Screening, diagnosis, and management of obstructive sleep apnea in dangerous-goods truck drivers: to be aware or not?

Self-reported sleep tendency poorly predicts the presence of obstructive sleep apnea in commercial truck drivers

BACKGROUND AND OBJECTIVES

Drowsy driving increases the risk of motor vehicle crashes in those with untreated obstructive sleep apnea (OSA). Although previous studies indicated that excessive daytime sleepiness (EDS) might not predict OSA, they were not conclusive due to their small study sizes or restricted participants to sleep clinic patients. The overall objective was to determine whether self-reported EDS can be used for case identification of OSA among commercial truck drivers.

METHODS

Commercial truck drivers (N = 19,699) were screened for OSA-related symptoms. EDS was determined using the Epworth Sleepiness Scale (ESS) ≥ 11 and all participants completed the home sleep apnea test using a type 4 portable monitor to derive the respiratory event index (REI). Regression analyses were used to characterize the association between EDS and REI.

RESULTS

EDS was associated with OSA severity (p for trend <0.001). The sensitivity and specificity values of EDS for identifying moderate-to-severe OSA (REI ≥15 events/hour) were 0.10 and 0.93, respectively, and 0.48 and 0.71 if BMI ≥25 kg/m2 was added. Those using BMI ≥25 kg/m2 with OSA-related signs yielded the best sensitivity and specificity of 0.77 and 0.50, which were not improved by the addition of EDS.

CONCLUSIONS

Despite the associations between EDS and OSA severity and between OSA and lethal crash, case-identification of OSA using the ESS in commercial truck drivers is poor. Thus, OSA screening strategy may need a special approach, including a hierarchical combination of screening tools (Swiss Cheese Model approach), and incorporation of home sleep apnea testing.

Long-term health outcomes for patients with obstructive sleep apnea: placing the Agency for Healthcare Research and Quality report in context-a multisociety commentary

This multisociety commentary critically examines the Agency for Healthcare Research and Quality (AHRQ) final report and systematic review on long-term health outcomes in obstructive sleep apnea. The AHRQ report was commissioned by the Centers for Medicare & Medicaid Services and particularly focused on the long-term patient-centered outcomes of continuous positive airway pressure, the variability of sleep-disordered breathing metrics, and the validity of these metrics as surrogate outcomes. This commentary raises concerns regarding the AHRQ report conclusions and their potential implications for policy decisions. A major concern expressed in this commentary is that the AHRQ report inadequately acknowledges the benefits of continuous positive airway pressure for several established, long-term clinically important outcomes including excessive sleepiness, motor vehicle accidents, and blood pressure. While acknowledging the limited evidence for the long-term benefits of continuous positive airway pressure treatment, especially cardiovascular outcomes, as summarized by the AHRQ report, this commentary reviews the limitations of recent randomized controlled trials and nonrandomized controlled studies and the challenges of conducting future randomized controlled trials. A research agenda to address these challenges is proposed including study designs that may include both high quality randomized controlled trials and nonrandomized controlled studies. This commentary concludes by highlighting implications for the safety and quality of life for the millions of people living with obstructive sleep apnea if the AHRQ report alone was used by payers to limit coverage for the treatment of obstructive sleep apnea while not considering the totality of available evidence.

CITATION

Patil SP, Billings ME, Bourjeily G, et al. Long-term health outcomes for patients with obstructive sleep apnea: placing the Agency for Healthcare Research and Quality report in context-a multisociety commentary. J Clin Sleep Med. 2024;20(1):135-149.

Worldwide prevalence and associated risk factors of obstructive sleep apnea: a meta-analysis and meta-regression

PURPOSE

This study aimed to identify the prevalence of obstructive sleep apnea (OSA) and associated risk factors globally.

METHODS

Six databases and registrations and three grey databases were explored for observational field research. Independently and impartially paired reviewers selected research, gathered data, and evaluated the methodological quality. Heterogeneity was investigated using subgroup analysis and meta-regression following the moderating variable in a meta-analysis of proportions with a random-effects model. The critical appraisal instrument developed by the Joanna Briggs Institute was used to evaluate the listed studies' methodology. The certainty of the evidence was evaluated using the GRADE tool.

