All That's Trucking

Sleep Apnea in Truckers Continues to Confuse

Are doctors going overboard in sending drivers for expensive sleep studies?

September 25, 2015

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I've known people, including truckers, who were diagnosed with sleep apnea and reported feeling an amazing, life-changing difference after they started using a C-PAP machine at night.

That wasn't the case for Joey Romero, an owner-operator in Fargo, ND. He finds the mask on his AutoPAP machine "highly uncomfortable" and says he doesn't feel any different, according to Forum News Service.

The story says local truckers have been far more likely to be sent for sleep testing following last year's implementation of the National Medical Examiner Registry.

A North Dakota Motor Carriers representative said he believes many of these doctors are recommending the expensive sleep tests (which are not always covered by insurance) based solely on the driver's neck size.

"A number of factors increase the likelihood of someone having sleep apnea," not just neck size, Arik Spencer, executive vice president of the association, was quoted as saying in the article. "Unfortunately, I think a lot of clinics are using the training to try to generate additional profit."

A large neck size and body mass index do make one more likely to have sleep apnea, but they should not be the only criteria. Rather, they should be an indication for doctors to delve a little deeper to see if patients should be sent for a sleep study.

At the moment, however, there's no federal law or regulation stating that.

About sleep apnea

If you're not familiar with sleep apnea, the Greek word "apnea" literally means "without breath." In obstructive sleep apnea, the most common type, the sleeping patient's tongue falls back against his or her soft palate, and the soft palate and uvula fall back against the back of the throat, effectively closing the airway. When the sleeper expands the chest to inhale, no air enters the lungs.

People with untreated sleep apnea stop breathing repeatedly during their sleep, sometimes hundreds of times during the night and often for a minute or longer. In most cases the sleeper is unaware of these breath stoppages because they don't trigger a full awakening. But they do keep you from getting the restful sleep you need.

The National Heart, Lung and Blood Institute (part of the government's National Institute of Health) says doctors diagnosing sleep apnea "will ask you questions about how you sleep and how you function during the day."

For instance, a common sign of sleep apnea is fighting sleepiness during the day, at work, or while driving. You may find yourself rapidly falling asleep during the quiet moments of the day when you're not active.

"Your doctor also will want to know how loudly and often you snore or make gasping or choking sounds during sleep. Often you're not aware of such symptoms and must ask a family member or bed partner to report them.

"Your doctor will check your mouth, nose, and throat for extra or large tissues... Adults who have sleep apnea may have an enlarged uvula (U-vu-luh) or soft palate. The uvula is the tissue that hangs from the middle of the back of your mouth. The soft palate is the roof of your mouth in the back of your throat."

Others signs and symptoms of sleep apnea include:

  • Morning headaches
  • Memory or learning problems and not being able to concentrate
  • Feeling irritable, depressed, or having mood swings or personality changes
  • Waking up frequently to urinate
  • Dry mouth or sore throat when you wake up

Confusion over rules and guidelines

In 2000, and again in 2008 and 2012, the medical review board (MRB) and medical expert panel made recommendations to the Federal Motor Carrier Safety Administration (FMCSA) concerning screening, diagnosis, treatment, and monitoring of commercial drivers for obstructive sleep apnea (OSA). These guidelines have been inconsistently applied across the industry by and among companies, owner-operators, drivers, and DOT medical examiners—resulting in uncertainty, confusion, and the perception of unfairness. - See more at: http://www.sleepreviewmag.com/2015/02/analysis-fmcsa-bulletin/#sthash.vw6Z50ab.dpuf

In 2000, 2008 and 2012, the Medical Review Board made recommendations to the FMCSA about screening, diagnosis, treatment and monitoring for commercial drivers with obstructive sleep apnea. As Edward D. Michaelson wrote earlier this year in Sleep Review, these guidelines have been inconsistently applied. 

In 2013, in response to industry concerns about the confusion over sleep apnea diagnosis and commercial driver medical certification, a law was passed requiring the FMCSA to follow a formal rulemaking process allowing industry comment, rather than allowing guidance to become a "de facto" regulation. (FMCSA said it would propose such a rule, but there's no sign of it yet.)

In 2014 came the National Registry of Certified Medical Examiners.

Some training facilities were skirting the law by telling examiners to test for sleep apnea.

But all that didn't solve the problem. Last fall, due to trucking industry complaints, two U.S. representatives stated in a letter to the FMCSA that some training facilities were skirting the law by telling examiners to test for sleep apnea.

