Sleep and sleep-disordered breathing in commercial long-haul truck drivers

Evaluation of advanced emergency braking systems in drowsy driving-related real-world truck collisions

STUDY OBJECTIVES

The effectiveness of advanced emergency braking systems (AEBS) in preventing drowsy driving-related truck collisions remains unclear. We aimed to evaluate the damage-mitigation effect of AEBS on drowsy driving-related collisions involving large trucks using collision rate and damage amount.

METHODS

Data collected by a Japanese transportation company from 1699 collisions involving 31 107 large trucks over 7 years were analyzed post hoc. The collision rate (number of trucks with collisions/total number of trucks) and damage amount (total amount of property damage and personal injury) were compared based on whether the collisions were caused by drowsy or nondrowsy driving and whether the trucks were equipped with AEBS or not.

RESULTS

For all and nondrowsy driving-related collisions, the collision rate for the 12 887 trucks with AEBS (1.62 and 1.20 collisions/truck/7 years, respectively) was significantly lower than that for the 18 220 trucks without AEBS (1.94 and 1.56 collisions/truck/7 years, respectively; p = .04 and p = .008, respectively). However, for drowsy driving-related collisions, the collision rate did not significantly differ between trucks with and without AEBS. The damage amount in neither type of collision (drowsy vs. nondrowsy) significantly differed between trucks with and without AEBS.

CONCLUSIONS

Regarding the collision rate of large trucks, AEBS was effective in nondrowsy driving-related collisions, but not in collisions involving drowsy driving. The damage amount was not mitigated for trucks with and without AEBS regardless of the collision type. The limited effect of AEBS for damage mitigation suggests the need for combined use with other safety-support systems that intervene in driving operations.

Achieving adherence to positive airway pressure in commercial drivers using an employer-mandated remote management programme

Background

Obstructive sleep apnoea (OSA) is common in commercial drivers, and associated with increased risk of crashes if untreated, making diagnosis and effective treatment crucial in this population.

Study design and methods

This is a retrospective summary of a clinical programme based on telemedicine and remote treatment monitoring developed with a national trucking company to screen new hires in the USA for OSA and implement positive airway pressure (PAP) management. New hires were informed of the programme and consented as part of their employment. Drivers who did not comply with the evaluation or with PAP after diagnosis were removed from driving commercial vehicles by the company or did not pursue further employment.

Results

A total of 975 drivers were enrolled. Among screened drivers, 35.5% were cleared without a sleep study, 15.0% were cleared following a sleep study (apnoea-hypopnoea index (AHI) <5 events·h-1), 22.1% had mild OSA (AHI 5-15) and 27.4% had moderate-severe OSA (AHI ≥15). Those with moderate-severe OSA were more obese (body mass index 36.2±6.3 kg·m-2) and had more comorbidities. Of 269 drivers starting PAP, 160 (59.5%) maintained participation in a care management programme, 80 (29.7%) resigned or were terminated, 23 (8.6%) were cleared to discontinue PAP and six (2.2%) were complex cases requiring transfer of care. Illustrating effectiveness, those that maintained participation had excellent PAP adherence (5.27±1.61 h·night-1; 88.5±12.9% days used; 79.7±17.7% days used ≥4 h).

Interpretation

Remote assessment of OSA and PAP management in commercial drivers is feasible and effective. This approach has wide-ranging applications, particularly in populations and areas with a lack of sleep medicine providers.

A New Screening Tool (BAMSA) for Sleep Apnea in Male Professional Truck Drivers

Obstructive sleep apnea (OSA) is common in professional truck drivers. It is important that OSA is recognized since undiagnosed and/or untreated sleep apnea is a risk factor for sleepiness-related traffic accidents. In this study, we developed a new simple tool to screen for obstructive sleep apnea (OSA) in this population. Altogether, 2066 professional truck drivers received a structured questionnaire. A total of 175 drivers had a clinical examination and were invited to participate in sleep laboratory studies, including cardiorespiratory polygraphy. We studied associations of different risk factors with the presence of sleep apnea. We established a new simple screening tool for obstructive sleep apnea (OSA) that was compared to other existing screening tools. A total of 1095 drivers completed the questionnaire. Successful cardiorespiratory polygraphy was obtained for 172 drivers. Full data were available for 160 male drivers included in the analyses. The following five risk factors for sleep apnea formed the BAMSA score (0 to 5): BMI > 30 kgm-2, age > 50 years, male gender, snoring at least one night per week, and the presence of apnea at least sometimes. BAMSA showed a sensitivity of 85.7% and a specificity of 78.8% in detecting AHI ≥ 15 when using a cut-off point of 4, and the ROC area was 0.823. BAMSA is a sensitive and easy-to-use tool in predicting obstructive sleep apnea in male professional drivers.

Advanced emergency braking system reduces the risk of motor vehicle collisions caused by falling asleep while driving in patients with untreated obstructive sleep apnea

Obstructive sleep apnea leads to excessive daytime sleepiness and cognitive dysfunction, which are risk factors for motor vehicle collisions. We aimed to clarify if vehicles with an advanced emergency braking system could reduce motor vehicle collisions caused by falling asleep while driving among patients with untreated obstructive sleep apnea. We enrolled patients with untreated obstructive sleep apnea who underwent polysomnography. The questionnaires included the Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, history of drowsy driving accidents, and use of an advanced emergency braking system. Multivariate analysis was performed, and odds ratios and 95% confidence intervals were calculated. This study included 1097 patients (mean age, 51.2 ± 12.9 years). Collisions caused by falling asleep while driving were recorded in 59 (5.4%) patients, and were more frequently observed in vehicles without an advanced emergency braking system (p = 0.045). Multivariate analysis showed that these collisions were associated with use of an advanced emergency braking system (odds ratio [95% confidence interval]: 0.39 [0.16-0.97], p = 0.04), length of driving (2.79 [1.19-6.50], p = 0.02), total sleep time (2.40 [1.62-3.55], p < 0.0001), sleep efficiency (0.94 [0.90-0.98], p = 0.003) and periodic limb movement index (1.02 [1.01-1.03], p = 0.004). The collision risk caused by falling asleep while driving in vehicles with an advanced emergency braking system was significantly lower. This study indicates that advanced emergency braking systems may be a preventive measure to reduce motor vehicle collisions among patients with untreated obstructive sleep apnea.

