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

Quality assessment of clinical practice guidelines for adult obstructive sleep apnea: A systematic review

OBJECTIVE

Clinical Practice Guidelines (CPGs) are crucial in standardizing the management of obstructive sleep apnea (OSA) in adults. However, there has been insufficient evaluation of the overall quality of CPGs for adult OSA. This review aimed to comprehensively assess the overall quality of CPGs in the field of adult OSA.

METHODS

A systematic search was conducted on various literature databases, guideline-related databases, and academic websites from January 2013 to December 2023 to select CPGs relevant to adult OSA. The methodological and reporting quality of the eligible CPGs were thoroughly appraised by three reviewers using the AGREE II instrument and RIGHT checklist, respectively.

RESULTS

This review included 44 CPGs, consisting of 42 CPGs in English and 2 CPGs in Chinese. The assessment of methodological quality revealed that four domains attained an average standardized score above 60%. Among the domains, "clarity of presentation" received the highest standardized score of 85.10%, while the lowest standardized score was observed in the "rigor of development" domain with the value of 56.77%. The evaluation of reporting quality indicated an overall reporting rate of 51.30% for the eligible CPGs, with only three domains achieving an average reporting rate higher than 50%. The domain with the highest reporting rate was "basic information" at 60.61%, while the domain with the lowest reporting rate was "review and quality assurance" at 15.91%. Furthermore, a significantly positive correlation was found between the AGREE II standardized scores and the RIGHT reporting rates (r = 0.808, P < 0.001).

CONCLUSIONS

The overall quality of the currently available guidelines for adult OSA demonstrated considerable variability. Researchers should prioritize the utilization of evidence-based methods and adhere to the items listed in the RIGHT checklist when developing CPGs to enhance efficient clinical decision-making and promote the translation of evidence into practice.

Self-reported sleep tendency poorly predicts the presence of obstructive sleep apnea in commercial truck drivers

BACKGROUND AND OBJECTIVES

Drowsy driving increases the risk of motor vehicle crashes in those with untreated obstructive sleep apnea (OSA). Although previous studies indicated that excessive daytime sleepiness (EDS) might not predict OSA, they were not conclusive due to their small study sizes or restricted participants to sleep clinic patients. The overall objective was to determine whether self-reported EDS can be used for case identification of OSA among commercial truck drivers.

METHODS

Commercial truck drivers (N = 19,699) were screened for OSA-related symptoms. EDS was determined using the Epworth Sleepiness Scale (ESS) ≥ 11 and all participants completed the home sleep apnea test using a type 4 portable monitor to derive the respiratory event index (REI). Regression analyses were used to characterize the association between EDS and REI.

RESULTS

EDS was associated with OSA severity (p for trend <0.001). The sensitivity and specificity values of EDS for identifying moderate-to-severe OSA (REI ≥15 events/hour) were 0.10 and 0.93, respectively, and 0.48 and 0.71 if BMI ≥25 kg/m2 was added. Those using BMI ≥25 kg/m2 with OSA-related signs yielded the best sensitivity and specificity of 0.77 and 0.50, which were not improved by the addition of EDS.

CONCLUSIONS

Despite the associations between EDS and OSA severity and between OSA and lethal crash, case-identification of OSA using the ESS in commercial truck drivers is poor. Thus, OSA screening strategy may need a special approach, including a hierarchical combination of screening tools (Swiss Cheese Model approach), and incorporation of home sleep apnea testing.

Knowledge of Obstructive Sleep Apnea Among the General Population in Arar, Northern Region of Saudi Arabia

BACKGROUND

Obstructive sleep apnea (OSA) can have serious health consequences if left untreated, including an increased risk of heart disease, stroke, and diabetes. Raising awareness about this condition can help reduce the stigma surrounding sleep disorders and encourage individuals to seek help if they suspect they may have OSA. It is important for the general population to be informed about this condition in order to promote better overall health and well-being.

OBJECTIVE

To assess the level of knowledge of OSA among the general population of Arar, Northern region of Saudi Arabia.

METHODOLOGY

 This study is a cross-sectional descriptive study to assess the knowledge of OSA in the general population in the northern region of Saudi Arabia. We used an online self-administered questionnaire to collect sociodemographic data and questions about the subject's awareness.

RESULTS

Four hundred thirty-nine individuals participated in this study. The majority of them 337 (76.8%) were female. About 181 (41.2%) of the studied participants were in the age category of 15-25 years and 66.3% had heard about sleep apnea. Nearly 316 (72%) reported that sleep apnea is considered dangerous. Snoring, low sleep quality, and coughing were the main symptoms of sleep apnea. Moreover, obesity, smoking, and chronic diseases were the main causes of sleep apnea, according to the participants' knowledge. About 37 (8.4%) of participants said that they were diagnosed with sleep apnea, and 30 (6.8%) of them revealed that sleep apnea affected their quality of life.

CONCLUSION

Knowledge of OSA in Saudi Arabia is considered inadequate. General population knowledge of OSA can be improved through a multi-faceted approach that involves public education campaigns, continuous medical education for healthcare professionals, and policy-level interventions.

