It is ironic that one of the most mobile professions—commercial driving—leads to one of the most sedentary lifestyles. Truck drivers spend much of their time behind the steering wheels of their rigs or waiting for their trucks to be loaded or unloaded. Commercial drivers eat on the road (meaning a lot of fast food) and sleep in their cabs. Deadlines are stressful, and money is lost when the truck is stationary.
Not surprisingly, then, truck drivers are at risk of developing conditions related to a lifestyle associated with poor diet, little exercise, and inadequate sleep. Obesity, high blood pressure, heart disease, diabetes, and sleep apnea are not uncommon in this segment of the population. Any of these disorders can have negative effects on the life and livelihood of the afflicted driver, but sleep apnea has garnered particular attention, in part because of its potentially negative effect on driver safety.
Driver fatigue has received enough media attention to raise awareness and concern among regulatory bodies, consumers, and the commercial driving industry itself, though perhaps not enough to have pushed any recent changes through yet. But they are coming.
“We [anticipate] the FMCSA [Federal Motor Carrier Safety Administration] is going to administer some sort of standard that everyone’s going to adhere to within the next year or so,” says Jeffrey Durmer, MD, PhD, FA, chief medical officer and medical director of FusionSleep/Sleep4Safety, headquartered in Johns Creek, Ga. In preparation, many trucking companies are developing programs intended to address the issue of sleep and safety in this unique population.
HEALTHY, WEALTHY, AND SAFE
A diagnosis of sleep apnea does not have to mean unsafe roads or unemployed drivers. Commercial drivers diagnosed with sleep apnea may not have a history of sleepiness; even so, this does not mean that health and safety issues are not a concern. As the disorder progresses, sleepiness may develop or worsen, but it is not always present at initial testing.
“That’s one reason the Department of Transportation-certifying physicians we work with are all comfortable signing off on a 90-day certificate. Now, if the driver has a history of sleepiness or crash-related falling asleep behind the wheel, that brings up a different issue,” Durmer says.
Even without safety concerns, however, there are still significant benefits to diagnosing and treating sleep disorders, including sleep apnea, in the commercial driver population. “I think the most compelling issue for companies is they really can’t ignore the data, which right now suggests there is an epidemic of sleep-disordered breathing and apnea in truck drivers—up to a third,” Durmer says.
Research bears this out. George lists two studies that found the prevalence of sleep apnea in the truck driver population is about 15% to 18%.1 Moreno et al reported approximately 26% of truck drivers fall within the high-risk group for obstructive sleep apnea.2 In another study of commercial vehicle drivers, findings indicated 36% of drivers suffer at least a mild form of the disorder.3
Liability is therefore high on the list of concerns for trucking companies, insurers, and other associated parties. “If there were a large accident and the driver had apnea but was not adequately treated or even investigated for it, [the company] could be held liable,” Durmer says.
In addition to increasing safety (and reducing liability), treating sleep apnea brings other benefits, including improvements in driver health and fewer health care expenses for the company. Durmer cites savings ranging between $2,000 and $6,000 per driver per year, depending on the company.4,5
“Treated drivers have fewer short-term disability stays. Their medical expenses are reduced. And typically, retention rates are higher compared to the rest of the fleet,” says Douglas Kerstetter, national sales manager for the Sleep Service Center, Milwaukee. Unfortunately, this population can be hard to pin down—verbally, geographically, and physically.
KEEPING TRUCKERS HONEST
“I would say probably the biggest challenge that remains is one of education because there are a lot of misconceptions around the topic of sleep apnea in trucking,” Kerstetter says. Drivers and companies fear the loss of driving time, reduced revenue, and too much regulation.
“I think the educational component is probably paramount to teach people that by treating sleep disorders, they really have an opportunity to improve their own health and the quality of their lives and their families’ lives as well. And the additional benefit, of course, is the reduced risk of accidents and the safety gains that come from it,” Kerstetter says.
Without this knowledge, drivers may be leery discussing symptoms of sleep disorders and therefore not as forthcoming as they could be. “They may not want to admit that they do have some kind of sleep deprivation going on,” says Bob Perry, president of Roadside Medical Clinics + Lab in Las Vegas.
