Sleep Apnea and Trucking: On the Road to Health and Safety

Sleep Apnea and Trucking: On the Road to Health and Safety

The American Sleep Apnea Association (ASAA) organized and presented the Sleep Apnea Trucking Conference 2010 (SATC 2010) this May in Baltimore, MD. The conference was cosponsored by the Federal Motor Carrier Safety Administration (FMCSA) and American Trucking Associations (ATA). This day-long program brought together major stakeholders concerned with public policy issues for obstructive sleep apnea (OSA) and the commercial motor vehicle (CMV) driver in an effort to increase awareness, present current programs and research in development, and stimulate forward thinking to work together on this public health issue.

The speakers, and over 400 audience members, included those from governmental agencies (regulatory and advisory), professional truckers (Owner Operator Independent Drivers Association [OOIDA] and major trucking firms), sleep apnea management programs, and the medical community (sleep and occupational medicine). The American College of Chest Physicians (ACCP) was one of many additional supporters. The program was preceded by an evening reception with welcome by Edward Grandi, Executive Director of ASAA, and Mark Berger of Precision Pulmonary Diagnostics. Speakers included Anne Ferro, FMCSA Administrator; Christopher Hart, Vice-Chairman of the National Transportation Safety Board (NTSB); and Jeffrey Burns, Esq., who serves several organizations for improved highway safety, including the Truck Safety Coalition.

Meeting Highlights
Dr Mary Gunnels (FMCSA Office of Medical Programs) emphasized the large trucking population (400,040 medical examinations monthly) targeted by future regulations. There is increasing awareness of the relationship of obesity and general health concerns, as well as the increase for the risk for OSA. Sleep apnea and sleep disorders are sources for fatigue, and fatigue has been identified as a cause of motor vehicle crashes. The upcoming national registry for medical examiners will include new language and education about sleep apnea.

Dr Martin Walker (FMCSA Chief of Research) reviewed data published May 2002 on the prevalence of OSA in CMV drivers of 28% (17.6% mild, 5.8% moderate, 4.7% severe), with increases noted with age and body mass index (BMI), as well as 6 or fewer hours of sleep. Severe OSA is associated with increased risk of severe crashes in CMV drivers.

Dr Walker questioned the current status of OSA diagnosis and treatment availability and adherence, and he called for better screening tools, more research on OSA with crash risk, low cost validated testing, determinants of compliance, and better outreach regarding health and safety issues. He presented information about the campaign, “Get on the Road to Better Health: Recognizing the Dangers of Sleep Apnea,” by the National Sleep Foundation and FMCSA. He discussed the FMCSA request for proposals for a Commercial Driver Individual Differences Study (CDIDS), studying 21,000 CMV drivers to identify 3,000 cases (crash within the last 3 yr) and 3,000 controls assessing driver factors with high risk for crashes, and a substudy of 1,200 undiagnosed drivers at risk for OSA to undergo testing and treatment to develop a cost effective approach and evaluate linkage to crash risk.

Public health issues, linked to the Department of Health and Human Services Healthy People 2020 (www.healthypeople.gov/HP2020), were discussed by Dr Karl Sieber (National Institute for Occupational Safety and Health - NIOSH). He indicated that the increased evaluation for OSA appears to be associated with decreased crashes and stressed importance of monitoring for insufficient sleep. He reviewed a cross-sectional study surveying long haul truck drivers, conducted at 50 truck stops nationally, including healthrelated scales, such as the Trucker Strain Monitor scale (De Croon et al. Int Arch Environ Health. 2001;74[6]: 429-436), a 10-item scale assessing workrelated fatigue and sleeping problems. He invited interested members to attend the CD health and wellness conference November 8-10, 2010 (www.TRB.org/Conferences/HealthWellness2010.aspx).

Dr Larry Epstein (Sleep Health Centers Chief Medical Officer) presented the medical overview of OSA symptoms, health risk, diagnosis, and treatment. This raised questions regarding treatment options and compliance from the audience. A common concern, and potential limitation, is the requirement for objective documentation of compliance. At this time, the only OSA treatment that can be objectively monitored is CPAP. Several dental professionals in the audience raised questions about oral appliance treatment. While potentially effective in many people with OSA, the lack of monitoring capability precludes this option for the commercial trucker.

