Screening for Sleep Apnea in Commercial Drivers
In a previous post “Every 17″ Gets a Sleep Test,” we discussed how you really have to use a rational process to screen and refer drivers for sleep apnea testing.
Here’s a recent comment from a driver to the FMCSA on the Sleep Apnea Rule docket:
Less than a month ago I had to update my 2 year medical card. I am a 35 year old female with no medical issues. I do not snore. I have never had any issues with sleep – my head hits the pillow and I am out and wake feeling well rested. I do not have high blood pressure.
My neck circumference is 13 inches – 4 inches less than the 17 inch “guideline” requirement for a sleep study. I do have a BMI of 35 and apparently a tongue that is high in my mouth (according to the DOT medical examiner)?
I am home nightly and never drive more than 150 miles in a day.
I went to the recommended DOT medical examiner that my employer provided. I was not asked any questions about my sleep habits, driving habits or health by this DOT medical examiner. She decided to require a sleep study test be done before renewing my medical card solely based on my BMI and tongue placement. The medical examiner even stated that the likelihood of the sleep test finding that I have sleep apnea is highly unlikely.
This required me to return to my primary physician to request the test be ordered, as she stated that she could not order the test herself. My primary physician, who I have been seeing for years, does not agree that a sleep study is needed, as I have no symptoms other than BMI.
What does one do when this test is not required for medical necessity, but only to satisfy guidelines places upon medical examiners, I assume to limit their own liability? What happens for folks like myself caught in the middle of the bureaucracy? I am required now to spend the funds to have this sleep study completed or I will lose my job.
For someone such as myself with no sleep concerns I was blindsided by this issue. And, there is nothing for me to do other than proceed with the expensive, unnecessary testing.
I have spent hours researching this topic now and have found hundreds of others in the same boat that I am in. Medical examiner requires the test, but primary physician does not agree. Something seems very wrong here when medical doctors are not in agreeance over treatment of a patient after a new regulation is in put into place. DOT doctors are being “guided” to require these sleep studies when in their own medical judgement, they are not necessary.
Latest Medical Review Board Recommendations
On August 22-23, 2016, the Medical Review Board (MRB) met and issued recommendations to FMCSA to consider for final rulemaking on obstructive sleep apnea in commercial truck drivers, including sleep apnea screening and ordering a sleep apnea test.
A BMI of 40+ by itself was considered enough to suspect and test for sleep apnea. The MRB recommended that for a BMI of 33+ at least 3 other criteria should be met for high suspicion of sleep apnea and to consider ordering a sleep test:
- Hypertension (treated or untreated);
- Type 2 diabetes (treated or untreated);
- History of stroke, coronary artery disease, or arrhythmias;
- Micrognathia or retrognathia;
- Loud snoring;
- Witnessed apneas;
- Small airway (Mallampati Classification of Class 3 or 4)
- Neck size > 17 inches (male), 15.5 inches (female);
- Hypothyroidism (untreated);
- Age 42 and above; or
- Male or post-menopausal female
In most cases the driver may be certified for a 90 day period while undergoing this evaluation. They should be disqualified if they have been involved in a sleep related crash or near-crash, or if they admit to being fatigued or sleepy during the wake hours and particularly while driving.
Does She fit these Criteria?
So in the case above, the 35 y/o female driver has a BMI > 33 but fits only one other risk factor, “Small airway or Mallampati 3 or 4”, and would not necessarily have to be sent for a sleep test.
Right now this is all discretionary for the medical examiner, but the latest MRB recommendations are consistent with and have built on current best practices.
I’m pretty aggressive when screening drivers for sleep apnea, but I think I would not have felt this young woman to be much of a risk and would not have ordered a sleep test in this case, based on the information given here as generally described.
Again, I was not her medical examiner and only s/he can really make that determination in this specific case.
Get the Algorithm
You can use the new recommended sleep apnea screening criteria in our algorithm, get it for free here:
In our course we teach all the research available to date to give you confidence to assess and manage these drivers appropriately, including:
- The impact obstructive sleep apnea has on large truck accidents, injuries and fatalities
- How to use the right screening tools on every driver, every exam
- How to order a sleep test, when to consider home sleep testing (HST) vs a polysomnography
- Interpretation of the test in collaboration with a sleep specialist
- How to determine when a driver needs treatment for sleep apnea
- Recommended treatments
- Certification or disqualification criteria and appropriate intervals
- How to determine compliance with treatment and guide further certification/disqualfication
- and more!