Obstructive Sleep Apnea and Work Accidents: Time for Action

Clinical Practice Guideline: Clinical Efficacy of Nasal Surgery in the Treatment of Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a common disorder characterized by upper airway obstruction during sleep. To reduce the morbidity of OSA, sleep specialists have explored various methods of managing the condition, including manifold positive airway pressure (PAP) techniques and surgical procedures. Nasal obstruction can cause significant discomfort during sleep, and it is likely that improving nasal obstruction would enhance the quality of life and PAP compliance of OSA patients. Many reliable studies have offered evidence to support this assumption. However, few comprehensive guidelines for managing OSA through nasal surgery encompass all this evidence. In order to address this gap, the Korean Society of Otorhinolaryngology-Head and Neck Surgery (KORL-HNS) and the Korean Society of Sleep and Breathing designated a guideline development group (GDG) to develop recommendations for nasal surgery in OSA patients. Several databases, including OVID Medline, Embase, the Cochrane Library, and KoreaMed, were searched to identify all relevant papers using a predefined search strategy. The types of nasal surgery included septoplasty, turbinate surgery, nasal valve surgery, septorhinoplasty, and endoscopic sinus surgery. When insufficient evidence was found, the GDG sought expert opinions and attempted to fill the evidence gap. Evidence-based recommendations for practice were ranked according to the American College of Physicians' grading system. The GDG developed 10 key action statements with supporting text to support them. Three statements are ranked as strong recommendations, three are only recommendations, and four can be considered options. The GDG hopes that this clinical practice guideline will help physicians make optimal decisions when caring for OSA patients. Conversely, the statements in this guideline are not intended to limit or restrict physicians' care based on their experience and assessment of individual patients.

Work-Related Sleep Disorders: Causes and Impacts

Insufficient sleep syndrome, shift work disorder, and obstructive sleep apnea (OSA) not only significantly impact the health of affected individuals, but also pose a threat to public safety. This article describes the clinical manifestations and impact of these sleep disorders, particularly as they pertain to workers' health and those with safety-sensitive positions. Sleep deprivation, circadian rhythm disruptions, and excessive daytime sleepiness-hallmarks of insufficient sleep, shift work disorder, and OSA, respectively-all lead to a series of cognitive deficits and impaired concentration that affect workers in a wide variety of fields. We describe the health consequences of these disorders along with treatment strategies, with a focus on current regulatory standards and the under-recognition of OSA in commercial drivers. Given its large scale, there is a need for improved guidelines and regulations for the screening, diagnosis, treatment, and long-term follow-up of OSA in commercial motor vehicle drivers. Increased recognition of the ways in which these sleep disorders impact workers will pave the way for significant improvements in occupational health and safety.

Changes in Attitudes of Life Insurance Companies Towards Patients with Sleep Apnea Syndrome Undergoing Continuous Positive Airway Pressure in Japan

Objective

Recent studies have revealed that sleep apnea syndrome (SAS) increases the risk of cardiovascular diseases and their risk factors, as well as the risk of traffic accidents. Although SAS screening and early treatment are important, truck drivers may avoid SAS screening to prevent the denial of their application for life insurance due to receiving continuous positive airway pressure (CPAP) treatment. Thus, this study investigated how life insurance companies handle patients on SAS treatment.

Material and Methods

We conducted a questionnaire survey on how they handle life insurance applications of patients with SAS on CPAP treatment for 46, 41, and 42 companies in 2009, 2015, and 2021, respectively, and analyzed the changes in their handling of life insurance applications of patients with SAS.

Results

The results revealed that while about 10 life insurance companies handle the application of life insurance of patients on CPAP treatment in the same way as healthy individuals, many life insurance companies handle them differently. This survey also revealed the differences in handling patients with SAS on CPAP treatment among companies and their policies regarding the reasons.

Conclusions

The survey revealed that there are differences among life insurance companies in handling patients with SAS on CPAP treatment. It is important to provide information about the companies that would not give disadvantages to patients with SAS on CPAP treatment who purchase life insurance. It is also crucial to provide life insurance companies with evidence of reduced risk of traffic accidents in patients with SAS on CPAP treatment.