Long-term health outcomes for patients with obstructive sleep apnea: placing the Agency for Healthcare Research and Quality report in context-a multisociety commentary

This multisociety commentary critically examines the Agency for Healthcare Research and Quality (AHRQ) final report and systematic review on long-term health outcomes in obstructive sleep apnea. The AHRQ report was commissioned by the Centers for Medicare & Medicaid Services and particularly focused on the long-term patient-centered outcomes of continuous positive airway pressure, the variability of sleep-disordered breathing metrics, and the validity of these metrics as surrogate outcomes. This commentary raises concerns regarding the AHRQ report conclusions and their potential implications for policy decisions. A major concern expressed in this commentary is that the AHRQ report inadequately acknowledges the benefits of continuous positive airway pressure for several established, long-term clinically important outcomes including excessive sleepiness, motor vehicle accidents, and blood pressure. While acknowledging the limited evidence for the long-term benefits of continuous positive airway pressure treatment, especially cardiovascular outcomes, as summarized by the AHRQ report, this commentary reviews the limitations of recent randomized controlled trials and nonrandomized controlled studies and the challenges of conducting future randomized controlled trials. A research agenda to address these challenges is proposed including study designs that may include both high quality randomized controlled trials and nonrandomized controlled studies. This commentary concludes by highlighting implications for the safety and quality of life for the millions of people living with obstructive sleep apnea if the AHRQ report alone was used by payers to limit coverage for the treatment of obstructive sleep apnea while not considering the totality of available evidence.

CITATION

Patil SP, Billings ME, Bourjeily G, et al. Long-term health outcomes for patients with obstructive sleep apnea: placing the Agency for Healthcare Research and Quality report in context-a multisociety commentary. J Clin Sleep Med. 2024;20(1):135-149.

Yield of overnight pulse oximetry in screening commercial drivers for obstructive sleep apnea

PURPOSE

To assess the efficacy of overnight pulse oximetry in screening male commercial drivers (CDs) for obstructive sleep apnea (OSA).

METHODS

Consecutive male CDs undergoing their annual scheduled occupational health visit were enrolled from ten transportation facilities. All subjects underwent a home sleep apnea test (HSAT) to determine the Respiratory Event Index (REI). Oxygen desaturation indices (ODIs) below the 3% and 4% thresholds were computed using the built-in HSAT pulse oximeter. We then assessed the association between ODI values and the presence of OSA (defined as an REI ≥ 5 events/hour) as well as moderate to severe OSA (REI ≥ 15 events/hour).

RESULTS

Of 331 CDs recruited, 278 (84%) completed the study protocol and 53 subjects were excluded due to inadequate HSAT quality. The included and excluded subjects were comparable in demographics and clinical characteristics. The included CDs had a median age of 49 years (interquartile range (IQR) = 15 years) and a median body mass index of 27 kg/m2 (IQR = 5 kg/m2). One hundred ninety-nine (72%) CDs had OSA, of which 48 (17%) were with moderate OSA and 45 (16%) with severe OSA. The ODI3 and ODI4 receiving operating characteristic curve value were 0.95 for predicting OSA and 0.98-0.96 for predicting moderate to severe OSA.

CONCLUSION

Overnight oxygen oximetry may be an effective means to screen CDs for OSA.

Truck collisions attributed to falling asleep at the wheel in two commercial drivers prescribed oral appliance therapy for obstructive sleep apnea

Falling asleep at the wheel is attributed to sleepiness, and obstructive sleep apnea is a significant cause of sleepiness that increases the risk of motor vehicle collisions due to falling asleep at the wheel. Although continuous positive airway pressure therapy for obstructive sleep apnea reduces the risk of motor vehicle collisions, similar evidence for alternatives such as oral appliance therapy is lacking. We discuss two truck collisions attributed to microsleep confirmed with dashcam video footage of commercial drivers with obstructive sleep apnea. Our results highlight the current situation where there is insufficient evidence for the prevention and reduction of the risk of motor vehicle collisions by oral appliance therapy, objective adherence monitoring of oral appliance therapy, and effectiveness confirmation tests. Therefore, it is suggested that for commercial truck drivers who require a high level of driving safety, careful selection for oral appliance therapy, systematic follow-up, and monitoring of the driver and truck status with dashcam video footage are crucial.

CITATION

Kumagai H, Tsuda H, Kawaguchi K, et al. Truck collisions attributed to falling asleep at the wheel in two commercial drivers prescribed oral appliance therapy for obstructive sleep apnea. J Clin Sleep Med. 2023;19(12):2117-2122.

Screening for Obstructive Sleep Apnea in truck drivers

Professional drivers show a higher prevalence of obstructive sleep apnea (OSA) compared with the general population. OSA has been widely associated with an increased risk of traffic accidents. This article aims to investigate the presence of risk factors for OSA, its prevalence and the value of screening tools in a truck drivers' cohort. Descriptive and analytical prospective study. Demographic, anthropometric, Epworth Sleepiness Scale, STOP-Bang and Berlin Questionnaire were used to select subjects with suspicion of OSA. Polysomnography (PSG) was performed in individuals with positive screening. Mean age was 44.6±7 years, mean body mass index was 28.7±4 kg/m². Of the 281 truck drivers screened, 88 were positive for potential OSA. Of these, 63 completed PSG study and the diagnosis was confirmed in 85.7% (prevalence of 19.2%). The following variables showed a positive correlation with the apnea-hypopnea index: neck circumference and STOP-Bang. The combination of a predominantly male population, obesity, age distribution and lifestyle could account for the high prevalence of OSA in this specific population. Questionnaires proved to be a valuable screening tool. Screening, treatment, and management of OSA should be a priority as a public safety policy.

Cannabis and sleep disorders: not ready for prime time? A qualitative scoping review

STUDY OBJECTIVES

To perform a qualitative scoping literature review for studies involving the effects of cannabis on sleep and sleep disorders.

METHODS

Two electronic databases, MEDLINE and EMBASE, searched for comprehensive published abstracted studies that involved human participants. Inclusion criteria were article of any type, published in English, a target population of cannabis users, and reported data on cannabis effect on sleep and sleep disorders. The Joanna Briggs Institute's (JBI) approach was elected as the methodology framework guidance in the scoping review process.

