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

About the author
Deborah Lockridge

Deborah Lockridge

Editor and Associate Publisher

Reporting on trucking since 1990, Deborah is known for her award-winning magazine editorials and in-depth features on diverse issues, from the driver shortage to maintenance to rapidly changing technology.

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