Maryland College of Occupational and Environmental Medicine April 2014 Fabrice Czarnecki, M.D., M.A., M.P.H., FACOEM fczarnecki@gablesgroup.com I have no disclosures to make.
Guidelines 2006: Joint Task Force BMI 35 2007: MEP BMI 33 2008: MRB BMI > 30 February 2012: Motor Carrier Safety Advisory Committee (MCSAC) and Medical Review Board (MRB) joint recommendations on OSA BMI 35
http://mcsac.fmcsa.dot.gov/documents/feb2012/final_re port_task%2011-05_feb_2012_meeting.docx
BMI & Commercial Drivers BMI < 25 11.3% BMI 25-30 38.4% BMI 30-35 30% BMI 35-40 13.8% BMI > 40 6.4% AJRCCM 2004
OSA and commercial drivers Hours of service Increased risk of crash
OSA screening in commercial drivers Ask for history of OSA Ask for history of CPAP use Document BMI Think difficult intubation
Symptoms of OSA (MRB/MCSAC) Loud snoring Witnessed apneas Sleepiness during wake period
Risk factors for OSA / high risk (MRB/MCSAC) Small or recessed jaw Small airway (Mallampati Scale score of Class 3 or 4) Neck size > 17 inches (male), 15.5 inches (female) Hypertension (treated or untreated) Type 2 diabetes (treated or untreated) Hypothyroidism (untreated)
Other risk factors for OSA (MRB/MCSAC) BMI greater than or equal to 28 kg/m 2 Age 42 and above Family history Male or post-menopausal female Experienced a single-vehicle crash
Certify drivers with OSA Untreated OSA with AHI 20 and no daytime sleepiness Effective treatment
CPAP treatment Annual recertification CPAP compliance 4 hours / 70% of nights
Disqualify Drivers who admit experiencing excessive sleepiness while driving Drivers who experienced excessive a crash associated with falling asleep Drivers who are not compliant with CPAP treatment
Conditional certification AHI > 20 until compliant with CPAP After surgery BMI 35 pending sleep study 60 days CPAP compliant (> 7 days): 90 days then 1 year
OSA diagnosis Methods of diagnosis include in-laboratory polysomnography, at-home polysomnography, or an FDA-approved limited channel ambulatory testing device which ensures chain of custody.
Comorbidities Does your patient have a history of: Hypertension Diabetes Coronary artery disease Narcolepsy Obstructive sleep apnea Restless leg syndrome Any other sleep disorder
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers www.leo-medical.com
OSA and LEOs Drive in routine and emergency situations Vigilance Situational awareness Executive functioning
OSA Screen everybody Recommend sleep study if BMI > 32 Performance is the issue Fitness for duty evaluation No risk of sudden incapacitation Inability to do the job?
Fitness for Duty Criteria Observed or confessed excessive sleepiness Motor vehicle crash likely related to sleep disturbance
Fitness for Duty Criteria Observed performance impairment of LEO job functions suspected to be due to somnolence and associated decreased vigilance, executive functioning, and judgment Previously diagnosed OSA; noncompliant, no recent F/U, or surgical treatment without objective follow-up
OSA Treatment CPAP: 70% / 4 hours Annual review of data or for cause Oral appliance Mild OSA Unable to tolerate CPAP Confirm treatment response with sleep study
OSA Treatment Compliance Form for treating physician Comorbidities
Shift Work Disorder Insomnia and/or excessive sleepiness Diagnosis by sleep specialist Treatment Sleep hygiene Medications
Shift Work Disorder Restrictions if no adequate response to treatment Is shift work an essential job function of LEOs?
Other Sleep Disorders Narcolepsy Restless leg syndrome Idiopathic hypersomnia
Appendix on Sleep Hygiene Recommendations for officers Recommendations for agencies
Standard on Comprehensive Occupational Medical Program for Fire Departments 2013 Edition www.nfpa.org/1582
Applicants Untreated OSA Obstructive apneas (e.g., sleep apnea) if unresponsive to treatment Category B Category B Medical Condition. A medical condition that, based on its severity or degree, could preclude a person from performing as a member in a training or emergency operational environment by presenting a significant risk to the safety and health of the person or others.
Members Untreated OSA Obstructive sleep apnea, if not properly treated, might compromise the member s ability to safely perform essential job tasks 2, 3, 5, 8, 12, and 13, and after further evaluation and a final medical determination of the member s condition, the physician shall report any applicable job limitations to the fire department.
Explanatory Material Assess compliance with CPAP or BiPAP Consider echo: Pulmonary hypertension Right ventricular hypertrophy
Treated OSA Get CPAP compliance log Sleep study if oral appliance Form to treating physician Obtain original sleep study
Untreated OSA Obtain original sleep study Request new sleep study Compliance?
Comorbidities Hypertension Diabetes Hypoxia Metabolic syndrome
Metabolic Syndrome Three or more of the following components: Abdominal obesity, defined as a waist circumference >40 in. in men, >35 in. in women Triglycerides > 150 mg/dl HDL cholesterol < 40 mg/dl for men, < 50 mg/dl for women Blood pressure > 135/85 mmhg Fasting blood glucose > 110 mg/dl
Metabolic Syndrome Annual imaging stress test to 12 METS Lifestyle adjustments Exercise prescription Referral to treating physician
New Cycle for NFPA 1582 2018 edition Draft in July 2015 for public input Submission of public comments www.nfpa.org/1582