RESULTS

A total of 40 unique publications were found. The majority (82.5%) were from the Americas with 60% published in the last decade. Of the 40 studies, only 25% were randomized control trials, and the sleep outcome measurements were similar and comparable in only 20%. Cannabis users studied were reported either 73% frequent users or 27% sporadic users. The utilization of cannabis showed improved sleep (21%), worse sleep (48%), mixed results (14%), or no impact at all (17%) in the studies published in the last 5 decades.

CONCLUSIONS

Our findings summarize the lack of robust evidence to support the use of cannabis for sleep disorders. The varied cannabis user-related characteristics may account for the inconsistent results identified. Further studies assessing cannabis and sleep are needed to discern what works in what context, how it works, and for whom.

CITATION

Amaral C, Carvalho C, Scaranelo A, Chapman K, Chatkin J, Ferreira I. Cannabis and sleep disorders: not ready for prime time? A qualitative scoping review. J Clin Sleep Med. 2023;19(5):975-990.

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.

Combining four screening tools for cost effective screening of OSA in train drivers: A UK experience

Background

Obstructive sleep apnoea (OSA) in drivers/workers has been implicated in railway and road traffic safety incidents; however, there are insufficient data on its prevalence and cost-effective screening methods.

Aim

This pragmatic study examines four OSA screening tools: the Epworth sleepiness scale (ESS), the STOP-Bang (SB), the adjusted neck circumference (ANC) and the body mass index (BMI), exploring their suitability and effectiveness separately and in combination.

Method

Using all four tools, 292 train drivers were opportunistically screened between 2016 and 2017. A polygraph (PG) test was carried out when OSA was suspected. Patients with an apnoea-hypopnea index (AHI) ≥5 were referred to a clinical specialist and reviewed annually. Those who had continuous positive airway pressure (CPAP) treatment were evaluated for compliance and control.

Results

Of the 40 patients who had PG testing, 3 and 23 participants met the ESS >10 and SB >4, criteria, respectively, whereas 25 participants each had an ANC >48 and a BMI >35 with a risk factor or ≥40 with none. OSA was detected in 3, 18 and 16 of them who met the ESS, SB and ANC criteria, respectively, and was positive for OSA in addition to 16 others who met the BMI criteria. A total of 28 (72%) were diagnosed with OSA.

Conclusion

Although when used individually, these screening methods are less effective/inadequate, combining them is easy, feasible and offers the maximum chance of OSA detection in train drivers.

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.

Enhancing public health and safety by diagnosing and treating obstructive sleep apnea in the transportation industry: an American Academy of Sleep Medicine position statement

Obstructive sleep apnea (OSA) may lead to serious health, safety, and financial implications-including sleepiness-related crashes and incidents-in workers who perform safety-sensitive functions in the transportation industry. Evidence and expert consensus support its identification and treatment in high-risk commercial 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 has led to questions about whether efforts to identify and treat OSA are warranted. In the absence of clear directives, we urge key stakeholders, including clinicians and patients, to engage in a collaborative approach to address OSA by following, at a minimum, the 2016 guidelines issued by a Medical Review Board of the Federal Motor Carrier Safety Administration, alone or in combination with 2006 guidance by a joint task force. The current standard of care demands action to mitigate the serious health and safety risks of OSA.

CITATION

Das AM, Chang JL, Berneking M, et al. Enhancing public health and safety by diagnosing and treating obstructive sleep apnea in the transportation industry: an American Academy of Sleep Medicine position statement. J Clin Sleep Med. 2022;18(10):2467-2470.

Fatigue in NTSB-investigations 2013-2019: evidence of accidents and injuries

ABSTRACTThis study updates the prevalence of operator fatigue as a causative factor in accidents investigated by the National Transportation Safety Board (NTSB) and the associated injury severity in fatigue-related accidents. 394 investigations were analyzed and 12% of them were identified fatigue. The prevalence of fatigue varied among the transportation modes, ranging from 28% of aviation to 7% of marine. Most fatigue-related accidents (48%) occurred during late night or morning. Compared to non-fatigued operators, fatigued operators were more involved in severe or fatal injuries (odds ratio (OR)  =  2.30; 95% confidence interval (CI) [1.66, 2.95]) and to injure non-operators (OR = 3.32; 95% CI [2.70, 3.95]). Obstructive sleep apnea (OSA) was identified as a probable cause, contributing cause, or finding in 15% of fatigued-related accidents, and 85.7% of these accidents, the operator met OSA screening criteria. Thus, opportunities remain for preventing fatigue-related accidents, including through more systematic operator screening for OSA.

Risk of obstructive sleep apnea and traffic accidents among male bus drivers in Ecuador: Is there a significant relationship?

Background

Obstructive sleep apnea (OSA) represents an important occupational health concern in the transportation industry, affecting a substantial percentage of transportation operators. Our study aims to determine the frequency of individuals at high risk of obstructive sleep apnea, and excessive daytime sleepiness, as well as any potential association between these conditions and traffic accidents among a sample of Ecuadorian bus drivers.

Methods

We conducted a cross-sectional study involving 340 commercial bus drivers from Ecuador. Descriptive statistics were used to determine frequency and proportions for demographic and clinical variables. A Kendall's tau-b was performed to ascertain the relationship between the STOP-Bang score towards the Epworth Sleepiness Scale (ESS) score and the number of accidents and near accidents.

