LIFESAVERS April 23, 2018 San Antonio, TX 2:15 3:45 PM Room 214 D Sleepiness and Accidents: A Crash Course EVOLVING SAFETY PRIORITIES AND SOLUTIONS Asleep at the Wheel Understanding and Preventing Drowsy Driving aasm.org Healthy sleep, sleepiness and sleep disorders: role in motor vehicle accidents Indira Gurubhagavatula, MD, MPH Associate Professor of Clinical Medicine Director, Occupational Sleep Medicine Perelman School of Medicine University of Pennsylvania Director, Sleep Disorders Clinic VA Medical Center Philadelphia, PA X Conflict of Interest Disclosures for Speakers 1. I do not have any potential conflicts to disclose. 2. I wish to disclose the following potential conflicts of interest: American Academy of Sleep Medicine (AASM) Type of Potential Conflict Details of Potential Conflict Grant/Research Support Consultant Speakers Bureaus Financial support Other 3. The material presented in this lecture has no relationship with any of these potential conflicts, OR 4. This talk presents material that is related to one or more of these potential conflicts, and the following objective references are provided as support for this lecture: 1. 2. 3. 11,000 physicians, scientists, allied health professionals, accredited sleep centers leader in setting standards and promoting excellence in sleep medicine health care 2014 Sleep and Transportation Safety Awareness Task Force (STSATF) 2017 Occupational Sleep Health and Wellness Presidential Committee Asleep at the Wheel: Understanding and Preventing Drowsy Driving Mission Sleepiness and Accidents: A Crash Course Healthy sleep, sleepiness and sleep disorders: role in motor vehicle accidents (35 min) Shift work and crash risk (25 min) Sleep deprivation and crash risk (25 min) Occupational Sleep Health and Wellness Presidential Committee Engage occupations and populations at risk for sleep deprivation Provide education Effects of sleep deprivation Fatigue management strategies Monitor regulatory agencies actions related to sleep health and safety risks in employees safety-sensitive positions, have sleep disorders 1
Some of our activities What determines alertness? HOMEOSTATIC DRIVE FOR SLEEP Position statement aboutaddressing sleepiness and accidents in EMS and ride hailing industry Educational materials on sleep apnea, shift work, insomnia, sleep hygiene, drowsy driving, fatigue management Response to withdrawal of Noticeof Proposed Rulemaking on sleep apnea Internal Factors Stress/anxiety Urgency Motivation External Factors Alcohol, caffeine Medications Noise Physical activity CIRCADIAN DRIVE FOR WAKEFULNESS Increased behavioral capability Reduced behavioral capability Outline What is the difference between healthy sleep and disordered sleep? What determines alertness? What are some sleep disorders that can impact driving safety? Obstructive sleep apnea Shift work Sleep deprivation Disorders that cause sleepiness Length of time awake Time of day Duration of sleep Quality of sleep Normal sleep architecture HOURS OF SLEEP Conditions associated with daytime sleepiness Sleep disorders Obstructive sleep apnea Other sleep disorders (e.g., periodic limb movements, restless legs syndrome, narcolepsy) Some medical disorders Some psychiatric disorders Some medications Some behaviors (sleep hygiene) 2
http://content.revolutionhealth.com/contentimages/n5551303.jpg http://www.thetmjcenter.com/sleep_apnea.jpg Asleep at the Wheel Obstructive Sleep Apnea EXAMPLE OF AN APNEA What is obstructive sleep apnea? Who is likely to have it? How common is it? What are the usual symptoms? What are the consequences? Can we diagnose it quickly and at low cost? Can it be treated? Does treatment help? Does treatment make sense economically? Sleep apnea: what actually happens? OSA AND OXYGEN LEVEL DURING SLEEP AWAKE ASLEEP sleep architecture during sleep apnea Why are some people at risk for sleep apnea? Sleep fragmentation No N3, REM Desaturation OBESITY OBESITY OBESITY Airway crowding Large tonsils Large tongue Small jaw Heredity Middle age/older Male gender Female gender, after menopause Nasal congestion Alcohol, sedatives, narcotics www.thoracic.org 3