RESULTS

A total of 8236 articles were collected during the database search, resulting in 99 articles included for qualitative synthesis, and 98 articles were included for the meta-analysis. The estimated combined prevalence of OSA was 54% [CI 95% = 46-62%; I2 = 100%]. Mean age, percentage of moderate-severe cases, and the sample's body mass index (BMI) did not affect the heterogeneity that was already present when meta-regressed (p > 0.05). Ninety-one studies were deemed to have a low risk of bias, while eight were deemed to have a moderate risk. For OSA prevalence outcomes, the GRADE criteria were considered very low.

CONCLUSION

Approximately half of the people worldwide have OSA. High BMI, increasing age, and male gender are described as risk factors in the literature, but these covariates do not affect pre-existing heterogeneity.

Screening for Obstructive Sleep Apnea in truck drivers

Professional drivers show a higher prevalence of obstructive sleep apnea (OSA) compared with the general population. OSA has been widely associated with an increased risk of traffic accidents. This article aims to investigate the presence of risk factors for OSA, its prevalence and the value of screening tools in a truck drivers' cohort. Descriptive and analytical prospective study. Demographic, anthropometric, Epworth Sleepiness Scale, STOP-Bang and Berlin Questionnaire were used to select subjects with suspicion of OSA. Polysomnography (PSG) was performed in individuals with positive screening. Mean age was 44.6±7 years, mean body mass index was 28.7±4 kg/m². Of the 281 truck drivers screened, 88 were positive for potential OSA. Of these, 63 completed PSG study and the diagnosis was confirmed in 85.7% (prevalence of 19.2%). The following variables showed a positive correlation with the apnea-hypopnea index: neck circumference and STOP-Bang. The combination of a predominantly male population, obesity, age distribution and lifestyle could account for the high prevalence of OSA in this specific population. Questionnaires proved to be a valuable screening tool. Screening, treatment, and management of OSA should be a priority as a public safety policy.

A multicomponent structured health behaviour intervention to improve physical activity in long-distance HGV drivers: the SHIFT cluster RCT

Background

Long-distance heavy goods vehicle drivers are exposed to a multitude of risk factors associated with their occupation. The working environment of heavy goods vehicle drivers provides limited opportunities for a healthy lifestyle, and, consequently, heavy goods vehicle drivers exhibit higher than nationally representative rates of obesity and obesity-related comorbidities, and are underserved in terms of health promotion initiatives.

Objective

The aim of this trial was to test the effectiveness and cost-effectiveness of the multicomponent Structured Health Intervention For Truckers (SHIFT) programme, compared with usual care, at both 6 months and 16–18 months.

Design

A two-arm cluster randomised controlled trial, including a cost-effectiveness analysis and process evaluation.

Setting

Transport depots throughout the Midlands region of the UK.

Participants

Heavy goods vehicle drivers.

Intervention

The 6-month SHIFT programme included a group-based interactive 6-hour education session, health coach support and equipment provision [including a Fitbit® (Fitbit Inc., San Francisco, CA, US) and resistance bands/balls to facilitate a ‘cab workout’]. Clusters were randomised following baseline measurements to either the SHIFT arm or the control arm.

Main outcome measures

Outcome measures were assessed at baseline, with follow-up assessments occurring at both 6 months and 16–18 months. The primary outcome was device-measured physical activity, expressed as mean steps per day, at 6-month follow-up. Secondary outcomes included device-measured sitting, standing, stepping, physical activity and sleep time (on any day, workdays and non-workdays), along with adiposity, biochemical measures, diet, blood pressure, psychophysiological reactivity, cognitive function, functional fitness, mental well-being, musculoskeletal symptoms and work-related psychosocial variables. Cost-effectiveness and process evaluation data were collected.