Results

In general, 18.5% (n = 63) of participants were found to be at high-risk for OSA. There was a weak positive correlation between STOP-Bang score and ESS score (τ^b = 0.244, p = .000). We also found a statistically significant, although negligible, correlation between the STOP-Bang score and the number of accidents (τ^b = 0.096, p = .039) and near accidents (τ^b = 0.120, p = .008).

Conclusion

Our results suggest that a considerable proportion of Ecuadorian bus drivers were at high-risk for obstructive sleep apnea. Higher STOP-Bang scores were correlated with an increased number of accidents and near accidents. Additional studies are needed to determine whether additional interventions could increase road safety by taking care of undiagnosed and untreated OSA cases in a timely manner.

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Untreated obstructive sleep apnea is a significant contributor to motor vehicle crashes.

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The main consequence related to OSA is excessive daytime sleepiness, which is associated with increased risk of accidents.

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A considerable proportion of Ecuadorian bus drivers were at high-risk for obstructive sleep apnea.

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Higher STOP-Bang scores were correlated with an increased number of accidents and near accidents.

Age-Related Effect of Sleepiness on Driving Performance: A Systematic-Review

Background: Several studies highlighted that sleepiness affects driving abilities. In particular, road traffic injuries due to excessive daytime sleepiness are about 10–20%. Considering that aging is related to substantial sleep changes and the number of older adults with driving license is increasing, the current review aims to summarize recent studies on this issue. Further, we intend to provide insights for future research. Methods: From the 717 records screened, ten articles were selected and systematically reviewed. Results: Among the selected articles, (a) five studies investigated sleepiness only by self-reported standardized measures; (b) two studies assessed sleepiness also using a behavioral task; (c) three studies obtained objective measures by electroencephalographic recordings. Conclusions: The available literature on the topic reports several limitations. Overall, many findings converge in evidencing that older drivers are less vulnerable to sleep loss and sleepiness-related driving impairments than young adults. These discrepancies in sleepiness vulnerability between age groups may be ascribed to differences in subjects’ lifestyles. Moreover, it has been hypothesized that older adults self-regulate their driving and avoid specific dangerous situations. We believe that an easy protocol to objectively evaluate the vigilance level in elderly and young adults is required, and further studies are needed.

Poor performance of screening questionnaires for obstructive sleep apnea in male commercial drivers

PURPOSE

Screening commercial drivers (CDs) for obstructive sleep apnea (OSA) reduces the risk of motor vehicle accidents. We evaluated the accuracy of standard OSA questionnaires in a cohort of CDs.

STUDY DESIGN AND METHODS

We enrolled consecutive male CDs at 10 discrete transportation companies during their yearly scheduled occupational health visit. The CDs had their anthropometric measures taken; completed the Berlin, STOP, STOP-BANG, OSAS-TTI, SACS, EUROSAS, and ARES questionnaires; and underwent a home sleep apnea test (HSAT) for the determination of their respiratory events index (REI). We assessed the questionnaires' ability to predict OSA (REI ≥ 5 events/h) and moderate-to-severe OSA (REI ≥ 15 events/h).

RESULTS

Among 315 CDs recruited, 243 (77%) completed the study protocol, while 72 subjects were excluded for inadequate HSAT quality. The demographics and clinical data were comparable in both the included and excluded subjects. The included CDs had a median age of 50 years (interquartile range (IQR) 25-70) and a mean body mass index of 27 ± 4 kg/m². One hundred and seventy-one subjects (71%) had OSA, and 68 (28%) had moderate-to-severe OSA. A receiver operating characteristic curve of the questionnaires were 0.51-0.71 for predicting OSA and 0.51-0.66 for moderate-to-severe OSA. The STOP-BANG questionnaire had an unsatisfactory positive predictive value, while all of the other questionnaires had an inadequate negative predictive value.

CONCLUSIONS

Standard OSA questionnaires are not suited for screening among CDs. The use of the HSAT could provide an objective evaluation of for OSA in this special population.

Use of polysomnography and home sleep apnea tests for the longitudinal management of obstructive sleep apnea in adults: an American Academy of Sleep Medicine clinical guidance statement

INTRODUCTION

Obstructive sleep apnea is an important and common disorder with associated health risks. Assuring successful longitudinal management is vital to patient health and sleep-related quality of life. This paper provides guidance from the American Academy of Sleep Medicine (AASM) regarding the use of polysomnography (PSG) and home sleep apnea tests (HSATs) after a diagnosis of obstructive sleep apnea has been established and, in most cases, treatment implemented.

METHODS

The AASM commissioned a task force of five sleep medicine experts. A literature search was conducted to identify studies that included adult patients with OSA who underwent follow-up PSG or an HSAT. The task force developed clinical guidance statements based on a review of these studies and expert opinion. The AASM Board of Directors approved the final clinical guidance statements.

CLINICAL GUIDANCE STATEMENTS

The AASM supports the following clinical guidance statements on indications for follow-up PSG and HSAT in adult patients with OSA. 1. Follow-up PSG or HSAT is not recommended for routine reassessment of asymptomatic patients with obstructive sleep apnea on PAP therapy, however, follow-up PSG or HSAT can be used to reassess patients with recurrent or persistent symptoms, despite good PAP adherence. 2. Follow-up PSG or HSAT is recommended to assess response to treatment with non-PAP interventions. 3. Follow-up PSG or HSAT may be used if clinically significant weight gain or loss has occurred since diagnosis of OSA or initiation of its treatment. 4. Follow-up PSG may be used for reassessment of sleep-related hypoxemia and/or sleep-related hypoventilation following initiation of treatment for OSA. 5. Follow-up PSG or HSAT may be used in patients being treated for OSA who develop or have a change in cardiovascular disease. 6. Follow-up PSG may be used in patients with unexplained PAP device-generated data. The ultimate judgment regarding propriety of any specific care must be made by the clinician, in light of the individual circumstances presented by the patient, available diagnostic tools, accessible treatment options and resources.

