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FMCSA issues advisory on Sleep Apnea.

The Federal Motor Carrier Administration (FMCSA) recently issued an advisory to all medical examiners who conduct DOT physicals under the NRCME program on sleep apnea. The full text of the advisory can be downloaded at

https://nationalregistry.fmcsa.dot.gov/NRPublicUI/documents/OSA%20Bulletin%20to%20MEs%20and%20Training%20Organizations-01122015.pdf

The advisory is in response to a call from Congressmen Buchon and Lupinski to ensure the agency clarified Congress’ mandate on sleep apnea screening and testing from Public Law 113-45 passed and signed by President Obama last November. The advisory was sent to medical professionals certified under the NRCME program to conduct DOT medical exams and training organizations who administer the training.

Points in the advisory sleep medicine drivers should be aware of include:

  • There is no requirement for screening for sleep apnea as part of a DOT medical exam.

This was a major reason there were calls for FMCSA to clarify OSA issues. Many of the training organizations giving the training on the NRCME program stressed the contents of the 3 major sets of medical recommendations made to FMCSA. These included various screening protocols.

The advisory stresses that a medical examiner may issue a conditional certification pending completion of additional testing only when in their expert medical opinion the driver has a disqualifying medical condition. This should be done through a combination of reported symptoms and medical history. No specific set of screening criteria of guidelines are required to be used by FMCSA. The advisory stresses that the medical examiner should explain this to the driver and explain the reasons for a conditional certification.

Driver being told by a medical examiner they will need to get a sleep study can get a second medical opinion from a different NRCME medical examiner. This has been covered in Land Line Magazine from OOIDA. The caveat is you MUST provide the second medical examiner the same information as the first. Falsifying or concealing information from a medical examiner is a federal felony and opens you to a whole can of worms in the event of even a non-preventable accident.

  • Home sleep tests for commercial drivers must include “chain of custody”.

“’Methods of diagnosis include in-laboratory polysomnography, at-home polysomnography, or other limited channel ambulatory testing devices which ensure chain of custody.”

There is no clarification available at this time as to what this means. Some vendors who use limited channel ambulatory testing devices also called home sleep studies (HST) for commercial drivers have developed affidavits the patient/driver signs attesting to the validity of the HST to establish legal chain of custody. Other vendors have proximity sensors that must be applied to the patient/drivers wrist and must be within a certain distance of the HST device.

There are vendors offering “DOT approved sleep studies”. Drivers should be aware that there is no such thing as a DOT approved sleep study.

In lab sleep studies (PSG) and in home PSG are also acceptable methods of testing for commercial drivers.

There are significant cost differences between in lab PSG ($ 1,750-3,000) and HST ($ 300-750).

  • Oral appliances are now acceptable for treating commercial drivers.

All three previous sets of guidance to DOT medical examiners on sleep apnea recommended not to certify drivers treated with oral appliances. This new advisory stresses the methods of treatment and effectiveness of treatment is a professional medical opinion of the treating specialist.

If you decide to explore an oral appliance as a treatment option you need to do your research. Work with a dental sleep medicine specialist. Some oral appliances melt and deform easily if left in a truck in the heat.

The Truckers for a Cause Chapter of A. W. A. K. E. awake.truckersforacause.com has an educational conference call with a dental sleep medicine expert on oral appliances for drivers.

  • For existing drivers CPAP compliance data requirements are not included.

The new language stresses the opinion of the treating healthcare professional rather than the old >4 hrs per night >70% of nights.

Whether or not drivers will now need to have an annual review of treatment for documentation of effective treatment for the DOT medical examiners is not clear. Whether this review of treatment must be done by an MD Board Certified in Sleep Medicine or any MD is not clear. Also whether or not treatment reviews can be done by RT’s, RPGST’s, RN, PA or other support staff in sleep medicine is unknown. As treatment options have been expanded to include oral appliances whether or not dentists or other Dental Sleep Medicine accreditation would be appropriate is unknown.

  • The advisory stresses the FMCSA’s goal is to address AHI>15.

This opens the questions on drivers diagnosed with an AHI<15 who do not show any symptoms.. It appears that a driver with an AHI<15 who in the expert medical opinion of a treating sleep specialist does not require treatment and is not showing symptoms of excessive daytime sleepiness and/or is not suffering from a respiratory dysfunction likely to cause loss of control of a commercial motor vehicle may be certified by the DOT medical examiner without treatment.

This advisory is the result of calls from both Congressmen and groups within trucking to clarify to DOT medical examiners the mandate given by Congress in public law 113-45 that there are no specific sleep apnea screening and testing requirements. Whether or not this advisory will get reactions from trucking groups for violating the congressional mandate to issue no new guidance without a formal rulemaking will be something to watch. The advisory does contain several points wanted by trucking but opposed by medical groups giving recommendations in the past.

Dr. Natalie Hartenbaum former President of the American College of Occupational and Environmental Medicine, Member of the 2006 Joint Task Force on Sleep Apnea in Commercial Motor Vehicle Operators, and an NRCME training program instructor put it.

“While the advisory does point out that FMCSA has no specific criteria, it does clearly remind examiners that OSA is a condition of potential concern which should not be ignored just because there is nothing official.  It advises examiner to consider commonly recognized risk factors in determining which drivers should be referred for additional testing. “

For more information about dealing with sleep apnea as a commercial motor vehicle operator check. www.truckersforacause.com. This is a support groups for truck drivers with sleep apnea run by truck drivers and part of the American Sleep Apnea Association.

 

 

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