Obstructive Sleep Apnea Concerning and Costly

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1 Illinois Association of Defense Trial Counsel Springfield, Illinois IDC Quarterly Volume 23, Number 2 ( ) Feature Article By: Mitchell A. Garber, MD, MPH, MSME Engineering Systems, Incorporated, Norcross, Georgia Obstructive Sleep Apnea Concerning and Costly Abstract: Increasingly, obstructive sleep apnea (OSA) is being recognized as an important factor in transportation and other accidents. This article describes OSA, how it is diagnosed and treated, risk factors for the disease, clinical and public risks from untreated OSA, and what is being done currently to address these risks, particularly in the transportation industry. Accidents In June 1995, while transiting Alaska s Inside Passage, a cruise ship ran aground of a well-known, charted, and marked submerged rock (NTSB, 1997). No injuries or deaths resulted from the accident, but the repairs and the delay before the vessel could return to service cost the cruise line approximately $27 million. In July 2000, a tractor-trailer traveling at 65 miles per hour approached a worksite in Jackson, Tennessee, and struck a highway patrol vehicle (NTSB, 2002). The patrol car was stopped with its lights flashing. Upon impact, it exploded, caught fire, and was pushed nearly 200 feet. The state trooper inside the patrol car was killed, and the driver of a second vehicle was seriously injured. In November 2001, a southbound train traveling at 13 miles per hour in Clarkston, Michigan, proceeded through a stop indication onto a single main track and struck a train traveling northbound at 30 miles per hour (NTSB, 2002a). Both crewmembers of the northbound train were killed. The two crewmembers of the southbound train sustained serious injuries. The total cost of the accident was approximately $1.4 million. In February 2008, an airline flight departed Honolulu on a flight to Hilo, Hawaii. About halfway through the flight, the pilots stopped responding to air traffic control communications (NTSB, 2009). The pilots then passed over Hilo and traveled 26 nautical miles off course over the ocean before resuming radio communications and returning to their destination. In May 2008, a Green Line transit train traveling at 38 miles per hour in Newton, Massachusetts, struck the rear of another Green Line train, which had stopped at a red signal (NTSB, 2009a). The operator of the striking train was killed; one passenger was seriously injured. Three crewmembers and four of the approximately 200 passengers sustained minor injuries. The total damage was estimated at approximately $8.6 million. What These Accidents Have In Common The National Transportation Safety Board (NTSB) is the federal agency charged with investigating transportation accidents and incidents in the United States. In each of the incidents Page 1 of 5

2 described above, the NTSB concluded that one or more of the vehicle operators was at risk for or had obstructive sleep apnea, and that the condition might have played a role in the accident. Symptoms, Diagnosis, and Treatment What is OSA? Obstructive sleep apnea occurs when the throat tissue of a sleeping person causes a mechanical obstruction in the airway, and the individual actually stops breathing. The affected individual does not get enough oxygen and must partially awaken in order to breathe again. The individual frequently experiences extreme daytime sleepiness, and may fall asleep within a few minutes in a quiet or monotonous environment. Bear in mind that people typically do not know that they have this condition; individuals who have had the disorder for a long time are often unaware that this sleepiness is abnormal. Diagnosis Obstructive sleep apnea is diagnosed through a polysomnogram a sleep study which is a clinical procedure that involves monitoring the sleeping patient under controlled conditions. One of the critical assessments in a polysomnogram is the respiratory disturbance index or apnea/hypopnea index, which measures the number of times per hour that the individual shows disturbances in breathing. Most clinicians consider a patient to have disordered breathing if the patient experiences more than 10 disturbances per hour. In the transportation incidents described earlier, the respiratory disturbance index for the vehicle operators varied from 68 to 89. Essentially, these operators were waking up at night more than once a minute in order to breathe. Treatment Treatment for OSA commonly begins with the use of a device worn at night to deliver air pressure that holds the airway open. The device is typically a mask or nasal pillows, and the treatment is referred to as continuous positive airway pressure or CPAP. The mask may be uncomfortable, but must be used every night to be effective a single night without the device will leave the individual essentially untreated, at least in terms of daytime sleepiness (Kribbs, et al., 1993). Other treatments are also available: these include surgery, oral appliances worn at night, weight loss, and for some patients, simple changes in sleeping position. Weight loss can often have a dramatic effect, but may be difficult to achieve until the individual has been treated for the disorder. In some cases, it might be necessary to repeat a sleep study after treatment to ensure that the treatment is effective. Risk Factors Snoring Who is at risk for the disorder? First and foremost, snorers. Not all snorers have obstructive sleep apnea, but everyone with OSA snores. If an individual has an airway obstruction but continues to breathe, there will be noise. The snoring may be mild or it may be dramatic; pauses in breathing may often be audible and quite concerning to sleep partners. Page 2 of 5