Earlier this year, FMCSA issued a bulletin on sleep apnea to medical examiners and training organizations. The stated purpose is to "remind healthcare professionals on FMCSA's National Registry of Certified Medical Examiners of the current physical qualifications standard and advisory criteria concerning the respiratory system, specifically how the requirements apply to drivers that may have obstructive sleep apnea."

The document emphasizes that "it is clear that FMCSA has considered OSA a respiratory dysfunction that interferes with oxygen exchange. And the agency recommends that, if a medical examiner believes the driver's respiratory condition is in any way likely to interfere with the driver's ability to safely control and drive a commercial motor vehicle, the driver should be referred to a specialist for further evaluation and therapy."

The bulletin says, "Medical examiners may exercise their medical judgment and expertise in determining whether a driver exhibits risk factors for having OSA and in determining whether additional information is needed before making a decision whether to issue the driver a medical certificate and the duration of that medical certification."

It specifically says its "advisory criteria do not include screening guidelines," but it "encourages medical examiners to consider ... common OSA symptoms such as loud snoring, witnessed apneas, or sleepiness during the major wake periods, as well as risk factors and consider multiple risk factors such as body mass index (BMI), neck size, involvement in a single-vehicle crash, etc."

So while the FMCSA "encourages" doctors to consider these things, ultimately it's totally up to the examiner's discretion. From my reading of the bulletin, apparently if he or she believes the best practice is to automatically send drivers with a certain BMI or neck size to get a sleep test, that's perfectly legitimate.

More schools for training and testing examiners have been established recently. Due to trucking industry complaints, 2 US representatives stated in a letter to the FMCSA that some training facilities are skirting the law by telling examiners to test for sleep apnea. - See more at: http://www.sleepreviewmag.com/2015/02/analysis-fmcsa-bulletin/#sthash.vw6Z50ab.dpuf

Yes, sleep apnea is a serious condition. Daytime sleepiness obviously is a danger for drivers behind the wheel. And from a personal standpoint, sleep apnea puts you at higher risk for heart problems, high blood pressure and stroke, and the lack of oxygen can cause cognitive problems. If you have these symptoms and your doctor hasn't talked to you about sleep apnea, bring it up at your next exam. The National Heart, Lung, and Blood Institute suggests keeping a sleep diary for a couple of weeks beforehand and bringing it to your appointment. (You can find a sample diary by downloading the Institute's Guide to Health Sleep.)

But if your doctor is sending drivers for expensive sleep testing based solely on neck size or BMI – especially if that practice has any ownership in a sleep-testing clinic – I would look for a different physician.

For more information:

American Sleep Apnea Association

National Heart, Lung, and Blood Institute

National Sleep Foundation

FMCSA Medical Requirements FAQ

Comments

  1. 1. Terry [ December 18, 2015 @ 06:14AM ]

    The trucking requirements have, and are, so regulated most firms are reporting a major shortage in finding CDL Drivers.
    This is a great example of the federal government being out of control. I've been in the safety profession for over 40 years with 13 years in federal safety enforcement and i've never seen anything like this. We currently have clinics where a driver will just walk in the door and the first thing coming out of the doctor's mouth is "you must have sleep apnea". The doctor then sends them off for an expensive sleep apnea evalution that involves overnight observation in many cases. Clinics and doctors are finding this to be an easy money grab using another government regulation as the reason.
    Government workers sitting on their rear in an office creating regulations and policy to justify their existence is typical of our government. If they stop creating reasons for more and more regulations their existence would be challenged and their high paying job would be put in question.
    DOT and the FMCSA are out of control as is the EPA and someone had better take control and back it off.
    I need to comply and enforce OSHA, MSHA, FRA, and EPA rules and regulations for my employer on a daily basis and the complexity and the burden for an employer is so massive I have no idea why they would want to even be in business.

  2. 2. Reg [ December 18, 2015 @ 04:46PM ]

    I feel that I am a victim of supposed medical professionals who to my knowledge have no expertise in sleep apnea. If I have to prove my abilities, shouldn't they prove their qualifications first. Why are truckers singled out for these types of scams? Maybe these rule makers should learn about being a driver before they try to regulate drivers.

  3. 3. Raymond [ May 11, 2016 @ 07:42PM ]

    I have been a little up on my weight these past few years. I couldn't tell you if my breathing stops when I sleep or not. My ex wife, and my girlfriend now has told me, I do not snore, nor make any kind of noise (other than mumbling in my sleep every once in a while).

