Recent car crash or fender bender? Truck crash? Check your sleep.

Obstructive Sleep Apnea and Risk of Motor Vehicle Crash: Systematic Review and Meta-Analysis

Of all occupations in the United States, workers in the trucking industry experience the third highest fatality rate, accounting for 12% of all worker deaths. In 2006, there were 368,000 police-reported large truck crashes, resulting in 4,321 fatalities and 77,000 injuries.¹ The Federal Motor Carrier Safety Administration (FMCSA) was established as a separate administration within the U.S. Department of Transportation (DOT) pursuant to the Motor Carrier Safety Improvement Act of 1999. The primary mission of the FMCSA is to reduce crashes, injuries and fatalities involving large trucks and buses. Among the strategies employed by the FMCSA to accomplish this goal are the development and maintenance of medical fitness standards for drivers of commercial vehicles; these standards are applied by medical examiners to commercial drivers, who are required by Federal statute to undergo medical qualification examinations at least every 2 years.

Obstructive sleep apnea (OSA) is a prevalent and potentially dangerous condition among commercial motor vehicle (CMV) drivers. While OSA is conservatively estimated to affect approximately 5% of the general population,² the condition appears to be much more prevalent in commercial drivers. Howard et al. estimated that 50% of more than 3000 commercial drivers were at risk for sleep apnea.³ Pack et al. found that 28.2% of 406 commercial drivers had at least mild sleep apnea and 4.7% had severe sleep apnea by conventional criteria.⁴ The majority of research indicates that OSA is a significant cause of motor vehicle crashes.^3,5–9 Thus, assessment of the risk of OSA and development of effective methods to identify and treat commercial drivers with OSA is an important part of the mission of the FMCSA. Since the most recent standards for medical examiners regarding OSA are from a Federal Highway Administration (FHWA) sponsored conference in 1991,¹⁰ these standards required an evidence-based update.

The current study was designed to provide evidence for updating the standards by conducting a systematic review of the relevant literature concerning OSA and CMV drivers. The literature consists predominantly of cohort and case-control studies. Given that few studies specifically enroll CMV drivers, studies that included non-CMV drivers were also evaluated.

The primary objective of this study was to determine whether individuals with OSA are at an increased risk for a motor vehicle crash when compared to individuals without OSA. If so, a secondary objective was to identify disease-related factors associated with an increased motor vehicle crash risk.

DESIGN/SETTING: Seven electronic databases (MEDLINE, PubMed (PreMEDLINE), EMBASE, PsycINFO, CINAHL, TRIS, and the Cochrane library) were searched (through May 27, 2009), as well as the reference lists of all obtained articles. We included controlled studies (case-control or cohort) that evaluated crash risk in individuals with OSA. We evaluated the quality of each study and the interplay between the quality, quantity, robustness, and consistency of the body of evidence, and tested for publication bias. Data were extracted by 2 independent analysts. When appropriate, data from different studies were combined in a fixed- or random-effects meta-analysis.

RESULTS: Individuals with OSA are clearly at increased risk for crash. The mean crash-rate ratio associated with OSA is likely to fall within the range of 1.21 to 4.89. Characteristics that may predict crash in drivers with OSA include BMI, apnea plus hypopnea index, oxygen saturation, and possibly daytime sleepiness.

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

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2792976/?tool=pubmed

I try to communicate with patients every day that fixing sleep apnea adds extra useful years to your life. JR

J Clin Neurophysiol. 2006 Feb;23(1):21-38.

Why a polysomnogram should become part of the diagnostic evaluation of stroke and transient ischemic attack.

Grigg-Damberger M.

Pediatric Sleep Services, University Hospital Sleep Disorders Center, and Department of Neurology, University of New Mexico School of Medicine, Albuquerque, New Mexico 87131, USA. mgriggd@salud.unm.edu

