So now we're going to a topic where the system is absolutely perfect. Needless to sound a little sarcastic this morning. Respiratory. These are the questions. Common sense. Any long-term cough, shortness of breath, lung disease, sleep disorder, pauses in breathing, loud snoring, have you ever had a sleep test? Now one of the fun things is the not sure about sleep disorders, not sure about sleep tests. What really bothers me even more are the no's. When I know that they have and they've failed them. Sleep apnea is a really uncomfortable topic that I hate to admit we may have gone a little overboard on. Yes it is, it put people at risk, but probably not as much at risk as some of the other medications and other issues that we're not paying as much attention to, but it is a significant problem. NTSB has noted it's a significant problem and we need to pay attention to it. A person is physically qualified if they have no established medical history or clinical diagnosis of a respiratory dysfunction likely to interfere with the ability to operate, control, and drive a motor vehicle safely. No diagnoses are included at all in the regulation. This is where we have to think. So it starts talking about in the first paragraph of the medical advisory criteria, which is advisory, it's guidance, not required, is that many conditions interfere, and these include but are not limited to, dot, dot, dot, dot, dot, pick a pulmonary condition, and obstructive sleep apnea. That's about the best we get in the shoulds. If the medical examiner detects a diagnosis or inadequately treat it, they need more information, confer with the treating provider, refer to a specialist. So get more information. Common sense, same as every other condition. That's about it. Then we have all these medical conditions, 42 to page 50. It's not a lot of pages for all the stuff that could fall into here, including obstructive sleep apnea. What are the common questions? How frequent and severe are the blank symptoms of this condition? Is the nature and severity of condition and the prevention and treatment regimen likely to interfere with? Has the individual with a history of allergy-related life-threatening conditions taken preventive measures? Does the individual have an unstable medical condition in addition to blank, such as cough or cough syncope or hypoxia at rest? Yes or no? Obviously, if the answer is yes, if they're not stable and controlled, the answer may be, no, we don't qualify them. But the question is, how severe is too severe to qualify? Evaluate on a case-to-case basis to determine whether the individual meets the physical qualification standards. Does that phrase sound familiar? It's going to be a lot more familiar over the next couple of modules. What do they say about antihistamines? They may have side effects in the first generations. You know, it can affect for up to 12 hours. Second-generation antihistamines are less sedating. Does that hint that maybe the person shouldn't be taking first-generation antihistamines and driving within 12 hours? Probably. Should the individual be looking at the duration of the medication to decide whether or not the duration of side effects, whether or not they should be driving? Probably. As a medical examiner, should you be reviewing the side effects and making that determination? Probably. Should you be considering whether the person may have developed tolerance to these medications? I always love the, I only take my Xanax as needed. I mean, you have your side effects only as needed. I'd rather the person be taking the medication on a regular basis. They probably will develop some tolerance to it. COPD. As the disease progresses, symptoms can become progressively more severe. That was a shocker to me. But as it becomes progressively more severe, they're probably less stable and able to operate a commercial motor vehicle safely because of a respiratory problem. Spontaneous pneumothorax. Have they had more than one? If they've had more than one, has it been addressed? Are they still symptomatic from it? It used to be a recommendation that if they had more than one and there wasn't any treatment, they shouldn't be qualified. Now, what's the underlying medical condition that caused it? Is that condition still there? Is that condition stable and controlled? Are they still at risk of impairment or incapacitation? And now we come to sleep apnea. Sleep apnea that we all love. Untreated, moderate or severe OSA may contribute to fatigue and unintended sleep episodes. I think most people who know about sleep apnea understand that. Deficits in attention, concentration, situational awareness, and memory. Yes. May interfere with control of a commercial motor vehicle. Yes. Untreated, moderate to severe. What that's saying is FMCSA and FRA is not really concerned about mild sleep apnea in most cases. The moderate to severe are the ones that have been