    When out on the road, I sleep like a bump on a log, and am never tired when driving, and I am always alert, checking my mirrors quite frequently, amd scanning the road ahead of me.

    So do I think sleep apnea is the cause for all this BS the Fed's are talking about? In my honest opinion, NO....

    Here's what I think the issues are:

    1. Drivers who go to off duty/sleeper berth, but stay up all night watching tv, playing games, or hanging out inside truck stops, and not getting the sleep they need.

    2. Using cellphones/texting, get into a crash, and claim they dozed off.

    3. Just not paying attention, or forget they are driving a truck.

    4. Falsifying their paper logs, and driving 18 or 20 hours a day.

    There are many other reasons why some drivers don't get the sleep they need.

    But I guess the FMCSA thinks they know how it is out here. So now, I can't drive, because I can't afford the $4000.00 a night sleep apnea test. Which I was told I may have to go back two or three times for testing, at $4000.00 a pop.

    If the FMCSA wants me to have that test, then they need to pay for it, not me.

    Guess I'll be making a living somewhere else.

  4. 4. Jose R Cora [ June 24, 2016 @ 07:01PM ]

    I went to get my medical certification and I was told that because my BMI and size 17 neck and #3 on my palate size I has to do a sleep study. But I think is just the Physical assistance that saw me .I think he is not qualify to make that call.

  5. 5. Roland [ July 06, 2016 @ 04:02PM ]

    I've just been hit with this stupidity and two of the three things I can't control. There are eight criteria according to my doctor including over the age of 50 and being a male neither of which I can control and since my neck was big well I get to do is sleep study test.

    Every company I have seen that allows you to home study test which runs about $200 to $250 all sell the CPAP equipment so how biased do you think they're going to be?

    After doing a bit of research I have found a company called Sleep Services that offers these home tests at $249.

    After a discussion with the gentleman on the phone I found out that they are the division of a very large Fleet Services Company that offers all kinds of services including drug testing for big fleets.

    Lots of fleets started to ask about sleep testing so they set up a separate division that does these tests they do not I repeat do not sell any kind of CPAP or therapy equipment and their doctors are paid contract employees so they are not biased when it comes to reading the results they are also dot compliant.

    The doctor I went to for my physical probably won't be happy because it's not one of the people that she recommended that I get the test from but looking them up they all sell the equipment at much greater markup then they should be I know because my brother has to use a CPAP and he bought a very good machine for $600.

    All of these companies sell the machines for $1,500 or more and they are the same bloody machines my brother paid $600 for.

    This is now the truck driver equivalent of Autism or ADHD..... suddenly everybody has it.

  6. 6. George Meredith MD [ August 15, 2016 @ 09:38AM ]

    On Improving Obstructive Sleep Apnea Surgery

    Understanding why so many otolaryngologists and other “sleep apnea doctors” report such low success rates for the traditional UPPP surgery. And understanding why so many otolaryngologists, in frustration, just throw up their hands and recommend nighttime breathing machines (CPAP) rather than corrective upper airway surgery for obstructive sleep apnea. Or, not recognizing the significant morbidity and the, not so rare, mortality rate in orthognathic (major jaw) surgery cases, these otolaryngologists and sleep apnea doctors, simply ship these patients off to some (distant) medical center like Palo Alto for extensive craniofacial surgical answers to their OSA. Obstructive Sleep Apnea surgery that could be done, in most cases, simpler, much less expensively, much more easily and much more safely, on a local level.

    Remembering that just 54 percent, of the really advanced adult obstructive sleep apnea (OSA) cases, will be able to use the CPAP, long term (5years).

    In truth, simply by keeping the soft palate trim conservative, and by doing a trim of the intranasal sidewall structures (PRIT), why the success rate for OSA surgery can be raised from 25% up to around 85%.....and the postoperative morbidity can be greatly reduced by avoiding the adult tonsillectomy (or in cases of marked tonsillar hypertrophy, doing a unilateral tonsillectomy) and by conservatively modifying extensive palatal surgery….why with these simple modifications, surgery for OSA can save millions of patients the long term misery of decades of CPAP use.
    To learn more about this, log on to the Amazon/Kindle eBook “On Improving Obstructive Sleep Apnea Surgery” by George Meredith MD. First 50 pages are free!

    George Meredith MD
    Virginia Beach

 

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All That's Trucking blog is just that – the editor's take on anything and everything related to trucking, with the help of guest posts from other HDT editors. Author Deborah Lockridge's career as an award-winning trucking journalist started in 1990.

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