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

Impact of COVID-19 pandemic on sleep parameters and characteristics in individuals living with overweight and obesity

Coronavirus disease 2019 (COVID-19) has been very challenging for those living with overweight and obesity. The magnitude of this impact on sleep requires further attention to optimise patient care and outcomes. This study assessed the impact of the COVID-19 lockdown on sleep duration and quality as well as identify predictors of poor sleep quality in individuals with reported diagnoses of obstructive sleep apnoea and those without sleep apnoea. An online survey (June-October 2020) was conducted with two samples; one representative of Canadians living with overweight and obesity (n = 1089) and a second of individuals recruited through obesity clinical services or patient organisations (n = 980). While overall sleep duration did not decline much, there were identifiable groups with reduced or increased sleep. Those with changed sleep habits, especially reduced sleep, had much poorer sleep quality, were younger, gained more weight and were more likely to be female. Poor sleep quality was associated with medical, social and eating concerns as well as mood disturbance. Those with sleep apnoea had poorer quality sleep although this was offset to some degree by use of CPAP. Sleep quality and quantity has been significantly impacted during the early part of the COVID-19 pandemic in those living with overweight and obesity. Predictors of poor sleep and the impact of sleep apnoea with and without CPAP therapy on sleep parameters has been evaluated. Identifying those at increased risk of sleep alterations and its impact requires further clinical consideration.

Sleep Testing as a Pre-requisite for Commercial Motor Driving License is a Need of the Hour

Commercial drivers, including pilots, suffering from untreated sleep-related disorders endanger many lives. This puts them at risk of increased daytime somnolence. Through this brief communication, we urge the authorities to make the sleep study mandatory for these drivers to diagnose underlying sleep disorders like sleep apnea.

Ventilatory Burden as a Measure of Obstructive Sleep Apnea Severity Is Predictive of Cardiovascular and All-Cause Mortality

Rationale: The apnea-hypopnea index (AHI), used for the diagnosis of obstructive sleep apnea, captures only the frequency of respiratory events and has demonstrable limitations. Objectives: We propose a novel automated measure, termed "ventilatory burden" (VB), that represents the proportion of overnight breaths with less than 50% normalized amplitude, and we show its ability to overcome limitations of AHI. Methods: Data from two epidemiological cohorts (EPISONO [Sao Paolo Epidemiological Study] and SHHS [Sleep Heart Health Study]) and two retrospective clinical cohorts (DAYFUN; New York University Center for Brain Health) were used in this study to 1) derive the normative range of VB, 2) assess the relationship between degree of upper airway obstruction and VB, and 3) assess the relationship between VB and all-cause and cardiovascular disease (CVD) mortality with and without hypoxic burden that was derived using an in-house automated algorithm. Measurements and Main Results: The 95th percentiles of VB in asymptomatic healthy subjects across the EPISONO and the DAYFUN cohorts were 25.2% and 26.7%, respectively (median [interquartile range], VBEPISONO, 5.5 [3.5-9.7]%; VBDAYFUN, 9.8 [6.4-15.6]%). VB was associated with the degree of upper airway obstruction in a dose-response manner (VBuntreated, 31.6 [27.1]%; VBtreated, 7.2 [4.7]%; VBsuboptimally treated, 17.6 [18.7]%; VBoff-treatment, 41.6 [18.1]%) and exhibited low night-to-night variability (intraclass correlation coefficient [2,1], 0.89). VB was predictive of all-cause and CVD mortality in the SHHS cohort before and after adjusting for covariates including hypoxic burden. Although AHI was predictive of all-cause mortality, it was not associated with CVD mortality in the SHHS cohort. Conclusions: Automated VB can effectively assess obstructive sleep apnea severity, is predictive of all-cause and CVD mortality, and may be a viable alternative to the AHI.

