June 1, 2013 The American Thoracic Society has released new clinical practice guidelines on sleep apnea, sleepiness, and driving risk on non-commercial drivers.
The new guidelines, which are an update of a 1994 ATS statement on this topic, appear in the June 1, 2013 American Journal of Respiratory and Critical Care Medicine.
"Up to 20 percent of crashes that occur on monotonous roads can be attributed to sleepiness, and the most common medical cause of excessive daytime sleepiness is obstructive sleep apnea (OSA)," said Kingman P. Strohl, MD, director of the Center for Sleep Disorders Research at Case Western Reserve University and chair of the committee that drafted the guidelines. "With these new guidelines, we aimed to provide healthcare practitioners with a framework for the assessment and management of sleepy driving in the evaluation of OSA."
The guidelines' recommendations include the following:
• All patients undergoing initial evaluation for suspected or confirmed OSA should be asked about daytime sleepiness and recent unintended motor vehicle crashes or near-misses attributable to sleepiness, fatigue, or inattention. Patients with these characteristics are considered high-risk drivers and should be warned about the potential risk of driving until effective therapy is initiated.
• Additional information that should be elicited during initial evaluation for suspected or confirmed OSA includes the clinical severity of the OSA and treatment that the patient has received, including behavioral interventions. Adherence and response to therapy should be assessed at subsequent visits. Drowsy driving risk should be reassessed at subsequent visits if it was initially increased.
• For patients in whom there is a high clinical suspicion of OSA and who have been deemed high-risk drivers:
o Polysomnography should be performed and, if indicated, treatment initiated as soon as possible, rather than delayed until convenient. For patients with no comorbidities and a high clinical suspicion for OSA, at-home portable monitoring is a reasonable alternative to polysomnography.
o Empiric continuous positive airway (CPAP) should not be used for the sole purpose of reducing driving risk.
• For patients with confirmed OSA who have been deemed high-risk drivers, CPAP therapy to reduce driving risk is recommended, rather than no treatment.
• For patients with suspected or confirmed OSA who have been deemed high-risk drivers, stimulant medications for the sole purpose of reducing driving risk are not recommended.
• Opportunities to improve clinical practice include the following:
o Clinicians should develop a practice-based plan to inform patients and their families about drowsy driving and other risks of excessive sleepiness, as well as behavioral methods that may reduce those risks.
o Clinicians should routinely inquire in patients suspected with OSA about non-OSA causes of excessive daytime sleepiness, co-morbid neurocognitive impairments, and diminished physical skills, which may additively contribute to crash risk and affect the efficacy of sleep apnea treatment. o Clinicians should familiarize themselves with local and state statutes or regulations regarding the compulsory reporting of high-risk drivers with OSA.
"Addressing the issue of drowsy driving requires the combined effort of physicians, patients, and policy makers," said Dr. Strohl. "The assessment for sleepiness before and with treatment of OSA, as outlined in these new guidelines, is an essential part of these joint efforts."
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