Author: Dr. David Thorpe
Often an issue for the truck driver, CPAP compliance for those driver’s with sleep apnea can be a problematic. It is even more complicated by the lifestyle requirements of the typical driver, most importantly frequently being away from home. It is also a significant issue when a driver goes in for their DOT medical exam and is one of the leading concerns expressed by motor carriers and drivers that appeared in the ATRI report that was released in April of 2017.
With CPAP being the most common treatment prescribed for drivers, finding ways to improve compliance is not only important for their continued ability to drive a CMV, but is also essential for their health. Sleep Apnea, if left untreated it can cause not only symptoms such as daytime sleepiness and mental lethargy but it can lead to many additional health problems. Those who do not successfully manage their sleep apnea will increase their chance to develop or experience a number of medical conditions including:
- High blood pressure
- Heart failure/heart attack
- Increased symptoms of ADHD (attention and concentration)
The benefit of being compliant is significant. To begin with, it is most often noticed by the patient (the driver) themselves. They report an improved quality of sleep and an increased level of alertness during the day. Their blood pressure decreases (another notable benefit to the truck driver) as well as improvement in other cardiovascular conditions such as irregular heart rates, and improved heart function even in those who have issues such as congestive heart failure.
WHAT IS COMPLIANCE?
One might expect that compliance would mean that a driver must wear his CPAP every night for up to 8 hours per night. This is not the case. The FMCSA defines compliance as using the therapy for an average of 4 hours a night for at least 70% of the nights. Unfortunately studies show that between 29% and 83% of patients overall, not just truck drivers, do not meet the criteria for compliance. For the average person this is typically caused by simply removing the CPAP early in the night and/or skipping use altogether. The truck driver has also to overcome the difficulty of using the device while on the road. With the advances of monitoring use such as smart cards and Web-based systems that check both the hours the CPAP machine has been running, and the amount of time it is used, it is imperative to the truck driver that they are fully compliant as defined, not only for health reasons, but to prove compliance during their DOT exam (which is mandatory).
WHAT ARE THE BARRIERS TO COMPLIANCE?
Researchers have looked at various factors in trying to predict compliance and have found a few that will indicate that a person is more or less likely to be compliant with use. Things such as age, gender and socioeconomic status have been ruled out as having some bearing on compliance, as have stress level, anger, anxiety, or depression. However, the severity of their condition as reflected in their apnea-hypopnea index (AHI – which indicates the number of apneas or hypopneas per hour) demonstrated a direct relationship with compliance. Those with a higher AHI tend to be more compliant, and if they have both sleep apnea and congestive heart failure and are treated with CPAP, they have less mortality.
Additionally, those patients who have already demonstrated poor compliance with the treatment of other conditions (such as being complaint with taking medication to treat diabetes and/or high blood pressure for example) will carry this forward with their compliance with CPAP therapy. Education or understanding the health-related risks of sleep apnea, along with those who complain of claustrophobia are also good predictors of poor CPAP compliance.
Lastly, the side effects and problems with the patient-CPAP system can cause the CPAP machine to be stuck in the closet, never to be used. The side effects include nasal drying, increased congestion, sneezing, problems with the patients sinuses, pressure sores on the bridge of the nose, difficulty exhaling, allergic reaction to the materials of the mask, air swallowing and gastric distension, machine noise, and skin creases the next morning. Most of these are avoidable however if everyone in the health care team does a proper job of education, application, and follow-up with the trouble-shooting and making corrections early in the start-up, as needed!
TIPS TO IMPROVE COMPLIANCE
Aside from improved education, application and follow-up with trouble-shooting what are some additional tips for the driver who uses a CPAP? Let’s look at what drivers can do to improve their compliance.
- Be proactive in treatment. Become knowledgeable with the disorder and treatment options. Should you have side effects and problems, seek out solutions as soon as they become an issue. Understand how the equipment works and what you should expect as well as your part in the process. Don’t hesitate to try something new if what you are currently doing is not working – this goes for CPAP supplies, your doctor and your CPAP supplier.
- Understand the latest CPAP technology. CPAP is constantly improving. Manufacturers are making machines lighter, more portable, comfortable, usable and efficient. Check with your supplier should be able to help you with new technology, masks and accessories.