Comparing the Driving Skills of Adolescents with Obstructive Sleep Apnea to Healthy Controls: The Results of a Case-Controlled Observational Study

Auto crashes are a leading cause of death and injury among adolescents. Untreated obstructive sleep apnea (OSA) can cause sleepiness and inattention, which could negatively impact novice drivers, but OSA-related studies have focused on older drivers. This study used a driving simulator to examine whether licensed 16-19-year-old adolescents with OSA have diminished driving skills. Twenty-one adolescents with OSA and twenty-eight without OSA (both confirmed using polysomnography) completed two randomly ordered driving trials in a simulator (with induced distractions versus without). A mixed ANOVA examined the between-subjects effect of the OSA group, the within-subjects effect of the distraction condition, and the group-by-condition interaction effect on the ability to maintain lane position and the frequency of extended eye glances away from the roadway. T-tests were also used to examine group differences in reported sleepiness and inattention during daily life. The distraction task increased extended off-road glances and difficulties maintaining lane position (p < 0.001). However, adolescents with OSA did not display worse eye glance or lane position than controls and there were no significant group-by-condition interactions. Although the groups differed on polysomonographic features, there were also no significant differences in reported sleepiness or inattention. The distraction task negatively impacted both groups of adolescent drivers, but those with OSA did not fare differentially worse. Most adolescents in our study had mild OSA (median obstructive apnea-hypopnea index = 4.4), the most common form in the community. It remains possible that youth with more severe OSA would show increased driving impairment.

Assessment of the cognitive function in adult Egyptian patients with obstructive sleep apnea using the Montreal Cognitive Assessment: a retrospective large-scale study

STUDY OBJECTIVES

Sleep apnea is a chronic disorder associated with multiple recognized comorbidities. Only a few studies focus on evaluating the cognitive profile in patients diagnosed with sleep apnea. The aim of the study was to assess the cognitive functions in this population using the Montreal Cognitive Assessment.

METHODS

The study cohort was 1,445 adult patients who were referred for overnight polysomnography, 764 cases and 681 healthy controls. All participants' clinical data and comorbidities were taken, and they all performed overnight polysomnography and Montreal Cognitive Assessment.

RESULTS

A significantly higher proportion (57.5%) of sleep apnea groups were males; 15.7% were illiterate compared to the non-sleep apnea group. Hypertension and diabetes mellitus were significantly more prevalent among studied patients with sleep apnea, and the mean total score for the Montreal Cognitive Assessment scale was significantly lower among those with sleep apnea at P < .001. Those with no sleep apnea showed a significantly higher function in all attributes compared to patients with sleep apnea-namely, language, orientation, abstraction, naming, attention, and recall (P < .05).

CONCLUSIONS

Logistic regression analysis was conducted to investigate predictors for occurrence of cognitive impairment (Montreal Cognitive Assessment score < 26) among the studied sample (n = 1,445). The overall model was significant at P < .001. Variables that showed significance in univariate analysis were entered in the model. Significant predictors for cognitive impairment were being male, older age, diabetic, hypertensive, and with a lower level of education and having sleep apnea.

CITATION

Mekky JF, Yousof S, Elsayed I, Elsemelawy R, Mahmoud H, Elweshahi H. Assessment of the cognitive functions in adult Egyptian patients with obstructive sleep apnea using the Montreal Cognitive Assessment: a retrospective large-scale study. J Clin Sleep Med. 2022;18(3):721-729.

Adaptation and validity of the Sleep Quality Scale among Chinese drivers

PURPOSE

Poor sleep quality is closed related with driving accidents. However, due to the lack of a valid instrument for assessing drivers' sleep quality, few studies have examined drivers' sleep quality and its associations with driving behaviours and traffic accidents in China. The aim of this paper is to revise the Sleep Quality Scale (SQS) and assess its reliability and validity in Chinese drivers.

METHODS

522 Chinese drivers aged from 18 to 56 years old agreed to complete the SQS, Daytime Sleepiness Perception Scale version 4 (DSPS-4), Self-report of Risky Driving Behavior (RD-SR) and Self-assessment of the Likelihood of Being Involved in a Risky Driving Situation (RD-SA).

