Obstructive Sleep Apnea and the Transportation Industry

Paul F. Schmook, RPSGT

OBSTRUCTIVE SLEEP APNEA

Obstructive Sleep Apnea, or OSA, is clinically defined as a cessation of breath for periods of 10 seconds or longer during sleep.

What happens when you stop breathing?

Imagine holding your breath because you’re swimming or trying to get rid of your hiccups. You’re anxious to gain that next breath again. When you’re sleeping, you’ve lost that natural ability to breath on demand. During an OSA event, your respiratory center sends a message to the hypothalamus part of the brain which creates an urgency to breath.

The result, either a full blown awakening or a micro-awakening. Full blown awakenings are normally associated with heavy breathing, gasping, choking or coughing.

Micro-awakenings often go unnoticed and the person may just roll over into another position. Many people with severe OSA have over 100 micro-awakenings per hour and not even realize this.

Any type of awakening kicks you out of deep or restorative sleep stages.

Furthermore, when you stop breathing:

• The oxygen level in your blood stream decreases; and
• Your heart rates slows down

When you start breathing after the awakening both the oxygen level in your bloodstream and heart rate spike, leading to what’s called Heart Rate Variability.

Symptoms of Obstructive Sleep Apnea

Excessive Daytime Sleepiness

Obesity or Abnormal Body Mass Index

Neck Circumference

Loud Snoring

Apnea Witnessed by Bed Partner

Gender

Age

Airway Type

Fatigue

Morning Headaches

Mood Swings/Irritability

Forgetfulness

Potential Complications from Untreated or Undiagnosed OSA

Congestive Heart Failure

Hypertension

Stroke

Diabetes

Chronic Insomnia

OSA SCREENING PROCESS

Screen all employees across the board

Set up sleep screening clinics at terminals

Rely on internal medical departments to screen employees

At-Risk Employees

Per the Federal Motor Carrier Safety Administration guidelines which were published on August 26, 2016, people who qualify for sleep testing will demonstrate a:

BMI > 40 Kg

Self-reported sleepiness during major wake periods or a fatigued related crash

Or

BMI >33 and <40

Plus three of the following:

• Hypertension
• Diabetes
• Stroke/Heart Disease
• Loud Snoring
• Witnessed Apnea
• Neck Circumference >17” in males and >15.5” in females
• Hypothyroidism
• Age >42 years
• Small Airway Mallampati Type III or IV

Home Sleep Study Referral Process

Ideally, it’s nice to ship home testing sleep equipment directly to the terminal

The terminal manager will be assigned to dispensing the equipment to the employee, and then attach a “Chain of Custody” bracelet to the employee’s wrist

If shipping to the terminal is not possible, then ship:

• Directly to the employee
• Or, to the employee’s medical providers office

If shipped to the employees residence,

• We can use Skype or FaceTime technology to ensure that the “Chain of Custody” bracelet is affixed properly

Sleep Study Contents

Sleep testing kits shipped to terminal managers or directly to employees will contain:

• ApneaLink testing device with nasal cannula, respiratory effort belt and oximetry
• Instructions
• Pre-paid shipping label
• Various paperwork including:
  • Medical histories specific to sleep only
  • Intakes and authorizations including HIPAA

On the Night of the Study

The employee will be contacted by one of our Sleep Coaches to ensure that the sleep testing device is assembled properly and that the “Start” button has been activated

Our operation runs 24 hours per day and every day of the year. Employees who experience complications will always have the ability to contact our call center for assistance.

In the morning directly after the study:

The employee will remove the testing equipment and place the device and paperwork into the shipping box, seal this and then affix the pre-paid label. Employees can then return the box to the terminal for shipping or stop by a local post office for delivery.

Sleep Study Data

• The raw data is downloaded and manually scored by a Registered Sleep Technologist
• The scored data is then uploaded to a Cloud where one of our board-certified sleep medicine physicians interpret the data and makes recommendations. Copies of these reports come to you for your files
• We have contracted with nearly 100 sleep specialists around the nation to provide professional services in a timely and efficient manner

Results

In the event your employee tests positive for OSA:

• We will send the employee an APAP device per physician’s orders

APAP vs. CPAP

CPAP (Continuous Positive Airway Pressure) is a fixed pressure setting

APAP (Automatic Positive Airway Pressure) adjusts pressures automatically on a breath to breath basis.

• Far more tolerable
• No need for re-titrations every two years.

APAP Trial

For the first two weeks of APAP use is critical for the outcome of success.

• New users will receive phone call from our sleep coaches to make sure the overall experience is good including mask fittings.
• After the successful two week trial is completed, we’ll contact your employee after 30 days for a follow and then every 180 days for re-supply. Again, our office is open 24 hours a day, every day of the year.

For unsuccessful trials:

• We can change out masks or adjust pressures if indicated.
• If we’ve run out of options, we’ll get your employee scheduled to visit a sleep specialist in the area.

Other options:

• Uvulopalatopharyngoplasy (UPPP): Surgery to remove excess tissue in the upper airway. 40% effective and extremely painful.
• Oral appliance: Approved for the treatment of Mild OSA. Difficult to tolerate, very expensive and non-returnable.

Compliance Monitoring

Employees who are currently using APAP should make arrangements to report compliance on a regular basis.

• Some employees will only use the APAP during the first two weeks to a month to prove sufficient compliance before a fitness for duty test.
• Liability
• APAP management
• General Reporting

APAP units are connected to the Cloud which allows us to monitor compliance and troubleshoot if the need arises, regardless of where the employee resides or vacations.

The minimal goal on APAP is 4 hours per night, 70% of the time. This meets the FMCSA guidelines.

Costs: Home Sleep Testing & Treatment

Traditional Insurance Billing

Re-Supply: Every 180 days, APAP users should receive new supplies.

Clinic: $1,000.00 per day per practitioner

Or

Sleep testing device with the ancillary supplies

Pre-paid shipping label

Physician interpretation

Chain of Custody bracelet

The complete program should cost about $250.00 per employee.

The APAP device should come with masks, tubing, heated humidity chambers and the rest of the supplies.

Complete Sleep Program: $1,000.00

Costs of including a sleep apnea program is the number one question people ask me.

• Home sleep testing should include everything necessary in conducting the test.