Applying principles of fatigue science to accident investigation: Transportation Safety Board of Canada (TSB) fatigue investigation methodology

Fatigue that is related to the amount and quality of sleep obtained can impair human performance in ways that can lead to accidents. As many transportation industries operate around the clock, fatigue and its effects cannot be eliminated completely; instead, they must be managed. A first step is to document the prevalence and role of fatigue in accidents that occur. The Transportation Safety Board of Canada (TSB) routinely investigates such transportation industry incidents to determine if fatigue was present, if it played a role, and if there were practices in place to effectively manage it and associated risks. Herein, we summarize and describe the TSB's fatigue investigation methodology in the hopes that investigators of other organizations and domains will find the concepts applicable to their operational context.

Clinical use of STOP-BANG and ESS questionnaires in the evaluation of obstructive sleep apnoea-related risk factors for motor vehicle accidents among public transport drivers in Delhi, India

PURPOSE

To assess the clinical use of Epworth Sleepiness Score (ESS) and STOP-BANG questionnaires in the evaluation of sleep apnoea-related risk factors for motor vehicle accident (MVA) among public transport drivers in Delhi, India.

METHODS

The present cross-sectional study is based on data collected between April 2018 and March 2019 from public transport drivers in Delhi. All drivers coming for gas filling to 43 compressed natural gas (CNG) stations in Delhi were included in the study. The evaluation of sleep apnoea-related risk factors for motor vehicle accident was done using ESS and STOP-BANG Score.

RESULTS

A total of 4094 drivers participated in this study, and 299 drivers (7%) gave a history of motor vehicle accidents during the preceding 3 years. Drivers with STOP-BANG score ≥ 3 had a higher risk for MVA (OR 1.59; 95% CI 1.26-2.02; p value < 0.0001). Score of ESS ≥ 10 carried a very high risk for MVA (OR 26.95; 95% CI 16.18-44.87; p value < 0.0001). The other risk factor of significance was alcoholism (OR 1.37; 95% CI 1.04-1.80; p value < 0.0248).

CONCLUSION

Among public transport drivers in Delhi, daytime sleepiness is the major contributing factor to motor vehicle accidents. ESS and STOP-BANG questionnaires may be good screening tools for the clinical evaluation of OSA. Community-based screening of OSA is required for identification of public transport drivers at high risk of MVA.

Personalized and Patient-Centered Strategies to Improve Positive Airway Pressure Adherence in Patients with Obstructive Sleep Apnea

Obstructive sleep apnea (OSA), a common sleep disorder characterized by repeated pauses in breathing during sleep, is effectively treated with positive airway pressure (PAP) therapy. The magnitude of improvements in daily functioning and reduced negative health risks are dependent on maintaining PAP adherence, which is a significant challenge. Evidence-based interventions to improve PAP use are not easily translated to clinical practice because they are labor-intensive and require specialty expertise. Further, to date, individualized care, inclusive of personalized medicine and patient- and person-centered care have been marginally incorporated in the field's understanding of OSA and PAP adherence. This integrative review describes current PAP adherence assessment processes, interventions to improve adherence, and outlines future opportunities to advance the field, particularly as it relates to individualizing care and the use of implementation science to apply evidence to practice.

Evaluating the Sleepy and Sleepless Patient

PURPOSE OF REVIEW

This article explains the clinical approach to patients presenting with sleepiness or sleeplessness in a neurologic practice setting. Addressing the patient's sleep symptoms may help improve symptoms of their other underlying primarily neurologic disorder.

RECENT FINDINGS

New diagnostic modalities at home such as home sleep apnea testing have improved access and diagnosis of sleep apnea. Consumer health tracking devices have also helped patients focus on their sleep duration and quality, prompting them to bring their concerns to their neurologist.

SUMMARY

Like many neurologic disorders, a detailed history and physical examination are critical in the evaluation of patients with sleepiness or sleeplessness. Patients who have neurologic disorders are more likely to have poor-quality sleep. Questions about the patient's sleep schedule or screening patients for common sleep disorders such as sleep apnea and restless legs syndrome (RLS) are useful to add to a typical neurologic evaluation to better recognize sleep disorders in this population. Polysomnography, home sleep apnea testing, multiple sleep latency tests, and actigraphy can be used with the available history and examination to determine the proper diagnosis and management plan for these patients.

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.

Educational, supportive and behavioural interventions to improve usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea

BACKGROUND

Although highly effective in the treatment of obstructive sleep apnoea (OSA), continuous positive airway pressure (CPAP) is not universally accepted by users. Educational, supportive and behavioural interventions may help people with OSA initiate and maintain regular and continued use of CPAP.

OBJECTIVES

To assess the effectiveness of educational, supportive, behavioural, or mixed (combination of two or more intervention types) strategies that aim to encourage adults who have been prescribed CPAP to use their devices.

SEARCH METHODS

Searches were conducted on the Cochrane Airways Group Specialised Register of trials. Searches are current to 29 April 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that assessed intervention(s) designed to inform participants about CPAP/OSA, to support them in using CPAP, or to modify their behaviour to increase use of CPAP devices.

DATA COLLECTION AND ANALYSIS

We assessed studies to determine their suitability for inclusion in the review. Data were extracted independently and were entered into RevMan for analysis. 'Risk of bias' assessments were performed, using the updated 'Risk of bias 2' tool, for the primary outcome, CPAP usage. Study-level 'Risk of bias' assessments were performed using the original 'Risk of bias' tool. GRADE assessment was performed using GRADEpro.

