Drowsy Driving is a Risk to Everyone on the Road

Does this sound familiar?  You're driving on a quiet stretch of highway.  Your eyelids start drooping.  You blink hard to keep your eyes focused.  Your head begins to nod, and you snap it up into position.  Yet you continue driving, thinking you can manage your obvious fatigue.

This is drowsy driving, and it is a danger to everyone on the road.

According to data collected by the National Highway Traffic Safety Administration, in 2009, drowsy driving crashes injured more than 30,000 people.  And, because police can't always determine with certainty when driver fatigue causes a crash, the actual number may be higher.

At the Department of Transportation, safety is our number one priority.  We have worked hard to reduce the risks of fatigue among airline pilots, commercial drivers, and rail and transit operators.  But we also recognize that drowsy driving is a problem for the rest of us on America's roads.

And we are working hard to make our roads safer.

Innovations introduced by our Federal Highway Administration have already helped.  Continuous shoulder rumble strips and raised lane dividers alert drivers when their vehicles drift.  Cable barriers reduce the risk of collisions.

And a new approach called Safety Edge will help even more.  This approach paves the edge of a road at an angle of 30 degrees instead of 90 degrees.  This more gradual separation allows a driver whose car has drifted to steer the vehicle back onto the roadway more safely.

Our National Highway Traffic Safety Administration has also entered into a cooperative agreement with a group of automakers to help develop vehicle-to-vehicle communications.  With features like Forward Collision Warning, Lane Change Assist, and Advanced Object Detection, vehicle-to-vehicle communication systems can alert drivers to potentially critical situations.

This technology holds great promise for increasing driver awareness and safety.

These technological advances to our roads and vehicles are terrific, but we can't win this fight without safer drivers. So please, when you are feeling fatigued, don't pick up your keys

Drowsy driving causes more than 100,000 crashes a year, resulting in 40,000 injuries and 1,550 deaths. As tragic as these numbers are, they only tell a portion of the story. It is widely recognized that drowsy driving is underreported as a cause of crashes. And this doesn't include incidents caused by driver inattention. NHTSA's programs to combat drowsy driving employs both educational and technological solutions. Education programs are directed toward specific subpopulations as well as the general driving public.

Statement from the Joint Task Forse of the American College of Chest Physicians, American College of Occupational and Environmental Medicine, and the National Sleep Foundation

Natalie Hartenbaum, MD, MPH, FACOEM
Nancy Collop, MD, FCCP
Ilene M. Rosen, MD, MSCE, FCCPBarbara Phillips, MD, MSPH, FCCP
Charles F. P. George, MD, FRCPC
James A. Rowley, MD
Neil Freedman, MD, FCCP
Terri E. Weaver, PhD, RN, CS, FAAN
Indira Gurubhagavatula, MD, MPH
Kingman Strohl, MD
Howard M. Leaman, MD
Gary L. Moffitt, MD
Mark R. Rosekind, PhD

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 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.

Medically Qualified to Drive Commercial Vehicles If Driver Meets Either of the Following In-Service Evaluation (ISE) Recommended If Driver Falls Into Any One of the Following Five Major Categories (3 mo maximum certification)

Out-of-Service Immediate Evaluation Recommended If Driver Meets Any One of the Following Factors

1)   No positive findings or any of the numbered in-service evaluation factors

2)   Sleep history suggestive of OSA (snoring, excessive daytime sleepiness, witnessed  apneas)

3)   Observed unexplained excessive daytime sleepiness (sleeping in examination or waiting room) or confessed excessive sleepiness

4)   Diagnosis of OSA with CPAP compliance documented

5)   Two or more of the following: 2. Motor vehicle accident (run off road, at-fault, rear-end collision) likely related to sleep disturbance, unless evaluated for sleep disorder in the interim

o   BMI _35 kg/m2;

o   Neck circumference greater than 17 inches in men, 16 inches in women;

o   Hypertension (new, uncontrolled, or unable to control with less than 2 medications).ESS _10 3. ESS _16 or FOSQ _18

