Medically qualified to drive commercial vehicles if driver meets either of the following:
In-service evaluation (ISE) recommended if driver falls into any one of the following five major categories (3-month maximum certification):
Out-of-service immediate evaluation recommended if driver meets any one of the following factors:
1. No positive findings or any of the numbered ISE factors
1. Sleep history suggestive of OSA (snoring, excessive daytime sleepiness, witnessed apneas)
1. Observed unexplained excessive daytime sleepiness (sleeping in examination or waiting room) or confessed excessive sleepiness
2. Diagnosis of OSA with CPAP compliance documented
2. Two or more of the following: (a) BMI ≥ 35 kg/m2; (b) neck circumference greater than 17 in. in men, 16 in. in women; (c) hypertension (new, uncontrolled, or unable to control with less than two medications)
2. Motor vehicle accident (run off road, at-fault, rear-end collision) likely related to sleep disturbance, unless evaluated for sleep disorder in the interim
3. ESS > 10
3. ESS ≥ 16 or FOSQ < 18
4. Previously diagnosed sleep disorder; compliance claimed, but no recent medical visits/compliance data available for immediate review (must be reviewed within 3 month period); if found not to be compliant, should be removed from service (includes surgical treatment)
4. Previously diagnosed sleep disorder, (d) noncompliant (CPAC treatment not tolerated), (e) no recent follow-up (within recommended time frame), (f) any surgical approach with no objective follow-up
5. AHI > 5 but <30 in a prior sleep study or polysomnogram and no excessive daytime somnolence (ESS < 11), no motor vehicle accidents, no hypertension requiring two or more agents to control
5. AHI > 30
Table 5.2
Recommendations for timeline managing evaluation, screening, and treating drivers with sleep apnea
Category | 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 OSA identified after at least 2 h of sleep) | |
Treatment | 1. First-line treatment for CMV drivers with OSA should be delivered by positive airway pressure (CPAP, bilevel PAP) |
2. All CMV drivers on PAP must use a machine that is able to measure time on pressure | |
3. A minimum acceptable average use of CPAP is 4 h within a 24-h period, but drivers should be advised that longer treatment would be more beneficial | |
4. Treatment should be started as soon as possible but within 2 weeks of sleep study | |
5. Follow-up by a sleep specialist should be done after 2–4 weeks of treatment | |
Return to work after treatment | 1. After approximately 1 week of treatment, contact between the patient and personnel from 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 surgery 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 machine to next session | |
4. At a minimum of 2 weeks after initiating therapy, but within 4 weeks, the driver should be 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), the driver can return to work but should be certified for no longer than 3 months | |
Return to work after treatment | 1. Oral appliances should only be used as a primary therapy if AHI <30 |
Treatment with oral appliances | 2. Before returning to service, must have follow-up sleep study demonstrating AHI ideally <5, but ≤ 10 while wearing oral appliance |
3. All reported symptoms of sleepiness must be resolved and blood pressure must be controlled or improving (must meet FMCSA criteria) | |
Return to work after treatment | Follow-up sleep study—AHI ideally <5 but ≤10 required to document efficacy |
Treatment with surgery or weight loss |
In 2008, a medical expert panel reviewed these recommendations as well as the relevant literature and concluded that overall the consensus guidelines had as high as a 0.94 positive predictive value. They further refined the guidelines lowering the BMI from 35 to 33 kg/m2 as well as the mandatory treatment apnea and hypopnea index (AHI) from 30/h to 20/h. In addition, they incorporated the use of portable sleep testing to confirm diagnosis of OSA [20]. The medical review board of the FMCSA adopted the medical expert panel’s recommendations but lowered the BMI even further to 30 kg/m2 [10]. In 2012, the FMCSA’s safety advisory committee recommended updated guidelines reraising the BMI criteria to 35 kg/m2. In April of that year, they even went as far as publishing these criteria in the Federal Register, but later that same day withdrew them. Due to concern over the cost of implementation, lack of resources, and the number of drivers impacted, none of these guidelines have ever been implemented. In October of 2013, the bill H.R. 3095 requiring changes to FMCSA guidelines regarding sleep apnea followed formal rule-making process and was signed into law by President Obama.
In November of 2013, the FAA was considering requiring all pilots with a BMI greater than 40 and a neck circumference greater than 17 in. to be evaluated by a board-certified sleep specialist. However, the FAA withdrew their proposal in December of 2013. House Bill H.R. 3578 requires the FAA to use formal rule-making process to adopt any new or revised requirements providing for screening, testing, or treating any sleep disorder recently passed in the House of Representatives. A similar bill is still pending in the Senate.