Results

A total of 382 participants (mean ± standard deviation age: 48.4 ± 9.4 years; mean ± standard deviation body mass index: 30.4 kg/m2 ± 5.1 kg/m2; 99% male) were recruited across 25 clusters. Participants were randomised (at the cluster level) to either the SHIFT arm (12 clusters, n = 183) or the control arm (13 clusters, n = 199). At 6 months, 209 (54.7%) participants provided primary outcome data. Significant differences in mean daily steps were found between arms, with participants in the SHIFT arm accumulating 1008 more steps per day than participants in the control arm (95% confidence interval 145 to 1871 steps; p = 0.022), which was largely driven by the maintenance of physical activity levels in the SHIFT arm and a decline in physical activity levels in the control arm. Favourable differences at 6 months were also seen in the SHIFT arm, relative to the control arm, in time spent sitting, standing and stepping, and time in moderate or vigorous activity. No differences between arms were observed at 16–18 months’ follow-up. No differences were observed between arms in the other secondary outcomes at either follow-up (i.e. 6 months and 16–18 months). The process evaluation demonstrated that the intervention was well received by participants and that the intervention reportedly had a positive impact on their health behaviours. The average total cost of delivering the SHIFT programme was £369.57 per driver, and resulting quality-adjusted life-years were similar across trial arms (SHIFT arm: 1.22, 95% confidence interval 1.19 to 1.25; control arm: 1.25, 95% confidence interval 1.22 to 1.27).

Limitations

A higher (31.4%) than anticipated loss to follow-up was experienced at 6 months, with fewer (54.7%) participants providing valid primary outcome data at 6 months. The COVID-19 pandemic presents a major confounding factor, which limits our ability to draw firm conclusions regarding the sustainability of the SHIFT programme.

Conclusion

The SHIFT programme had a degree of success in positively impacting physical activity levels and reducing sitting time in heavy goods vehicle drivers at 6-months; however, these differences were not maintained at 16–18 months.

Future work

Further work involving stakeholder engagement is needed to refine the content of the programme, based on current findings, followed by the translation of the SHIFT programme into a scalable driver training resource.

Trial registration

This trial is registered as ISRCTN10483894.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 12. See the NIHR Journals Library website for further project information.

Risk of work-related injury in workers with obstructive sleep apnea: A systematic review and meta-analysis

The objective of this study is to elucidate the relationship between obstructive sleep apnea (OSA) and the risk of work-related injuries (WRIs), synthesize the latest clinical evidence and conduct a systematic review and meta-analysis adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA 2020). Observational studies published before April 2020 in PubMed, Cochrane library, PsycINFO, Scopus, Google Scholar and Web of Science were included. Random-effects Mantel-Haenszel meta-analysis was performed. A total of 15 studies with 21,507 participants were included. Prespecified subgroup analyses based on study design and the characteristics of the enrollees were conducted. Overall, workers with OSA had 1.64-fold increased odds of being involved in WRIs compared to their counterparts (OR = 1.64, 95% CI = 1.24-2.16, p = 0.0005). In addition to the professional drivers that have been studied in the past, such a trend also existed in the general working population (OR = 1.68, 95% CI = 1.14-2.49, p = 0.01). We also found that workers with excessive daytime sleepiness (Epworth Sleepiness Scale score >10) had a 1.68-fold increased risk of WRIs compared to those with lower ESS scores (OR = 1.68, 95% CI = 1.22-2.30, p = 0.002). This study verified that OSA workers had a higher risk of WRIs, and such correlations do not show obvious differences in subgroups with different sample sizes, OSA diagnosis methods, job types or definitions of WRI. Based on the association between OSA and WRIs identified in our study, further studies investigating the protective effects of early identification and management of OSA on WRIs are warranted.

Sleepiness Behind the Wheel and the Implementation of European Driving Regulations

Sleep disturbance and sleepiness are established risk factors for driving accidents and obstructive sleep apnea (OSA) is the most prevalent medical disorder associated with excessive daytime sleepiness. Because effective treatment of OSA reduces accident risk, several jurisdictions have implemented regulations concerning the ability of patients with OSA to drive, unless effectively treated. This review provides a practical guide for clinicians who may be requested to certify a patient with OSA as fit to drive regarding the scope of the problem, the role of questionnaires and driving simulators to evaluate sleepiness, and the benefit of treatment on accident risk.