shown to be more likely to be associated with adverse outcomes, with crashes, with near crashes. So we're focusing on the moderate to severe sleep apnea that's untreated or inadequately treated. If the person's adequately treated, it does not mean they should not be certified. In fact, it means they should be certified as long as they're adequately treated and not having symptoms. One of the tests that's used by some is the Epwer Sleepiness Scale. I like to think of it as a stupidity test. It's kind of like saying, you're going for your drug test tomorrow. That I also consider. Give them enough time. If you only give them a day, they can't study for their drug test. Give them a week, they can study for their drug test and make sure everything's pretty good. But how likely are you to fall asleep sitting quietly at a stop sign in traffic? If you answer yes, you're too stupid to drive a truck. Come on. If you're going to fall asleep just sitting at a stop line, that's not a good sign. So you've got to ask these questions and really understand. The problem is the subjective questions are not going to really give you those questions, those answers. Are you too tired to drive? No, I'm not. Well, if you are, you shouldn't be coming here. Again, we've got to try, what are the objective measures that we can use? FMCSA is very, very specific. They do not require medical examiners to screen. They do not describe what screening tests should be done. They do not advise what criteria should be used in order to screen an individual. They do not advise what compliance is. It is up to the medical examiner to make that decision, looking at identifiable risk factors. Now, we have risk factors. I continue to talk about multiple risk factors for moderate to severe. Now, I don't know, but history of small airway. I can't tell by that if it's moderate to severe unless they're tested. Loud snoring, witness apnea, self-reported episodes of sleepiness, large neck size, obesity, hypertension, cardiovascular disease, history of diabetes, or other comorbid conditions associated with. This is not the same list for those of you that are familiar with the 2016 Medical Review Board recommendations, which are a little bit different. It doesn't talk about a BMI of 30, 33, 35, or 40. It just says obesity. But, refer multiple risk factors. If prior negative mild tests, you don't really need to repeat it unless risk factors have changed. If you're worried about moderate to severe, it's determined by the provider. And if symptoms get worse, we're going to follow up. And then considerations. Are there multiple risk factors? Are the symptoms likely to interfere with dot, dot, dot? And if diagnosed, has the treatment been safe or effective? One thing I think is really of value. Where it says, with respect to FMOSA, FMCSA doesn't have anything specific, which is true. And we need to remember this. FMCSA is not recommending, is not directing, is not instructing. FMCSA, very careful word. It says, for additional guidance on screening, diagnosing, and certifying individuals with moderate to severe OSA, one source MEs could, could is a permissive word. It is not a directive word. Could consider, as of November 2016, OSA advisory recommendations from the Medical Review Board. And they can be found here. When this came out, there were a ton of people who were saying, FMCSA is telling examiners to screen for sleep apnea. FMCSA is giving them criteria to screen for sleep apnea. No, FMCSA is giving us information that we may consider. Doesn't mean you have to consider it. But when I see it in the Medical Examiner Handbook, that was codified because it was published, at least the announcement for it was published, in the Federal Register to some extent. Examiners should consider that. Not follow it exactly, but certainly should be considering it. So therefore, I am going to go ahead and show you what I might consider from the 2016 Medical Review Board recommendations. Examiners should screen people for sleep apnea. End of story. Even if it's nothing more than what's the BMI. They should not issue a card for more than a year. An individual who has an established diagnosis of sleep apnea, regardless of severity. Because if they're severe enough to be treated, if they're mild and they desaturate significantly, if they're mild and they're having significant enough symptoms, the provider thinks they need to be treated. Now, as a caveat, we know that if there's a BMI and AHI of 5 to 15, in most cases you're going to say, they consider treatment. And ideally, a good sleep doc would say, give it a try. If it makes a difference, continue. If not, it probably isn't going to make a big difference in the long run. So it's getting those records and really looking at the records. A medical examiner may certify if the person is being treated adequately and for purposes of effective treatment are treated effectively