The medicolegal issues, presented by R. Clay Porter, Esq, comprise a large area of concern for truckers, businesses, health-care providers, and government. Open discussions regarding cases of traffic accidents in the trucking industry and general population focused on liability. Questions that were raised about how to determine when a driver is unsafe to drive addressed the differences in the medical guidelines vs legal requirements in the current language. Issues regarding fatigue risks, inaccuracies in documentation (logs, disclosed medications), and the weight of safety and risk on the driver were discussed. At this time, Department of Transporation disqualification takes priority over guidelines provided by the American Disabilities Act.

Dr Natalie Hartenbaum (Occumedix) brought out one of the group’s concerns regarding screening guides. The community has debated whether a BMI greater than 30 (screen most) vs BMI greater than 33 (screen highest risk) is the better parameter. She also highlighted that medical examiners must consider OSA when evaluating these individuals; that it is not in the driver’s best interest, or the public’s safety, to look the other way. She, too, discussed CPAP therapy as the current gold standard due to the need for objective compliance. Still unclear is the role of the sleep vs occupational medical provider to sign off on the medical certificate. The “wait period” of 1 month for treatment response raised numerous concerns about patient safety against job/employment security, while Dr Hartenbaum reminded the audience that this was no different than the medical recommendations for the newly diagnosed diabetic or person with coronary artery disease.

Bob Stanton, “just a trucker with sleep apnea” and co-founder of the Truckers with a Cause, a virtual AWAKE group, offered the view as a professional driver and one diagnosed with sleep apnea. While fully supportive of the importance of diagnosis and treatment, he raised a number of unique challenges for even the compliant trucker using CPAP on the road and in the cab of the truck. He also shared his concerns about the risk to livelihood for those without large industry support during initial diagnosis and treatment.

Several representatives from various sleep apnea management programs outlined methods of enhancing availability for diagnosis and treatment for those living on the road. The program concluded with speakers for Schneider National (Don Osterberg) and JB Hunt (Debra Plumlee) who have successfully incorporated such programs into their companies. Raphael Warshaw spoke on behalf of OOIDA and presented the particular challenges facing the individual owner-operator trucker who may not have the safety net of industry support for costs of diagnosis, treatment, and risk to livelihood of out of service time following the diagnosis.

In summary, the association of OSA, fatigue, and crash risk is largely accepted, but its magnitude within the trucking industry and the solution to the problem remain challenged. The Sleep Apnea and Trucking Conference raised many issues regarding sleep and appropriate health care for truck drivers. Who is responsible for clarifying the rules for identification of at-risk truckers? Who will cover the costs of screening programs, diagnosis, and related treatment? Who is responsible for monitoring compliance and ultimate medical clearance? As truck drivers are mobile and can be traveling for weeks at a time, there are unique challenges with access to testing and treatment facilities. Other acknowledged concerns include limited treatment options with CPAP as the only acceptable noninvasive therapy, documentation of adherence, and guidelines on how much adherence is adequate and the relationship of treatment to improved fatigue and accident risk reduction. How do all of these issues affect the industry-employed vs independent owner-operator trucker? Besides the public health and safety risk issues, there remain individual concerns regarding employment risk. Unfortunately, many of the logistic questions seemed to override the concern for the individual’s health and safety.

While there were no major decisions reached, there was general consensus that more dialogue is needed. While the regulatory bodies plan a continued search for objective data for future decision making, there was no response to the audience concerns for current definitive language. The audience was promised a new regulatory document in the making, with a call for better guidelines, more definitive statements, and a clearer path to diagnosis and treatment.

Many voiced the need to “do this again,” focusing on sleep-related health of the professional driver (trucker, bus driver, and others with a commercial drivers license). However, with a majority of Americans getting inadequate sleep, drowsy driving issues extend far greater than just sleep apnea in the professional driver, and future policies will hopefully reflect these high-risk health and safety issues. Additional information and links on this topic are available at the official SATC 2010 Web site, www.satc2010.org.

Dr Rochelle Goldberg, FCCP
Arizona Regional Medical Director
REM Medical, a Sleep HeathCenters® Company,
Phoenix, AZ
and
Dr Laura Herpel, FCCP
Assistant Professor of Medicine
Director, MUSC Sleep Center
Medical University of South Carolina
Charleston, SC