Describing economic benefits and costs of nonstandard work hours: A scoping review

BACKGROUND

The benefits of nonstandard work hours include increased production time and the number of jobs. While for some sectors, such as emergency services, around-the-clock work is a necessary and critical societal obligation, work outside of traditional daytime schedules has been associated with many occupational safety and health hazards and their associated costs. Thus, organizational- and policy-level decisions on nonstandard work hours can be difficult and are based on several factors including economic evaluation. However, there is a lack of systematic knowledge of economic benefits and costs associated with these schedules.

METHODS

We conducted a scoping review of the methodology and data used to examine the economic benefits and costs of nonstandard work hours and related interventions to mitigate risks.

RESULTS

Ten studies met all our inclusion criteria. Most studies used aggregation and analysis of national and other large datasets. Costs estimated include health-related expenses, productivity losses, and projections of future loss of earnings. Cost analyses of interventions were provided for an obstructive sleep apnea screening program, implementation of an employer-based educational program, and increased staffing to cover overtime hours.

CONCLUSIONS

A paucity of studies assess nonstandard work hours using economic terms. Future studies are needed to expand economic evaluations beyond the employer level to include those at the societal level because impacts of nonstandard work go beyond the workplace and are important for policy analysis and formulation. We pose the opportunity for researchers and employers to share data and resources in the development of more analyses that fill these research gaps.

Obstructive sleep apnea screening, diagnosis, and treatment in the transportation industry

Obstructive sleep apnea (OSA) is a common, identifiable, and treatable disorder with serious health, safety, and financial implications-including sleepiness- related crashes and incidents-in workers who perform safety-sensitive functions in the transportation industry. Up to one-third of crashes of large trucks are attributable to sleepiness, and large truck crashes result in more than 4,000 deaths annually. For each occupant of a truck who is killed, 6 to 7 occupants of other vehicles are killed. Treatment of OSA is cost-effective, lowers crash rates, and improves health and well-being. A large body of scientific evidence and expert consensus supports the identification and treatment of OSA in transportation operators. An Advanced Notice of Proposed Rulemaking regarding the diagnosis and treatment of OSA in commercial truck and rail operators was issued by the Federal Motor Carrier Safety Administration and Federal Railroad Administration, but it was later withdrawn. This reversal of the agencies' position has caused confusion among some, who have questioned whether efforts to identify and treat the disorder are warranted. In response, we urge key stakeholders, including employers, operators, legislators, payers, clinicians, and patients, to engage in a collaborative, patient-centered approach to address the disorder. At a minimum, stakeholders should follow the guidelines issued by a medical review board commissioned by the Federal Motor Carrier Safety Administration in 2016 alone, or in combination with the 2006 criteria, "Sleep Apnea and Commercial Motor Vehicle Operators," a Statement from the Joint Task Force of the American College of Chest Physicians, the American College of Occupational and Environmental Medicine, and the National Sleep Foundation developed by a joint task force. As research in this area continues to evolve, waiting is no longer an option, and the current standard of care demands action to mitigate the burden of serious health and safety risks due to this common, treatable disorder.

CITATION

Das AM, Chang JL, Berneking M, Hartenbaum NP, Rosekind M, Gurubhagavatula I. Obstructive sleep apnea screening, diagnosis, and treatment in the transportation industry. J Clin Sleep Med. 2022;18(10):2471-2479.

Predicting and mitigating fatigue effects due to sleep deprivation: A review

The deleterious effects of insufficient sleep have been well-established in the literature and can lead to a wide range of adverse health outcomes. Some of the most replicated findings demonstrate significant declines in cognitive functions such as vigilance and executive attention, psychomotor and cognitive speed, and working memory. Consequently, these decrements often lead individuals who are in a fatigued state to engage in substandard performance on everyday tasks. In the interest of curtailing these effects, prior work has attempted to identify mechanisms that predict fatigue onset and develop techniques to mitigate its negative consequences. Nonetheless, these results are often confounded by variables such as an individual’s resistance to fatigue, sleep history, and unclear distinctions about whether certain performance decrements are present due to fatigue or due to other confounding factors. Similar areas of research have provided approaches to produce models for the prediction of cognitive performance decrements due to fatigue through the use of multi-modal recording and analysis of fatigue-related responses. Namely, gathering and combining response information from multiple sources (i.e., physiological and behavioral) at multiple timescales may provide a more comprehensive representation of what constitutes fatigue onset in the individual. Therefore, the purpose of this review is to discuss the relevant literature on the topic of fatigue-related performance effects with a special emphasis on a variety of physiological and behavioral response variables that have shown to be sensitive to changes in fatigue. Furthermore, an increasing reliance on sleep loss, meant to assist in meeting the demands of modern society, has led to an upsurge in the relevance of identifying dependable countermeasures for fatigued states. As such, we will also review methods for the mitigation of performance effects due to fatigue and discuss their usefulness in regulating these effects. In sum, this review aims to inspire future work that will create opportunities to detect fatigue and mitigate its effects prior to the onset of cognitive impairments.

Prevalence of sleep apnea and daytime sleepiness in professional truck drivers

INTRODUCTION

The prevalence of obstructive sleep apnea (OSA) among professional truck drivers has varied from 28 to 78% in previous studies. In this study we wanted to estimate the prevalence of OSA and OSA with both subjectively measured sleepiness and objectively measured ability to stay awake (ie obstructive sleep apnea syndrome, OSAS) among professional truck drivers in Finland.