Determinants of Sleepiness at Wheel and Missing Accidents in Patients With Obstructive Sleep Apnea

STUDY OBJECTIVES

Motor-vehicle crashes are frequent in untreated OSA patients but there is still uncertainty on prevalence as well as physiological or clinical determinants of sleepiness at the wheel (SW) in OSA patients. We assessed determinants of SW or sleepiness related near-miss car accident (NMA) in a group of non-professional drivers with OSA.

METHODS

A 237 consecutive, treatment-naïve PSG-diagnosed OSA patients (161 males, 53.1 ± 12.6 years) were enrolled. Self-reported SW was assessed by positive answer to the question, "Have you had episodes of falling asleep while driving or episodes of drowsiness at wheel that could interfere with your driving skill in the last year?" Occurrence of NMA in the last 3 years was also individually recorded. Habitual self-reported average sleep time was collected.

RESULTS

SW was found in 41.3% of patients but one-quarter of patients with SW did not report excessive daytime sleepiness. Predictors of SW were the following subjective factors: Epworth sleepiness scale score (ESS-OR 1.26; IC 1.1-1.4; p < 0.0001), depressive symptoms (BDI-OR 1.2; IC 1.06-1.18; p < 0.0001) and level of risk exposure (annual mileage-OR 1.9; IC 1.15-3.1; p = 0.007). NMAs were reported by 9.7% of patients, but more frequently by SW+ than SW- (22.4% vs. 0.7%; χ2 31, p < 0.0001). The occurrence of NMAs was significantly associated to ESS, BDI, habitual sleep duration and ODI (R 2 = 0.41).

CONCLUSION

SW is not predicted by severity of OSA. Evaluation of risk exposure, assessment of depressive symptoms, and reported NMA should be included in the clinical evaluation, particularly in patients with reduced habitual sleep time and severe nocturnal hypoxia.

Validation of the STOP-Bang questionnaire for screening of obstructive sleep apnea in the general population and commercial drivers: a systematic review and meta-analysis

Purpose

Obstructive sleep apnea (OSA) is a critical occupational health concern, but is often undiagnosed in the general population and commercial drivers. The STOP-Bang questionnaire is a simple, reliable tool to screen for OSA, which could improve public health in a cost-effective manner. The objective of this systematic review and meta-analysis is to assess the validity of the STOP-Bang questionnaire to detect OSA in these key populations.

Methods

We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PsycINFO, Journals @ Ovid, Web of Science, Scopus, and CINAHL for relevant articles from 2008 to March 2020. The quality of studies was appraised using Cochrane Methods criteria. To calculate pooled predictive parameters, we created 2 × 2 contingency tables and performed random-effects meta-analyses.

Results

Of 3871 citations, five studies that evaluated STOP-Bang in the general population (n = 8585) and two in commercial drivers (n = 185) were included. In the general population, prevalence of all OSA (AHI ≥ 5), moderate-to-severe OSA (AHI ≥ 15), and severe OSA (AHI ≥ 30) was 57.6%, 21.3%, and 7.8% respectively. In commercial drivers, the prevalence of moderate-to-severe OSA was 37.3%. The trends of high sensitivity and negative predictive value of a STOP-Bang score ≥ 3 illustrates that the questionnaire helps detect and rule out clinically significant OSA in the general population and commercial drivers.

Conclusion

This meta-analysis demonstrates that the STOP-Bang questionnaire is a valid and effective screening tool for OSA in the general population and commercial drivers.

Trial registration

PROSPERO No. CRD42020200379; 08/22/2020

Supplementary Information

The online version contains supplementary material available at 10.1007/s11325-021-02299-y.

