Clearing the air on CPAP

In another thread, I was prompted to start this thread about OSA. The following is copied and pasted from my website. Keep in mind the following is not meant to be medical advice, and I can't give individual recommendations to anyone on the forum. However, hopefully,the following will be helpful, and I will attempt to answer any general questions about OSA, CPAP, and the DOT regulations as I understand them in subsequent posts.

Obstructive Sleep Apnea (OSA) and Excessive Daytime Sleepiness: How OSA can affect you certification.
There has been a lot of talk about Obstructive Sleep Apnea, both from the FMCSA and drivers. Here, we will attempt to “demystify” the current guidelines so that you know what to expect when you get your physical
In regards to certification, the decision whether or not to certify can be explained by reading the medical examiners handbook .

http://nadme.vanbeeksystems.com/wp-...FMCSA_Medical_Examiner_Handbook-2014MAR18.pdf
That is quite a bit to wade through, so I will summarize the recommendations for certifying operators.
The guidelines about sleep apnea read like this:

“ A person is physically qualified to drive a commercial vehicle of that person has NO established medical history or clinical diagnosis of a respiratory dysfunction likely to interfere with his or her ability to control and drive a commercial motor vehicle safely.”
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Standards are criteria that the examiner has no leeway on, and they MUST be followed. These are also called “Physical qualification standards.” So, if a driver has a respiratory dysfunction that is likely to interfere with safe operation, then the driver MUST be disqualified, according to the regulations.
However, in the real world, that requirement is a bit vague. How can an examiner really tell whether or not the diagnosis or history of a “respiratory dysfunction” is “likely” to interfere with safe operation?
Because of uncertainty, and varying practices from one examiner to the next, the FMCSA sent a bulletin in January 2015 to clarify issues surrounding OSA. This can be reviewed here.

https://nationalregistry.fmcsa.dot....o MEs and Training Organizations-01122015.pdf
Neither the bulletin nor the examiners handbook explicitly states any specific disqualifying parameters, such Body Mass index (weight to height ratio), neck size, etc. There is nothing that says “If your BMI is above such and such number, then a sleep study is warranted.” There is no guideline that says “if the neck circumference is greater than X inches” then an individual must be disqualified, or be referred to get a sleep study. In short, the medical examiner is being told to use his or her best judgment regarding whether or not OSA is or isn’t likely to be present, and whether or not to refer for further testing, based on history and physical exam.
What is in the handbook is a rational approach to determine clinically whether or not OSA is an issue or not. That is why it is important to answer to the best of your ability about excessive daytime sleepiness, snoring, whether or spouse or significant other tells you that you stop breathing at when you sleep, etc. This will keep both you and the roads safe.
There is significant latitude given to the examiner to use his or her medical judgment. Also, if it is determined that you likely have OSA, don’t get discouraged. Talk to your examiner about what different options are available. A temporary permit can even be issued in many cases, even with a Obstructive Sleep Apnea diagnosis.

 

Good questions - but not one with an easy answer. It would depend on why the study was ordered in the first place, and whether or not there are any changes in your health. For example, if you had a sleep study did not show any sleep apnea at all, and nothing changed in your health history (no weight gain, no increase in snoring, etc.), then you may not need another one at re-cert, and perhaps you will never need another test.

However, the way the sleep study is read is not just a yes or no answer, and there are different severities of sleep apnea - mild, moderate, severe. Depends on how many "arousals" there were averaged per hour (not that kind of arousal - arousal here means a "semi-awakening" but not enough to remember) and if/how many times the oxygen level dropped. The reports can be very complicated.

So if it was determined that you did not have sleep apnea, but you were close to the cut-off, your examiner may request another one in a year or two to make sure it did not progress. If it was absolutely stone cold negative - then probably not.

 

Body mass index, or BMI is a formulation of weight divided by height. Easy online calculators are available, 6'2.5" at 260 is a BMI of 32.9.

http://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm

Underweight - BMI less than 18.5
Ideal 18.5-24.9
Overweight 25-29.9
Obese 30-34.9
Morbidly obese 35 or greater

However, BMI is not the only factor to consider when screening for OSA. There is the "STOP-BANG" questionnaire
http://www.sleepapnea.org/assets/files/pdf/STOP-BANG Questionnaire.pdf

that is often employed. BMI is one factor (here greater than 35), others are neck circumference, loud snoring, feeling tired, etc. Also included is age greater than 50, and being male, and others. Screening is recommended if the score is 3 or more.

So if you are a 51 year old male with a BMI > 35, then according to this screening you would be at a "high risk of OSA" and would likely be referred for screening. At your height, 6'2.5", you would need to weight 276 lbs to get to the BMI of 35.

I would discourage the use of the BMI as a stand alone tool to determine who needs to be screened for OSA, however. Some people would get screened unnecessarily and others would be missed - skinny people can get OSA, too, albeit less frequently.

I do not know of any exploitation - if I send someone for a sleep study test, it does not change my bottom line - if anything it creates more work. But if I feel someone really needs the test, I would absolutely order it.

Healthcare fraud is in focus, so if there are any episodes of suspected kick-back schemes then I would report it, and so should you if you see it.

On the other hand - if an examiner misses a case of OSA, and then that OSA causes a driver to wreck, that would be bad for the examiner and everyone else - so some fear, or "defensive" medicine may or may not be driving some of it.