Why Some Truck Drivers Are Asked to Take a Sleep Apnea Test

Lawrence Buirse

The link between impaired driving, sleep apnea, and DOT physicals

It’s common to associate impaired driving with driving under the influence of drugs or alcohol. But there’s another form of impaired driving that is just as dangerous, and it doesn’t involve the use of illicit substances. It’s called drowsy driving, and for companies with commercial motor vehicle (CMV) operators, this form of impaired driving creates a uniquely dangerous scenario for both company drivers and other drivers and passengers on the roads.

Driving while drowsy can impair a driver’s performance behind the wheel. And while no illicit substances may be involved, the effects can be comparable to a drunk driver incident. According to National Safety Council (NSC) research, the physical effects of being awake for more than 20 consecutive hours are comparable to being legally drunk, and the physical effects of losing even two hours of sleep are similar to having three beers.¹ Statistically, a fatigued driver is three times more likely to be involved in a car crash.¹

The Federal Motor Carrier Safety Administration (FMCSA) has regulations designed to limit a commercial driver’s number of hours behind the wheel — and thus, reduce the risk and harmful effects of driving while drowsy.² But the cause of driver fatigue may not be long work hours. It could be the result of not getting enough sleep, and that lack of sleep could be a sign of a bigger problem, such as sleep apnea. Sleep apnea is a sleep disorder in which a person’s breathing stops and restarts repeatedly while asleep.³ The most common form of this sleep-related breathing disorder is obstructive sleep apnea (OSA).³ Most people who suffer from OSA experience certain symptoms during sleep, such as:

Loud snoring
Gasping/choking sounds
Restlessness (i.e., waking up constantly)

OSA sufferers may also complain of excessive daytime drowsiness, dry mouth upon awakening, and headaches.⁴ When suffering from OSA, a person’s respiratory functions are disrupted while asleep, as the body is constantly fighting to breathe. These breathing disruptions can last for seconds or even minutes and can happen as often as 30 times per hour.⁵ Consequently, a person with OSA may struggle to stay alert and function at a normal or required level. For a commercial driver with OSA, this could mean operating an 80,000-pound semi-truck (with a loaded trailer) across hundreds of miles for several hours while fighting off sleepiness and fatigue. Drowsiness can compromise a truck driver’s ability to master certain required skills like eye-hand coordination and manual dexterity. While no evidence suggests that every truck driver with symptoms of sleep apnea will encounter these performance challenges, there is enough data available to justify the need for medical examiners to screen truck drivers for health conditions like OSA, which can hinder their ability to safely operate a commercial vehicle.

Sleep apnea and DOT physicals for CMV drivers

Anne-Marie Puricelli, MD, JD, Concentra® national medical director of transportation and transportation medical expert panel chair, is a medical examiner with a wealth of experience evaluating the health of drivers who must meet certain Department of Transportation (DOT) standards to maintain their commercial driver’s license (CDL). According to Dr. Puricelli, not only can a health condition like sleep apnea be a key contributor to driver fatigue and impaired driving; it can also serve as a disqualifying condition during the DOT certification process.

“While federal regulations do not require CMV drivers to complete and pass a sleep apnea exam for DOT certification, FMCSA guidelines require medical examiners to apply a pulmonary standard, which ultimately enables examiners to determine if a respiratory condition like sleep apnea could interfere in a driver’s ability to operate a commercial motor vehicle safely,” says Puricelli.

During a DOT physical, a driver completes a health questionnaire that is reviewed by a medical examiner. There is also a physical examination that helps to tell the driver’s full health story. An examiner will consider several risk factors during the exam that can be associated with OSA.

“The medical examiner looks for any deformities likely to interfere with breathing or swallowing,” says Puricelli. “Often, we document what is called the Mallampati score, which is a predictor of obstructive sleep apnea. Basically, we score based on which structures are visible in the back of the throat. The less visible the structures, the higher the score,” explains Puricelli. “We can go up to four, and a score of three or four is associated with sleep apnea.”

Ultimately, a medical examiner could recommend sleep apnea testing to either rule out the condition or officially diagnose it and develop a treatment plan that enables the driver to manage the sleep disorder for both personal health advantages and for renewal of a medical examiner’s certificate of recertification.

The controversy over testing drivers for OSA

Because there is no federal guidance requiring sleep apnea testing for CMV drivers, it is not uncommon for a medical examiner to draw the ire of a truck driver by recommending a sleep study before rendering a decision during the DOT medical exam and CMV certification process. Some drivers fear that being diagnosed with sleep apnea may cause them to lose their job — a concern that could influence some drivers to downplay any signs or symptoms of sleep apnea during a DOT physical exam. According to Puricelli, a diagnosis of OSA does not seal a truck driver’s fate. OSA is just one of several potentially disqualifying medical conditions. Other conditions including high blood pressure, diabetes, and certain cardiovascular disorders can also disqualify a driver.