This can make screening for sleep apnea challenging and has inspired the development of new processes to identify those at risk and those suffering from this sleep-breathing disorder. Demographic data collected typically include gender (men are more likely to have sleep apnea than women); physical parameters, such as height, weight, and neck size; BMI (obesity increases risk); medical history, complete with medications; and comorbidities, including high blood pressure, diabetes, and heart disease. Observational data may include the presence or absence of snoring, middle-of-the-night gasping for air, and daytime fatigue.
In many cases, the data is collected using surveys and/or questionnaires. Popular options include the Apnea Risk Evaluation System Questionnaire (ARES Q), the Berlin Questionnaire, the Epworth Sleepiness Scale (ESS), the Pittsburgh Sleep Quality Index (PSQI), the Stanford Sleepiness Scale, and the STOP Questionnaire. Unfortunately, these have disadvantages in a wary patient population.
“The average truck driver is not going to volunteer symptoms related to daytime fatigue, daytime sleepiness, or inattentiveness while driving,” says Mark Berger, MD, chief executive officer of Precision Pulmonary Diagnostics (PPD), Houston.
Berger, in conjunction with his colleague Wendy Sullivan, RN, vice president of project implementation and health and safety consultative services at PPD, launched a new sleep-focused questionnaire in 2006, the Somni-Sage Questionnaire, in part to work around the reluctance of truck drivers to share information. Data the team has collected over the past 4 years indicate drivers have a tendency to be reluctant (Berger and his team are currently preparing the data for publication).
The Somni-Sage Questionnaire, now patented, was developed based on research collected solely from commercial drivers. It is administered through a secure HIPAA-compliant Web portal and features approximately 35 questions, which the driver can answer within 15 minutes.
“It’s running a high positive predictive value for the presence of sleep apnea in a truck driver,” Berger says. PPD uses the survey as part of its screening process to identify drivers most at risk for sleep apnea.
“We wanted a method to identify which truck drivers in a fleet would be at risk for having sleep apnea because you obviously don’t want to do an overnight sleep test, even with an overnight limited channel monitor, on every single truck driver just because they’re a truck driver,” Berger says. Rather, it is more time- and cost-effective to perform diagnostic testing on the subsegment that appears to be at greatest risk.
COMFORT AND CONVENIENCE
Diagnostic testing for sleep apnea presents challenges with such a mobile population. However, today’s driver-specific sleep programs have found ways to meet these challenges, primarily by moving their testing centers to the road, setting up centers independently or in partnership at trucking hubs.
Roadside Medical Clinics + Lab has partnered with Pilot Travel Centers LLC, which recently merged with Flying J to create a network of more than 550 interstate travel centers and travel plazas. Currently, there are six clinics open within the network; Roadside Medical Clinics + Lab hopes to have 80 clinics running in 3 years. “So we are located where [truck drivers] are sleeping every night anyway. They just sleep in one particular spot nearer to the clinic rather than down the road,” Perry says. The drivers, therefore, don’t have to worry about finding a space to park their rigs or be off schedule.
“We only take them off their schedule for perhaps 6 hours, 7 hours at the most,” Durmer says. FusionSleep/Sleep4Safety also offers driver sleep testing on-site in partnership with the companies that have contracted its services. “The program is designed to go into the trucking terminal, the truck stop, or wherever is designated by the company to be a location where the drivers go to sleep,” Durmer says.
With these programs, the truck driver is given an ambulatory limited channel testing device to use that evening while sleeping in their usual circumstances, generally the cab. Wakefulness tests are not typically employed. “The model does not compromise quality in any way because we use a type 3 device and often a type 2 device,” Durmer says, noting the addition of ECG leads that can pick up milder cases of sleep apnea.
Sleep Service Center also employs ambulatory monitoring in its treatment pathway. Kerstetter says that the device that they utilize is the most studied ambulatory device on the market.
The next morning, the truck driver brings in the device, and it is typically interpreted immediately by a board-certified sleep physician to determine a diagnosis and treatment path. At FusionSleep/Sleep4Safety, “They interpret the testing data together with the previously acquired medical data remotely through the FusionSleep HIPAA-compliant electronic medical records system,” says Durmer. “This allows for real-time analysis, medical decision making, and reporting.” If sleep apnea is confirmed, the truck driver is often fitted on-site for a CPAP (continuous positive airway pressure) or APAP (automatic continuous airway pressure) device before heading back on the road.
