The Link Between

Truck Drivers, Crashes

& Obstructive Sleep
Apnea

Tom Lamphere BS, RRT, RPFT

Executive Director, PSRC
Adjunct Instructor, Gwynedd Mercy College

Objectives
1. Define Obstructive Sleep Apnea and
review the incidence of it among the truck
driver population.

2. Review the most current NSTHA Driver

Fitness Medical Guidelines

3. Discuss the recommendations of the 2008

Expert Panel on OSA and Commercial
Motor Vehicle (CMV) driver safety.

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 Definitions
Apnea
 Interruption of normal ventilatory
exchange for at least 10 seconds or the
cessation of airflow ( at the level of the
nostrils and the mouth).

 Inspiration of less than 25% of a normal

breath.

 May also be defined as at least a 4% drop

in SaO2 when breathing stops.

Definitions
Hypopnea
 A decrease in breathing that is not as severe as an
apnea.
 Can be defined as 69% to 26% of a normal breath.

Apnea-Hypopnea Index (AHI)

 Calculated by dividing the # of apneas and
hypopneas by the number of hours of sleep. AHI
values are typically categorized as 5-15 Mild, 15-
30 Moderate, and above 30 listed as Severe.

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 Definitions
Central Sleep Apnea
 Cessation of airflow resulting from the
absence of ventilatory effort

Obstructive Sleep Apnea (OSA)

 Lack of ventilatory exchange due to
pharyngeal occlusion

Incidence / Prevalence
 According to National Institute of Health
(NIH), estimated 18 million Americans
have some type of sleep disorder (1:15
people)

 An estimated 12 million Americans have

OSA (1:22 people)

 An estimated 10 million Americans have

undiagnosed OSA (1:27 people)

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 Other Definitions

CDL: Commercial Driver License

Other Definitions

Traditional Truck Driver: Non-Traditional Truck Driver:

One who drives a truck!!! One who drives a truck!!!

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 Other Definitions

Commercial Motor Vehicle Commercial Motor Vehicle

(CMV) (CMV)

Little Known Facts…

 Of all occupations in
the U.S., workers in
trucking industry
experience the 3rd
highest fatality rate of
all worker deaths
 About 2/3 of trucker
deaths are related to
highway crashes.

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 Little Known Facts…
 In 2005, there were 4,932 fatal crashes
involving trucks and 5,212 fatalities

 In 2005, there were 137,144 nonfatal crashes

of which 59,405 had an injury to at least one
person (89,681 total injuries)

 A 2006 report by the Fed. Motor Carrier

Safety Admin. estimated the cost of each
crash involving a large truck was $91,112
while the average cost of a fatal crash was
$3,604,518.

Another Cost….
5,212 fatalities x $3,604,518 =

$18,786,747,816
(that’s almost $19 billion a year)

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 So What Does This Have
To Do With Sleep???

Incidence of OSA In Truck

Drivers…
 Multiple studies have been
completed but results vary.
 Nearly all studies indicate
a higher rate for
commercial truck drivers
than the general
population.
 Overall prevalence is
somewhere between 17% -
28%.

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 Incidence of OSA In Truck Drivers…
 There are approximately
14 million commercial drivers
licensed in the U.S.
 Approximately 2.4 to 3.9
million of these individuals are
predicted to suffer from OSA
 U.S. National Transportation
Safety Board estimates 31% of
fatal-to-the-driver commercial
truck crashes and 17% of ALL
fatal crashes are caused by
driver fatigue

What Do Truckers Think?

Not Me!

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 Bottom Line….
 Even if truckers have same prevalence as
the rest of the population (1:27)…

14,000,000 licensed CMV drivers

=
518, 500 licensed CMV drivers with OSA

How Does One Obtain A

Commercial Driver License (CDL)?
 There is a federal requirement that each state
have minimum standards for the licensing of
commercial drivers.
 Requirements include:
1. Knowledge tests
2. Skills tests
3. At least 21 years of age to driver interstate
(18 years to drive intrastate)
4. Completed Medical Examiner’s Certificate

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Medical Examiner’s Certificate
 “Department of Transportation Physical”

 Required by the Federal Motor Carrier Safety

Regulations (FMCSR)

 Includes SOME information gathering on sleep

related issues…..but not much!