RESULTS

The final Chinese version of the SQS contained 23 items across four factors: difficulty in getting up, difficulty in falling asleep, sleep recovery and daytime dysfunction. Second, man scored lower on the difficulty in falling asleep factor but higher on the sleep recovery factor than women. Third, low to moderate correlations were found between the SQS factors and the DSPS-4, RD-SA and RD-SR, indicating that the validity of the revised scale was satisfactory. More importantly, daytime dysfunction factor is an effective predictor of violation involvement and accident involvement.

CONCLUSION

The revised SQS has acceptable reliability and validity and can be used as a tool to measure the sleep quality of Chinese drivers.

Metrics of sleep apnea severity: beyond the apnea-hypopnea index

Obstructive sleep apnea (OSA) is thought to affect almost 1 billion people worldwide. OSA has well established cardiovascular and neurocognitive sequelae, although the optimal metric to assess its severity and/or potential response to therapy remains unclear. The apnea-hypopnea index (AHI) is well established; thus, we review its history and predictive value in various different clinical contexts. Although the AHI is often criticized for its limitations, it remains the best studied metric of OSA severity, albeit imperfect. We further review the potential value of alternative metrics including hypoxic burden, arousal intensity, odds ratio product, and cardiopulmonary coupling. We conclude with possible future directions to capture clinically meaningful OSA endophenotypes including the use of genetics, blood biomarkers, machine/deep learning and wearable technologies. Further research in OSA should be directed towards providing diagnostic and prognostic information to make the OSA diagnosis more accessible and to improving prognostic information regarding OSA consequences, in order to guide patient care and to help in the design of future clinical trials.

Impact of the COVID-19 pandemic on obstructive sleep apnea: recommendations for symptom management

STUDY OBJECTIVES

In the context of the current COVID-19 pandemic situation, we address the following important questions: (1) How can patients be identified for possible OSA while sleep clinic testing is temporarily unavailable or limited? and (2) What measures can be suggested to improve sleep health until proper diagnosis and treatment become safe and available again?

METHODS

As a proxy for home or in-laboratory testing, validation of a symptom-based measure of OSA risk is presented, based on an ongoing larger prospective study of 156 family medicine patients with OSA (88 women, 68 men; mean age, 57 years) and 60 control participants (36 women, 24 men; mean age, 54 years) recruited from the community. Participants completed the Sleep Symptom Checklist (SSC) and a range of other self-report measures; primary care patients also underwent a polysomnographic sleep study.

RESULTS

Results showed that (1) individuals with OSA reported more symptoms on the SSC related to insomnia, daytime symptoms, sleep disorders, and psychological maladjustment than did the control group (all P < .001), and (2) their sleep-related symptoms were significantly more severe than those of the control patients. In addition, several polysomnographic indices in recently diagnosed untreated individuals with OSA were significantly correlated with SSC measured sleep disorder symptoms, and SSC scores significantly distinguished participants with OSA from control participants.

CONCLUSIONS

Our findings suggest that family practitioners can effectively prescreen patients for possible OSA by inquiring about 5 items that form the SSC sleep disorders subscale. If OSA is suspected, then we can recommend a range of behavioral techniques to improve symptoms. The current pandemic causes us to reflect that the provisional targeting of symptoms and guidance regarding mitigation strategies while waiting for specialist care could serve patients well at any time.

Treatment of Obstructive Sleep Apnea: Choosing the Best Positive Airway Pressure Device

Positive airway pressure (PAP) remains primary therapy for most patients with obstructive sleep apnea (OSA). CPAP, APAP, and BPAP are all reasonable therapies that can be used for patients with uncomplicated OSA across the spectrum of disease severity. BPAP should be considered for patients who are nonadherent to CPAP or APAP therapy because of pressure intolerance. Several additional factors should be considered when choosing the type of PAP device for a given patient, including associated symptoms and comorbid medical problems, cost, access to online data management and patient portals, and the portability for the device for patients who travel frequently.

