31
AASMMembershipSectionsNewsletter
■
Issue #5
ObstructiveSleepApneaand
theFederalMotorCarrierSafety
AdministrationCommercial
DriverExamination
KatheG.Henke, PhD
TheFederalMotorCarrier Safety
Administration (FMCSA) develops
guidelines and rules for thedriver
with excessivedaytime sleepiness,
hypersomnolence andobstructive sleep
apnea.The recommendations discussed
in this article arebasedon those from
theMedical Expert Panel and theFederal
MotorCarrier SafetyAdvisoryCommittee.
Medical examiners are still bound touse
“best practices”when examining adriver.
Best practices are those recommendedby
these committees and are the standardof
care at this time.
TheFMCSAhas implemented anew
examiner certificationprocess.This consists
of a class ondriver certification issues,
followedby a certification examination.
As ofMay2014, only thosedoctorswho
havepassed the certification exam and
been listed in theNational Registryof
CertifiedMedical Examinersmay legally
performDepartment ofTransportation
examinations.This examiner cut-offdate
hasnothing todowith theObstructive
SleepApnea (OSA) guidelines,which are
currently active and areoutlinedbelow.
More informationmaybe found in
The
Medical Examiner’sHandbook
, published
by theFMCSA. It canbe foundon their
website
here:
mehandbook/part_4_guide_ep.aspx#con-
guide.
According to theFMCSA, drivers should
be evaluated for symptoms ofOSA such
as snoring,witnessed apnea and sleepiness
during thedaytime. Risk factors forOSA
may include small or recessed jaw; small
airway; neck size greater thanor equal
to17 inches in themaleor 15.5 inches in
the female; hypertension; type II diabetes;
hypothyroidism; BMI greater than28;
aged42or greater; familyhistory;maleor
postmenopausal female; and single-vehicle
crash.
Recommendedmethods of diagnosis
include in-laboratorypolysomnography,
at-homepolysomnographyor anFDA-
approved ambulatory testingdevice that
ensures chainof custody.Thedriver should
be testedwhileusinghis or her chronic
medications.Ahome sleep studymay
underestimate the apnea-hypopnea index
(AHI)when compared to an in-laboratory
sleep study if thehome studydoesnot
measure total sleep time. If the clinician
believes theAHI is greater than the level
reportedby thehome study, then the
clinician should consider recommending an
in-laboratory sleep study.
OSAdiagnosis precludes unconditional
certification; however, adriverwithOSA
maybe conditionally certified if thedriver
has untreatedOSAwith anAHI of less
thanor equal to20 and thedriver does
not admit to excessive sleepiness during
theday, or if thedriver’sOSA is being
effectively treated. For driverswith anAHI
of greater than20, orwith excessivedaytime
sleepiness andAHI less thanor equal to
20, effectivepositive airwaypressure (PAP)
therapy shouldbe established through
either titrationduring in-laboratory
polysomnographyor through at home auto-
titratingPAPmachines.Thewaitingperiod
is onemonth after initiationof PAP therapy.
A60-day conditional certification
depends on successful and compliant
therapyduring that one-monthwaiting
period.Minimal acceptable compliance
withPAP treatment consists of at least four
hours per dayon70%of days. If adriver
being treateddemonstrates compliance
within this 60-day conditional certification
period, hemay receive an additional 90-day
conditional certification.After 90days,
if thedriver is still compliant, hemaybe
certified for thebalanceof the year from
thedateof his exam.Drivers being treated
for sleep apnea should remain symptom-
free and agree to continueuninterrupted
therapy andundergoyearlyobjective
testing either throughmonitoringof the
PAPmachine’s recordeddata,multiple
sleep latency testingormaintenanceof
wakefulness testing.AdriverwithOSA
diagnosismaybe recertified annuallybased
ondemonstrated continued compliance
with treatment.
Conditional certification is also
considered for thedriverwhohas
undergone surgery forOSA and is
awaitingpostop sleep-test findings.
Oropharyngeal surgery, facial bone surgery
and tracheostomymaybe considered for
treatment of somedrivers.Adrivermay
be certified if threemonths have elapsed
since surgery, andheor shedoesnot report
excessivedaytime sleepiness.A repeat sleep
study shouldbe considered to test for the
presenceof ongoing sleep apnea.This driver
will need annual recertification.There is
limiteddata regarding compliance and
long-termoutcomeswithdental appliances
and these technologies arenot approved as
qualifying therapy at this time.
Conditional certification is also
considered for thedriverwith aBMI greater
thanor equal to35who is awaiting a sleep
study for suspected sleep apnea.Thiswill
likelybe applicable to a largeproportion
of drivers.Adrivermaybe conditionally
certified for 60days pending a sleep study.
Persistent or chronic sleepdisorders
causing excessivedaytime sleepiness are
disqualifying.Driver-disqualifying sleep-
related conditions includeuntreated
symptomaticobstructive sleep apnea;
primary alveolar hypoventilation syndrome;
narcolepsy; idiopathic central nervous
systemhypersomnolence; and restless leg
syndrome (RLS) associatedwith excessive
daytime sleepiness.Adriverwith excessive
daytime somnolence shouldbe temporarily
disqualifieduntil the above conditions are
ruledout byobjective testing. It should