3 Obesity Obesity is a significant risk factor for obstructive sleep apnea, and accounts for the remarkable increase in the prevalence of the disease over the last quarter-century. Based on a definition of obesity using a body mass index (BMI) of 30 or above, the U.S. Centers for Disease Control and Prevention (CDC) publishes the following statistics: 1980: Only 15% of US adults were obese (Fryar, et al., 2012). 2010: Nearly 36% of the US adult population was obese, with an even more marked rise in the extremely obese population (Fryar, et al., 2012). For reference, a 5 10 individual would have to weigh about 210 pounds to reach a BMI of 30. Of the individuals in another study with an average BMI of 40 (nearly 280 pounds for our 5 10 individual), more than 50% had undiagnosed OSA (Resta, et al., 2001). Neck Size Independent of body weight, a large neck circumference or collar size has also been associated with an increased risk of obstructive sleep apnea, particularly once it reaches more than 17 inches in men or 16 inches in women (Davies & Stradling, 1990). High Blood Pressure High blood pressure has also been very strongly associated with obstructive sleep apnea, though it is likely that this is an effect of the disorder rather than a cause. One study involved men whose blood pressure could not be well-controlled on three or more medications; 96% of these men had previously undiagnosed obstructive sleep apnea (Logan, et al., 2001). In addition to high blood pressure, untreated obstructive sleep apnea has been associated with heart disease, diabetes, stroke, and many other serious medical conditions (Rajagopalan, 2011). Consequences Beyond the dangers that OSA poses to the people who have it, individuals with untreated OSA may also present a significant risk to the public. An individual with OSA is more likely to fall asleep while operating a vehicle or other dangerous equipment. In addition, the individual may suffer from fatigue-related impairment of psychomotor and cognitive function, which also increases the risk of an accident, particularly when it comes to tasks that require vigilance. In one study, individuals with untreated OSA had more than a six-fold increase in the risk of a motor vehicle accident (Teran-Santos, Jimenez-Gomez, & Cordero-Guevara, 1999). This increase exceeds the risk elevation for individuals with a blood alcohol level of 0.10 percent (Compton, et al., 2002). Conclusion What s Being Done Almost every major U.S. newspaper and most transportation trade publications have published articles about OSA. In recent years, government agencies, academic organizations, employers, and Page 3 of 5

4 others have given substantial attention to OSA. Many have identified or recommended screening protocols for commercial drivers and other vehicle operators (Hartenbaum, et al., 2006; NTSB, 2009b; FMCSA, 2012). At least one major trucking company has implemented a screening and treatment program for obstructive sleep apnea. This program resulted in a reduction in the number of accidents, a decrease in health care costs, and an improvement in driver retention (Berger, et al., 2005). The Bottom Line Obstructive sleep apnea is an often-unrecognized contributor to serious accidents. It is a dangerous disorder to the individuals who have it (often without knowing it), to the public exposed to these sleepy workers, and to the companies that employ individuals with untreated OSA. Companies (especially transportation companies) that have not implemented education and evaluation programs to address the risks associated with this disorder are doing a disservice to the employees, the public, and their own bottom line. Workers who ignore the advice of their spouses, health care providers, or employers regarding screening, evaluation, or treatment are jeopardizing their own health and the safety of those around them. References Berger, M.B., et al., (2005). A corporate driven sleep apnea detection and treatment program: results and challenges. Proceedings of the International Truck and Bus Safety and Security Symposium, Alexandria, Virginia, Compton, R., et al., (2002). Crash Risk of Alcohol Impaired Driving. Proceedings of the 16th International Conference on Alcohol, Drugs and Traffic Safety, Montreal, Quebec, Canada Davies, R.J., & Stradling, J.R. (1990). The relationship between neck circumference, radiographic pharyngeal anatomy, and the obstructive sleep apnoea syndrome. European Respiratory Journal, 3, Federal Motor Carrier Safety Administration (2012). MCSAC-MRB Task Report. Fryar, C.D., et al., (2012). NCHS Health E-Stat: Prevalence of Overweight, Obesity, and Extreme Obesity Among Adults: United States, Trends Through National Center for Health Statistics. Retrieved from the World Wide Web on November 17, 2012 from Kribbs, N.B., et al., (1993). Effects of one night without nasal CPAP treatment on sleep and sleepiness in patients with obstructive sleep apnea. The American Review of Respiratory Disease, 147, Hartenbaum, N., et al., (2006). Sleep apnea and commercial motor vehicle operators. Journal of Occupational and Environmental Medicine, 48, S4 S37. Logan, A.G., et al., (2001). High Prevalence of Unrecognized Sleep Apnoea in Drug-Resistant Hypertension. Journal of Hypertension, 19, Page 4 of 5