SUBJECTS AND METHODS

Altogether 2066 professional truck drivers received a structured questionnaire. 175 drivers had a clinical examination and sleep laboratory studies, which included respiratory polygraphy (RP) and maintenance of wakefulness test (MWT). Three groups were formed: 75 subjects with suspected sleep apnea, 75 healthy controls and a random sample of 25 subjects.

RESULTS

1095 drivers answered the questionnaire. RP was performed on 172 drivers and 167 drivers participated in MWT. The mean age was 40.7 years and the mean BMI was 27.7 kgm^-2. The prevalence of sleep apnea in professional truck drivers using various criteria were: AHI ≥5: 40.1%, AHI≥ 15: 16.2% and, AHI≥ 30: 7.2%. The prevalence depended on clinical history. Prevalence of AHI≥5 varied between 20 and 56.9% and prevalence of AHI≥15 was 4.3-25%. Altogether 4.8% of subjects with AHI ≥15 had abnormally short sleep latency in MWT (<19.4 min).

CONCLUSIONS

Moderate sleep apnea is common among professional truck drivers but significant inability to stay awake, defined as MWT <19.4 min, is found in about one of twenty professional drivers.

What Medical Conditions Limit or Medically Disqualify Truck Drivers: A Large Cross Sectional Study

Commercial Motor Vehicle drivers must be medically certified to obtain/maintain a commercial driver license. 88,246 exams from 2005 to 2012 were analyzed for relationships between health and certification length. Relationships were quantified using adjusted odds ratios (ORs). Most conditions and/or examination findings had statically significantly limited medical certification. Obesity > 35 kg/m2, hypertension and diabetes mellitus requiring medication were most common. Significant and meaningful relationships were found for opioid or benzodiazepine use (OR = 7.30), heart disease (OR = 5.19), musculoskeletal conditions (OR = 5.13), seizures (10.18), stroke (OR = 6.73), neurological (OR = 18.51) and vascular (OR = 11.83). Drivers with 2 or more of 13 medical conditions were statistically significantly more likely to have limited medical certification (OR = 122.35) or disqualification (OR = 4.91). Drivers with any condition are more likely to have limited medical certification. There is variability in medical certification lengths related to medical conditions and differences between examiners.

The prevalence of metabolic syndrome in drivers: A meta-analysis and systematic review

BACKGROUND

Metabolic syndrome is an increasing disorder, especially in night workers. Drivers are considered to work during 24 hours a day. Because of job characteristics such as stress, low mobility and long working hours, they are at risk of a metabolic syndrome disorder.

OBJECTIVES

The purpose of this study is a meta-analysis and systematic review of the prevalence of metabolic syndrome in drivers.

METHODS

In this systematic review, articles were extracted from national and international databases: Scientific Information Database (SID), Iran Medex, Mag Iran, Google Scholar, Science Direct, PubMed, ProQuest, and Scopus. Data analysis was performed using meta-analysis and systematic review (random effect model). The calculation of heterogeneity was carried out using the I2 index and Cochran's Q test. All statistical analyses were performed using STATA software version 11.

RESULTS

A total of nine articles related to the prevalence of metabolic syndrome in drivers in different regions of the world from 2008 to 2016 were obtained. The total sample size studied was 26156 with an average of 2906 samples per study. The prevalence of metabolic syndrome in drivers was 34% (95% CI: 30-37)CONCLUSIONS:According to the results of this study, the prevalence of metabolic syndrome in drivers is high. Occupational stress, unhealthy diet and physical inactivity cannot be cited as causes of metabolic syndrome prevalence in drivers. Therefore, to maintain and to improve the health of this group, the implementation of preventive, therapeutic and rehabilitation measures for these people as well as training should be considered.

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.

Screening for Sleepiness and Sleep Disorders in Commercial Drivers

Sleep disorders in commercial drivers are common and treatable. Left unidentified, they lead to a host of adverse consequences, including daytime sleepiness, adverse health effects, economic costs, and public safety risks owing to sleepiness-related crashes. The best studied of these is obstructive sleep apnea, which is common and identifiable among commercial drivers. This article provides an overview of screening, and specific approaches to screen for and manage obstructive sleep apnea in commercial drivers with the goal of reducing the risk of vehicular crashes.

Sleepiness and Driving: Benefits of Treatment

Drowsy driving is common and causes 21% of fatal crashes. Individuals at risk include young men, shift workers, older adults, and people with chronic short sleep duration, untreated obstructive sleep apnea (OSA), and narcolepsy. Untreated OSA is a particular concern in commercial drivers, who are at higher risk for the disorder. Treatment for sleep problems such as sleep extension for chronic short sleep, positive airway pressure (PAP) for OSA, pharmacologic treatments, and drowsy driving countermeasures may reduce the risk of crashes. Implementing screening measures to identify common sleep problems contributing to drowsy driving continues to be of high importance.

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.

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.

A retrospective analysis of cardiometabolic health in a large cohort of truck drivers compared to the American working population

BACKGROUND

Truck drivers face many health challenges, including lifestyle, diet, inactivity, stressors, and social support.

METHODS

A repeated cross-sectional analysis compared 88,246 truck drivers with data from (n = 11 918) the National Health and Nutrition Examination Survey (NHANES). Trends over time for body mass index (BMI), high blood pressure, diabetes mellitus, heart disease, and sleep disorders were analyzed, adjusting for potential confounders.

RESULTS

Truck drivers had significantly worsening health metrics between 2005 and 2012 compared to NHANES participants. Truck drivers were significantly more likely to be obese and morbidly obese with prevalence odds ratios (POR) and 95% confidence intervals (95%CI) of 1.99 (1.87, 2.13) and 2.34 (2.16, 2.54), respectively. Measured blood pressure, self-reported high blood pressure, diabetes mellitus, and heart disease all significantly increased. Also, sleep disorders increased among truck drivers from 2005 to 2012 (POR = 6.55, 95%CI 5.68, 7.55).

