Author: Dr. David Thorpe
In the past few weeks I have received numerous questions on sleep apnea. Interestingly, many of the drivers who have sent in a question has been female drivers! In response to your questions regarding sleep apnea, in addition to it being National Women’s Health Week (May 14th – May 20th), I decided to focus this blog post on women truck drivers and sleep apnea. So, is sleep apnea different for men and women? I had to do a little research to find out myself. The answer actually surprised me.
First, I contacted my friend and one of our channel partners for PMP, Mr. Greg McDermond of Phoenix Sleep Solutions. Many of you hear Greg on “I Heart Radio” on a regular basis on the Steve Sommers show. He provided some very enlightening information.
Secondly, I simply looked for articles and what research existed that I could find. There is actually a significant amount of information that is available to review about the differences between men and women.
DO WOMEN SUFFER FROM SLEEP APNEA?
All individuals suffer from sleep apnea, women too! A study completed in 2013 at UCLA indicated that women are less likely however to be diagnosed with sleep apnea. This doesn’t necessarily mean that they suffer any less, or have different risk factors or consequences for suffering from it. It seems that women actually exhibit different symptoms
What is most often identified as a symptom is loud snoring, waking up and gasping for air or snorting. These are very common symptoms for men. Although women may exhibit some of these symptoms too, they however report additional and less obvious symptoms like fatigue, anxiety and depression. In many cases the telltale signs are much less obvious in women then they are in men.
Consequently, it’s easy to understand why men are twice as likely to be diagnosed with sleep apnea than women are?
WHAT ARE THE PREDICTIVE FACTORS ASSOCIATED FOR SLEEP APNEA?
Some of the risk factors for suffering sleep apnea are well known within the trucking industry. Obesity or being significantly overweight is probably the most understood. This is often measured by something known as your BMI or Body Mass Index. This is a calculation made based on an individual’s height and weight. BMI’s that go above 28 will indicate that a person is overweight typically. The higher the BMI, therefore the greater the chance for suffering sleep apnea. This is true for both men and women.
Other factors include age (being older than 40), neck circumference (a neck circumference that is greater than 17 inches for men and 16 for women) and whether or not a person has a small upper airway, recessed chin, small jaw/large overbite (all of which lesson the ability to take in air) are all risk factors.
Other issues include a family history of sleep apnea, smoking and alcohol use. Additionally, ethnicity appears to be related with African-Americans being at greater risk. And of course, as already mentioned, men are twice as likely to suffer from sleep apnea although the reasons may be more to lack of understanding and diagnosis than gender.
ARE THE HEALTH RISKS DIFFERENT?
Not really, for those who suffer sleep apnea regardless of gender, getting 8 hours of sleep can be less refreshing than 4 hours. It also significantly raises health and safety concerns beyond other sleep disorders. Those who suffer from sleep apnea are at greater risk for cardiovascular diseases including hypertension, atrial-fibrillation, heart failure, diabetes and stroke. It is a serious condition with serious consequences.
HOW IS IT DIAGNOSED?
Aside from suffering from the risk factors already mentioned, medical providers sometimes use questionnaires such as the Epworth sleepiness scale, and the Stop Bang questionnaire as a screening tool.
The gold standard for diagnosis is a sleep study. This is referred to as polysomnography. This is a test that records your brain waves, the oxygen level in your blood, heart rate and breathing, as well as eye and leg movements during the study. It is not only a test for sleep apnea, but is a valuable diagnostic test for many other sleep disorders.
The test is usually done at a sleep disorder unit within a hospital or sleep center, but recent advances in testing have now created the opportunity to perform these studies at home. This approach (at home testing) has become increasingly more popular with truck drivers not only due to its convenience, but also because it is less disruptive with regular driving schedules. It also is much less expensive.
IS SLEEP APNEA THE SAME FOR EVERYONE DIAGNOSED WITH THE CONDITION?
Not all sleep apneas are alike. Also, not all require treatment. Severity is based on the number of apnea events per hour (referred to as the Apnea-Hypopnea Index).
Those who suffer less than 5 events per hour typically are not considered to have sleep apnea. Those that 5 + are considered to suffer a Mild form of sleep apnea. If they suffer 15+ per hour, this is considered Moderate sleep apnea. For those who suffer 30 or greater hypopnea events per hour, this is a Severe form of sleep apnea. These drivers are of course at greater risk.
Treatment is not required for all of those who suffer sleep apnea. Studies have shown that C-PAP use is only effective for individuals who suffer 15 or greater hypopnea events per hour. A review of prescriptive practices however reveals that most sleep centers prescribe a C-PAP or other treatment when an individual suffers 5 or greater events. Why this is so is only speculative, but it appears to be consistent throughout the industry.