defined as resolution or as determined by board certified sleep doc. Immediately disqualified. Excessive sleepiness while driving. Makes sense. Observed sleeping behind the wheel while operating the vehicle. Have had a crash while driving due to fall asleep situations. Or noncompliant with treatment. That, again, is just common sense. Whether the medical review board says that or not, if they've had a crash, if they've fallen asleep, if they're not being adequately treated when it's been recommended, they probably shouldn't be certified. Or disqualify any driver who's especially high risk and then re-qualify them once they are certified. Now, this is a conditional certification. Body mass index, 90 days, bring them back, see if they're compliant, and if so, you can certify them for a period of time. Now, when do we screen them? And this is like the big question that everybody's asking. Individuals with the following criteria, BMI greater than or equal to 40, should be screened for sleep apnea. A former aviation chief surgeon, whatever, chief surgeon made a statement that said, it goes without saying that almost anyone who has a BMI above 40 has sleep apnea until proven otherwise. The FAA has some really nice guidelines on screening for sleep apnea that look pretty similar to this. So, it may be reasonable for an examiner to look at other modes that are safety sensitive and what are they using for their criteria for different medical conditions. And we'll talk about that with a couple of other conditions later on. So, BMI of 40. It's not a requirement. However, it's probably not a bad thing to be considering. Individuals have a BMI between 33 and 39 and three other risk factors. The medical review board, one member said it should be two or more risk factors. Somebody else thought it might have been four. So, again, what are the concerns? Well, these things are known to be associated with obstructive sleep apnea. Hypertension, diabetes, coronary artery stroke, arrhythmias, micronathia, retronathia, loud snoring, witnessed apneas. You can read on Malampati. Problem is people can't really determine a Malampati score very well, and I'll show next slide on that one. But there were enough triggers that examiners should be screening. Most of the larger clinic networks are screening for sleep apnea, and then making that determination of whether or not a sleep study is necessary. Is it best practice? Probably. Is it required? No. And I'm gonna just, the last thing I'm gonna show on this, but if you look at the back of the airway, it's class one, wide open airway. Class two is kind of closed off. Class three, there was a study done by one of the Penn residents, I don't know how many years ago, that they took a bunch of OCDocs and a couple of ENTs and had them say, okay, is this a Malampati two or three? The ENTs, we assumed they knew what they were doing. We showed the OCDocs. It was all over the place. Most of them could differentiate one and four. You know, one and two, maybe. Three and four, maybe. But two and three, no way. And of course, our criteria is three or four is the refer for sleep testing. And then I'm just not gonna go through all of these, but it talks about how do you do a test, do a home test, the problem with your home, I do an in-lab test, that really is a multi-channel observed test. It's kind of easy to beat a home sleep test, but not impossible, you know, but you can oftentimes pick up on when they have, meh, stayed awake and had a lot of coffee and watched TV all night, so didn't have their apneic episodes, because they really weren't laying down. So you want to make sure you're working with a really good, reliable sleep group that can do that and say, yeah, this was done and it's negative, but the other thing to keep in mind is that most sleep studies will underestimate. I just wanted to include all this in the handout for you. I'm not gonna go through each and every one. Oral appliances may be appropriate. Generally, they're not really effective for severe and borderline or moderate. Most dentists are still using them for mild to moderate to severe as well. Most of these require a follow-up test to make sure that they are efficacious and the individual is using them, so you want to have some way of monitoring the use. Bariatric surgery, a lot of individuals who have obstructive sleep apnea with a very high AHI being apnea hypopnea index, that's the measurement to look at severity of obstructive sleep apnea. If they have surgery, if they have what's called a UP3, uvula polyplasty, they may still have residual tissue that still may be blocking the airway. What's important, though, is where the pressure may need to have been 18, which is really hard to tolerate, they may only need a pressure of maybe seven or eight to keep their airway open, so it's more likely to be tolerated. And as you're seeing as we're going through things, there