Awake at the Wheel: Importance of Sleep Apnea Testing in Transportation

About ten percent of the US population has sleep apnea. That number jumps to thirty percent when you examine professional truck drivers. It is of paramount importance that truck drivers are being properly screened by their medical examiner, accurately tested, and are compliant with CPAP treatment if diagnosed.

By John Varela, RPSGT, Vice President of Sleep Medicine, WorkSTEPS

According to the American Trucking Association, there are approximately 3.5 million professional truck drivers in the U.S. We see them on the road every day, operating 18-wheelers for nearly double a typical, eight-hour workday. The average passenger vehicle weighs 4,000 pounds while a fully loaded “big rig” can weigh up to 80,000 pounds. Imagine if one of those drivers falls asleep at the wheel; the events that follow could be catastrophic. What processes are in place to ensure such situations are avoided?

About ten percent of the US population has sleep apnea. That number jumps to thirty percent when you examine professional truck drivers. This increase can be attributed to a lack of physical movement and the commonly poor driver diet, as they are typically behind the wheel for long periods of time and eat for convenience while they are on the road. There is a strong correlation between driver lifestyle and sleep apnea, and these factors can also result in a higher risk for heart disease and diabetes.

What exactly is obstructive sleep apnea? “Apnea” means to stop breathing for 10 seconds or longer; thus “sleep apnea” means that it happens during sleep. Obstructive sleep apnea (OSA) occurs when the upper airway collapses, which is common in people who are overweight. An example of this occurs with the excess flesh around the neck, commonly known as a "double chin." Outwardly protruding flesh around the neck means there will likely be inwardly protruding flesh too, which can constrict and obstruct the airway within. A snore occurs when air is trying to pass through an obstructed airway, making snoring a common symptom of OSA. While not all people who snore have sleep apnea, most people with sleep apnea snore.

Testing Sleep Apnea in Truck Drivers

All truck drivers are required to have a commercial driver’s license (CDL). If a driver is diagnosed with sleep apnea, a dangerous condition for over the road workers, they must become compliant with requirements from the Federal Motor Carrier Safety Administration (FMCSA) before they receive their Department of Transportation (DOT) medical certificate. There are certain factors recommended by the FMCSA that CDL medical examiners look for when determining if the driver should be tested for sleep apnea, including:

  • BMI of 33 to 40 percent
  • A neck circumference of 17 inches or greater for men; 15.5 or greater for women
  • Medical issues with hypertension, high blood pressure, Type 2 Diabetes, and/or elevated sugar levels in their urine
  • A history of stroke, heart attack, coronary heart disease and/or arrhythmias

When testing for sleep apnea, professionals use the Apnea-Hypopnea Index (AHI) to measure how many apnic events occur per hour of sleep. As mentioned above, a greater number of drivers and over-the-road workers are affected by sleep apnea than the general population. FMCSA’s Medical Review Board (MRB) found that if a driver has moderate or severe OSA, their crash risk increases significantly.

While sleeping, we typically don’t remember when we wake up or toss and turn throughout the night. Ninety percent of patients with sleep apnea aren’t even aware that they have OSA. It is of paramount importance that truck drivers are being properly screened by their medical examiner, accurately tested, and are compliant with CPAP treatment if diagnosed. Until a driver can recognize they are working in a sleep deficit due to OSA, does it exist? Or is it just their everyday life?

Industry Standards for Sleep Testing

The industry standards for sleep testing can be both time-consuming and financially difficult to work with. The medical examiner allows ninety days to be in compliance and most drivers don’t have a primary care physician (PCP) to ask for an immediate referral from. This often means they need to call a traditional sleep lab directly. The average national wait time for a sleep lab testing is fifty-five days, and testing costs are, at minimum, $1,500 out-of-pocket. In addition, a Continuous Positive Airway Pressure (CPAP) machine can cost anywhere from $1,500 to $3,500. A driver could potentially spend over $3,000, and still not be in compliance within the 90-day period required by the medical examiner.

