As the National Transportation Safety Board cites sleep apnea as a factor in New York City-area train crashes, the need for sleep apnea testing and treatment regulations will once again come to the forefront. The NTSB has been advocating for measures to reduce fatigue-related accidents in the transportation industry for years.
Generally focused on trucking, high-profile rail accidents have the NTSB broadening that focus to include rail, aviation and marine. The safety agency’s yearly most-wanted list has mentioned fatigue-related accident reduction for the past several years. The 2017-2018 list states: “... fatigued drivers ... regularly cause accidents.”
The NTSB advocates for finding and treating fatigue-related medical issues such as obstructive sleep apnea — a well-known and scientifically documented medical problem — that increases the risk for a crash. It states that fatigue can be just as deadly in trucking as alcohol and drug impairment.
The Federal Motor Carrier Safety Administration and the Federal Railroad Administration published an advance notice of proposed rulemaking in March 2016, titled “Evaluation of Safety Sensitive Personnel for Moderate-to-Severe Obstructive Sleep Apnea.” This was directed at individuals in safety-sensitive positions in trucking and other transportation areas. After numerous public hearings, open comment periods, meetings and additional scientific data, the ANPRM was withdrawn on Aug. 8.
The decision to withdraw is baffling as the FMCSA made it clear that OSA remains a serious concern for trucking and that it intends to update the Medical Examiners Handbook to reflect the knowledge gained over the past 10-plus years. Drivers will continue to be referred for sleep tests but without an official rule, the industry remains confused on the subject.
Here are some observations on OSA and transportation from my 35 years of experience in the field of sleep medicine, including many years working with the transportation industry. These address several issues and misunderstandings that have been circulating.
1. CMV drivers are different. True. These individuals are professionals with special training, job demands, pay structure and scheduling demands. But CMV drivers need to breathe during sleep the same as everyone else. No amount of training and experience can negate the effects of untreated OSA in anyone. Ignoring the issue does a huge disservice to these individuals’ health.
2. The current system is adequate. Not entirely true. Some improvements have been made in initial evaluation, driven by changes in CME standards. However, the process for diagnosis and treatment delivery often is still all over the board. Standards of care remain variable regarding in-lab sleep studies versus home sleep apnea testing, the type of positive airway pressure (PAP) therapy used, the use of maintenance of wakefulness testing and compliance monitoring. In addition, the traditional health insurance approach does not often understand the needs of truckers.
3. Insurance doesn’t cover testing and treatment. Mostly false. While insurance generally covers sleep apnea testing and treatment, drivers might not have access to resources that provide these services in a cost-effective and timely manner. Most people need help navigating co-pays and deductibles but drivers may also need to deal with scheduling and geographical logistics.
4. OSA is not a problem. False. The body of scientific data is overwhelming. But it is just as important to consider the personal perspective. Most people with undiagnosed OSA don’t know they have it, as most do not wake up gasping for breath. OSA can render your sleep nonrestorative and make you profoundly sleepy, but most people are poor historians of their sleep quality and their degree of impaired alertness.
5. The current system produces too many false positives. This statement is difficult to evaluate. There may be an isolated false positive. I encourage people to look for AASM-accredited sleep centers and board-certified sleep specialists to make sure they are getting the best possible care.
6. Sleep medicine is “voodoo medicine.” False. Sleep medicine is an AMA-recognized subspecialty with providers across the United States. Because it is relatively new, it may be the case that some physicians were not exposed to it during their training.
7. Most people cannot wear PAP therapy. False. There is no right therapy for 100% of people who have OSA. However, with the right education and ongoing support, 96% to 97% of drivers can be successful. I have seen these results consistently year after year.
8. We need more studies. False. When the Department of Transportation withdrew the proposed rule for OSA, it said that there wasn’t enough information to proceed. The data from scientific studies, the NTSB, the affected public and professional organizations are overwhelming. With this information amassed over many years, it’s clear that we need more action, not studies.
SleepSafe Drivers wholeheartedly supports the legislation proposed by Sens. Chuck Schumer and Cory Booker that would require DOT to test train operators and commercial bus and truck drivers for sleep apnea. We need a rule that is fair and enhances safety but does not unnecessarily keep people from earning a living. These goals are not mutually exclusive; they are doable — in fact, we do them every day.
D. Alan Lankford, Ph.D., FAASM, is the chief science officer at SleepSafe Drivers, an organization that provides transportation and high-risk occupations a cost-effective program for sleep apnea and fatigue management. Lankford participated in FMCSA’s Medical Review Board/Motor Carrier Safety Advisory committee meetings as the suggested recommendations and guidelines were developed for OSA.