MAIN RESULTS

Forty-one studies (9005 participants) are included in this review; 16 of these studies are newly identified with updated searches. Baseline Epworth Sleepiness Scale (ESS) scores indicate that most participants suffered from excessive daytime sleepiness. The majority of recruited participants had not used CPAP previously. When examining risk of bias for the primary outcome of hourly machine usage/night, 58.3% studies have high overall risk (24/41 studies), 39.0% have some concerns (16/41 studies), and 2.4% have low overall risk (1/41 studies). We are uncertain whether educational interventions improve device usage, as the certainty of evidence was assessed as very low. We were unable to perform meta-analyses for number of withdrawals and symptom scores due to high study heterogeneity. Supportive interventions probably increase device usage by 0.70 hours/night (95% confidence interval (CI) 0.36 to 1.05, N = 1426, 13 studies, moderate-certainty evidence), and low-certainty evidence indicates that the number of participants who used their devices ≥ 4 hours/night may increase from 601 to 717 per 1000 (odds ratio (OR), 1.68, 95% CI 1.08 to 2.60, N = 376, 2 studies). However, the number of withdrawals may also increase from 136 to 167 per 1000 (OR 1.27, 95% CI 0.97 to 1.66, N = 1702, 11 studies, low-certainty evidence). Participants may experience small improvements in symptoms (ESS score -0.32 points, 95% CI -1.19 to 0.56, N = 470, 5 studies, low-certainty evidence), and we are uncertain whether quality of life improves with supportive interventions, as the certainty of evidence was assessed as very low. When compared with usual care, behavioural interventions produce a clinically-meaningful increase in device usage by 1.31 hours/night (95% CI 0.95 to 1.66, N = 578, 8 studies, high-certainty evidence), probably increase the number of participants who used their machines ≥ 4 hours/night from 371 to 501 per 1000 (OR 1.70, 95% CI 1.20 to 2.41, N = 549, 6 studies, high-certainty evidence), and reduce the number of study withdrawals from 146 to 101 per 1000 (OR 0.66, 95% CI 0.44 to 0.98, N = 939, 10 studies, high-certainty evidence). Behavioural interventions may reduce symptoms (ESS score -2.42 points, 95% CI -4.27 to -0.57, N = 272, 5 studies, low-certainty evidence), but probably have no effect on quality of life (Functional Outcomes of Sleep Questionnaire (FOSQ), standardised mean difference (SMD) 0.00, 0.95% CI -0.26 to 0.26, N = 228, 3 studies, moderate-certainty evidence). We are uncertain whether behavioural interventions improve apnoea hypopnoea index (AHI), as the certainty of evidence was assessed as very low. We are uncertain if mixed interventions improve device usage, increase the number of participants using their machines ≥ 4 hours/night, reduce study withdrawals, improve quality of life, or reduce anxiety symptoms, as the certainty of evidence for these outcomes was assessed to be very low. Symptom scores via the ESS could not be measured due to considerable heterogeneity between studies.

AUTHORS' CONCLUSIONS

In CPAP-naïve people with OSA, high-certainty evidence indicates that behavioural interventions yield a clinically-significant increase in hourly device usage when compared with usual care. Moderate certainty evidence shows that supportive interventions increase usage modestly. Very low-certainty evidence shows that educational and mixed interventions may modestly increase CPAP usage. The impact of improved CPAP usage on daytime sleepiness, quality of life, and mood and anxiety scores remains unclear since these outcomes were not assessed in the majority of included studies. Studies addressing the choice of interventions that best match individual patient needs and therefore result in the most successful and cost-effective therapy are needed.

Screening for obstructive sleep apnoea in professional drivers

Professional drivers show a higher prevalence of obstructive sleep apnoea (OSA) compared with the general population. Furthermore, there is concern about the association between OSA and car crash risk given that drivers with OSA show an increased risk for car accidents. Despite this risk, OSA is often underdiagnosed and undertreated in this population, mainly due to lack of appropriate screening and sleep study referrals. Polysomnography (PSG), the gold standard test, is inappropriate for systematic screening because of its high expense, complexity and relative inaccessibility in this population. Therefore, there is a strong demand for good screening tools, including both subjective and objective data that may assist in early identification of possible OSA among professional drivers and, thus, aid in PSG examination referral and OSA management in an accredited sleep centre. However, there is considerable disagreement over screening methods and criteria for triggering a sleep study referral in different countries. There is also a strong need for further research in the area of OSA screening of commercial drivers in order to improve the diagnostic accuracy of screening tools and ensure that patients with OSA are accurately identified.

OSA is usually undiagnosed and undertreated in professional drivers. Barriers to OSA diagnosis are lack of appropriate screening and sleep study referrals. Screening tools, including both subjective and objective data, may assist in early identification.http://bit.ly/31nD4A9

Sleep misalignment and circadian rhythm impairment in long-haul bus drivers under a two-up operations system

OBJECTIVES

The objective of the study was to describe working and sleep conditions and to assess how sleep opportunities are associated with obtained sleep and alertness, in a sample of long-haul bus drivers working with a two-up operations system.

METHODS

Measures of subjective sleep and sleepiness, actigraphy, circadian temperature rhythm, and psychomotor vigilance tasks were obtained from a sample of 122 drivers from Argentina. Variables were compared between high and low fatigue risk groups, which were formed using a median split of a fatigue risk score. The score was calculated based on drivers' total working hours, maximum shift duration, minimum short break duration, maximum night work per seven days, and long break frequencies.