CONCLUSION

These data suggest disproportionate increases in poor health among truck drivers from 2005 to 2012.

Management of Obstructive Sleep Apnea in Commercial Motor Vehicle Operators: Recommendations of the AASM Sleep and Transportation Safety Awareness Task Force

ABSTRACT

The American Academy of Sleep Medicine Sleep and Transportation Safety Awareness Task Force responded to the Federal Motor Carrier Safety Administration and Federal Railroad Administration Advance Notice of Proposed Rulemaking and request for public comments regarding the evaluation of safety-sensitive personnel for moderate-to-severe obstructive sleep apnea (OSA). The following document represents this response. The most salient points provided in our comments are that (1) moderate-to-severe OSA is common among commercial motor vehicle operators (CMVOs) and contributes to an increased risk of crashes; (2) objective screening methods are available and preferred for identifying at-risk drivers, with the most commonly used indicator being body mass index; (3) treatment in the form of continuous positive airway pressure (CPAP) is effective and reduces crashes; (4) CPAP is economically viable; (5) guidelines are available to assist medical examiners in determining whether CMVOs with moderate-to-severe OSA should continue to work without restrictions, with conditional certification, or be disqualified from operating commercial motor vehicles.

Multiple Conditions Increase Preventable Crash Risks Among Truck Drivers in a Cohort Study

OBJECTIVE

This study aims to quantify the crash risk for truck drivers with multiple comorbid medical conditions, after adjusting for confounders.

METHODS

This retrospective cohort of 38,184 drivers evaluated concomitant medical conditions and subsequent crash data between January 1, 2005, and October 31, 2012. Hazard ratios (HRs) and 95% confidence intervals (95% CIs) were calculated for any cause and preventable crashes of varying severity.

RESULTS

Drivers with three or more medical conditions had a significantly increased risk of preventable Department of Transportation (DOT) reportable crashes (HR = 2.53, 95% CI = 1.65 to 3.88) and preventable crashes with injuries (HR = 2.23, 95% CI = 1.09 to 5.31) after adjustment for covariates. Similarly, adjusted HRs were 2.55 (95% CI = 1.37 to 4.73) for any cause DOT-reportable crashes and 3.21 (95% CI = 1.18 to 8.75) for any cause crashes with injuries.

CONCLUSIONS

Having three concomitant medical conditions may be a statistically significant risk factor for preventable and any cause DOT-reportable crashes and crashes with injuries.

The Urban Built Environment and Obesity in New York City: A Multilevel Analysis

Purpose.

To examine whether urban form is associated with body size within a densely-settled city.

Design.

Cross-sectional analysis using multilevel modeling to relate body mass index (BMI) to built environment resources.

Setting.

Census tracts (n = 1989) within the five boroughs of New York City.

Subjects.

Adult volunteers (n = 13,102) from the five boroughs of New York City recruited between January 2000 and December 2002.

Measures.

The dependent variable was objectively-measured BMI. Independent variables included land use mix; bus and subway stop density; population density; and intersection density. Covariates included age, gender, race, education, and census tract–level poverty and race/ethnicity.

Analysis.

Cross-sectional multilevel analyses.

Results.

Mixed land use (Beta = 2.55, p < .01), density of bus stops (Beta = −.01, p < .01) and subway stops (Beta = −.06, p < .01), and population density (Beta = −.25, p < .001), but not intersection density (Beta = −.002) were significantly inversely associated with BMI after adjustment for individual- and neighborhood-level sociodemographic characteristics. Comparing the 90th to the 10th percentile of each built environment variable, the predicted adjusted difference in BMI with increased mixed land use was −.41 units, with bus stop density was −.33 units, with subway stop density was −.34 units, and with population density was −.86 units.

Conclusion.

BMI is associated with built environment characteristics in New York City.

Definition and Importance of Autonomic Arousal in Patients with Sleep Disordered Breathing

Autonomic arousal at the end of sleep apnea events are not well-explored. We prospectively studied 20 patients with obstructive sleep apnea (OSA) and 24 healthy volunteers for 2 nights with cardiorespiratory polysomnography and continuous noninvasive blood pressure (Portapres). Recordings were scored visually for cortical and autonomic arousal. In the OSA group, 2151 cortical arousals and in the controls 1089 cortical arousals were scored. Respiratory arousal caused most frequently an increase of highest mean arterial blood pressure in patients and controls. A useful definition for autonomic arousal for OSA and controls based on blood pressure and heart rate analysis was developed.

The association between insomnia and cardiovascular risk factors in bus drivers in Iran

BACKGROUND

Road accidents are one of the most important issues in Iran which more than eighteen thousand persons are died annually because of this problem. Among the major reasons for this issue, sleepiness and cardiovascular disorder can be mentioned.

OBJECTIVE

To investigate the association between insomnia and cardiovascular risk factors among professional drivers who are at high risk during driving.

METHODS

A total of 1232 male bus drivers were included in the study and two different kinds of data sets were collected: (1) Sleep disorder information using Athens Insomnia Scale (AIS) and (2) Cardiovascular parameters such as systematic measurement of blood pressure, electrocardiography (ECG), total cholesterol, and triglyceride.

RESULTS

Our study demonstrated that the prevalence of insomnia in professional bus drivers was 8 percent. The study showed significant association between age, diastolic hypertension and work experience with final awakening earlier than desired (P < 0.05), the rate of the triglyceride level and total sleep duration (p = 0.02), and BMI and sleepiness during the day (P < 0.05).

CONCLUSIONS

Our study suggested that elevated serum triglyceride levels and increased diastolic blood pressure may be associated with some sleep complaints in drivers.