Medical Examiner’s Certificate

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Interpretation of Medical Standards
 The FMCSA has published recommendations
called “Advisory Criteria” to help medical
examiners in determining whether a driver
meets the physical qualifications for
commercial driving.

 Many conditions interfere with oxygen

exchange and may result in incapacitation
including emphysema, chronic asthma,
carcinoma, tuberculosis, chronic bronchitis
and sleep apnea.

Interpretation of Medical Standards

 If the medical examiner detects a respiratory
dysfunction, that in any way is likely to
interfere with the driver's ability to safely
control and drive a commercial motor vehicle,
the driver must be referred to a specialist for
further evaluation and therapy.

 Just one problem….

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 How Do They Diagnosis Sleep
Problems???

What if Sleep Apnea is Suspected?

 “It is recommended that operators with

suspected sleep apnea (symptoms of snoring
and hypersomnolence), or with proven but
untreated sleep apnea, not be medically
qualified for commercial motor vehicle
operation until the diagnosis has been
eliminated or adequately treated.”

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 What if Sleep Apnea is Known?
 “…individuals with known OSA be allowed to
obtain certification to drive only after successful
therapy has resulted in multiple sleep latency
testing values within the normal range or repeat
sleep study during treatment that shows
resolution of apneas.”

 “.. subjects obtaining medical qualification

should agree, as a condition of continuing
qualification, that their sleep apnea therapy
continue in an uninterrupted fashion while they
maintain the operator certification.”

What About Narcolepsy?

 The guidelines recommend disqualifying a
CMV driver with a diagnosis of Narcolepsy,
regardless of treatment because of the
likelihood of excessive daytime somnolence.

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 Statistics Don’t Lie….
 Although the scope of the problem can be
argued, the fact that OSA exists in the
population of CDL holders cannot be denied.

 Fatigue is also a well known cause of highway

crashes and is estimated to be the cause of 17%
of all fatal crashes.

 What should be done to improve the statistics?

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 What IS This Report?
 A two day conference was held with a five member
expert panel, ECRI, Manila Consulting and the U.S.
Department of Transportation’s Federal Motor
Carrier Safety Administration (FMCSA) in August,
2007. The goal of the conference was to:
1. Review existing FMCSA guidelines for medical
examiners which pertain to individuals with or
suspected of having OSA.
2. Discuss available evidence pertaining to the
consequences to public safety of certifying people
with OSA.
3. Recommend changes to FMCSA guidelines deemed
necessary based on the available evidence.

Summary of Recommendations
 Guideline 1: General Guideline
1. A dx of OSA should preclude an individual
from obtaining unconditional certification to
drive a CMV for the purpose of interstate
commerce.

2. Individuals with an OSA diagnosis MAY be

certified to drive a CMV if the individual:
 Has untreated OSA with an AHI < 20 AND
 Has no daytime sleepiness OR
 Has OSA that is being effectively treated

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 Guideline 2: Immediate Disqualification
1. Certain populations should not be certified or recertified
to drive a CMV. These include individuals who:
 Report excessive sleepiness while driving OR
 Have had a crash associated with falling asleep OR
 Have an AHI that is > 20, until they are adherent to
PAP OR
 Have undergone surgery & who are pending the
findings of a 3 months post-op evaluation OR
 Have been found to be non-compliant with their tx OR
 Have a BMI or > 33 kg/m2 (pending sleep study eval)

Guideline 3: Conditional Certification

1. The following groups of individuals with OSA be
allowed to conditionally drive a CMV :
 Individuals with a BMI > 33 kg/m2 be certified for one
month pending the findings of a sleep study (pref. 1 week)
 Individuals recently diagnosed with OSA be certified for
one month during which time they will be started on
CPAP. At the end of the month, conditional certification
can be granted for 3 months if there is documented
compliance of CPAP use for the previous 2 weeks. After
3 months (with documented compliance) conditional
certification can be extended to 1 year. After 1 year, re-
evaluation and re-certification should occur and
compliance with CPAP evaluated (> 4hr/night; 70% days).