is not a slide for the Inspire machine, which we all see on TV all the time and I want to throw my shoe at the TV sometimes. It is fine, probably, for people who have mild sleep apnea. It was not recommended for people who have a BMI above 40. It is probably okay in some situations. It is not approved or not approved by FMCSA. It is really up to the examiner, the sleep provider, and whether the individual is comfortable using it. It may be fine for some. That's your decision, and I can't tell you yes, no. Do I have some drivers who are using it, yes. Do I have some that I say, nope, not good enough, yes. And that's really going back and using that individual assessment. This is just the history of sleep apnea. We've been talking about this since 2015. FMCSA had a bulletin out, and what they say in this handbook is that the guidance in the Medical Examiner Handbook 2024 replaces the 2015 statement on sleep apnea. So if you have the 2015, which is in your syllabus, look at it for interest, but then throw it away. In 2016, the Medical Review Board made recommendations. In 2016, there was an advance notice to propose rulemaking from both the FRA and the FMCSA that we're going to do rulemaking on obstructive sleep apnea. It got withdrawn. There's now some other things in FMC, FRA, where we're looking at fatigue risk management programs. And then in 2024, we now have, this is what examiners should be doing, multiple risk factors in the handbook, and then could consider, which is that 2016 recommendation. Narcolepsy is covered in epilepsies and seizures. Narcolepsy is really considered a loss of consciousness. Sometimes I wonder how they figure out where things fit in, but that's not my job. A couple of questions. Can a driver be qualified using oxygen in interstate commerce? It depends. In most cases, if they need oxygen to drive and to do their work, their condition's probably not adequately stable and controlled. And these are reminding. Remember back in the olden days where there was a recommendation for individuals who smoked? They have a pulmonary function test. That is absolutely, totally gone. So just take it out of your mind if you've ever seen that before. And that's respiratory. Yes? It's a practical question. So say you see somebody, you know, strong, suspiciously bad, do you mark them as pending or you give them X amount of time, like a three-month thing to do this thing? I don't mean to be laughing, but one of the nurse practitioners I work with, it's kind of become an ongoing joke, but I said my answer is, it depends. And it really does depend. I mean, if they give you a history that, you know, they've been treated before and they don't like being treated, and so they stop their CPAP machine, I'd disqualify that person, end of story. If I think they're at high risk because their BMI is 40 and they have three other risk factors, I'm gonna probably send them and let them get tested first. If they come back and they're falling asleep in my room and I'm down the end of the hallway and I hear them snoring all the way down and I see other things that make me suspicious, I might disqualify them. I might put them in determination pending. Determination pending depends on, and I'll talk more, a lot more about it because it is one of those confusing areas, but if they have a current valid medical certificate and they're working for, I'm gonna keep picking on Schneider National, and Schneider's really good about sleep apnea, but they're working for Schneider National and for whatever reason. If I take them out of service and they're not looking for a job with SWIFT, they can't work their other job either. If they're in determination pending while they're getting that sleep study, they can keep working on their old certificate. So keep that question in mind when we get. So if it's a determination pending? Let's talk about determination pending. Well, we'll talk about determination pending later on, but just keep that in the back of your mind. So it really depends on what the situation is and how suspicious I am that they're at imminent risk of a crash. Do I think that they're probably okay for 30 days to get that sleep study? I may give them a 30-day certificate if their certificate expired. There is no requirement here at all. It's your assessment of how likely are they to become, to experience sudden or gradual impairment or incapacitation over the duration of the certificate that I'm going to give them. Does that pending have a certain date? Nope, we'll talk about pending after, because there's a whole lot of stuff behind pending. I'll give you guys mics. So I have been involved with the American Academy of Sleep Medicine for a long time. I think sleep and fatigue and transportation issues is really very interesting to me. I've been there token ock dock. Except I came in a couple of times. I'm going to give you my, this is not, number one, you're