Martin Duke, MD, MRO February 20, 2014

1. Martin Duke, MD, MRO February 20, 2014

2. Agenda • What is OSA? • Obstructive Sleep Apnea Cycle • Steps in OSA Evaluation

3. What is OSA? • OSA is defined as a condition, where during sleep, a narrowing or closure of the upper airway causes repeated sleep disturbances. • These sleep disturbances lead to poor sleep quality and excessive daytime sleepiness.

4. Obstructive Sleep Apnea Cycle The muscles that keep airways open in the day relax at night The throat is blocked by collapse of posterior pharynx during sleep Obstruction of air flow Oxygen levels in the blood fall The brain starts to arouse the person from sleep Breathing is restored Sleep resumes Obstruction recurs

5. Steps in OSA Evaluation • Screening • Treatment Methods and Outcomes • Certifications for Work

6. Screening • Factors with high risk • Neck size > 17” (male); > 16” (female) • BMI > 35 (Weight x 703 / Height x Height) • Hypertension – new, uncontrolled, or hard to control • Type 2 Diabetes • Loud Snoring • Daytime sleepiness in monotonous situations • Self Assessment Questionnaires • Epworth Sleepiness Scale (ESS) > 10 Indicates level of daytime sleepiness

7. Epworth Sleepiness Scale Form Measures general level of daytime sleepiness Was a great screening item but the CDL drivers got ‘wise’ and began to reduce their dozing answers Can still be used but with caution

8. Screening Factors with high risk Neck size > 17” (male); > 16” (female) BMI > 35 Hypertension – new, uncontrolled, or hard to control Type 2 Diabetes Loud Snoring Daytime sleepiness in monotonous situations Self Assessment Questionnaires Epworth Sleepiness Scale (ESS) > 10 Berlin Questionnaire I – Snoring II – Sleepiness III – Physical (BMI & BP)

9. Berlin Questionnaire Level of risk is based on responses in symptom categories. In categories 1 and 2, high risk is characterized by continuing symptoms (more than three or four times a week) in two or more questions on snoring and on sleepiness during wake time or driving, respectively. For category 3, high blood pressure or body mass index >30 are considered high risk. Patients with high-risk features in any two of the three categories warrant referral to sleep clinic.

10. Screening Factors with high risk Neck size > 17” (male); > 16” (female) BMI > 35 Hypertension – new, uncontrolled, or hard to control Type 2 Diabetes Loud Snoring Daytime sleepiness in monotonous situations Self Assessment Questionnaires Epworth Sleepiness Scale (ESS) > 10 Berlin Questionnaire Sleep Study AHI > 30 from current study or reported in prior study (not currently being treated)

11. Apnea Hypopnea Index (AHI) • Categorizes severity of sleep apnea. • Counts number of times the patient has apnea/hypopnea per night • This number is divided by total hours slept, giving an average of episodes/hour for interpretation

12. Apnea Hypopnea Index (AHI) AHI is determined by: • Laboratory Sleep Study • Cost $1500 - $3000; reimbursement depends on insurance plan • In-home Study • May underestimate AHI • Does not consider total sleep time • ME must use clinical judgment in interpretation • Cost $250 - $1000; reimbursement depends on insurance plan

13. Screening Factors with high risk Neck size > 17” (male); > 16” (female) BMI > 35 Hypertension – new, uncontrolled, or hard to control Type 2 Diabetes Loud Snoring Daytime sleepiness in monotonous situations Self Assessment Questionnaires Epworth Sleepiness Scale (ESS) > 10 Berlin Questionnaire Sleep Study AHI > 30 currently or in prior study Physical findings Mallampati Score = 3 or 4

14. Mallampati Scale • Airway size can be classified using the Mallampati Scale

15. Treatment Methods and Outcomes • CPAP (Continuous Positive Airway Pressure) • Machine must auto-titrate pressure and record interval used. • If treated for one week, can be certified for 90 days if: • Demonstrate minimal use of machine 4 hours per night, 70% of nights • No report of excessive sleepiness in major wake period • Annual recertification with or without sleep study • Bariatric Surgery • Certifiable 6 months after surgery – awaiting weight loss • CPAP compliance for 6 months • Clearance by treating physician • No report of excessive sleepiness in major wake period • Requires repeat sleep study • Annual recertification with or without sleep study

16. Treatment Methods and Outcomes • Other Surgery • Oropharyngeal Surgery • Facial Bone Surgery • Tracheostomy • Implanted Neurostimulator • Certifiable 1 month after surgery • Clearance by treating physician • No report of excessive sleepiness in major wake period • Requires repeat sleep study • Annual recertification with or without sleep study

17. Treatment Methods and Outcomes Other Treatments Dental Appliances Not approved by FMCSA Can be used but must have a sleep study to prove efficacy

18. Certifications • Immediate disqualification – any of the following: • Excessive sleepiness during major wake periods • Automotive crash attributed to falling asleep • Non compliant in treatment of previous diagnosed sleep disorder

19. Conditional Certification • Driver has AHI > 20 until CPAP Compliant • BMI > 35 pending sleep study • Two or more risk factors • Process for certification • 60 days pending sleep study and CPAP treatment • Additional 90 days if complaint with treatment • After 90 days certification for one year if continued compliance • Recertification annually with or without sleep study

20. Questions?