Differential associations of hypoxia, sleep fragmentation, and depressive symptoms with cognitive dysfunction in obstructive sleep apnea

Obstructive sleep apnea (OSA) is characterized by recurrent episodes of partial or complete cessation of breathing during sleep and increased effort to breathe. This study examined patients who underwent overnight polysomnographic studies in a major sleep laboratory in Saudi Arabia. The study aimed to determine the extent to which intermittent hypoxia, sleep disruption, and depressive symptoms are independently associated with cognitive impairments in OSA. In the sample of 90 participants, 14 had no OSA, 30 mild OSA, 23 moderate OSA, and 23 severe OSA. The findings revealed that hypoxia and sleep fragmentation are independently associated with impairments of sustained attention and reaction time (RT). Sleep fragmentation, but not hypoxia, was independently associated with impairments in visuospatial deficits. Depressive symptoms were independently associated with impairments in the domains of sustained attention, RT, visuospatial ability, and semantic and episodic autobiographical memories. Since the depressive symptoms are independent of hypoxia and sleep fragmentation, effective reversal of cognitive impairment in OSA may require treatment interventions that target each of these factors.

Risk factors and clinical prediction formula for the evaluation of obstructive sleep apnea in Asian adults

Obstructive sleep apnea is a highly prevalent cyclic repetitive hypoxia-normoxia respiratory sleep disorder characterized by intermittent upper-airway collapse. It is mainly diagnosed using in-laboratory polysomnography. However, the time-spatial constraints of this procedure limit its application. To overcome these limitations, there have been studies aiming to develop clinical prediction formulas for screening of obstructive sleep apnea using the risk factors for this disorder. However, the applicability of the formula is restricted by the group specific factors included in it. Therefore, we aimed to assess the risk factors for obstructive sleep apnea and develop clinical prediction formulas, which can be used in different situations, for screening and assessing this disorder. We enrolled 3,432 Asian adult participants with suspected obstructive sleep apnea who had successfully undergone in-laboratory polysomnography. All parameters were evaluated using correlation analysis and logistic regression. Among them, age, sex, hypertension, diabetes mellitus, anthropometric factors, Berlin questionnaire and Epworth Sleepiness Scale scores, and anatomical tonsil and tongue position were significantly associated with obstructive sleep apnea. To develop the clinical formulas for obstructive sleep apnea, the participants were divided into the development (n = 2,516) and validation cohorts (n = 916) based on the sleep laboratory visiting date. We developed and selected 13 formulas and divided them into those with and without physical examination based on the ease of application; subsequently, we selected suitable formulas based on the statistical analysis and clinical applicability (formula including physical exam: sensitivity, 0.776; specificity, 0.757; and AUC, 0.835; formula without physical exam: sensitivity, 0.749; specificity, 0.770; and AUC, 0.839). Analysis of the validation cohort with developed formulas showed that these models and formula had sufficient performance and goodness of fit of model. These tools can effectively utilize medical resources for obstructive sleep apnea screening in various situations.

Sleep Apnea Screening for Commercial Drivers: A Retrospective Comparison of the 2016 FMCSA MRB Recommendations and the 2006 Joint Task Force Consensus Guidelines

OBJECTIVE

Compare the 2016 Federal Motor Carrier Safety Administration (FMCSA) and 2006 Joint Task Force (JTF) Guidelines for commercial drivers' obstructive sleep apnea (OSA) screening.

METHODS

Retrospective review of all commercial driver medical examinations performed in 2017 at an academic occupational medicine clinic. Screening criteria from both the JTF and FMCSA were applied, separately, and jointly. Statistical tests were applied as appropriate.

RESULTS

Applying the FMCSA or JTF criteria separately to 706 commercial drivers, the positive OSA screening yields were 15.7% and 16.9%, respectively. Using both criteria produced an overall positive OSA screen yield of 20.1%. Positive predictive values for applying both guidelines ranged from 72.7% to 95.5%.

CONCLUSIONS

The combined use of the 2016 FMCSA and 2006 JTF OSA screening criteria in series has a higher screening yield than using either guideline individually.

Validity analysis of respiratory events of polysomnography using a plethysmography chest and abdominal belt

PURPOSE

Respiratory inductive plethysmography (RIP) is recommended as an alternative respiratory sensor for the identification of each apnea and hypopnea event in polysomnography. Using this sensor, the cumulative RIP results from the chest and abdomen (RIP sum) and time-derived results of the RIP sum (RIP flow) are calculated to track respiratory flow. However, the effectiveness of this sensor and the calculated respiratory results is still unclear, and validation studies for the scoring of respiratory events in polysomnography are rare.

METHODS

Two hundred subjects were selected according to the severity of obstructive sleep apnea. A sleep specialist re-evaluated the respiratory events based on RIP flow data in a single-blind study. Statistical analysis was conducted with paired respiratory events scored in each of the RIP flow and polysomnography datasets.

RESULTS

All respiratory events scored from the RIP flow were strongly correlated with those identified with standard sensors of polysomnography, regardless of disease severity. Most of the respiratory parameters from RIP flow trended toward underestimation. The RIP flow obtained from the alternative RIP sensor was appropriate for the diagnosis of obstructive sleep apnea based on a receiver operating characteristic curve.