not going to see a lot on OSA on this. It's because it's so controversial and there's no regulation about it other than you can have a respiratory disorder from drive if it's going to affect your ability to drive, right? So don't get wrapped around the head about sleep apnea too much when you're studying for this exam because it's unlikely it'll be on there. However, you are going to encounter this in your practice all the time. So I'll give you some pointers that I have learned. Number one, talk to the driver. Help them understand their pathology or why you suspect they have the pathology. I don't get very far when I tell them about being sleepy. Not everyone with sleep apnea is sleepy and not everyone that's sleepy crashes. In fact, the number one cause of excessive daytime sleepiness in this country is not a sleep disorder, it's lack of sleep. So you're going to not get very far trying to tell a professional driver who is used to driving fatigued because of the hours of service requirements for them that they're going to fall asleep and crash their car. Yeah, that's a concern, but it's probably not what's going to kill them with their sleep apnea. What kills people with sleep apnea is their heart disease and there are other things that come with sleep apnea. So I find that I get a lot more traction of having this guy go take a test that's going to probably cost him money out of his pocket to get it done when I talk to him about the things that we're trying to prevent, like heart attacks and strokes. I get a lot further with that. So I explain to him generally, having untreated sleep apnea is very similar to having untreated hypertension. There's a lot of strain on your cardiovascular system and eventually that's going to fade. So if you want to continue to drive until you're 60, 70 or beyond and retire and enjoy the fruits of your labor, go get your sleep apnea test. If you want to be one of those guys that's in a nursing home at age 50 waiting for someone to come change his diaper because he had a stroke that couldn't have been prevented by a simple test, go for it. So I find that the drivers are a lot more receptive when I talk to them about the cardiovascular disease risk because they understand, you know, well, I don't want a heart attack. I don't want it to kill me. You already have it. You already have a heart attack. So that means you're going to want to continue to receive evaluations because you are overweight, you have high blood pressure, you have a big neck, you're in the shape of your palate, and we're all thinking you can't do anything about it. But we want to check out. So do that. Inspire is, she touched on that. There's not a lot of long-term data with that. It's too new. And again, you got to make sure that it works. Just because they got their Inspire doesn't mean it works. So again, there's some pretty strict, I personally do a lot of due diligence before I certify. I haven't seen too many drivers with it in my practice, but I know it's up and coming. And then, yeah, so tell people why you care about sleep apnea and you'll get a lot further with them than if you just tell them to go get a sleep test. And there's two kinds of sleep tests, generally. There's the whole sleep apnea test or HSAT. Those are cheap. You can do them at home. It's usually a watch device, watch pad. They're good for detecting sleep apnea, though they tend to under, as Natalie said, they tend to underestimate or under-diagnose. They are not ideal for people who have a lot of comorbidities. So people with heart failure or bad heart disease or bad lung disease, they're not the best test. But the in-lab polysomnogram, where they go to sleep in the sleep lab and they get hooked up to everything, which is great because that detects everything. Home sleep apnea tests are good for one thing, sleep apnea testing. They won't detect anything else. The polysomnogram is the gold standard. It detects everything, but it's pricey. So I generally let the sleep doc make the call. I'm not a sleep specialist. I mean, I know a lot about it, but that doesn't mean I'm a specialist. I'm not boarded in it. Just like I don't tell the cardiologist what kind of stress test to order. That's up to them. So anyway. Yes, ma'am. Yes. Yes, it can be turned on and off. It's downloadable and it's invasive. It's a surgery, so they need to be recovered from the surgery. Yes. And that's part of what I ask for. I don't limit it to that. It's like asking a diabetic for just their A1C. I don't do that. So I do get required, you know, and I want to know that it works. Same with the oral mandibular. The OMADs are the dental devices that the dentists like to push. And you gotta make sure it works. Come on. All right. And we're gonna have more time for questions, but we'll plow on, because we're doing good.

sleep apnea

driver safety

respiratory health

medical certification

fatigue risks

COPD