As obesity becomes more common, so does sleep apnea prevalence data from 1994 was used to model current prevalence rates, based on recent age, sex, BMI data from NHANES Prevalence of moderate to severe apnea 1994 (Young et al) (state employees, age 30-60 years) Men Women 9% 4% 2007-2010 (Peppard et al) 30-49 years 10% 3% 50-70 years 17% 9% Peppard, Am J Epidemiol, 177 (9):1006-1014; 2013 Costs of crashes due to undiagnosed OSA (2015, U.S.) AASM, 2016 Studies have linked OSA to crashes In-lab sleep study Research studies that were evaluated 18 studies in car drivers; 2 in truckdrivers Odds of crash 1.21-4.89 Brain waves Eye movement Chin, leg muscles Chest and abdomen effort Airflow, snoring Oxygen level 85% of cases remain undiagnosed http://www.fmcsa.dot.gov/facts-research/research-technology/report/fmcsa-rt-04-008.pdf Tregear et al, JCSM 2009, Dec 155(6); 573-581. NIGHTTIME APNEAS, HYPOPNEAS (observed by others) Snoring Choking, Gasping Frequent urination Life with sleep apnea worse with weight gain LOW OXYGEN ADRENALINE AROUSALS DAYTIME Sleepiness Crash risk mood, memory, concentration, attention, decisionmaking reaction time Morning headache Impotence produc vity Absenteeism LONG-TERM Hypertension Heart disease Stroke Pre-diabetes Death Brain waves Eye movement Chin, leg muscles Chest and abdomen effort Airflow, snoring Oxygen level Portable sleep study http://www.fette-thimm.de/img/embletta400.jpg 4
https://www.respshop.com/images/dreamstation-cpap-machine-2.jpg https://sleepright.com.au/wp-content/uploads/2012/05/resmed-s10-cpap-300x226.png http://www.1800cpap.com/images/products/detail/iconautoplussenseawakecpap.jpg Asleep at the Wheel Is sleep apnea treatable? http://amysorrells.files.wordpress.com/2012/06/flat_bicycle_tire.jpg In addition to improving oxygen level and sleep quality, what are the benefits of CPAP? CPAP lowers crash risk 1 blood pressure 2,3 heart disease, stroke 5,6,7 mortality 7,8 health care costs 9,10 CPAP improves alertness 1 performance on driving simulator 1 quality of life 4 1 Tregear, Sleep, 2010 2 Haentjens, Archives IntMed, 2007 3 Bazzano, Hypertension, 2007 4 Sanner, EurRespir J, 2000 5 Buchner, AJRCCM, 2007 6 Marin, Lancet, 2008 7 Yaggi, NEJM, 2005 8 Martinez-Garcia, AJRCCM, 2009 9 Albarrak, Sleep, 2005 10 Ronald, Sleep Res Online, 1998 Continuous positive airway pressure (CPAP) How do we know if patients are using CPAP? http://www.everettclinic.com/crs/aha/cpap.jpg Continuous positive airway pressure (CPAP) Monitoring therapy Did they wear it? Did the mask leak? Is apnea still present? http://www.sleepwise.com.au/images/d912193040.gif http://www.resmed.com/uk/images/cpap_treatment.jpg http://www.cpaptalk.com/in-house-cpap-news/images/encorepro/compliancescreen.jpg http://www.cpapxchange.com/cpap-machines-bipap-machines/sleepmapper-screens.png 5
Summary Sleep apnea is common causes sleepiness is linked to crashes, as well as major economic and health outcomes can be diagnosed in the home/berth CPAP treatment is inexpensive is accessible lowers crash risk improves many health conditions lowers health care costs can be tracked in realtime Occupational Sleep Health and Wellness: Dream Team Omer Ahmed, MD Michael Berneking, MD Jacob Collen, D Binal Kancherla, MD Shannon Sullivan, MD Indira Gurubhagavatula, MD, MPH (Chair) Questions? 6