Co-Morbidity, Mortality, Quality of Life and the Healthcare/Welfare/Social Costs of Disordered Sleep: A Rapid Review

Sleep disorders are frequent (18%-23%) and constitute a major risk factor for psychiatric, cardiovascular, metabolic or hormonal co-morbidity and mortality. Low social status or income, unemployment, life events such as divorce, negative lifestyle habits, and professional requirements (e.g., shift work) are often associated with sleep problems. Sleep disorders affect the quality of life and impair both professional and non-professional activities. Excessive daytime drowsiness resulting from sleep disorders impairs efficiency and safety at work or on the road, and increases the risk of accidents. Poor sleep (either professional or voluntary) has detrimental effects comparable to those of major sleep disorders, but is often neglected. The high incidence and direct/indirect healthcare and welfare costs of sleep disorders and poor sleep currently constitute a major medical problem. Investigation, monitoring and strategies are needed in order to prevent/reduce the effects of these disorders.

The Association Between Cardiovascular Disease Risk Factors and Motor Vehicle Crashes Among Professional Truck Drivers

OBJECTIVE

This study assesses relationships between the Framingham cardiovascular disease risk (CVD risk) score and prevalence of US Department of Transportation (DOT)-reportable crashes in commercial motor vehicle (CMV) drivers, after controlling for potential confounders.

METHODS

Data were analyzed from CMV drivers (N = 797) in a large cross-sectional study. CVD risk was calculated for each driver. Adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs) between CVD risk and DOT-reportable crashes were calculated.

RESULTS

Drivers in the two highest CVD risk groups had significantly higher likelihood of crash (OR = 2.08, 95% CI = 1.20 to 3.63 and OR = 1.99, 95% CI = 1.05 to 3.77, respectively) after adjusting for confounders. There was a significant trend of increasing prevalence of crashes with an increasing CVD risk score (P = 0.0298).

CONCLUSION

Drivers with a high CVD risk had a higher likelihood of a crash after controlling for confounders.

Repeated Cross-Sectional Assessment of Commercial Truck Driver Health

OBJECTIVE

To assess relationships and trends over time in individual conditions and multiple conditions among a large sample of independent, nonoverlapping truck drivers using a repeated cross-sectional study design.

METHODS

Commercial driver medical examinations were conducted on 95,567 commercial drivers between January 1, 2005, and October 31, 2012. Specific medical conditions that have been identified by the Federal Motor Carrier Safety Administration's Medical Review Board as possibly increasing crash risk were examined. Prevalence and trends over time were analyzed.

RESULTS

A total of 8 of the 13 conditions significantly increased from 2005 to 2012. Prevalence of multiple concomitant conditions also increased, with prevalence odds ratios as high as 7.39 (95% confidence interval, 3.92 to 13.98) for four or more conditions in 2012 as compared with 2005.

CONCLUSIONS

Individual and multiple conditions thought to be associated with increased crash risk significantly increased between 2005 and 2012.

Commercial Driver Medical Examinations: Prevalence of Obesity, Comorbidities, and Certification Outcomes

Supplemental Digital Content is Available in the Text.

Objective:

The objective of this study was to assess relationships between body mass index (BMI) and comorbid conditions within a large sample of truck drivers.

Methods:

Commercial driver medical examination data from 88,246 commercial drivers between 2005 and 2012 were analyzed for associations between BMI, medical disorders, and driver certification.

Results:

Most drivers were obese (53.3%, BMI >30.0 kg/m²) and morbidly obese (26.6%, BMI >35.0 kg/m²), higher than prior reports. Obese drivers were less likely to be certified for 2 years and more likely to report heart disease, hypertension, diabetes mellitus, nervous disorders, sleep disorders, and chronic low back pain (all P < 0.0001). There are relationships between multiple potentially disqualifying conditions and increasing obesity (P < 0.0001). Morbid obesity prevalence increased 8.9% and prevalence of three or more multiple conditions increased fourfold between 2005 and 2012.

Conclusions:

Obesity is related to multiple medical factors as well as increasing numbers of conditions that limit driving certification.

Increased Muscle Sympathetic Nerve Activity and Impaired Executive Performance Capacity in Obstructive Sleep Apnea

STUDY OBJECTIVES

To investigate muscle sympathetic nerve activity (MSNA) response and executive performance during mental stress in obstructive sleep apnea (OSA).

METHODS

Individuals with no other comorbidities (age = 52 ± 1 y, body mass index = 29 ± 0.4, kg/m2) were divided into two groups: (1) control (n = 15) and (2) untreated OSA (n = 20) defined by polysomnography. Mini-Mental State of Examination (MMSE) and Inteligence quocient (IQ) were assessed. Heart rate (HR), blood pressure (BP), and MSNA (microneurography) were measured at baseline and during 3 min of the Stroop Color Word Test (SCWT). Sustained attention and inhibitory control were assessed by the number of correct answers and errors during SCWT.

RESULTS

Control and OSA groups (apnea-hypopnea index, AHI = 8 ± 1 and 47 ± 1 events/h, respectively) were similar in age, MMSE, and IQ. Baseline HR and BP were similar and increased similarly during SCWT in control and OSA groups. In contrast, baseline MSNA was higher in OSA compared to controls. Moreover, MSNA significantly increased in the third minute of SCWT in OSA, but remained unchanged in controls (P < 0.05). The number of correct answers was lower and the number of errors was significantly higher during the second and third minutes of SCWT in the OSA group (P < 0.05). There was a significant correlation (P < 0.01) between the number of errors in the third minute of SCWT with AHI (r = 0.59), arousal index (r = 0.55), and minimum O2 saturation (r = -0.57).

CONCLUSIONS

As compared to controls, MSNA is increased in patients with OSA at rest, and further significant MSNA increments and worse executive performance are seen during mental stress.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov, registration number: NCT002289625.

Hegmann K, Ott U, Thiese M, A. Murtaugh M. Long haul truck drivers’ views on the barriers and facilitators to healthy eating and physical activity

Purpose

– The purpose of this paper is to explore truck drivers’ views toward diet, physical activity, and health care access to inform the development of a weight loss intervention.