European Respiratory Society statement on sleep apnoea, sleepiness and driving risk

Obstructive sleep apnoea (OSA) is highly prevalent and is a recognised risk factor for motor vehicle accidents (MVA). Effective treatment with continuous positive airway pressure has been associated with a normalisation of this increased accident risk. Thus, many jurisdictions have introduced regulations restricting the ability of OSA patients from driving until effectively treated. However, uncertainty prevails regarding the relative importance of OSA severity determined by the apnoea–hypopnoea frequency per hour and the degree of sleepiness in determining accident risk. Furthermore, the identification of subjects at risk of OSA and/or accident risk remains elusive. The introduction of official European regulations regarding fitness to drive prompted the European Respiratory Society to establish a task force to address the topic of sleep apnoea, sleepiness and driving with a view to providing an overview to clinicians involved in treating patients with the disorder. The present report evaluates the epidemiology of MVA in patients with OSA; the mechanisms involved in this association; the role of screening questionnaires, driving simulators and other techniques to evaluate sleepiness and/or impaired vigilance; the impact of treatment on MVA risk in affected drivers; and highlights the evidence gaps regarding the identification of OSA patients at risk of MVA.

Comparison of commonly used screening tools for determining obstructive sleep apnea amongst aviation employees

INTRODUCTION

Epidemiological evidence suggests the prevalence of Obstructive Sleep Apnea (OSA) ranges 9-38%. Multiple screening tools are used to aid diagnosis. In professions that require high levels of attentiveness, safety, and responsibility for other's lives, inaccuracies and biases are probable for self-reported data. We sought to assess the best screening tool for OSA amongst aircraft pilots and air traffic controllers (ATCs).

METHODS

Data were collected as part of routine clinical care for patients presenting to Sleep Disorders Specialized Clinic. A total 1384 patients attended the clinic (2012-2018), of which 254 were either pilots or ATCs. Patients responded to three questionnaires, regularly used for OSA screening: 1) Epworth Sleepiness Scale (ESS); 2) Berlin Questionnaire (BQ); 3) STOP-BANG Questionnaire (SBQ). We used non-parametric ROC analysis, sensitivity, and specificity measures, along with positive and negative predictive values (PPV/NPV) to determine the most accurate diagnostic instrument.

RESULTS

The ROC (95% CI) for the ESS, BQ, and SBQ was 0.49 (0.39-0.59), 0.58 (0.49-0.67), and 0.56 (0.47-0.65), respectively. When the SBQ was used in combination with the ESS, the sensitivity was high at 100% (78.2-100.0), as were the PPV and NPV, 83.3% (58.6-96.4) and 100.0 (2.5-100.0), respectively.

CONCLUSION

The SBQ, in combination with the ESS, was the most reliable diagnostic tool for OSA in pilots and ATCs. Physicians should prioritize use of these screening tools for predicting OSA when assessing those working in the aviation industry and similar occupational groups, such as drivers. Given the scarcity of literature in this population, we recommend future studies replicate ours to either confirm or refute the findings.

Cluster randomised controlled trial to investigate the effectiveness and cost-effectiveness of a Structured Health Intervention For Truckers (the SHIFT study): a study protocol

INTRODUCTION

Heavy goods vehicle (HGV) drivers exhibit higher than nationally representative rates of obesity, and obesity-related comorbidities, in comparison to other occupational groups. Their working environments are not conducive to a healthy lifestyle, yet there has been limited attention to health promotion efforts. We have developed a Structured Health Intervention For Truckers (the SHIFT programme), a multicomponent, theory-driven, health-behaviour intervention targeting physical activity, diet and sitting in HGV drivers. This paper describes the protocol of a cluster randomised controlled trial designed to evaluate the effectiveness and cost-effectiveness of the SHIFT programme.

