What DOT drivers need to know about sleep apnea
Because sleep apnea affects the quality of sleep, it also affects alertness and performance during the day. This is particularly concerning for commercial motor vehicle drivers. In a Federal Motor Carrier Safety Administration (FMCSA) sponsored study conducted by the University of Pennsylvania and the American Transportation Research Institute of the American Trucking Associations, researchers found that almost one-third (28 percent) of commercial truck drivers have mild to severe sleep apnea.
While the FMCSA has no regulations or criteria specifically on screening, testing, and treatment of sleep apnea, it does grant the Medical Examiner the discretion to determine if an individual is at greater risk for the condition. In screenings during the medical certification process, Medical Examiners may rely on their medical judgment and may consider the relevant medical best practices and expert recommendations.
What is sleep apnea?
Sleep apnea is a potentially dangerous sleep disorder. When a person has sleep apnea, their breathing can become abnormal while they sleep, and they can experience multiple extended pauses in breathing. The term “apnea” refers to a pause in breath that lasts for 10 seconds or more. Those with sleep apnea may wake up multiple times throughout the night as they struggle to breathe. While these waking moments may be so brief that they go unnoticed, it can prevent someone from reaching the phases of deep sleep needed to be rested and alert during the day. If untreated, sleep apnea can lead to serious health conditions such as high blood pressure, stroke, and arrhythmias.
Symptoms related to sleep apnea include:
- Loud snoring
- Episodes of pauses in breath for greater than 10 seconds during sleep
- Gasping for air during sleep
- Insomnia
- Dry mouth upon waking
- Morning headache
- Irritability
- Excessive daytime sleepiness
- Struggling to focus while awake
Risk factors for CMV drivers
During a DOT physical, the Medical Examiner may take note of any risk factors and issues that could interfere with breathing or swallowing. Risk factors may include:
- Age (For drivers older than 42 years)
- Sex (Male or post-menopausal female)
- BMI (over 40 or over 33 while meeting three other risk requirements)
- Neck circumference (Greater than 17 inches for males or greater than 15.5 inches for females)
- Hypertension
- Type II diabetes
- Smoking habits
- History of stroke, coronary artery disease, or heart arrhythmias
- Small airways
- Receding chin
Testing for OSA (Obstructive Sleep Apnea)
If deemed necessary by a Medical Examiner, drivers will undergo testing for obstructive sleep apnea (OSA). Obstructive sleep apnea is the most common type of sleep apnea.
To test for sleep apnea, a driver may be referred to a sleep specialist to undergo a polysomnography, also known as a sleep study. These sleep studies can be performed in a laboratory setting, which is preferred method of the FMCSA, or at home. Home sleep studies require at least five hours of recorded sleep time, and its validity must be determined by a board-certified sleep specialist.
During the study, sleep specialists use the Apnea-Hypopnea Index (AHI) to determine the severity of a driver’s sleep apnea. The AHI is the number of apneas (pauses) and hypopneas (shallow respirations) recording per hour of sleep. Based on the AHI, the severity of OSA is classified as follows:
- None/Minimal: AHI < 5 per hour
- Mild: AHI ? 5, but < 15 per hour
- Moderate: AHI ? 15, but < 30 per hour
- Severe: AHI ? 30 per hour
The disqualifying level of sleep apnea is moderate to severe, as it typically interferes with safe driving. The medical examiner must qualify and determine a driver’s medical fitness for duty.
Treatment Options
The treatment options for sleep apnea can vary based on the severity of the disorders. For drivers with mild cases, they may be encouraged to lose weight, improve their diet, or invest in over-the-counter aids such as nasal strips. For moderate to severe cases, the most common treatment is utilizing a Continuous Positive Airway Pressure (CPAP) machine. CPAP machines work to keep the airway open. The device pushes filtered, pressurized air into the lungs through a mask that fits over the nose and mouth during sleeping hours.
Compliance Recommendations
To initially meet compliance standards, the driver must:
- Document PAP use for a time period no less than 30 consecutive days (minimum records requirement for initial certification), and
- Provide PAP use records that demonstrate at least 4 hours per night use on 70 percent of nights (minimum compliance standard), and
- Report no excessive sleepiness during the major wake period.
A driver may be re-certified for up to 1 year. At the yearly physical, a driver is required to bring their CPAP report to demonstrate that the condition is under control. Drivers will be re-certified for the following year if the following conditions are met:
- The driver must document PAP use for a time period no less than the number of days between the expiration of the driver’s previous medical card and the time at which they receive their medical exam (minimum records requirement – re-certification), and
- The driver’s PAP use records must demonstrate at least 4 hours per night use on 70 percent of nights (minimum compliance standard), and
- The driver does not report excessive sleepiness during the major wake period.
If a driver fails to meet compliance standards, the Medical Examiner may provide a 30-day certification to allow the driver to produce 30 days of consecutive PAP use data that meets the minimum compliance standard. After which:
- The Medical Examiner may issue a 60-day certification to allow the driver to produce 60 days of consecutive PAP use data that meets the minimum compliance standard.
- After the driver demonstrates compliance with 60 days of PAP use data, the Medical Examiner may issue a 90-day certification to allow the driver to produce 90 days of consecutive PAP use data that meets the minimum compliance standard.
- After the driver demonstrates compliance with 90 days of PAP use data, the Medical Examiner may issue a 1-year certification.
- If the driver cannot produce 30 days of consecutive PAP use data, the driver must be disqualified and cannot be re-certified until he or she is able to provide 30 days of compliant PAP use data.
Frequently Asked Questions
What if a driver declines treatment?
If a driver decides to forgo treatment or becomes non-compliant, they will be disqualified from holding a CMV license until they are treated effectively and can present a report of 30 days of compliant PAP use data.
Do drivers with a history of negative diagnosis of sleep apnea need to retest?
For a new sleep study to be required, one or more additional risk factors beyond those that required the original sleep study must be present or a 10 percent increase in weight must have been recorded. If age of 42 is the only additional risk factor that has changed, there should be a 3 year period between the prior sleep study and a newly recommended sleep study.
Should drivers discontinue routine medications for the sleep study?
All drivers should be tested while on their usual chronic medications. If there is a concern regarding one of their medications, such as a sleep aid, it should be discussed with the sleep specialist prior to testing.
What happens if my at-home sleep study is determined to be inadequate?
If the Medical Examiner in consultation with the sleep specialist determine that the at-home sleep study is not valid, then a laboratory-based sleep study must be performed.
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Sources
Pack A.I., Dinges D.F, & Maislin G. (2002). A study of prevalence of sleep apnea among commercial truck drivers (Report No. DOT-RT-02-030). Washington, DC: U.S. Department of Transportation, FMCSA.
U.S. Department of Transportation, FMCSA. (2020, April 24). FMCSA Medical Examiner Handbook. Federal Motor Carrier Safety Administration. Retrieved March 4, 2022, from https://www.fmcsa.dot.gov/advisory-committees/mrb/draft-fmcsa-medical-examiner-handbook-4-23-2020.