Design/methodology/approach

– The authors conducted four focus groups via teleconference (one) or in person (three). Each focus group included eight to ten truck drivers. Sessions were digitally recorded and transcribed. The authors used thematic analysis of the participant responses to develop themes and subthemes.

Findings

– Truck drivers desired good health, however, many knowledge gaps were identified. Drivers were aware of some healthy foods, but lacked knowledge of appropriate energy intake and healthy weight. Drivers expressed many barriers to eating healthy food and engaging in physical activity on the road. Participants suggested strategies and resources to improve their diet and increase physical activity.

Research limitations/implications

– This qualitative study included a convenience sample of 30 long-haul truck drivers. Consensus of themes and subthemes was achieved by four sessions. Issues facing long-haul truck drivers may be different than other truck drivers. Additional qualitative research should be conducted along with interventions focussed on healthy behaviors that can be implemented in the mobile working environment.

Originality/value

– This is the first focus group study of truck drivers that targets eating and physical activity. Future weight loss intervention designs should address the lack of knowledge and skills. To succeed, interventions should implement strategies to address perceived barriers: access, time limitations, and high cost of healthy lifestyle habits.

Sleep apnea and occupational accidents: Are oral appliances the solution?

BACKGROUND

Dental practitioners have a key role in the quality of life and prevention of occupational accidents of workers with Obstructive Sleep Apnea Syndrome (OSAS).

AIM

The aim of this study was to review the impact of OSAS, the Continuous Positive Airway Pressure (CPAP) therapy, and the evidence regarding the use of oral appliances (OA) on the health and safety of workers.

MATERIALS AND METHODS

Searches were conducted in MEDLINE (PubMed), Lilacs and Sci ELO. Articles published from January 1980 to June 2014 were included.

RESULTS

The research retrieved 2188 articles and 99 met the inclusion criteria. An increase in occupational accidents due to reduced vigilance and attention in snorers and patients with OSAS was observed. Such involvements were related to excessive daytime sleepiness and neurocognitive function impairments. The use of OA are less effective when compared with CPAP, but the results related to excessive sleepiness and cognitive performance showed improvements similar to CPAP. Treatments with OA showed greater patient compliance than the CPAP therapy.

CONCLUSION

OSAS is a prevalent disorder among workers, leads to increased risk of occupational accidents, and has a significant impact on the economy. The CPAP therapy reduces the risk of occupational accidents. The OA can improve the work performance; but there is no scientific evidence associating its use with occupational accidents reduction. Future research should focus on determining the cost-effectiveness of OA as well as its influence and efficacy in preventing occupational accidents.

The role of sleepiness, sleep disorders, and the work environment on heavy-vehicle crashes in 2 Australian states

Heavy-vehicle driving involves a challenging work environment and a high crash rate. We investigated the associations of sleepiness, sleep disorders, and work environment (including truck characteristics) with the risk of crashing between 2008 and 2011 in the Australian states of New South Wales and Western Australia. We conducted a case-control study of 530 heavy-vehicle drivers who had recently crashed and 517 heavy-vehicle drivers who had not. Drivers' crash histories, truck details, driving schedules, payment rates, sleep patterns, and measures of health were collected. Subjects wore a nasal flow monitor for 1 night to assess for obstructive sleep apnea. Driving schedules that included the period between midnight and 5:59 am were associated with increased likelihood of crashing (odds ratio = 3.42, 95% confidence interval: 2.04, 5.74), as were having an empty load (odds ratio = 2.61, 95% confidence interval: 1.72, 3.97) and being a less experienced driver (odds ratio = 3.25, 95% confidence interval: 2.37, 4.46). Not taking regular breaks and the lack of vehicle safety devices were also associated with increased crash risk. Despite the high prevalence of obstructive sleep apnea, it was not associated with the risk of a heavy-vehicle nonfatal, nonsevere crash. Scheduling of driving to avoid midnight-to-dawn driving and the use of more frequent rest breaks are likely to reduce the risk of heavy-vehicle nonfatal, nonsevere crashes by 2-3 times.

A prospective study of the role of sleep related disordered breathing as a risk factor for motor vehicle crashes and the development of systemic complications in non-commercial drivers

Introduction

Sleep related disordered breathing (SRDB), is an established risk factor for motor vehicle crashes (MVCs) involving commercial drivers. The role of SRDB in motor vehicle crashes involving non-commercial drivers is not well established.

Methods

Drivers involved in MVCs who were admitted to an American College of Surgeons accredited Level I trauma center for treatment of their injuries, and who could give informed consent and provide verbal responses to screening questionnaires were eligible for enrolment in this study. Two questionnaires previously validated for screening patients at risk for sleep disturbances (The Epworth Sleepiness Scale (ESS) and The Berlin Questionnaire (BQ)) were administered. Questionnaire results associated with an 85% sensitivity for predicting obstructive sleep apnea were considered positive. In this study we tested the hypothesis that patients at risk for SRDB, as measured by validated questionnaires, are at an increased risk being involved in MVCs.

Results

Between March and October 2010, 71 consecutive patients were offered enrolment in this study with 56 agreeing to participate in this study. Six were previously diagnosed with SRDB with only one being compliant and effectively treated at the time of their MVC. Forty-two patients (75%) had responses to the questionnaires that indicated that the patients were at high risk for SRDB. Six patients suffered systemic complications, including pleural effusions, pneumonia and arrhythmias, during their hospitalization with five (83%) having abnormal questionnaire responses indicating that the patient was at high risk for SRDB.

Conclusions

The high incidence of positive responses to the sleep questionnaires is consistent with the hypothesis that SRDB is potentially a significant risk factor for MVCs. Furthermore the observation that systemic complications were seen more commonly in those with SRDB, while not unexpected, is a novel observation. Further studies are needed to validate these findings in a larger cohort of patients as well as determining if these patients are truly at a greater risk for systemic complications. If replicated these observations would suggest that effective therapy for disordered sleep could play a significant role in an injury prevention process.