METHODS AND ANALYSIS

HGV drivers will be recruited from a logistics company in the UK. Following baseline measurements, depots (clusters) will be randomised to either the SHIFT intervention or usual-care control arm (12 clusters in each, average cluster size 14 drivers). The 6-month SHIFT intervention includes a group-based interactive 6-hour education session, worksite champion support and equipment provision (including a Fitbit and resistance bands/balls to facilitate a 'cab workout'). Objectively measured total daily physical activity (steps/day) will be the primary outcome. Secondary outcomes include: objectively measured light-intensity physical activity and moderate-to-vigorous physical activity, sitting time, sleep quality, markers of adiposity, blood pressure and capillary blood markers (glycated haemoglobin, low-density lipoprotein-cholesterol, high-density lipoprotein-cholesterol). Self-report questionnaires will examine fruit and vegetable intake, psychosocial and work outcomes and mental health. Quality of life and resources used (eg, general practitioner visits) will also be assessed. Measures will be collected at baseline, 6 and 12 months and analysed according to a modified intention-to-treat principle. A full process evaluation and cost-effectiveness analysis will be conducted.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Loughborough University Ethics Approvals Sub-Committee (reference: R17-P063). Study findings will be disseminated through publications in research and professional journals, through conference presentations and to relevant regional and national stakeholders via online media and at dissemination events.

TRIAL REGISTRATION NUMBER

ISRCTN10483894.

The Association of Obstructive Sleep Apnea Syndrome and Accident Risk in Heavy Equipment Operators

Background and Objectives: Obstructive sleep apnea syndrome (OSAS) is the most frequent sleep disorder, characterized by the repeated collapse of the upper respiratory tract during sleep. In this study, we aimed to determine the prevalence of OSAS in heavy equipment operators and to determine the relationship between the work accidents that these operators were involved in and the OSAS symptoms and severity. In doing this, we aimed to emphasize the association of OSAS, which is a treatable disease, and these accidents, which cause loss of manpower, financial hampering, and even death. Materials and Methods: STOP BANG questionnaire was provided to 965 heavy equipment operators and polysomnography (PSG) was performed, in Izmir Esrefpasa Municipality Hospital, to the operators at high risk for OSAS. Demographic data, health status, and accidents of these operators were recorded. Results: All operators who participated in the study were male. The ages of the cases ranged from 35 to 58 and the mean age was 45.07 ± 5.54 years. The mean STOP BANG questionnaire results were 4.36 ± 3.82. In total, 142 operators were identified with high risk for OSAS and PSG could be performed on 110 of these 142 operators. According to the PSG results of the operators, 41 (37.3%) patients had normal findings, while 35 (31.8%) had mild, 20 (18.2%) had moderate, and 14 (12.7%) had severe OSAS. Among those 110 patients, 71 (64.5%) of the cases had no history of any accidents, 25 (22.8%) were almost involved in an accident due to sleepiness, and 14 (12.7%) were actually involved in an accident. There was a statistically significant relationship between the accident rate and OSAS severity (p: 0.009). Conclusion: Based on the data acquired in the present study, a positive correlation was determined between the accident statuses of drivers with OSAS severity. We want to attract attention to the necessity of evaluating the OSAS symptoms in professional heavy equipment operators during the certification period and at various intervals afterwards, and to carry out OSAS evaluations by PSG for those having a certain risk.

Psychophysical stress and strain of maritime pilots in Germany. A cross-sectional study

Introduction

Maritime pilots work in an irregular deployment system (rotation system) with unpredictable work assignments under high levels of physical and mental stress. Fatigue or chronic diseases, e.g. coronary heart disease, peptic ulcers or gastritis can occur as a consequence. This can lead to long-term limitations of pilots’ work ability. The aim of this study is to analyse current stress and strain in maritime pilots.

Methods

Initially, all German pilots were interviewed with an online questionnaire about their living and working situation (response rate 43%). Subsequently, a medical and psychological examination of a random sample was carried out with pilots working in a 4-month rotation system compared with those working in a 1-week system. Most of the measurements took place at the beginning and the end of continuous work assignments each lasting several weeks (pre vs post-rotation). The questionnaires RESTQ-work 27, Resilience Scale RS-13 and Berlin Questionnaire were used as well as a sleeping diary. Furthermore, cardiovascular parameters (during rest and under ergometric stress), activity and blood parameters, urine stress hormones, and the pupillary unrest index were surveyed.