6)   Previously diagnosed sleep disorder

7)   Previously diagnosed sleep disorder: compliance claimed, but no recent medical visits/compliance data available for immediate review (must be reviewed  within 3-mo period); if found not to be compliant, should be removed from service (includes surgical treatment)

8)   Noncompliant (CPAP treatment not tolerated);

a)    No recent follow up (within recommended time frame);

b)   Any surgical approach with no objective follow up.

c)    AHI _5 but _30 in a prior sleep study or polysomnogram and no excessive daytime somnolence (ESS _11), no motor vehicle accidents, no hypertension requiring 2 or more agents to control

d)   AHI _30 AHI indicates apnea–hypopnea index; BMI, body mass index; CPAP, continuous positive airway pressure; ESS, Epworth Sleepiness Scale; FOSQ, Functional Outcomes of Sleep Questionnaire; OSA, obstructive sleep apnea.

S2 Sleep Apnea and Commercial Motor Vehicle Operators

The recommendation categories focus on the following:

• Screening;
• Diagnosis;
• Treatment;
• Compliance and efficacy;
• Return to work after treatment for OSA; and
• Follow up.

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;

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;

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 refer-Screening Recommendation for Commercial Drivers with Possible or Probable Sleep Apnea.

1.     Oral appliances should only be used as a primary therapy if AHI _30 Treatment with oral appliances

2.     Before returning to service, must have follow-up sleep study demonstrating AHI ideally _5, but _10 while wearing oral appliance

3.     All reported symptoms of sleepiness must be resolved and blood pressure must be controlled or improving (must meet FMCSA criteria)

Return to work after treatment

1.     Follow-up sleep study—AHI ideally _5 but _10 required to document efficacy Treatment with surgery or weight loss AHI indicates apnea–hypopnea index; CPAP, continuous positive airway pressure; FMCSA, Federal Motor Carrier Safety Administration; PAP, positive airway pressure; OSA, obstructive sleep apnea; CMV, commercial motor vehicle.

From OccuMedix, Inc. (Dr Hartenbaum), Dresher, Pennsylvania; the Department of Medicine, Division of Pulmonary/Critical Care Medicine

(Dr Collop), Johns Hopkins University, Baltimore, Maryland; the Department of Medicine, Divisions of Sleep Medicine and Pulmonary, Allergy & Critical Care Medicine (Dr Rosen), University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; the Division of Pulmonary Critical Care and Sleep Medicine (Dr Phillips), University of Kentucky College of Medicine, Lexington, Kentucky; the Department of Medicine, Division of Respirology (Dr George), University of Western Ontario, and the Sleep Laboratory, London Health Sciences Centre, South Street Hospital, London, Ontario, Canada; the Department of Medicine, Division of Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine (Dr Rowley), Wayne State University School of Medicine, Harper University Hospital, Detroit, Michigan; The Sleep and Behavior Medicine Institute and Pulmonary Physicians of the North Shore (Dr Freedman), Bannockburn, Illinois; Biobehavioral and Health Sciences Division (Dr Weaver), University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania; the Department of Medicine, Divisions of

Sleep, Pulmonary and Critical Care Medicine (Dr Gurubhagavatula), University of Pennsylvania Medical Center, Philadelphia, Pennsylvania; the Department of Medicine, Director (Dr Strohl), Center for Sleep Disorders Research, Case Western Reserve University School of Medicine, Louis Stokes DVA Medical Center, Cleveland, Ohio; the IHC Health Services to Business (Dr Leaman), Intermountain WorkMed, Salt Lake City, Utah; and Arkansas Occupational Health (Dr Moffitt), Springdale, Arkansas; Alertness Solutions (Dr Rosekind), Cupertino, CA.

Copyright © 2006 by American College of Occupational and Environmental Medicine