Sleep disordered breathing in primary care medicine

Primary care medicine plays a key role in the delivery of health care. Sleep disorders medicine is a new specialty and standard medical school curricula do not contain any or only very little training in sleep medicine. Unrecognized and therefore untreated sleep disorders account for a large loss of human life and socio-economic damage. Recognition of sleep disorders, in particular sleep-disordered breathing at the primary care level is thus a major element in health care delivery. The objective of this study was to assess the occurrence of the risk of sleep-disordered breathing (SDB) in a large primary care population. 852 primary care patients received a validated questionnaire which contained items based on signs and symptoms of SDB, periodic limb movement disorder (PLMD), and insomnia. A polygraphically validated algorithm was used to identify patients with a high suspicion of having sleep disordered breathing. Based on this algorithm 20% of the study participants had a high risk for SDB, 18.5% of PLMD and 25% of insomnia.Most commonly daytime sleepiness and fatigue was associated in patients with a positive likelihood of SDB, PLMD, and insomnia. Fifty percent of all primary care patients reported to snore while 31% of snorers reported to snore every night. SDB was twice as common in men than in women and associated with a significantly higher body mass index. A popular validated scale to assess the degree of daytime sleepiness, the Epworth sleepiness scale, was not always useful to document the degree of daytime sleepiness.We conclude that SDB, PLMD, and insomnia are very frequent sleep disorders in primary care patients yielding the need to include assessment of these sleep disorders in the medical history of primary care physicians.

Impaired vigilance and increased accident rate in public transport operators is associated with sleep disorders

OBJECTIVES

Sleep disturbances can impair alertness and neurocognitive performance and increase the risk of falling asleep at the wheel. We investigated the prevalence of sleep disorders among public transport operators (PTOs) and assessed the interventional effects on hypersomnolence and neurocognitive function in those diagnosed with obstructive sleep apnea (OSA).

METHODS

Overnight polygraphy and questionnaire data from 101 volunteers (72 males, median age 48 range [22-64] years, 87 PTOs) employed at the Gothenburg Public Transportation Company were assessed. Treatment was offered in cases with newly detected OSA. Daytime sleep episodes and neurocognitive function were assessed before and after intervention.

RESULTS

At baseline, symptoms of daytime hypersomnolence, insomnia, restless legs syndrome as well as objectively assessed OSA (apnea hypopnea index (AHI, determined by polygraphic recording)=17[5-46]n/h) were highly present in 26, 24, 10 and 22%, respectively. A history of work related traffic accident was more prevalent in patients with OSA (59%) compared to those without (37%, p<0.08). In the intervention group (n=12) OSA treatment reduced AHI by -23 [-81 to -5]n/h (p=0.002), determined by polysomnography. Reduction of OSA was associated with a significant reduction of subjective sleepiness and blood pressure. Measures of daytime sleep propensity (microsleep episodes from 9 [0-20.5] to 0 [0-12.5], p<0.01) and missed responses during performance tests were greatly reduced, indices of sustained attention improved.

CONCLUSIONS

PTOs had a high prevalence of sleep disorders, particularly OSA, which demonstrated a higher prevalence of work related accidents. Elimination of OSA led to significant subjective and objective improvements in daytime function. Our findings argue for greater awareness of sleep disorders and associated impacts on daytime function in public transport drivers.

Evaluation of a single-channel nasal pressure device to assess obstructive sleep apnea risk in laboratory and home environments

STUDY OBJECTIVES

To evaluate the sensitivity and specificity of a portable single-channel (intra-nasal pressure) sleep apnea device (ApneaLink) in both the laboratory and at home for assessment of sleep apnea risk in comparison with standard polysomnography (PSG).

METHODS

Fifty-five participants underwent simultaneous recordings of standard PSG and ApneaLink in the laboratory. Of these, 38 participants also used the ApneaLink device in their own homes for one night. PSG respiratory events were scored using standard criteria. Intra-nasal pressure signals were analyzed using the ApneaLink automated computerized algorithm provided to yield estimates of airflow for detection of apneas and hypopneas. Apnea-hypopnea indices (AHI) were compared.

RESULTS

There was high sensitivity and specificity for the ApneaLink AHI when compared to simultaneous PSG at comparable AHI levels (AHI ≥ 15 events/h; sensitivity 100%, specificity 92%; positive and negative predictive values 70% and 100%, respectively). Home-measured ApneaLink AHI sensitivity and specificity were also reliable when compared with PSG (AHI ≥ 5, 81% and 77%, respectively; AHI ≥ 15, 67% and 91%), and improved slightly when two nights' data were used (AHI ≥ 5, 88% and 85%; AHI ≥ 15, 67% and 93%).

CONCLUSIONS

The ApneaLink demonstrated good sensitivity and specificity in quantifying AHI when compared to PSG in a population with and without confirmed OSA. This simple, easy-to-use device may be useful in de novo large-scale occupational or underserved community OSA diagnostic programs to identify those with unambiguous disease who need immediate treatment or indicate those who may be at increased risk of OSA.

Excessive sleepiness prevalence in public transportation drivers of a developing country

OBJECTIVE

To determine the prevalence of excessive sleepiness (ES) in bus and auto-rickshaw drivers from Lima, Peru.

METHODS

We conducted a cross-sectional study of Lima's bus and auto-rickshaw drivers to estimate ES prevalence in this population. Survey sites were private transportation companies, systematically selected with a snowball approach. ES was assessed with the Spanish-validated version of the Epworth sleep questionnaire (ESQ) with a cutoff score >10. We obtained relevant demographic information.