Results

60 pilots were recorded with an average age of 48.7 years (SD 8.3 years). Among the parameters collected, there were no significant differences between pre and post-rotation examinations. Pilots with a 4-month rotation system experienced a much higher subjective strain level in RESTQ work-27 (OR 10.12 (95% CI 1.21–84.59)). According to the sleep diaries of the pilots working in a 4-month rotation system, reduced levels were found concerning the pre and post-rotation subjective performance level (p = 0.042 and 0.029), subjective sleep duration (p = 0.032) and current subjective feeling post-rotation (p = 0.036). Objectively measured arterial hypertension was significantly more frequent among pilots working 4 months at a time (OR 21.41 (95% CI 1.26–364.05)). In addition, elevated levels of total cholesterol, triglycerides and uric acid were more common among this group of pilots (p = 0.038, p = 0.033 and p = 0.038). In particular, the risk of hypertriglyceridemia was increased (OR 4.41 (95% CI 1.15–16.91)).

Discussion

Maritime pilotage represents a very straining profession that has been studied very little up to this point. The present results indicate that 4-month rotation systems lead to higher levels of subjective and objective strain than 1-week rotation systems. Interventions are therefore recommended; especially a change in the rotation system should be considered.

Excessive daytime sleepiness in obstructive sleep apnea: implications for driving licenses

PURPOSE

Excessive daytime sleepiness (EDS) while driving is a major international public health issue resulting in a more than doubled risk of motor vehicle accidents (MVAs). Obstructive sleep apnea (OSA) is the most frequent medical cause of EDS. Therefore, the European Union Directive 2014/85/EU determined that "untreated moderate to severe OSA coincident with EDS constitutes a medical disorder leading to unfitness to drive." The paper aims are to provide a brief review of sleepiness and its implications for driving safety, as well as to describe the subjective and objective methods to accurately evaluate EDS in order to assess fitness to drive in patients with OSA.

METHODS

We examined databases including PubMed, Medline, and EMBASE using the search terms "sleepiness at the wheel, excessive daytime sleepiness, sleepiness measure, sleep-wake cycle, obstructive sleep apnea, driving license, fitness to drive."

RESULTS

Significant interindividual variability in EDS exists in patients with comparable severity of OSA. Objective methods of measuring EDS are too expensive and time consuming to be suitable for the certification of driving licenses. The reliability of subjective methods depends upon the clinical setting and subjective tools assess only limited aspects of EDS. Objective measures, such as biochemical biomarkers, must, therefore, support subjective methods.

CONCLUSIONS

Extensive data have supported different subjective and objective methods for the appraisal of EDS in patients with OSA depending upon the clinical and experimental setting. Challenges remain to determine an appropriate tool for the evaluation of fitness to drive.

Sleep and Mental Health in Truck Drivers: Descriptive Review of the Current Evidence and Proposal of Strategies for Primary Prevention

Background: Professional truck drivers (TDs) are exposed to stressful working (and living) conditions and are vulnerable. They report physical and mental health problems and psychological distress more frequently than the general population and their problems can affect safety on the roads. Actions to improve TDs’ health and reduce the risks of (co-)morbidity or unsafe driving are imperative. Methods: The published studies dealing with the TDs’ sleep habits and mental health were reviewed to define the scenario and organize the preventive strategies proposed thus far. Results: Awareness among TDs of the high risk for health and safety due to (often co-existing) untreated sleep and mental health problems is critical. Alcohol and prescribed or illicit drugs are often misused to compensate for depression, anxiety, job strain, fatigue, and social isolation. Polypharmacy and dependence increase the chance of unsafe behaviors on the road. The TDs’ access to healthcare services is scant, and participation in industry-sponsored wellness programs is limited. Conclusions: Primary prevention is a first unavoidable step to deal with sleep and mental health problems. Educational programs, online support and tele-health assessment/monitoring would help improve the well-being, safety and health of professional TDs and increase safety on the road.