RESULTS

Considering a standardized one-day period, sleep in the bus accounted for 1.9±0.1 h of total sleep (57±1% efficiency), sleep at destination for 1.6±0.2 h of total sleep (90±1% efficiency), and sleep at home for 3.8±0.2 h of total sleep (89±1% nap efficiency and 90±1% anchor sleep efficiency). In drivers exposed to high-risk working schedules, the circadian temperature rhythm was weaker (lower % of variance explained by the model) (22.0±1.7% vs. 27.6±2.0%, p <0.05) and without a significant acrophase.

CONCLUSIONS

Drivers obtained a total amount of weekly sleep similar to the recommended levels for adults, but distributed at different locations and at different times during the day. High-risk working schedules were associated with disruption of circadian temperature rhythms. These results point out to the need of the implementation of shift-work scheduling strategies to minimize sleep misalignment and circadian desynchronization in long-haul bus drivers.

Driving with undiagnosed obstructive sleep apnea (OSA): High prevalence of OSA risk in drivers who experienced a motor vehicle crash

Objective: Obstructive sleep apnea (OSA) is a risk factor for motor vehicle crashes (MVC), and patients with diagnosed OSA have a higher likelihood of being involved in a traffic accident. OSA, however, is often underdiagnosed in the general population. The purpose of this study was to assess the risk of undiagnosed OSA among hospitalized patients involved in MVCs.Methods: This is a prospective, observational pilot study of adult trauma patients admitted to a Level 1 trauma center after being the driver in a MVC. Patients were administered the STOP-Bang to assess risk of OSA and were asked questions about the circumstances of the MVC. Patients with a STOP-Bang score 5-8 were considered to be at high risk for OSA. Differences between variables were assessed using independent t-tests and chi-square.Results: Eighty patients participated in the study, and 26% (n = 21) were considered to be at high risk for OSA based on the STOP-Bang score. Compared to patients at low and intermediate risk, patients at high risk for OSA were significantly older (p < .001), had longer hospitalization (p = .06), and were less likely to discharge home from the hospital (p = .01). Patients at moderate and high risk had higher rates of hospital readmission within 1 year of discharge, when compared to the low risk group. Eighty-four percent of all crashes involved a single occupant (driver) in the vehicle, 58% involved only a single vehicle, and 40% occurred on a rural road. There were no significant differences between risk groups for number of vehicles involved in the accident, location of the accident, or number of vehicle occupants.Conclusions: Results of this pilot study suggest that more than one-quarter of drivers hospitalized after motor vehicle crashes were at high risk for OSA. Diagnosed or undiagnosed OSA is a significant public health concern and an established risk factor for motor vehicle accidents. Standardized screening for risk of sleep apnea should be considered by primary care physicians when guiding patients on health and behavior decisions, particularly in regards to driving and road safety.

Efficacy and adherence of auto-CPAP therapy in patients with obstructive sleep apnea: a prospective study

Introduction

The use of auto-continuous positive airway pressure (auto-CPAP) therapy has been recommended for subjects with moderate-to-severe obstructive sleep apnea (OSA) without significant comorbidities. This study is aimed at evaluating the efficacy and adherence of auto-CPAP therapy in subjects with OSA.

Methods

It was a perspective and descriptive study. All study subjects who had apnea-hypopnea index (AHI) > 30/h, measured by polysomnography, were included. They were treated with auto-CPAP and followed-up for 6 months for evaluating the effect of CPAP-therapy on clinical and biological features and treatment adherence.

Results

One hundred and thirty-nine subjects with severe OSA were accepted for auto-CPAP therapy at inclusion. BMI was 28.4±3.8 kg/m²; neck and abdomen circumferences were 38.2±6.4 and 85.7±11.6. Epworth and Pichot scores were 18.4±6.3 and 28.3±4.5, respectively; AHI was 39±7/h and arousal index was 39±13/h. At 6^th month, 96.4% of study subjects continued to use auto-CPAP-therapy within 6.5±2.4 h/night. There was a significant correlation between the modification (Δ) of Epworth scores and (Δ) AHI after 3 and 6 months of auto-CPAP-therapy (R=0.568 and p=0.003; R=0.745 and p=0.002; respectively). At 6^th month follow up, the main side effects of auto-CPAP were difficult sleeping, dry mouth or nose, skin marks or rashes, discomfort when breathing, and nasal congestion (36.1%, 32.0%, 20.8%, 16.0%, and 11.9%, respectively).

Conclusion

Auto-CPAP is effective in treatment of Vietnamese patients with severe OSA in short term follow up.

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.

Interhemispheric Brain Switching Correlates with Severity of Sleep-Disordered Breathing for Obstructive Sleep Apnea Patients

(1) Background: Alternating interhemispheric slow-wave activity during sleep is well-established in birds and cetaceans, but its investigation in humans has been largely neglected. (2) Methods: Fuzzy entropy was used to calculate a laterality index (LI) from C3 and C4 EEG channels. The subjects were grouped according to an apnoea-hypopnoea index (AHI) for statistical analyses: Group A AHI < 15 (mild); Group B 15 ≤ AHI < 30 (moderate); Group C AHI ≥ 30 (severe). The LI distribution was analysed to characterise the brain activity variation in both hemispheres, and the cross-zero switching rate was given statistical tests to find the correlations with the severity of obstructive sleep apnea and sleep states, i.e., wake (W), light sleep (LS), deep sleep (DS), and REM. (3) Results: EEG brain switching activity was observed in all sleep stages, and the LI distribution shows that, for obstructive sleep apnea patients, the interhemispheric asymmetry of brain activity is more obvious than healthy people. A one-way ANOVA revealed a significant difference of switching rate among three groups (F(2,95) = 7.23, p = 0.0012), with Group C shows the least, and also a significant difference among four sleep stages (F(3,94) = 5.09, p = 0.0026), with REM the highest. (4) Conclusions: The alternating interhemispheric activity is confirmed ubiquitous for humans during sleep, and sleep-disordered breathing intends to exacerbate the interhemispheric asymmetry.