CONCLUSIONS

Scored respiratory events from RIP flow data effectively reflected the respiratory flow and statistically correlated with the results from standard polysomnography sensors. Therefore, analyzing RIP flow utilizing an RIP sensor is considered a reliable method for respiratory event scoring.

Sleep and Transportation Safety: Role of the Employer

Human fatigue is an important factor in transportation safety and a major causal factor of accidents. Employers play a vital role in minimizing fatigue-related risk, and are legally liable for damages arising from failure to address the risk. By taking an active role as stakeholders in transportation safety, employers not only reduce their risk of adverse safety events and limit their legal liability but may also benefit from improvements in productivity, morale, and health care expenditures. Employers should focus on reducing fatigue-related risk, with ongoing support from sleep safety research.

[Sleep-disordered breathing in occupational places: from screening to Health and Productivity Management]

BACKGROUND

Sleep-disordered breathing (SDB), represented by sleep apnea, is highly prevalent in the general population and is associated with alcohol intake and obesity. Since SDB is further associated with hypertension, diabetes, and future cardiovascular diseases, as well as accidents and injuries in workplaces, there is a need for complete SDB assessment in workers, including screening and the application of diagnostic and therapeutic approaches.

RESULTS

Currently, it appears that SDB assessment is not sufficiently conducted, even among commercial motor vehicle (CMV) drivers, despite CMV drivers with SDB being at a high risk of serious traffic accidents. Based on a discussion conducted in The Study Group for Sleep Disordered Breathing in Work Places, we summarized the current situation in Japan and tried to elucidate the bottleneck of these approaches. Then, the situation in Japan was compared with that in South Korea; Professor Chol Shin substantiated that the situation in South Korea was similar to that in Japan. However, recently published data on CMV drivers in the United States showed that appropriate treatment of SDB reduced the risk of traffic accidents among CMV drivers. This will encourage the implementation of the required processes, from screening to maintenance of treatment.

CONCLUSION

We propose a new approach based on "harmonizing work with treatment and prevention" and "Health and Productivity Management (HPM)" as a solution for implementing SDB programs.

Harmonizing work with the treatment and prevention of sleep disordered breathing in commercial motor vehicle drivers: implications for health and productivity management

The desastrous traffic accidents to date have provided the relevance for promotion of harmonization of work with treatment and prevention of sleep disordered breathing (SDB) in transport sectors. SDB is highly prevalent in commercial motor vehicle (CMV) drivers and is one cause of cognitive impairment and consequent traffic accidents, potentially costing billions and leading to many deaths. Various screening, diagnostic, and therapeutic approaches, some well established, are explored in this paper. Although drivers with SDB need to be appropriately diagnosed and treated, some are reluctant to continue their treatment or never submit to screening because of a lack of information. Thus, CMV drivers need to be well informed and screened, in addition to being encouraged to continue the treatment. The harmonization of work with treatment and prevention aids these objectives, providing benefits not only for individual health but also for transport companies, and further being an essential step towards uptake of "health and productivity management" in the transport sectors.

Snoring and breathing pauses during sleep: interview survey of a United Kingdom population sample reveals a significant increase in the rates of sleep apnoea and obesity over the last 20 years - data from the UK sleep survey

STUDY OBJECTIVES

(1) To determine the prevalence of snoring, breathing pauses during sleep and obstructive sleep apnoea syndrome in the United Kingdom (UK) and determine the relation between these events and obesity and other sociodemographic variables. (2) To compare and integrate this data with published UK population data.

METHODS

A total of 664 women and 575 men aged 18-100 years who formed a representative sample of the non-institutionalised UK population participated in an online interview survey directed by a previously validated computerised system.

RESULTS

Overall, 38% of men and 30.4% of women report that they snore at night. Furthermore, 8.7% of men and 5.6% of women state that they stop breathing at night. Comparing our data to published data from the 1990s, this study observes a highly significant increase in the rates of reported breathing pauses during sleep (sleep apnoea) in the UK over the last 20 years (p < 0.0001). In addition, we observe a highly significant increase in the prevalence of obesity (BMI>30) in the UK population between 1994 and 2015 (p < 0.0001). Integration of our data with NHS and public health England data on obesity confirms this increase.

CONCLUSIONS

Our data demonstrate a significant increase in the rates of reported breathing pauses during sleep (sleep apnoea) and obesity in the UK over the last 20 years. Sociodemographic and behavioural changes have likely contributed to this. Moreover, our data also suggests that sleep disordered breathing (SDB) is widely underdiagnosed in the UK.