Diagnosis, treatment, and CDL status

When diagnosed with sleep apnea, a medical examiner may recommend that a driver is granted conditional certification for 90 days pending a sleep evaluation and treatment plan from a sleep specialist. Seeking treatment and complying with a prescribed treatment plan will position a CMV driver to become medically qualified to drive again.

It’s important to note that most sleep apnea cases can be successfully treated, and treatment can vary based on case severity.

“A diagnosis of moderate-to-severe OSA is a condition that must be corrected or brought under acceptable control before a driver is certified,” explains Puricelli.

To drivers with mild cases, Puricelli says a treating physician may recommend losing weight or trying a sleep apnea dental device. For drivers with moderate or severe cases, a physician may recommend a continuous positive airway pressure (CPAP) machine or CPAP alternative device approved by the U.S. Food and Drug Administration (FDA). A driver’s treating physician should discuss sleep test results and the prescribed treatment plan with the medical examiner to help ensure the driver can be granted medical clearance to operate a commercial vehicle.

The signs and risk factors of sleep apnea

First, not every truck driver will be recommended for a sleep test, and sleep apnea is not the only health condition a medical examiner considers. As previously stated, there are numerous chronic conditions that can place a driver’s DOT certification in jeopardy. During a DOT physical, a medical examiner may discuss some of the most common conditions, such as:

Diabetes
High blood pressure
Heart disease
Hypothyroidism
Stroke

A driver’s blood pressure, blood-sugar level, vision, and hearing are checked during the exam, along with the lungs, spine, extremities, and other regions of the body. A medical examiner will also record a driver’s weight, neck size, and body mass index (BMI). A driver’s medical history will also factor into the exam. If the physical reveals some indicators that are known to increase the risk of sleep apnea, a driver may be asked about signs and scenarios often associated with the sleep disorder, including:

Complaints of loud snoring from family or friends
Noticeable breathing stoppages while asleep
Constant complaints of sleepiness and/or fatigue
Past auto accident(s) potentially caused by sleepiness

Some signs of sleep apnea may not be self-detectable. A person may exhibit signs but blame their cause on other factors, such as stress, long work hours, or even another health condition. If a health problem hasn’t been properly identified, the appropriate remedy may not be applied. And the health and safety implications of an untreated condition like sleep apnea can be severe.

Testing is about more than safety and compliance

Testing truck drivers for potentially disqualifying medical conditions like sleep apnea is a required safety measure that helps to protect the driver, the driver’s employer (if applicable), and the public. Testing can also help drivers proactively address warning signs of other preventable, chronic health conditions. Like many chronic health conditions, the first step is diagnosis; the second step is treatment. If neither step is taken, not only can it lead to the development of a condition like sleep apnea. Untreated sleep apnea can also increase the risk of developing other serious health problems.⁶

“Medical evidence suggests that sleep apnea can contribute to the development of or worsening of chronic conditions such as hypertension, heart disease, and diabetes,” explains Puricelli. “Conversely, a person suffering from a chronic condition – or a combination of chronic conditions – may be at higher risk of developing sleep apnea.”

Drivers with undiagnosed, untreated sleep apnea can be a danger to themselves and anyone else they encounter while operating a commercial vehicle, but the medical implications can jeopardize their overall health and well-being – occupational and safety risks aside.

Understanding the value of sleep apnea testing

Sleep apnea testing is meant to be a precaution — not a hindrance — during the DOT certification process. By recommending a clinical sleep apnea test, a medical examiner is attempting to detect a respiratory dysfunction that, if untreated, could interfere with a driver’s ability to operate a commercial vehicle. For a truck driver with chronic drowsiness possibly associated with an undiagnosed sleep disorder, a recommendation for sleep apnea testing could be a lifesaver. The prevalence of sleep apnea combined with the associated health and safety risks only reinforce the necessity to test drivers if certain signs and symptoms are present.

Concentra specializes in DOT physical exams

Concentra is a leading provider of DOT physicals and other federally regulated and non-regulated tests and screenings. If a Concentra medical examiner recommends a sleep apnea test during a DOT physical, the Concentra medical center may offer a listing of national sleep study providers. Drivers may also be encouraged to consult their primary care physician for a sleep study referral. For more information about DOT physicals and sleep apnea testing, visit www.concentra.com/physical-exams/dot-physicals/.

References:

Fatigue – You're More Than Just Tired. National Safety Council. (n.d.).
Summary of Hours of Service Regulations. Federal Motor Carrier Safety Administration. (n.d.).
National Heart, Lung, and Blood Institute. (n.d.). What is sleep apnea? Sleep Apnea.
National Heart Lung and Blood Institute. (n.d.). Sleep Apnea Symptoms. Sleep Apnea.
U.S. National Library of Medicine. (n.d.). Sleep apnea. MedlinePlus.
The Dangers of Uncontrolled Sleep Apnea. Johns Hopkins Medicine. (2022, March 10).