Obstructive sleep apnea (OSA) has been demonstrated to significantly increase safety and health risks. Medical research has shown that OSA is a significant cause of motor vehicle crashes (resulting in a two- to sevenfold increased risk) and increases the possibility of an individual developing significant health problems such as hypertension, stroke, ischemic heart disease, and mood disorders. Studies suggest that commercial motor vehicle (CMV) operators have a higher prevalence of OSA than the general population. U.S. federal statute requires CMV drivers to undergo medical qualification examinations at least every 2 years—the federal medical standard that deals with OSA is section 49 CFR 391.41(b)(5) of the Federal Motor Carrier Safety Regulations. This section states that the driver 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 safely.”
Recently, the Federal Motor Carrier Safety Administration (FMCSA) changed the medical examination reporting form to include a question that asks a driver whether he or she has a sleep disorder, pauses in breathing while asleep, daytime sleepiness, or loud snoring. So far, the only guidance available from FMCSA on the diagnosis and treatment of OSA in CMV drivers was issued in 1991, the result of a report from a conference sponsored by the Federal Highway Administration. However, in the past 15 years, there has been a tremendous increase in the scientific and clinical knowledge regarding the diagnosis and treatment of OSA. This new information is not reflected in the current FMCSA guidance and has created challenging and, at times, conflicting approaches to managing OSA in commercial drivers.
Because public safety has always been of the highest priority when determining acceptable risk in relation to medical conditions in CMV drivers (this differs significantly from the usual approach in clinical medicine), it is well accepted that when assessing risk of accidents due to a medical condition, CMV drivers are held to a higher medical standard than the general population.
Given the public safety risks associated with OSA, its prevalence in the CMV driver population, and the fact that the guidance on OSA diagnosis and management is 15 years old, the American College of Chest Physicians, the American College of Occupational and Environmental Medicine, and the National Sleep Foundation convened a Task Force to address this important safety and medical risk in CMV drivers. The Task Force pursued the following activities: 1) review the existing scientific literature related to the diagnosis and management of OSA; 2) review the medical standards and guidelines related to OSA from U.S. Department of Transportation agencies and equivalent international groups; 3) review other relevant reports and recommendations from the National Transportation Safety Board, FMCSA, and others; 4) draft a preliminary document of findings; 5) develop recommendations related to screening, diagnosis, treatment, return to work, and follow up; and 6) address other relevant topics such as compliance, duration of certification, and research needs.
This report of the Task Force provides the detailed findings of the extensive reviews conducted of documents from diverse resources on many relevant topics. The detailed reviews address the following areas: 1) definition of sleep apnea; 2) current regulations, recommendations, and guidelines; 3) identification of patients at risk for sleep apnea and diagnosis; 4) objective assessment of sleepiness and performance; 5) identification of CMV drivers with sleep apnea who are at high risk for crashes; 6) management of sleep apnea in the CMV driver; 7) practical considerations; and 8) additional research questions. Findings formed the foundation for consensus recommendations regarding the diagnosis and management of OSA in commercial drivers. The information presented in the eight sections are not summarized here, but rather provided in detail with references in the report. The recommendation categories focus on the following:
- Compliance and efficacy;
- Return to work after treatment for OSA; and
- Follow up.
The tables included in this article provide an overview of these recommendations. However, the Task Force recommends that the commercial driver medical examiner (CDME) evaluate each driver individually and make a judgment about his or her fitness for duty based on specific criteria, including those listed in the tables in this article. These criteria cannot predict every situation faced by the examiner, and the final judgment belongs to the CDME. Additional testing is optional, based on clinical judgment, to document absence of excessive somnolence.