- Get a CPAP that fits! Mask issues – specifically the way they fit – are often the reason patients don’t use their machines every night. No single CPAP mask is right for everyone, and it may take a few trials to find the ideal mask. Make sure the size is correct and the fit is comfortable to your facial structure when you’re awake, because if not, it will be difficult to fall asleep. Consider having a few masks in different styles so you can change if you experience soreness in pressure points or just to change things up.
- Keep your machine, mask and tubing clean! Make the cleaning of your CPAP mask and tubing part of your daily routine. CPAP cushions and tubes that aren’t cleaned can lead to stuffy nose, colds and bacteria. These issues will negatively impact CPAP therapy and reduce compliance. Special wipes and cleaners are available to make this job easier. Also, the SoClean has been a very useful and popular item and the convenience factor alone is worth it.
- Replace CPAP filters when needed. Without a clean filter, CPAP patients miss out on optimal treatment, even if they do comply with usage recommendations. As dust and particle collect in the filter, they restrict airflow, which forces the machine to work harder. Moreover, dust and debris can collect in the filter, they restrict airflow, and forces the machine to work harder. The dust and debris can also affect the user’s breathing passages. Replacing the filter is truly easy, and should not be neglected.
- Buy only what you need to improve CPAP compliance. It’s not always necessary to buy a new CPAP masks if only parts need to be replaced. Cushions will break down and headgear will eventually lose its pliability after many washings. When buying a mask, find out what parts can be replaced and stock up a few, because compliance is always easier when the equipment is comfortable and well-working.
- Lastly, set reasonable expectations. If you are new to CPAP use, you will be experience some changes to your life style. Understand that overall it will improve your quality of life in general, even with the added responsibility of wearing a CPAP while asleep. Sometimes it will take time to get comfortable with all the new elements, so be patient and set reasonable expectations. Turn to resources and forums, chat board and equipment suppliers. More importantly, always work toward consistency and full compliance with your recommended therapy.
ADDITIONAL CONSIDERATIONS THAT MAY HELP COMPLIANCE
If you have more than one mask, and some drivers do (one for home and one for on the road), do not forget to bring in the CPAP compliance report from both machines. Remember the overall requirement is to be complaint 4 hours per night, with 70% of daily use. Not having both reports will definitely affect these numbers. It would be a shame to be compliant, gain all of the health benefits, and then be out of the cab for a few days because you did not provide both reports.
If compliance continues to be an issue, you can consider other forms of treatment. One gaining greater interest are oral appliances. Although they were approved for use by the FMCSA, it wasn’t until recently that technology has been developed to track compliance with this form of treatment. Make sure that if you choose to go this route, that what is provided can track compliance for you.
WHAT DO I NEED THE DAY OF MY DOT MEDICAL EXAM?
In closing, remember sleep apnea is a real condition. Despite the fact that the FMCSA has moved away from the rule making process regarding sleep apnea, medical examiners are still required to ensure that the driver is still medically qualified to driver. Most will follow what guidance existed at the time of their training, as well as some who actually look into what advanced information is available for the decision making process. This will mean that there will be variability in how decisions are made between medical examiners leading to greater concern for drivers. The questions all drivers express will be “what do I need when I go in so that I can pass my physical?
Here is what I would suggest:
- If the driver has a BMI of 35 or greater (you can google a BMI calculator on any PC or smart device), they should consider proactively being tested. If a driver also suffers from high blood pressure, or has diabetes or suffered a previous stroke, they should definitely be tested prior to going in for your exam. Lastly, if their BMI is 40 or greater, regardless of their current health status, you should be tested prior to your exam. Being proactive will eliminate unnecessary delays in certification.
- If the driver currently is diagnosed with sleep apnea, make sure you are compliant with treatment as we have defined in this post.
- Prior to going in for your exam, make sure you have a CPAP compliance report printed off and ready to go. Paper is better than showing the medical examiner something on your phone demonstrating compliance. Most medical examiners will want something that they can put into your file.
- Lastly, as mentioned, if the driver has more than 1 machine, make sure they print off both compliance report’s to provide to the medical examiner the proper and complete compliance information.
By following the above recommendations, drivers will be more compliant with CPAP use, improve their health and stay on the road!
For more information, contact Dr. Thorpe at firstname.lastname@example.org