Implications of OSA on Work and Work Disability Including Drivers

Forced expiratory volume in one second: A novel predictor of work disability in subjects with suspected obstructive sleep apnea

Whether the association of work disability with obstructive sleep apnea (OSA) is mainly due to the disease, i.e. the number and frequency of apneas-hypoapneas, or to coexisting factors independent from the disease, is not well-established. In this study, we aim to evaluate work ability in a group of subjects undergoing OSA workup and to identify the major contributors of impaired work ability. In a cross-sectional study, we enrolled 146 consecutive subjects who have been working for the last five years and referred to the sleep disorders outpatients' clinic of the University-Hospital of Ferrara, Italy, with suspected OSA. After completing an interview in which the Work Ability Index (WAI) and the Epworth Sleepiness Scale (ESS) questionnaires were administered to assess work ability and excessive daytime sleepiness, respectively, subjects underwent overnight polysomnography for OSA diagnosing and spirometry. Of the 146 subjects, 140 (96%) completed the tests and questionnaires and, of these, 66 exhibited work disability (WAI < 37). OSA was diagnosed (apnea-hypopnea index ≥ 5) in 45 (68%) of the 66 subjects. After controlling for confounders, a lower level of forced expiratory volume at 1 second (FEV1), [odds ratio 0.97 (95% CI 0.95-1.00)], older age [1.09 (95% CI 1.03-1.15)], excessive daytime sleepiness [3.16 (95% CI 1.20-8.34)] and a worse quality of life [0.96 (95% CI 0.94-1.00)], but not OSA [1.04 (95% CI 0.41-2.62)], were associated with work disability. Patients with a higher number of diseases, in which OSA was not included, and a lower quality of life had an increased probability of absenteeism in the previous 12 months. In subjects with suspected OSA, FEV1 can be an important predictor of work disability.

Occupation and Obstructive Sleep Apnea: A Meta-Analysis

OBJECTIVE

Obstructive sleep apnea (OSA) remains a prevalent condition, but its occupational burden is unclear. We carried out a systematic review to characterize the consistency and magnitude of occupational associations with OSA.

METHODS

We studied OSA within three occupational categories: commercial drivers, organic solvent-exposed workers, other selected occupations. We performed a meta-analysis on the prevalence of OSA among drivers and the risk of OSA associated with solvent exposure.

RESULTS

The pooled OSA prevalence in drivers was 41% (95% confidence interval [CI] 26% to 56%) for apnea hypopnea-index (AHI) is greater than 5, and 15% (95% CI 12% to 19%) for AHI is greater than 15. Exposure to solvents was associated with increased but non-statistically significant risk of OSA: summary relative risk, 2.38 (95% CI 0.89 to 6.32). Evidence of occupational association was inconsistent for other factors.

CONCLUSIONS

OSA is common among commercial drivers and potentially associated with occupations involving likely solvent exposure.

Validated Measures of Insomnia, Function, Sleepiness, and Nasal Obstruction in a CPAP Alternatives Clinic Population

STUDY OBJECTIVES

Although efficacious in the treatment of obstructive sleep apnea (OSA), continuous positive airway pressure (CPAP) can be difficult to tolerate, with long-term adherence rates approaching 50%. CPAP alternatives clinics specialize in the evaluation and treatment of CPAP-intolerant patients; yet this population has not been studied in the literature. To better understand these patients, we sought to assess insomnia, sleep-related functional status, sleepiness, and nasal obstruction, utilizing data from validated instruments.

METHODS

After approval from the Emory University Institutional Review Board, a retrospective chart review was performed from September 2015 to September 2016 of new patient visits at the Emory CPAP alternatives clinic. Patient demographics and responses were recorded from the Insomnia Severity Index, Functional Outcomes of Sleep Questionnaire-10 (FOSQ-10), Epworth Sleepiness Scale, and Nasal Obstruction Symptom Evaluation questionnaires.

RESULTS

A total of 172 patients were included, with 81% having moderate-severe OSA. Most of the patients demonstrated moderate-severe clinical insomnia and at least moderate nasal obstruction. FOSQ-10 scores indicated sleep-related functional impairment in 88%. However, most patients did not demonstrate excessive daytime sleepiness.

CONCLUSION

This patient population demonstrates significant symptomatology and functional impairment. Because of the severity of their OSA, they are at increased risk of complications. In order to mitigate the detrimental effects of OSA, these significantly impacted patients should be identified and encouraged to seek CPAP alternatives clinics that specialize in the treatment of this population.

The utility of the elbow sign in the diagnosis of OSA

BACKGROUND

Multiple questionnaires have been used to predict the diagnosis of OSA. Such models typically have multiple questions requiring cumulative scoring for interpretation. We wanted to determine whether a simple two-part questionnaire has predictive value in the pretest clinical evaluation for OSA.