Impact of a shift in treatment funding on a multidisciplinary sleep clinic: a cohort study

Multidisciplinary Sleep Clinics for sleep apnea have long existed, bringing together neurologists, sleep specialists, dentists, orthodontists and surgeons. In Belgium, a shift in funding for obstructive sleep apnea treatment was implemented from January 1st, 2017. Funding was allowed for moderate to severe obstructive sleep apnea and the rules shifted for treatments delivery and monitoring by authorised medical opinion. We aimed to assess whether a shift in treatment funding was associated with a change in the multidisciplinary sleep practice. Sample consisted of all patients discussed in the sleep multidisciplinary team meetings of the University Hospital of Liege from January 2016 to December 2018. Interrupted times series, Mann-Whitney U tests and descriptive statistics were produced. There were no differences in patients age, male sex preponderance, body mass index, clinical presentation and level of obstruction. Baseline obstructive sleep apnea severity was significantly lower (mean apnea-hypopnea index and mean oxygen desaturation index lowered with p = 0.0189 and p = 0.0466, respectively) after the funding rules changed. Oral appliance and ENT surgery were more often offered after the shift in funding. The key changes of the new funding rules for obstructive sleep apnea were reflected in the patient selection and management by sleep multidisciplinary team meeting. Funding terms could influence the care we give, not only in treatment options, but also in patients selection.

OSA in Professional Transport Operations: Safety, Regulatory, and Economic Impact

OSA is common among commercial vehicle operators (CVOs) in all modes of transportation, including truck, bus, air, rail, and maritime operations. OSA is highly prevalent and increases the risk of drowsiness-related crashes in CVOs. Internationally, specific regulations regarding its identification and management vary widely or do not exist; medical examiners and sleep medicine specialists are urged to use available guidance documents in their absence. Education, screening, prompt identification and treatment, and ongoing surveillance to ensure effective therapy can lower the risk of fatigue-related crashes.

Distinguishing Obstructive Versus Central Apneas in Infrared Video of Sleep Using Deep Learning: Validation Study

Background

Sleep apnea is a respiratory disorder characterized by an intermittent reduction (hypopnea) or cessation (apnea) of breathing during sleep. Depending on the presence of a breathing effort, sleep apnea is divided into obstructive sleep apnea (OSA) and central sleep apnea (CSA) based on the different pathologies involved. If the majority of apneas in a person are obstructive, they will be diagnosed as OSA or otherwise as CSA. In addition, as it is challenging and highly controversial to divide hypopneas into central or obstructive, the decision about sleep apnea type (OSA vs CSA) is made based on apneas only. Choosing the appropriate treatment relies on distinguishing between obstructive apnea (OA) and central apnea (CA).

Objective

The objective of this study was to develop a noncontact method to distinguish between OAs and CAs.

Methods

Five different computer vision-based algorithms were used to process infrared (IR) video data to track and analyze body movements to differentiate different types of apnea (OA vs CA). In the first two methods, supervised classifiers were trained to process optical flow information. In the remaining three methods, a convolutional neural network (CNN) was designed to extract distinctive features from optical flow and to distinguish OA from CA.

Results

Overnight sleeping data of 42 participants (mean age 53, SD 15 years; mean BMI 30, SD 7 kg/m²; 27 men and 15 women; mean number of OA 16, SD 30; mean number of CA 3, SD 7; mean apnea-hypopnea index 27, SD 31 events/hour; mean sleep duration 5 hours, SD 1 hour) were collected for this study. The test and train data were recorded in two separate laboratory rooms. The best-performing model (3D-CNN) obtained 95% accuracy and an F₁ score of 89% in differentiating OA vs CA.

Conclusions

In this study, the first vision-based method was developed that differentiates apnea types (OA vs CA). The developed algorithm tracks and analyses chest and abdominal movements captured via an IR video camera. Unlike previously developed approaches, this method does not require any attachment to a user that could potentially alter the sleeping condition.

Impact of Habitual Snoring on Subjective Dental Esthetics in University Population

OBJECTIVE

The aims of this study were to assess the prevalence of snoring in the University population and to test the null hypothesis that there is no impact of habitual snoring on the self-perceived of dental esthetics.

