What Would You Do?

This recurring newsletter is designed to keep your mind sharp and well-informed about DOT regulations and guidelines. 

Stay informed, stay compliant! 

Scenario: 

A 53-year-old male presents for a DOT physical. Their medical history is positive for hypertension, controlled with medication. Their blood pressure during the exam was 128/79. Their BMI is 36 and their neck size is 18.5”. There is no other significant medical history, and no other significant exam findings. He denies ever having a sleep study. 

What would you do?

Discussion:

The first paragraph from the sleep apnea section of the 2024 Medical Examiner Handbook (MEH) states, 

“If left untreated, moderate-to-severe OSA [AHI > 15] may contribute to fatigue and unintended sleep episodes with resulting deficits in attention, concentration, situational awareness, and memory. These deficits may interfere with an individual’s ability to control and drive a CMV safely. In addition, untreated moderate-to-severe OSA is associated with cardiovascular and cerebrovascular morbidity, metabolic disease, and mortality. However, if treated, moderate-to-severe OSA does not preclude certification.”

Let’s focus on the last sentence. To preclude is to prevent or inhibit. FMCSA is stating that individuals with moderate-to-severe sleep apnea that is treated are not precluded (prevented) from being certified. Or to simplify, when an individual with moderate-to-severe sleep apnea is being effectively treated, they can be certified.

So, if FMCSA is advising that treated individuals can be certified, what about the individuals that are not being affectively treated? We'll leave that for you to determine.

Regulations vs Guidelines

The next paragraph in the MEH has caused a lot of confusion. It states,

“The FMCSRs do not include requirements for MEs to screen individuals for OSA or provide requirements regarding whether to recommend that an individual be referred for OSA testing. The FMCSRs also do not specify preferred diagnostic testing methods, treatment methods, or requirements by which to assess compliance for OSA treatment.”

The confusion comes from examiners not understanding the difference between regulations and guidelines. The “R” in FMCSRs stands for “Regulations”. In at least the last 10+ years, there has been no regulations regarding sleep apnea. FMCSA has, however, provided guidance and recommendations. 

In fact, the very next paragraph in the MEH provides such guidance. They suggest, “If an ME observes multiple risk factors for moderate-to-severe OSA, the ME should consider recommending that the individual be referred for a sleep study if not evaluated previously.” These risk factors include, but may not be limited to:

• History of a small airway [Mallampati score of 3-4.]

• Loud snoring

• Witnessed apneas

• Self-reported episodes of sleepiness during the major wake periods

• Obesity, high body mass index (BMI) [The CDC considers a BMI > 30 to be obese.]

• Large neck size

• Hypertension

• Cardiovascular disease

• History of stroke, diabetes, or other co-morbid conditions

The final paragraph of the MEH section on sleep apnea provides further guidance. It states,

“For additional guidance on screening, diagnosing, and certifying individual with moderate-to-severe OSA, one source MEs could consider is the November 21, 2016, OSA advisory recommendations. They are available at https://www.fmcsa.dot.gov/advisory-committees/mrb/final-mrb-task-16-01-letter-report-mcsac-and-mrb”

Conclusion:

As noted in the scenario, the driver has a history of hypertension which is well-controlled. This alone should limit the driver to a 1-year certification interval. 

This driver has three risk factors that are included in the list provided in the MEH. According to FMCSA, “…the ME should consider recommending that the individual be referred for a sleep study”.

If an ME decides to order a sleep study, it’s customary to provide the driver with a temporary certificate – usually 3 months – to allow time to obtain a sleep study and start treatment, if needed.

The 2016 OSA advisory recommendations that are mentioned in the final paragraph of the sleep apnea section recommend that a driver with sleep apnea only be certified for 1 year. They also recommend that drivers using a sleep-assistive device must demonstrate compliance with the use of the device, which would be using the device for 4 hours or more per night for at least 70% of nights. This compliance report should be from the time they were last certified.