A driver can choose to search online for an Independent Diagnostic Testing Facility (IDTF), but they usually do not offer Chain of Custody (CoC) monitoring, which is required by FMCSA and the American Academy of Sleep Medicine (AASM) for at home-testing of DOT patients. An IDTF may appear to be a good option since they are usually mail-order, making them faster and significantly cheaper, but without CoC the driver may not receive a valid test. It is critical for the testing group to be able to establish CoC to prove the driver who ordered the test is the person the test was performed on.  

Furthermore, if the IDTF is also the durable medical equipment (DME) provider selling them a CPAP, there is risk of fraudulent testing in order to diagnose the patient with OSA. Older styles of at-home sleep tests often don’t use Food and Drug Administration (FDA)  approved auto-scoring algorithms, which leaves room for manipulation or fraudulent scoring. I have personally run second opinion tests for drivers who did not have sleep apnea, but were given fraudulent diagnosis in order to be sold a CPAP.

When a driver is able to be tested within the 90-day requirement, average sleep lab wait times mean they may not be compliant when CPAP is required, within that 90-day window. Thus, when it comes to required sleep testing, there are five key factors in making the decision on what company to choose for your test; what is the cost,  where will they test, how long will it take, do they have CoC for at home testing, and are they a reputable company that will do a legitimate test? The cheapest option isn’t always the best option.

Getting Drivers Back on the Road

There are ways to get truck drivers compliant and on the roads in less time than what industry standards lead us to believe. Through our nationwide network of providers, WorkSTEPS delivers OSA testing, provides treatment devices, and trains the driver on their use for optimal health and sustained DOT-compliance. Our process results in decreased loss in driving time, shorter time-to-compliance and higher driver retention.

WorkSTEPS provides US-DOT-approved overnight testing in drivers’ own beds that can be set up anywhere in the U.S. This gets drivers recertified and back on the roads quickly. In addition, we provide in-person patient education and setup at employer locations along with personalized equipment, fitted by registered sleep professionals.

Beyond testing and set up, WorkSTEPS Sleep medical staff monitor driver CPAP compliance and maintain contact with drivers throughout treatment to ensure simple CDL medical recertification. Our use of cloud-based software allows accessible monitoring by program managers to ensure drivers are healthy and compliant.

Sleep Testing Technology

The days of having to hook up a giant sleep testing machine are over. Itamar Medical is the producer of WatchPAT, the leading OSA home sleep testing device on the market. WorkSTEPS Sleep has been a preferred partner of Itamar’s WatchPAT services for  the transportation industry for more than two years. WatchPAT is a cost-saving, mobile, and cloud-based alternative to overnight sleep clinics, which allows drivers to complete their OSA testing in the comfort of their own bed. WatchPAT has the only FDA-approved auto-scoring algorithm, which prevents human error and data manipulation in the diagnostic process, making it significantly more accurate than its competitors.

Other industry-leading software solutions like Salesforce and Twistle, a mobile based integrated patient care management app, also allow for ease and efficiency in operating WorkSTEPS’ OSA testing and treatment programs.

Marrying traditional healthcare with occupational healthcare can yield indisputable results when it comes to getting people back in the workforce in a timely manner. By implementing rapid testing and technology based CPAP compliance solutions, we can keep commercial drivers working, decrease company risk, and keep the driving public safer.

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About John Varela

John Varela is the Vice President of Sleep Medicine for WorkSTEPS, where he brings traditional healthcare service and treatment principals to the occupational health space. With 18 years of experience in the neurophysiology of sleep and treatment of sleep disorders, he is one of the few professionals in sleep medicine who understands the nuances of its role in the transportation industry. Varela has developed one of the most efficiently-run occupational health OSA testing and treatment programs in the United States. As a subject matter expert in lean production system models, he has combined standard clinical processes with technology solutions to deliver the highest level of sleep testing and treatment of OSA for occupational health patients.

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