By Sree Roy

An interesting string of events happened at the end of 2013. Federal Air Surgeon Fred Tilton, MD, announced that commercial pilots with BMIs of 40 or more would soon be required to undergo obstructive sleep apnea (OSA) evaluations before being certified to fly. He held his ground for weeks, despite opposition, even from House General Aviation Caucus members. Then, in a sudden turnaround, Tilton put the policy on hold, indicating the FAA will work with stakeholders in 2014.

Also in 2013, the President signed a law mandating rulemaking regarding OSA and commercial motor vehicle operators. Many applauded the move, while others saw it as a delaying tactic, pointing out the lack of a timetable.

Why the controversy? As I spoke to stakeholders, I realized that maybe this flip-flopping scenario shouldn’t have been so surprising after all. There is much at stake for many parties. Some of the most salient issues are as follows.

  1. Employment at Risk: Though OSA is a treatable condition and a protected disability, transportation workers have unique obstacles to meeting the 90-day diagnosis-to-compliance requirement that would turn their conditional DOT medical cards into the needed 1-year cards. Ironically, one of the biggest obstacles arises out of the jobs themselves—the requirement to constantly travel makes it difficult to keep a sleep doctor appointment.
  2. Shouldering the Costs: Many times, it’s the individual who must pay all OSA-related expenses. Many truckers and pilots are not eligible for their employer’s insurance benefits. Under the Affordable Care Act’s individual mandate, these workers likely have some health insurance, but high deductible plans are still likely to saddle them with the entire bill. Manufacturers, physicians, and dentists are making progress here: Refined home sleep testing to APAP protocols and compliance-measuring oral appliances will allow for more affordable options.
  3. Liability and Lawsuits: Most guidance so far focuses on high BMI and large neck circumference. While these are risk factors, many other OSA cases may be overlooked. And if only a subset of workers must be tested, what happens if a worker not meeting the screening criteria causes an accident that is related to OSA? To Tilton’s credit, his now-paused guidance indicated that over time screening would be mandatory for all pilots, not just for those with high BMIs.
  4. Changing Certifier Requirements: The National Registry of Certified Medical Examiners takes effect this summer, which means doctors who want to conduct DOT exams must pass a training course and exam. Editorial advisory board member Edward Michaelson, MD, anticipates this change will result in better trained examiners, less opportunity for patients to “doctor shop,” and, since a driver’s CDL will be linked to the examiner’s registry number, more frequent OSA diagnosis.
  5. Compliance Concerns: For commercial transportation workers who meet the 90-day requirement and are willing to use CPAP, there are still day-to-day hurdles, such as truck idling laws that may not allow the power needed for heated humidification. Even seemingly simple tasks like CPAP cleaning become complicated when the only options are a truck stop or an airplane lavatory.

I don’t have the solutions to these knotty issues. Clearly neither does Tilton nor any other individual. But I’m optimistic that many stakeholders working together will arrive at a compromise that will move us all forward. Stay tuned for an in-depth feature story later this year and to our e-newsletter for developments.

Sree Roy is editor of Sleep Review.