guidelines, CMV operators who are being treated for sleep apnea can return to work a minimum of one month after initiation of treatment. The task force's recommendations include reducing return-to-work time to two weeks after treatment initiation in certain situations. Reevaluation after four weeks to ensure compliance with therapy and improvement in symptoms is also recommended, the information stated.
"Sleep apnea is a highly treatable disorder," according to the information from the group. "The new return-to-work standards we suggest are more reflective of current clinical knowledge related to the treatment of sleep apnea. With appropriate therapy and compliance, drivers who suffer from sleep apnea will be addressing a significant risk for impaired performance on the job."
The information also said that a study sponsored by the FMCSA and the American Trucking Associations estimated that nearly one in three commercial truck drivers suffers from mild to severe OSA. The study found that the risk of having sleep apnea depended on two major factors -- age and degree of obesity -- with prevalence increasing with both. Population projections by FMCSA indicate the number of older drivers will increase by 50 percent over the next 20 years. Other research demonstrates that drivers with undiagnosed OSA have an increased risk (two-to-seven-times) for falling asleep at the wheel. It also increases the possibility of an individual developing significant health problems, such as hypertension, stroke, and ischemic (restricted blood flow) heart disease.