Treatment of Adult Obstructive Sleep Apnea With Positive Airway Pressure: An American Academy of Sleep Medicine Systematic Review, Meta-Analysis, and GRADE Assessment

INTRODUCTION

The purpose of this systematic review is to provide supporting evidence for the clinical practice guideline for the treatment of obstructive sleep apnea (OSA) in adults using positive airway pressure (PAP).

METHODS

The American Academy of Sleep Medicine commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies that compared the use of PAP with no treatment as well as studies that compared different PAP modalities. Meta-analyses were performed to determine the clinical significance of using PAP in several modalities (ie, continuous PAP, auto-adjusting PAP, and bilevel PAP), to treat OSA in adults. In addition, meta-analyses were performed to determine the clinical significance of using an in-laboratory versus ambulatory strategy for the initiation of PAP, educational and behavioral interventions, telemonitoring, humidification, different mask interfaces, and flexible or modified pressure profile PAP in conjunction with PAP to treat OSA in adults. Finally, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used to assess the evidence for making recommendations.

RESULTS

The literature search resulted in 336 studies that met inclusion criteria; 184 studies provided data suitable for meta-analyses. The data demonstrated that PAP compared to no treatment results in a clinically significant reduction in disease severity, sleepiness, blood pressure, and motor vehicle accidents, and improvement in sleep-related quality of life in adults with OSA. In addition, the initiation of PAP in the home demonstrated equivalent effects on patient outcomes when compared to an in-laboratory titration approach. The data also demonstrated that the use of auto-adjusting or bilevel PAP did not result in clinically significant differences in patient outcomes compared with standard continuous PAP. Furthermore, data demonstrated a clinically significant improvement in PAP adherence with the use of educational, behavioral, troubleshooting, and telemonitoring interventions. Systematic reviews for specific PAP delivery method were also performed and suggested that nasal interfaces compared to oronasal interfaces have improved adherence and slightly greater reductions in OSA severity, heated humidification compared to no humidification reduces some continuous PAP-related side effects, and pressure profile PAP did not result in clinically significant differences in patient outcomes compared with standard continuous PAP.

Benefit of continuous positive airway pressure on work quality in patients with severe obstructive sleep apnea

BACKGROUND

The objective of this prospective study was to assess the effect of CPAP therapy on job productivity and work quality for patients with severe obstructive sleep apnea (OSA).

METHODS

A convenience sample of patients diagnosed with severe OSA using polysomnography or polygraphy and with a therapeutic indication for CPAP was enrolled in our study. Patients completed two self-administered questionnaires: the first before CPAP therapy and the second during the first 6 months after CPAP treatment. OSA symptoms were evaluated through self-administered questionnaires assessing potential effects on occupational activity: excessive daytime sleepiness was rated by the Epworth Sleepiness Scale (ESS), emotional status was rated by the Hospital Anxiety and Depression (HAD) scale, work quality was rated by the Work Role Functioning Questionnaire (WRFQ).

RESULTS

Forty patients (30 men, mean age 47.3 ± 8.3, mean BMI 31.6 ± 7.4, mean apnea-hypopnea index 51.8 ± 16.3) showed a beneficial effect of CPAP therapy on ESS score (mean 11.6 to 8.2, p < 0.0001), the anxiety dimension (mean 57.5% to 20%, p = 0.0002), and the overall anxiety-depressive score (mean 50% to 22.5%, p = 0.0006). Mean WRFQ scores were significantly improved in the second questionnaire for the dimensions of timetable requirements (69.3% to 83.5%, p < 0.0001), productivity requirements (71.4% to 82.2%, p < 0.0001), mental requirements (72.0% to 84.3%, p < 0.0001), and social requirements (82.6% to 91.4%, p < 0.003).

CONCLUSIONS

We observed that adherence to CPAP therapy for patients with severe OSA mitigates the impact of symptoms on work including excessive daytime sleepiness, impairment of work ability, and anxiety and depressive disorders.

Sleep apnea and its role in transportation safety

Obstructive sleep apnea (OSA) is a main cause of excessive daytime sleepiness and increases the risk for driving accidents, which can be normalized by treatment with continuous positive airway pressure ventilation. Since it is estimated that OSA is not diagnosed in about 80% of cases, recognition of patients at risk for driving accidents is a problem from both medical and societal points of view. Strategies to screen and identify subjects at high risk for driving accidents are under study in order to improve safety on the road, especially for commercial drivers, who show a high prevalence of OSA.

Sleep and obesity risk in adults: possible mechanisms; contextual factors; and implications for research, intervention, and policy

Obesity is a major public health problem among US adults. Insufficient sleep and sleep disorders are prevalent and may contribute to the public health problem of obesity. This review addresses several key questions regarding sleep and obesity in adults, including the following: (1) What constitutes adequate sleep in adults? (2) What are the consequences of inadequate sleep in adults? (3) What factors influence sleep in adults? (4) How can adults improve their sleep? (5) How can we implement these in adults? (6) How can these issues be addressed in future research and policy decisions? Although a comprehensive review of all of these is beyond the scope of this article, this review brings these concepts together toward a discussion of the role of sleep in the health of US adults.