CLOSE AND COMPREHENSIVE
Precision Pulmonary Diagnostics shares similar program goals but uses a different pathway. PPD subcontracts independent diagnostic testing facilities that are accredited (or pending accreditation) with either the American Academy of Sleep Medicine or The Joint Commission. These facilities perform the diagnostic testing component of PPD’s comprehensive sleep apnea management program. The sites are national, with about 30 in current operation.
Drivers are still tested overnight on-site but with a type 1 polysomnogram. Although PPD is exploring the use of limited channel monitors, Berger cites a reduced need to bring drivers back as a distinct advantage of an attended diagnostic test. “If there is a technical difficulty, it can be remedied immediately, so the chance of having to bring a driver back because of a technical issue related to the diagnostic test is almost zero. In addition, it is the reference standard and the most comprehensive test,” Berger says.
The scope is another advantage in terms of liability concerns. “The legal implications of a diagnosis or a misdiagnosis of sleep apnea in a commercial driver are potentially huge, so we feel strongly that the most comprehensive study ought to be the one used in this patient population to rule out the presence of sleep apnea or to assess its severity,” Berger says.
Depending on test results and the decision of the physician, if a driver is found to have sleep apnea, they are typically fitted for an APAP or CPAP device. This is frequently equipped with a compliance monitoring system that is set up to download according to the specific program the driver is enrolled in. “Some of the organizations are interested in daily compliance monitoring. Other programs go with weekly, monthly, or quarterly compliance monitoring,” Kerstetter says.
The device transmitters send information related to how often and how long it has been used, the pressures that have been employed, leak issues, and efficacy. “It can calculate an apnea index and an apnea-hypopnea index, which have been shown in studies to be equivalent to polysomnographic AIs and AHIs,” Kerstetter says.
Not only is the information used to ensure patient compliance with treatment, but it also can identify potential obstacles to compliance. “Night-to-night information is available from the PAP devices we use to objectively track compliance as well as efficacy,” says Durmer. “Obstacles to compliance and efficacy can also be detected such as leakage from the pressure system that may equate to a misfitting mask or driver discomfort.”
A truck driver may be reluctant to use the device because of issues related to fit, comfort, and/or claustrophobia. “Just telling them there’s someone watching them is not enough. What we really need and what we stress in the program is actually having a compliance coach, somebody who is there to help you—not to yell at you if you don’t use it, but to solve the problems of using CPAP for the first time,” Durmer says.
Working through these issues early can help to ensure long-term compliance. “There are lots of studies that show if you can get somebody compliant in the first 3 months, you have much higher long-term success at 2 years than when not having achieved successful use in the first 3 months,” Durmer says.
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FusionSleep/Sleep4Safety, therefore, aims to have truck drivers using an APAP or CPAP device at least 6 hours a night 90% or more of the time, a higher standard that is typical (“Medicare standards require 4 hours or more,” Durmer says).
Generally, if the driver maintains compliance, no further action is required; reporting is generally on an exception basis, according to Kerstetter. “If a company sets up a protocol, and there’s an individual who falls outside of that requirement, then we can alert the firm that the individual is outside of the guidelines that have been set up,” Kerstetter says. Of course, this is another irony: even while on the road, truck drivers can still be closely monitored, but at least they’ll get a good night’s sleep.
Renee Diiulio is a freelance writer based in Manhattan Beach, Calif. She can be reached at .
- George CF. Sleepiness, sleep apnea, and driving: still miles to go before we safely sleep. Am J Respir Crit Care Med. 2004;170:927-928.
- Moreno CR, Carvalho FA, Lorenzi C, et al. High risk for obstructive sleep apnea in truck drivers estimated by the Berlin questionnaire: prevalence and associated factors. Chronobiol Int. 2004;21:871-9.
- Federal Motor Carrier Safety Administration. Tech brief: Sleep apnea crash risk study. US Department of Transportation. Available at: www.fmcsa.dot.gov/facts-research/briefs/SleepApneaCrash-RiskStudy-TechBrief.htm. Accessed September 1, 2010.
- Hoffman B, Wingenbach DD, Kagey AN, Schaneman JL, Kasper D. The long-term health plan and disability cost benefit of obstructive sleep apnea treatment in a commercial motor vehicle driver population. J Occup Environ Med. 2010;52:2010.
- Osterberg D. Fatigue management‹sleep disorders. Presented at: National Tank Truck Carriers Conference; May 12, 2009.