MATERIALS AND METHODS

Berlin Questionnaire and esthetic component of the index of orthodontic treatment need was given to 700 students and employees aged 17-59 years (22 ± 4.5). Both snorers and nonsnorers were assessed for orthodontic treatment need. Chi-square and Student t-test were used to compare the difference between both groups using SPSS Statistics for Windows, Version 23.0. (IBM Corp, Armonk, NY).

RESULTS

The prevalence of snoring was 19.2% (male 11.8% and female 7.4%). Nodded off or fall asleep during driving a car or while waiting at least twice a month were reported in 46%. The prevalence of tiredness and fatigue after sleep from 3 to 4 times a week was 36.9% and during the working time was 33.6%. Based on the Berlin Questionnaire stratification for risk of obstructive sleep apnea (OSA), 8.2% were considered as a high-risk patient for OSA, (males: 3.8% and females: 4.4%). About 38.3% of the participants with habitual snoring have gone through orthodontic treatment, while only 28.5% of nonsnoring participant have done that. About 12.3% of snoring participant consider themselves in need of orthodontic treatment compared to 6.6% of a nonsnoring participant (P < 0.04).

CONCLUSION

The null hypothesis is rejected; snoring has an impact on the self-perceived of dental esthetics. Snoring participant seeks orthodontic treatment more than the nonsnoring participant in our University population.

The management, privacy and medico-legal issues of electronic CPAP data in Australia and New Zealand: Electronic CPAP data management in Australia and New Zealand

STUDY OBJECTIVE

Continuous Positive Airway Pressure (CPAP) is considered to be the gold standard treatment for obstructive sleep apnoea (OSA). CPAP monitoring systems allow tracking of patient CPAP adherence and treatment efficacy, by measuring residual sleep-disordered breathing, hours of CPAP use, and mask leak etc. The American Thoracic Society (ATS) published a position paper in 2013 highlighting issues of interpreting CPAP data such as a lack of consistency between CPAP manufacturers data algorithms, legal implications of CPAP data and implications for CPAP adherence. This paper extends on this work by investigating these issues in an Australasian context.

METHOD

A review of current literature on CPAP monitoring systems, privacy and security of CPAP data for major Australasian CPAP providers, and CPAP adherence was undertaken. A legal review was also commissioned for issues related to privacy and security of CPAP data.

RESULTS

CPAP manufacturers' utilize different algorithms for respiratory event detection and clinicians need to be aware the implications for interpreting CPAP data. Australasian CPAP manufacturers have created security/privacy policies with the intent to follow relevant legislation to protect patients' CPAP data, however they do need to be constantly reviewed and updated to avoid data breaches and changes to agreements. No guarantees can be provided by the Australasian Sleep Association on CPAP manufacturers' compliance with these policies and there is the potential for some degree of liability for physicians and CPAP providers associated with CPAP data. Lastly, providing patients with feedback on their CPAP usage and OSA management appears to have positive influence CPAP adherence.

CONCLUSIONS

CPAP data provides many opportunities to increase OSA patient care and to help patients self-manage this chronic condition. However, issues relating to lack of standardization of CPAP parameters, privacy, security, and legal implications will need to be managed in this changing technologic and clinical environment.

Treatment of Obstructive Sleep Apnea: Choosing the Best Positive Airway Pressure Device

Positive airway pressure (PAP) remains primary therapy for most patients with obstructive sleep apnea (OSA). CPAP, APAP, and BPAP are all reasonable therapies that can be used for patients with uncomplicated OSA across the spectrum of disease severity. BPAP should be considered for patients who are nonadherent to CPAP or APAP therapy because of pressure intolerance. Several additional factors should be considered when choosing the type of PAP device for a given patient, including associated symptoms and comorbid medical problems, cost, access to online data management and patient portals, and the portability for the device for patients who travel frequently.