Obstructive Sleep Apnea With or Without Excessive Daytime Sleepiness: Clinical and Experimental Data-Driven Phenotyping

Introduction: Obstructive sleep apnea (OSA) is a serious and prevalent medical condition with major consequences for health and safety. Excessive daytime sleepiness (EDS) is a common-but not universal-accompanying symptom. The purpose of this literature analysis is to understand whether the presence/absence of EDS is associated with different physiopathologic, prognostic, and therapeutic outcomes in OSA patients. Methods: Articles in English published in PubMed, Medline, and EMBASE between January 2000 and June 2017, focusing on no-EDS OSA patients, were critically reviewed. Results: A relevant percentage of OSA patients do not complain of EDS. EDS is a significant and independent predictor of incident cardiovascular disease (CVD) and is associated with all-cause mortality and an increased risk of metabolic syndrome and diabetes. Male gender, younger age, high body mass index, are predictors of EDS. The positive effects of nasal continuous positive airway pressure (CPAP) therapy on blood pressure, insulin resistance, fatal and non-fatal CVD, and endothelial dysfunction risk factors have been demonstrated in EDS-OSA patients, but results are inconsistent in no-EDS patients. The most sustainable cause of EDS is nocturnal hypoxemia and alterations of sleep architecture, including sleep fragmentation. These changes are less evident in no-EDS patients that seem less susceptible to the cortical effects of apneas. Conclusions: There is no consensus if we should consider OSA as a single disease with different phenotypes with or without EDS, or if there are different diseases with different genetic/epigenetic determinants, pathogenic mechanisms, prognosis, and treatment.The small number of studies focused on this issue indicates the need for further research in this area. Clinicians must carefully assess the presence or absence of EDS and decide accordingly the treatment. This approach could improve combination therapy targeted to a patient's specific pathology to enhance both efficacy and long-term adherence to OSA treatment and significantly reduce the social, economic, and health negative impact of OSA.

Can subjective sleep problems detect latent sleep disorders among commercial drivers?

INTRODUCTION

Long-haul truck drivers experience poor sleep health and heightened accident rates, and undiagnosed sleep disorders contribute to these negative outcomes. Subjective sleep disorder screening tools may aid in detecting drivers' sleep disorders. This study sought to evaluate the value of subjective screening methods for detecting latent sleep disorders and identifying truck drivers at-risk for poor sleep health and safety-relevant performance.

MATERIALS AND METHODS

Using cross-sectional data from 260 long-haul truck drivers, we: 1) used factor analysis to identify possible latent sleep disorders; 2) explored the construct validity of extracted sleep disorder factors by determining their associations with established sleep disorder risk factors and symptoms; and 3) explored the predictive validity of resulting sleep disorder factors by determining their associations with sleep health and safety-relevant performance.

RESULTS

Five latent sleep disorder factors were extracted: 1) circadian rhythm sleep disorders; 2) sleep-related breathing disorders; 3) parasomnias; 4) insomnias; 5) and sleep-related movement disorders. Patterns of associations between these factors generally corresponded with known risk factors and symptoms. One or more of the extracted latent sleep disorder factors were significantly associated with all the sleep health and safety outcomes.

DISCUSSION

Using subjective sleep problems to detect latent sleep disorders among long-haul truck drivers may be a timely and effective way to screen this highly mobile occupational segment. This approach should constitute one component of comprehensive efforts to diagnose and treat sleep disorders among commercial transport operators.

Is the Epworth Sleepiness Scale a useful tool for screening excessive daytime sleepiness in commercial drivers?

The significant social and economic impact of excessive daytime sleepiness makes sleep evaluation a primary medical need in commercial drivers. However, the best screening tool is still matter of debate. In our cohort of 221 commercial drivers, only ten (4.5%) had Epworth Sleepiness Scale scores indicative of excessive daytime sleepiness. These findings and the lack of concordance in estimating excessive daytime sleepiness among commercial drivers in previous studies using the same psychometric measure indicate that the Epworth Sleepiness Scale is not a reliable tool. This may be due to the low internal consistency of the scale in non-clinical samples and the possible intentional underscoring of sleepiness due to a perceived threat of driver's license suspension. Moreover, the reliability of the Epworth Sleepiness Scale results may be strongly influenced by the administration setting. The clinical application of inexpensive less time-consuming new tools like performance tests should be considered for the objective evaluation of excessive daytime sleepiness in commercial drivers.