Several studies exploring the predictive value of the JTF guidelines have reported its high predictive positive value ranging from 79 to 100 % [9, 12, 13]. Platt et al. recently argued that these recommendations are not comprehensive enough. In their study, they reported that one-third of drivers screened negative by the JTF criteria had an AHI greater than 20 per hour [16]. They argued the only way to ensure identifying all drivers with sleep apnea is to implement mandatory testing for all commercial drivers regardless of their examination findings. The argument against mandatory screening for all individuals in these industries is cost and disruption to industries. It is estimated that mandatory screening in the trucking industry alone would exceed a billion dollars annually [21]. Opponents of the mandatory screening in all drivers further argue that not all individuals with sleep apnea will actually have accidents. Interestingly, studies have shown that although almost all of commercial medical examiners (CME) (92 % surveyed) support utilizing the JTF recommendations, the majority (68 %) are not using these guidelines or any other. Reported reasons for not screening included being unaware of them (36 %), guidelines are too complicated (12 %), fear of loss of clients (10 %), and driver inconvenience (10 %). Thirty-nine percent of the examiners surveyed wanted additional evidence prior to incorporating them and another 21 % reported incorporating them only if they became community standard [22]. An objective measure of sleepiness which predicts potential risk for accidents is still needed.
The current void of federal regulation leaves examiners, drivers, and companies stuck in a no man’s land. Some companies motivated by economic savings or concern over propagation of litigation against drowsy drivers have embraced these recommendations and have implemented their own screening programs. Schneider Trucking in 2005 implemented a test program at one of their terminals which showed a 73 % reduction in preventable driving accidents among the group of 225 drivers treated for sleep-disordered breathing and a 47.8 % reduction in per member healthcare costs. An added benefit was in an industry of high turnover, driver retention was 2.29 times that of the previous year [23]. Although more and more trucking companies are incorporating mandatory screening and treatment programs, these companies still remain in the minority. Other companies due to concerns over implementation costs or perceived difficulties with driver retention and competition have taken a “wait-and-see” approach, meeting the current minimum requirements while keeping informed of changes to the industry. Twenty-nine to sixty-seven percent of drivers recommended for additional testing have been shown to seek out other companies or medical examiners with less stringent guidelines [12, 14]. This is known as “doctor shopping.” Until there is a national registry of driver examination results stored and reviewed in a single common database, given the mobility of this population, many will hop to another company or doctor to get their certification.
Examination
In the absence of formal guidelines and with so many different factors involved, it is difficult to have a fixed approach. Clinicians should be vigilant for individuals working in industries where sleepiness may lead to catastrophic consequences. Every patient situation is unique and must be evaluated on an individual basis with the clinician’s expertise, experience, and clinical judgment ultimately directing the individual diagnosis, treatment options, and follow-up for each patient. For most of these individuals, their evaluation should be a multidisciplinary approach involving coordination with their primary care provider as well as medical examiner and if appropriate a sleep medicine specialist. Since the most accurate assessment involves a combination of both subjective and objective assessment criteria, establishing an environment where the individual feels safe to report symptoms is important. All clinical decisions regarding the worker’s timeline for fitness of work certification should be made within context of minimizing disruptions. Any delay in testing impacts the worker’s ability to work and increases negativity toward testing and treatment.
History and physical examination should look for symptoms or comorbidities which likely suggest sleep apnea. These findings may include history of loud snoring, age over 50, small upper airway, family history of OSA, hypertension, type 2 diabetes, untreated hypothyroidism, excessive sleepiness, witnessed apneas, or gasping for breath in their sleep. The examiner should be vigilant for any contradictory responses or other indications that the patient is impacted by excessive sleepiness such as sleeping in the waiting room or history of vehicular accidents. The examiner should also incorporate several objective measures correlated with sleep apnea like blood pressure, BMI, neck size, gender, and age [20]. If at this point the examiner’s clinical assessment indicates OSA or the driver has two or more of the following objective criteria: BMI ≥ 35, large neck (≥17 in. for males or ≥15.5 in. for females), and new or uncontrolled hypertension, then they should be referred to a sleep specialist for additional evaluation, testing, and if necessary management.
For drivers being referred for additional assessment, if the history does not suggest significant subjective sleepiness, then he should be provided with a 30-day card in order to consult with the sleep specialist and undergo testing if indicated [19]. For those at high risk for sleep-related accident (previous accident or observed falling asleep unintentionally on the job), his medical certification should be held until such time his sleepiness is satisfactorily resolved [19]. In industries without medical certification requirements, the worker should be advised to take a leave of absence until his sleepiness is resolved.
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