Costos e impacto económico del síndrome de apnea-hipopnea obstructiva del sueño (SAHOS) para la salud pública

El síndrome de apnea-hipopnea obstructiva del sueño (SAHOS) no tratado se asocia con costos directos e indirectos significativos. Este trastorno también tiene un impacto negativo sobre el desempeño y la seguridad laboral y está implicado en una proporción considerable de accidentes automovilísticos. El diagnóstico oportuno y la terapia óptima han mostrado disminución en la utilización de los sistemas de salud y en los costos, al tiempo que atenúan los riesgos adversos. Del mismo modo, el SAHOS no tratado se asocia con incremento en las tasas de desempleo. Para los profesionales de la salud, tener un paciente con SAHOS involucrado en una colisión automovilística es de crucial importancia debido al daño personal y público, así como la potencial discapacidad física por el accidente. En Latinoamérica se requiere de la medición de los costos directos e indirectos dado el problema de salud pública que tiene asociado el SAHOS y las implicaciones mencionadas.

Assessment of patients' medical fitness to drive by primary care physicians: A cross-sectional study

OBJECTIVES

Motor vehicle collisions (MVCs) are a significant health burden in Saudi Arabia. The literature has consistently indicated that chronic medical conditions, such as diabetes, heart disease, stroke, obstructive sleep apnea, and neurodevelopmental disorders, increase the risk of MVCs. Therefore, assessment of driver fitness by primary care physicians (PCPs) remains a major health intervention that might reduce MVCs. We studied the practices of PCPs in assessing medical fitness to drive in at-risk patients.

METHODS

We conducted a cross-sectional study of all 88 government-funded primary care centers in the city of Riyadh, Saudi Arabia. We administered a self-reported questionnaire to PCPs that inquired about their driving risk assessment for specific medical conditions.

RESULTS

Among all PCPs and centers, 189 PCPs (63%) from 74 centers (84%) participated in our survey. The mean age of the PCPs was 40 ± 10 years, and 108 (57%) were men. The average clinical experience of the group was 13 ± 9 years. Fewer than half of PCPs considered diabetes mellitus (45%) and obstructive sleep apnea (46%) as potential risks for MVCs. Approximately 45% of PCPs did not notify any authority or relatives of potential driving issues that they noticed in their patients. Only 15% of the participants believed that PCPs were responsible for alerting authorities about their fitness to drive.

CONCLUSIONS

PCPs did not adequately assess their patients' driving history and eligibility. Efforts are needed to improve awareness among PCPs regarding the effects of chronic medical conditions on driving.

Factors that affect simulated driving in patients with obstructive sleep apnoea

Patients with obstructive sleep apnoea syndrome (OSAS) are at increased risk of involvement in road traffic accidents (RTAs) [1]. Clinicians diagnosing OSAS need to advise patients about driving but there are no validated tools and no robust objective data about which factors are important [2]. There are position statements, based solely on expert opinion, from various professional bodies [3–6]. In general, they conclude that a patient with significant daytime sleepiness and a recent RTA or near miss attributable to sleepiness, fatigue or inattention, should be considered a high-risk driver [3–6]. In a recent survey using clinical vignettes, we have shown that there is considerable variability in the advice that patients are likely to receive [7]. This indicates that clinicians require more robust guidance.

Objective data for advising sleep apnoea sufferers whether they are at increased risk of an accident when drivinghttp://ow.ly/TWPgm

Prevalence and risks of habitual snoring and obstructive sleep apnea symptoms in adult dental patients

OBJECTIVES

To determine the prevalence of habitual snoring and risk of obstructive sleep apnea (OSA) among dental patients and investigate factors associated with high-risk OSA.

METHODS

This cross-sectional study was performed at the Department of Preventive Dental Sciences, College of Dentistry, University of Dammam, Kingdom of Saudi Arabia, between October and December 2014. A total of 200 consecutive female and male dental patients were included in this study. Subjective and objective assessments were carried out. Habitual snoring and risk of OSA were assessed using the Arabic version of the Berlin questionnaire. Two trained investigators carried out the objective measurements of anthropometric data, blood pressure, oxygen saturation, pulse rate, and clinical examination of upper-airway, and dental occlusion. 