RESULTS

Four hundred and thirty-four bus and auto-rickshaw drivers were eligible for analysis. The overall ES prevalence was 32.7 percent (95% confidence interval [CI]: 28-37.2). ES prevalence was higher in bus drivers than in auto-rickshaw drivers, 38 percent (95% CI: 31.7-44.2) and 26.9 percent (95% CI: 20.6-33.1), respectively (P = .01). We used data from all subjects to obtain regression equations for ESQ score with several predictors. Being a bus driver, working additional nighttime hours per week, having depression or anxiety, and alcohol abuse had small but significant associations with ESQ scores.

CONCLUSION

ES prevalence in Lima's public transportation drivers is in a medium range as suggested by previous regional studies.

Portable diagnostic devices for identifying obstructive sleep apnea among commercial motor vehicle drivers: considerations and unanswered questions

Obstructive sleep apnea (OSA), a syndrome defined by breathing abnormalities during sleep, can lead to fatigue and excessive daytime sleepiness (EDS) with an increased risk of motor vehicle crashes. Identifying commercial motor vehicle operators with unrecognized OSA is a major public health priority. Portable monitors (PMs) are being actively marketed to trucking firms as potentially lower-cost and more accessible alternatives to the reference standard of in-laboratory polysomnography (PSG) in the diagnosis of OSA among commercial motor vehicle operators. Several factors regarding PMs remain uncertain in this unique patient population: their sensitivity and specificity; the cost-benefit ratio of the PMs versus PSG; potential barriers from human factors; and evolving technologic advancement. Human factors that alter test accuracy are a major concern among commercial drivers motivated to gain/maintain employment. Current available data using PMs as a diagnostic tool among CMV operators indicate relatively high data loss and high loss to follow-up. Loss to follow-up has also been an issue using PSG in commercial motor vehicle operators. Furthermore, PM testing and PM results interpretation protocols may have no sleep specialist oversight, and sometimes minimal physician oversight and involvement. Additional studies comparing unattended and unmonitored PMs directly against full in-laboratory PSG are needed to provide evidence for their efficacy among commercial motor vehicle operators.

Impact of sleep apnea on economics

Obstructive sleep apnea syndrome (OSA) alters sleep quality and is associated with sleepiness and decreased cognitive functioning. It has therefore always been recognized as a major public health issue with potential societal consequences: accidents, increased morbidity, and cognitive deficits impairing work efficiency. The number of patients diagnosed and treated for OSA has increased drastically in the last few years. In response to this epidemic, health authorities have encouraged studies investigating how patients cope with OSA and also its diagnosis, comparing ambulatory to hospital-based polysomnography. Based on epidemiological knowledge, this review aims to carefully describe the possible links between sleep apnea and public health concerns along with identifying the certitudes and missing data concerning the consequences of sleep apnea on accidents, work, economics and health-related quality of life.

Sleep disorders, medical conditions, and road accident risk

Sleep disorders and various common acute and chronic medical conditions directly or indirectly affect the quality and quantity of one's sleep or otherwise cause excessive daytime fatigue. This article reviews the potential contribution of several prevalent medical conditions - allergic rhinitis, asthma, chronic obstructive pulmonary disease, rheumatoid arthritis/osteoarthritis - and chronic fatigue syndrome and clinical sleep disorders - insomnia, obstructive sleep apnea, narcolepsy, periodic limb movement of sleep, and restless legs syndrome - to the risk for drowsy-driving road crashes. It also explores the literature on the cost-benefit of preventive interventions, using obstructive sleep apnea as an example. Although numerous investigations have addressed the impact of sleep and medical disorders on quality of life, few have specifically addressed their potential deleterious effect on driving performance and road incidents. Moreover, since past studies have focused on the survivors of driver crashes, they may be biased. Representative population-based prospective multidisciplinary studies are urgently required to clarify the role of the fatigue associated with common ailments and medications on traffic crash risk of both commercial and non-commercial drivers and to comprehensively assess the cost-effectiveness of intervention strategies.

Obstructive sleep apnoea and anaesthesia

Obstructive sleep apnoea (OSA) correlates positively with obesity and age, both of which are becoming increasingly prevalent. Obstructive sleep apnoea occurs much more frequently in clinical practice than formerly diagnosed, and that this condition represents complex challenges for difficulty in mask ventilation, laryngoscopic intubation, accelerated arterial desaturation, postoperative monitoring and discharge status. In this review article pathophysiology, diagnosis, and perioperative management of this group of patients have been discussed in detail.

Age-related safety in professional heavy vehicle drivers: a literature review

With Australia facing a looming shortage of heavy vehicle drivers the question is raised as to whether it is desirable or prudent to encourage older professional heavy vehicle drivers to remain in the transport sector for longer, particularly those of heavy vehicles or recruit drivers of a younger age.

AIM

To review age-related safety and identify other factors that contribute to accidents experienced by heavy vehicle drivers.

METHODS

A search was conducted of national and international peer-reviewed literature in the following databases: MedLine, Embase, Cinahl, PsychInfo and the Canadian Centre for Occupational Health & Safety. A manual search was performed to obtain relevant articles within selected journals.

RESULTS

A limited number of studies reported age-specific accident rates for heavy vehicles for the spectrum of driver age that included drivers younger than 27 years and those over 60 years of age. Heavy vehicle drivers younger than 27 years of age demonstrated higher rates of accident/fatality involvement which decline and plateau until the age of 63 years where increased rates were again observed. Other contributing factors to heavy vehicle accidents include: long hours and subsequent sleepiness and fatigue, employer safety culture, vehicle configuration particularly multiple trailers, urbanisation and road classification.

CONCLUSIONS

Drivers of heavy vehicles are over-involved until age 27 years however a characteristic 'U' shaped curve indicates a higher risk of accident involvement for both younger and older drivers. More detailed analyses of "at-fault" involvement and inability to avert an accident and other factors that contribute to accidents across the ages of heavy vehicle drivers may give further clarification to the degree of safety of both younger and older commercial heavy vehicle drivers.