METHODS

A questionnaire consisting of two questions--(1) Does your bed partner ever poke or elbow you because you are snoring? and (2) Does your bed partner ever poke or elbow you because you have stopped breathing?--was prospectively administered to patients evaluated in a sleep disorders clinic prior to undergoing polysomnography. Age, sex, BMI, and Epworth Sleepiness Scale data were collected.

RESULTS

Among the 128 patients who had a polysomnogram, answering "yes" to being awakened for snoring increased the OR of an apnea-hypopnea index≥5/h 3.9 times compared with "no." Answering "yes" to being awakened for apneic spells was associated with an OR of 5.8 for an apnea-hypopnea index≥5/h compared with "no." These associations did not differ by sex, BMI, Epworth Sleepiness Scale or answering "yes" to the other question. Subjects>50 years old with OSA were less likely to report a positive elbow sign and had a significantly lower OR for being awakened for apneic spells than those<50 years old. The sensitivity and specificity of being awakened for apneic spells was 65% and 76%, respectively, with a positive predictive value of 90%. Subgroup analysis revealed that in men with a BMI>31 a positive elbow sign had a specificity of 96.6% for a diagnosis of OSA.

CONCLUSIONS

Among patients referred to a sleep disorders clinic, a positive response to being elbowed/poked for apneic spells significantly improves the pretest prediction of OSA.

Effect of continuous positive airway pressure on type 2 diabetes mellitus and glucose metabolism

BACKGROUND

Obstructive sleep apnea (OSA) is a prevalent condition that is associated with significant comorbidities, including obesity, hypertension, cardiovascular disease, and insulin resistance. Continuous positive airway pressure (CPAP) is an effective treatment for OSA. The effect of CPAP on glucose metabolism in patients with OSA has been controversial. This study evaluates the impact of CPAP on patients with OSA and type 2 diabetes mellitus (T2DM) or prediabetes.

MATERIALS AND METHODS

PubMed, Ovid Medline, and EMBASE were searched for original English language studies performed on or after 2003. Subjects were aged > 18 years, were diagnosed with OSA via polysomnography, and had either T2DM or prediabetes according to laboratory evaluation.

RESULTS

Of the 22 articles that met the selection criteria, 17 studies (77%) showed that a prolonged use of CPAP produced significant changes in glucose metabolism of patients who had T2DM and prediabetes. These changes were observed in studies measuring glycosylated hemoglobin (HbA1c), postprandial or nocturnal glucose, and insulin sensitivity or resistance. Of the 17 studies, 4 showed improvement in HbA1c levels or increased insulin sensitivity only after long-term use of CPAP for ≥ 3 months.

CONCLUSION

This literature review shows that CPAP improves not only hypoxia while restoring normal breathing during sleep, but also glucose metabolism in patients with OSA and T2DM or prediabetes. A few studies have shown that patients can experience even better results with long-term CPAP treatment (≥ 3 months of daily use) for > 4 hours a night. Therefore, this improvement in glucose metabolism with the use of CPAP may contribute to T2DM prevention and decrease further progression of the disease. However, additional studies are needed to confirm these findings.

Obstructive sleep apnea and driving: A Canadian Thoracic Society and Canadian Sleep Society position paper

Untreated patients with obstructive sleep apnea (OSA) are at increased risk for motor vehicle collisions; however, it is unclear how this should be translated into fitness-to-drive recommendations. Accordingly, the Canadian Thoracic Society (CTS) Sleep Disordered Breathing Clinical Assembly and the Canadian Sleep Society (CSS) assembled a CTS-CSS working group to propose recommendations with regard to driving in patients with OSA. Recommendations for assessing fitness to drive in noncommercial drivers: 1. Severity of OSA alone is not a reliable predictor of collision risk and, therefore, should not be used in isolation to assess fitness to drive; 2. The severity of sleep apnea should be considered in the context of other factors to assess fitness to drive; 3. The decision to restrict driving is ultimately made by the motor vehicle licensing authority; however, they should take into account the information and recommendations provided by the sleep medicine physician and should follow provincial guidelines; 4. For patients prescribed continuous positive airway pressure (CPAP) therapy, objective CPAP compliance should be documented. Efficacy should also be documented in terms of reversing the symptoms and improvement in sleep apnea based on physiological monitoring; 5. For patients treated with surgery or an oral appliance, verification of adequate sleep apnea treatment should be obtained; and 6. A driver diagnosed with OSA may be recertified as fit to drive based on assessment of symptoms and demonstrating compliance with treatment. The assessment should be aligned with the provincial driver's license renewal period. Commercial vehicles: Assessment of fitness to drive should be more stringent for patients operating commercial vehicles. In general, the CTS-CSS working group was in agreement with the Medical Expert Panel recommendations to the Federal Motor Carrier Safety Administration in the United States; these recommendations were adapted for Canadian practitioners.