The recommendations, proffered by the American College of Chest Physicians (ACCP), the American College of Occupational and Environmental Medicine (ACOEM) and the National Sleep Foundation, include a more thorough screening and evaluation process; modified criteria for returning to work after treatment; and providing follow-up and recertification recommendations.
The recommendations are being published as a supplement to the September issue of the Journal of Occupational and Environmental Medicine.
While sleepiness and inattention which are common symptoms of obstructive sleep apnea (OSA) are believed to contribute to many commercial vehicle crashes each year, current screening and treatment procedures for commercial drivers "are ambiguous and not reflective of the latest advancements in the diagnosis and management of OSA," according to Nancy Collop, M.D., FCCP, of ACCP's Sleep Institute.
"Conflicting approaches to screening and management of OSA have left drivers undiagnosed, which puts the driver and general public at risk," Collop said. "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 [commercial motor vehicle] drivers who suffer from this serious condition."
Recommendations Based on Latest Research
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 states 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."
The new recommendations are based on an extensive review of the latest sleep apnea research and existing medical guidelines related to OSA from Department of Transportation agencies, according to the task force.
The 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, according to the task force.
Sleep experts advise that the diagnosis and severity of sleep apnea be established using the apnea-hypopnea index, the task force adds.
Screening Process Should Be Based on Severity
The joint task force 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 3 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).
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 co-morbidities.
For those diagnosed with sleep apnea, experts strongly recommend using positive airway pressure for a minimum of 4 hours within a 24-hour period via a machine that is able to measure time on pressure. Current guidelines do not specify minimum use of positive airway pressure.
"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. In addition, outdated guidance from FMCSA has left medical examiners in conflict with current sleep guidelines," said ACOEM's Natalie Hartenbaum, M.D., MPH, FACOEM. "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."
Task Force Advocates Shorter Return-to-Work Time
Although the task force recommends more thorough screening, its recommendations suggest a shorter return-to-work time.
Under current FMCSA guidelines, commercial motor vehicle operators who are being treated for sleep apnea can return to work a minimum of 1 month after initiation of treatment. The task force's recommendations include reducing return-to-work time to 2 weeks after treatment initiation in certain situations.
Reevaluation after 4 weeks to ensure compliance with therapy and improvement in symptoms also is recommended.
"Sleep apnea is a highly treatable disorder," said Barbara Phillips, M.D., FCCP, of the National Sleep Foundation. "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."