5 National Transportation Safety Board (1997). Marine Accident Report: Grounding of the Liberian Passenger Ship Star Princess on Poundstone Rock, Lynn Canal, Alaska, June 23, NTSB MAR National Transportation Safety Board (2002). Work Zone Collision Between a Tractor-Semitrailer and a Tennessee Highway Patrol Vehicle, Jackson, Tennessee, July 26, NTSB HAR National Transportation Safety Board (2002a). Collision of Two Canadian National/Illinois Central Railway Trains near Clarkston, Michigan, November 15, NTSB RAR National Transportation Safety Board (2009). Report of Incident Number SEA08IA080. National Transportation Safety Board (2009a). Collision Between Two Massachusetts Bay Transportation Authority Green Line Trains, Newton, Massachusetts, May 28, NTSB RAR National Transportation Safety Board (2009b). Safety Recommendation Letter to the Federal Motor Carrier Safety Administration dated October 20, 2009 regarding NTSB Safety Recommendations H and H Rajagopalan, N. (2011). Obstructive sleep apnea: Not just a sleep disorder. Journal of Postgraduate Medicine, 57, Resta, O., et al., (2001). Sleep-Related Breathing Disorders, Loud Snoring and Excessive Daytime Sleepiness in Obese Subjects. International Journal of Obesity and Related Metabolic Disorders, 25, Teran-Santos, J., Jimenez-Gomez, A. & Cordero-Guevara, J. (1999). The Association Between Sleep Apnea and the Risk of Traffic Accidents, Cooperative Group Burgos-Santander. New England Journal of Medicine, 340, About the Author Mitchell A. Garber MD, MPH, MSME is a Senior Managing Consultant at Engineering Systems Inc. (ESI). Dr. Garber is a physician and engineer with over 20 years of military and civilian experience in transportation accident investigation. He was the first and only full-time Medical Officer for the U.S. National Transportation Safety Board, and participated in well over 1,000 investigations in all transportation modes. Dr. Garber also presented testimony to Congress regarding medical issues in transportation accidents. He specializes in the investigation of medical issues in transportation and other accidents, including the evaluation of pathology, toxicology, human performance, and biomechanics. About the IDC The Illinois Association Defense Trial Counsel (IDC) is the premier association of attorneys in Illinois who devote a substantial portion their practice to the representation of business, corporate, insurance, professional and other individual defendants in civil litigation. For more information on the IDC, visit us on the web at Statements or expression of opinions in this publication are those of the authors and not necessarily those of the association. IDC Quarterly, Volume 23, Number Illinois Association of Defense Trial Counsel. All Rights Reserved. Reproduction in whole or in part without permission is prohibited. Illinois Association of Defense Trial Counsel, PO Box 588, Rochester, IL , , , idc@iadtc.org Page 5 of 5

ROBERT C. PRITCHARD DIRECTOR MICHAEL O. FOSTER ASSISTANT DIR. SLEEP APNEA

ROBERT C. PRITCHARD DIRECTOR MICHAEL O. FOSTER ASSISTANT DIR. SLEEP APNEA A Person is physically qualified to drive a motor vehicle if that person; -(5) has no established medical history or clinical diagnosis