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 Guideline 4: Confirmation of Dx and/or
Stratification of Severity

1. The following groups of individuals should be

required to undergo evaluation & if necessary,
stratify severity of OSA:

 Individuals categorized as high risk for OSA

according to Berlin Questionnaire OR
 Those with BMI > 33 kg/m2 OR
 Those judged to be at risk for OSA based on
clinical evaluation

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Guideline 5: Clinical Evaluation-Identification
of Individuals w/ Undiagnosed OSA
1. The Medical Examiner’s role should include
identifying undiagnosed OSA by:
 Actively screening for OSA in all individuals who are
applying for certification for CMV
 Looking for symptoms of OSA including: Chronic
loud snoring; Witnessed apneas during sleep;
Daytime sleepiness
 Risk factors for OSA including: Advancing age; BMI
> 28 kg/m2; Small jaw; Lg neck; Small airway; Family
hx; Hx of hypertension; Type 2 diabetes;
Hypotyroidism

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Guideline 6: Method of Diagnosis & Severity

1. The preferred method of diagnosis & assessment

of disease severity is overnight polysomnography

2. Acceptable alternative methods for assessment of

risk in CMV drivers include objective recording
devices, validated against PSG that include at
least 5 hrs of measurement of:
 Oxygen saturation AND Nasal Pressure AND
sleep/wake time

Guideline 7: Treatment of OSA

1. Positive Airway Pressure (PAP) is preferred

method of therapy. Adequate PAP should be
determined by either an in-laboratory titration
study or an auto-titration system w/o in-laboratory
titration.
2. Optimal treatment efficacy ocurs with 7 hrs or
more of use during sleep. However, an acceptable
CPAP use is at least 4 hours of use per night on at
least 70% of nights.

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Guideline 8: Alternative Treatment of OSA

1. Dental appliances & surgery are considered

potential alternatives to PAP therapy.

2. There is no method of measuring compliance in

individuals treated with dental appliances.
Therefore, the use of dental appliances cannot be
considered an acceptable alternative to PAP in
individuals who require certification to drive a
CMV.

Guideline 9: Bariatric Surgery

1. Obese individuals who have moderate to severe
OSA and who undergo bariatric surgery may be
certified if:
 They are compliant with PAP OR
 Are 6 months post-surgery (allows time for wt loss)
AND
 Are cleared by their treating clinician AND
 Have a sleep exam indicating their AHI is < 10 AND
 They are no longer excessively sleepy
(Re-evaluate within 2 yrs OR if > 5% weight gain)

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Guidelines 10 - 12: Oropharyngeal or Facial
Bone Surgery or Tracheostomy
1. Individuals who have moderate to severe OSA
and who undergo either oropharyngeal or facial
bone surgery or tracheostomy may be certified if:
 They are > 1 month post surgery AND
 Are cleared by their treating clinician AND
 Have a sleep exam indicating their AHI is < 10 AND
 They are no longer excessively sleepy
**ANNUAL Recertification is required to ensure AHI <
10 & no daytime sleepiness

Guideline 13: Patient Education

1. Individuals who meet the criteria for certification
to drive a CMV:

 Patient with OSA who meet the criteria for

certification should receive education on:
 Importance of adequate sleep
 Lifestyle changes (healthy eating, wt loss, etc.)
 Smoking cessation
 Exercise
 Reduced alcohol intake

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 Guideline 13: Patient Education
 Patient with OSA who meet the criteria for
certification should receive education on:
 Importance of treatment compliance (if relevant)
 Consequences of untreated OSA including:
 Loss of certification
 Crash / Death
 Shorter survival
 Cognitive dysfunction
 Heart Disease, Reflux, Headaches
 Reduced quality of life

Are These Recommended Guidelines

REQUIRED?
 The recommended guidelines were created in an
effort to help the Medical Examiner in their
evaluation of an applicant. They are NOT
required to use them.

 ….but there is no reason not to since they

contain the most up to date information and
recommendations from experts in the field of
sleep medicine.

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 What’s Next?
 June, 2010 - “Mark R. Rosekind, Ph.D., took the
oath of office today as a Member of the National
Transportation Safety Board. Member Rosekind is
an internationally recognized fatigue expert who has
conducted research and implemented programs in
diverse settings, including all modes of
transportation, healthcare, law enforcement, elite
athlete and military groups.”
 Very likely that some sort of federal requirement for
sleep diagnostic testing will be implemented.
 Polysomnography? Cost & availability is a problem.
Portable Sleep Monitoring? Cheaper, more easily
available but accuracy is questionable.

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