RESULTS

Habitual snoring was present in 18.2% of the females and 81.8% of the males (p less than 0.05). Breathing pauses during sleep of more than once a week occurred in 9% (n=17) of the sample. Of the males, 78.3% were at high risk of OSA compared with 21.7% of the females. Multivariate analysis for risk of OSA revealed that obese patients were almost 10 times more likely to report OSA symptoms than their non-obese counterparts (odds ratio: 9.9, 95% confidence intervals: 4.4-22.1). Tongue indentations, tonsil size, and a high Epworth Sleepiness Scale score were also independent risks of OSA.

CONCLUSION

Tongue indentations and tonsil grades III and IV were significantly associated with risk of OSA. This validates the important role of dentists in the recognition of the signs and symptoms of OSA.

Commercial Motor Vehicle Driver Obstructive Sleep Apnea Screening and Treatment in the United States: An Update and Recommendation Overview

ABSTRACT

No regulatory mandate exists in the United States (U.S.) for comprehensive obstructive sleep apnea (OSA) risk assessment and stratification for commercial motor vehicle (CMV) drivers. Current Federal Motor Carrier Safety Administration (FMCSA) requirements are outdated and depend largely on subjective report, a less reliable strategy in an occupational setting. Without FMCSA standards, sleep specialists, occupational medical examiners and employers rely on a collection of medical consensus recommendations to establish standards of care. These recommendations advise OSA risk assessment through a combination of focused medical history, physical examination, questionnaires, and accident history, which increase OSA detection compared to current FMCSA standards. For those diagnosed with OSA, consensus-based risk stratification helps identify CMV drivers who may benefit from OSA treatment and establish minimum standards for assessing treatment efficacy and adherence. Unfortunately no consolidated recommendation exists; rather, publications span medical and governmental literature in a patchwork fashion that no longer fully reflect current practice due to subsequent advances in OSA diagnosis, treatment, and technology. Based on searches of medical literature, internet materials, and reference lists from existing publications, an overview and discussion of key published recommendations regarding OSA assessment and treatment in CMV operators is provided. Suggestions for incorporating these recommendations into clinical sleep medicine practice in the U.S. are presented. The challenge for sleep specialists is maintaining the delicate balance between recommendations impacting standard of care and associated medico-legal impact with stakeholder interests from medical, regulatory, industry and public perspectives while providing high quality and efficient care.

Car Crashes and Central Disorders of Hypersomnolence: A French Study

Background

Drowsiness compromises driving ability by reducing alertness and attentiveness, and delayed reaction times. Sleep-related car crashes account for a considerable proportion of accident at the wheel. Narcolepsy type 1 (NT1), narcolepsy type 2 (NT2) and idiopathic hypersomnia (IH) are rare central disorders of hypersomnolence, the most severe causes of sleepiness thus being potential dangerous conditions for both personal and public safety with increasing scientific, social, and political attention. Our main objective was to assess the frequency of recent car crashes in a large cohort of patients affected with well-defined central disorders of hypersomnolence versus subjects from the general population.

Methods

We performed a cross-sectional study in French reference centres for rare hypersomnia diseases and included 527 patients and 781 healthy subjects. All participants included needed to have a driving license, information available on potential accident events during the last 5 years, and on potential confounders; thus analyses were performed on 282 cases (71 IH, 82 NT2, 129 NT1) and 470 healthy subjects.

Results

Patients reported more frequently than healthy subjects the occurrence of recent car crashes (in the previous five years), a risk that was confirmed in both treated and untreated subjects at study inclusion (Untreated, OR = 2.21 95%CI = [1.30–3.76], Treated OR = 2.04 95%CI = [1.26–3.30]), as well as in all disease categories, and was modulated by subjective sleepiness level (Epworth scale and naps). Conversely, the risk of car accidents of patients treated for at least 5 years was not different to healthy subjects (OR = 1.23 95%CI = [0.56–2.69]). Main risk factors were analogous in patients and healthy subjects.

Conclusion

Patients affected with central disorders of hypersomnolence had increased risk of recent car crashes compared to subjects from the general population, a finding potentially reversed by long-term treatment.