Abstract

Neurologists need to recognize, diagnose, and treat obstructive sleep apnea (OSA) in patients with stroke or transient ischemic attack (TIA). Increasing medical evidence suggests that OSA is an independent risk factor for stroke and TIA. Stroke (or TIA) is more likely a cause, rather than a consequence, of OSA because PSG studies have shown: 1) apneas in stroke are typically obstructive, not central or Cheyne-Stokes in type; 2) apneas are just as frequent and severe in patients with either TIA or stroke; 3) OSA severity is not influenced by the acuteness or location of the stroke; 4) untreated OSA patients have more strokes, stroke morbidity, and mortality than those who are treated. OSA alone can induce hypertension, especially in younger men. A causal relationship has recently been demonstrated between OSA and hypertension. A distinctive feature of OSA-induced hypertension is loss of the normal nighttime fall in blood pressure ("nondippers"). Data from the Sleep Heart Health Study showed a dose-response association between OSA severity and the presence of hypertension 4 years later. Hypertension or ischemic heart disease usually develops in untreated patients with OSA over time without particular worsening of OSA. Studies have shown sleep itself is not a risk factor for stroke because most stroke and TIAs begin between 6 am and noon, while the individual is awake. However, OSA promptly be considered in stroke beginning during sleep because 88% of strokes that develop during sleep occur in "nondippers." Premature death in OSA patients is most often cardiovascular, but occurs while the patients are awake. The risk of myocardial infarction is increased 20-fold in untreated OSA. Treating OSA patients with continuous positive airway pressure can prevent or improve hypertension, reduce abnormal elevations of inflammatory cytokines and adhesion molecules, reduce excessive sympathetic tone, avoid increased vascular oxidative stress, reverse coagulation abnormalities, and reduce leptin levels. If all this can be achieved by a polysomnogram, then this test should become part of a neurologist's armamentarium for stroke and TIA.

PMID: 16514349 [PubMed - indexed for MEDLINE]

At-Home Sleep Testing Equal to Overnight in a Sleep Lab in Treatment Results

At-Home Sleep Testing Equal to Overnight in a Sleep Lab in Treatment Results ...and CPAP outcomes are equivalent

ATS 2010, NEW ORLEANS—Patients with suspected obstructive sleep apnea (OSA)

may no longer have to spend an expensive and uncomfortable night at a sleep center to

monitor their sleep-disordered breathing. According to new research, those who

performed sleep testing in their home with portable monitors showed similar

improvements after three months of treatment with continuous positive airway pressure

(CPAP) in daytime function as compared to patients who underwent overnight testing in

a sleep center.

Furthermore, patient adherence to CPAP over the first three months of treatment was

similar in patients with OSA who received home versus in-lab testing.

http://www.thoracic.org/newsroom/press-releases/conference/articles/2010/sleep-testing-at-home.pdf

Is the outcome of home sleep testing worse than the lab? No!

Chest. 2010 Feb 19. [Epub ahead of print]

Outcomes of home - based diagnosis and treatment of Obstructive Sleep Apnea.

Skomro RP, Gjevre J, Reid J, McNab B, Ghosh S, Stiles M, Jokic R, Ward HA, Cotton D.

1 University of Saskatchewan, Saskatoon, SK., Canada.

Abstract

INTRODUCTION: Home diagnosis and therapy of OSA may improve access to testing and CPAP treatment. We compared subjective sleepiness, sleep quality, quality of life, blood pressure and CPAP adherence after four weeks of CPAP therapy in subjects diagnosed and treated at home and in those evaluated in the sleep laboratory.

Conclusions: Compared with the home-based protocol, diagnosis and treatment of OSA in the sleep laboratory does not lead to superior four-week outcomes in sleepiness scores, sleep quality, quality of life, blood pressure, and CPAP adherence.

PMID: 20173052 [PubMed - as supplied by publisher]

http://www.ncbi.nlm.nih.gov/pubmed/20173052

Floppy Eyelids Increase the risk of Sleep Apnea

Floppy Eyelids and Sleep Apnea - Your optometrist can save your life...

When physicians see a patient with floppy eyelid syndrome, they should also screen for obstructive sleep apnea-hypopnea syndrome, new research has shown.

In a small study, those with the condition -- characterized by rubbery upper eyelids -- had a 12.5-fold increased risk of obstructive sleep apnea, Daniel G. Ezra, MD, of Moorfields Eye Hospital in London, and colleagues reported in the April issue of Ophthalmology.

http://www.medpagetoday.com/Pulmonology/SleepDisorders/19372

Sleep Apnea Tied to Increased Risk of Stroke - Adds 10 years

Sleep Apnea Tied to Increased Risk of Stroke

Even Mild Sleep Apnea Puts Men in Danger

"Our findings provide compelling evidence that obstructive sleep apnea is a risk factor for stroke, especially in men, " noted Redline. "Overall, the increased risk of stroke in men with sleep apnea is comparable to adding 10 years to a man’s age. Importantly, we found that increased stroke risk in men occurs even with relatively mild levels of sleep apnea. "

http://www.nih.gov/news/health/apr2010/nhlbi-08.htm

Gret news!

I am now in network with Kelsey Seybold and Humana!

JR