HOW IS IT TREATED?
Typically, sleep apnea is treated with a device known as a continuous positive airway pressure device (CPAP). A CPAP is a mask that fits over the nose and/or mouth, and gently blows air into the airway to help keep it open during sleep. This method is highly effective and is most often used. It does present some difficulty in getting used to, and it is not uncommon for drivers to need at least a few weeks before it becomes second nature. Those who use it consistently will eventually appreciate the improvement in the sleep process, and how much better they feel as a result.
Other forms of treatment also include the use of a nasal expiratory positive airway pressure where a disposable valve covers the nostrils; treatment using a hypoglossal nerve stimulator where a stimulator is implanted in the patient’s chest and leads connected to the hypoglossal nerve that controls tongue movements as well as having a breathing sensor. There are also surgical procedures that remove a part of the soft pallet (called an uvulectomy) to lesson obstruction.
In addition to these treatments, there is an oral device that is becoming more popular with the general public. It is typically provided by a dentist who has extra training. A problem exists for the truck driver because there exists no ability to provide a compliance report (which demonstrates how much time you use the device). Therefore this form of treatment is not advised to be used by the truck driver although it is not prohibited by the FMCSA.
WHAT IS THE FMCSA REGULATION FOR SLEEP APNEA?
Frankly, no regulation exists for sleep apnea currently. That means there is no law that the driver, or the medical examiner to follow which has led to much confusion for both in how to address this problem with truck drivers.
What does exist is something known as “guidance”. Guidance means that this is a suggested way of dealing with sleep apnea. How it is interpreted by the medical examiner has been an area of great frustration within the trucking industry however. It is interpreted to mean different things to different medical examiners thereby leading to a variety of ways it is imposed on the industry. Some examiners make decisions to have a sleep study done, where others do not. There even exists some controversy over testing with certain occupational facilities requiring more testing because they own their own sleep centers. I think we all know who those facilities are. No need to drop names.
So what does the guidance say, and what would the best approach for a medical examiners and driver be in deciding if a sleep study is truly needed?
First, understand that the key in the determination is to realize that the FMCSA is most concerned with moderate to severe sleep apnea (15 apnea events per hour or greater). So screening for this is the first criteria that must be established.
In doing so, the examiner will review some of the questions on the exam for relating to loud snoring and inquire about sleepiness while driving, witnessed apneas (typically by a spouse), and family history of sleep apnea.
The examiner will then review other risk factors such as those discussed previously such as BMI, Neck size, age, gender and ethnicity. Remember smoking can also be a risk factor.
Best practice decisions (made by medical examiners based on their opinion and not based on a regulation) should be based on having a BMI of 35 or greater, with a larger neck circumference (17 inches for men, 16 for women). A driver should also have at least some screening (such as an Epworth sleepiness scale). If there are no other risk factors present and screening is not clear as to risk, the driver would not be at significant risk for suffering moderate to severe sleep apnea. It would be however, up to the medical examiner to decide if a sleep study is needed. Unfortunately decisions as mentioned can go either way.
If the driver has a history of diabetes, high blood pressure or previous history of stroke, or suffers some of the other risk factors, they should have a sleep study performed. Also, increasing obesity (anyone with a BMI of greater than 40), will make it necessary to have a sleep study.
Depending on the results of the sleep study (whether or not you suffer from sleep apnea and treatment is required), the medical examiner will either certify the driver for 2 years if the driver does not suffer from sleep apnea, or a maximum of 1 year if they do.
Furthermore, if the driver is prescribed a CPAP, guidance recommends a 1 month waiting period (a time where a driver may not drive while under a new treatment or recovering from a treatment). The waiting period after surgery is 3 months.
Drivers will be required to re-certify yearly while being treated, and need to provide a compliance report that demonstrates 70% of daily use at least 4 hours per day. There no longer any need to have an annual sleep study, however medical examiners should use subjective methods with their drivers such as the Epworth or Stop Band questionnaires.
As you can see, there are some differences between men a women drivers as it relates to sleep apnea. The differences appear to be in the greater difficulty in recognizing the symptoms, and delay’s in testing. Unfortunately the effects and consequences of suffering from the condition appear equally as harmful in both genders.
A question may relate to being proactive with testing and not waiting for your DOT physical. I have been asked this a number of times over the years. The answer is yes. It is important to not only do this for your health, but it may eliminate the need for waiting periods etc. Make sure that when you do have your exam however, you come in prepared. Have your compliance report in your hand before you go. It will prevent any delays in certification!