Original ArticleScreening, diagnosis, and management of obstructive sleep apnea in dangerous-goods truck drivers: to be aware or not?
Introduction
Obstructive sleep apnea (OSA) is a common health problem that affects 10–17% of men [1] and increases with advancing age [2]. Obstructive sleep apnea is characterized by recurrent episodes of apneas and hypopneas during sleep, and is associated with repetitive episodes of intermittent hypoxemia, intrathoracic pressure changes, arousals, and excessive daytime sleepiness (EDS) [3]. In addition, OSA is frequently associated with the development of hypertension, obesity, cardiovascular and cerebrovascular disorders, and abnormalities in glucose metabolism [4].
Because of EDS, OSA increases the risk of motor vehicle accidents (MVAs) by two to eight times, according to previous studies [5], [6], [7], [8]. At the wheel, EDS contributes in causing about 20% of the total amount of car accidents [9], [10], and lethality is higher in sleep-related accidents when compared with the ones due to other causes (11.4% vs 5.6%) [9]. Furthermore, prior to treatment, most OSA patients under-report their sleepiness and driving impairments. Sleep apnea patients report not just EDS, but also being tired, fatigued, or having a lack of energy; these complaints may be more frequent than sleepiness in this population [11].
Obstructive sleep apnea and EDS are significant public safety concerns for all safety-sensitive occupations, especially for commercial driving. In a meta-analysis of OSA and risk of motor vehicle crash, Tregear et al. [12] reported that individuals with untreated OSA clearly had an increased risk for MVAs, and the mean crash-rate ratio associated with OSA was in the range of 1.21–4.89. Parameters that predicted crash were body mass index (BMI), apnea–hypopnea index, oxygen saturation, and daytime sleepiness. However, only two studies about occupational accidents at the wheel were available [13], [14] at the time of the meta-analysis of Tregear et al. [12], in which the authors concluded that there was limited evidence for the association between work-related traffic accidents and OSA. Further evidence about the high risk of MVAs in professional drivers with OSA has been shown in other more recent studies [15], [16], [17], [18]. Moreover, data support that treatment of OSA reduces the risk of MVA. Despite the fact that data are limited to non-commercial drivers, a meta-analysis showed that treatment with continuous positive airway pressure (CPAP) is effective in limiting MVA risk among drivers with OSA [19].
Although the most important risk factors for OSA are known [12], [20], [21], and commercial drivers are considered an at-risk population, OSA in this work category remains underdiagnosed [20]. Identifying and treating commercial drivers with OSA could decrease crash-related injuries and fatalities, and improve driver safety and health. Nevertheless, the underestimation of the importance of OSA as a risk factor for occupational accidents during commercial drivers' medical examinations has been highlighted in several studies [22], [23]. Moreover, commercial vehicle drivers at high risk of OSA too frequently show resistance to OSA assessment because of the potential consequences on medical certification and employment [24], [25], [26]. Another unresolved issue in this work category is the achievement of follow-up of compliance with CPAP in treated commercial drivers [24].
During the last few years in the United States, on the basis of accident investigation, the National Transportation Safety Board has urged several agencies of the Department of Transportation, including the Federal Motor Carrier Safety Administration (FMCSA), to adopt mandatory OSA screening for transport operators [25]. Also, the task force of the American College of Chest Physicians, the American College of Occupational and Environmental Medicine, and the National Sleep Foundation have promulgated expert consensus guidelines for OSA screening [27]. In 2008, the FMCSA changed the commercial drivers medical examination to include a question about sleep disorders, pauses in breathing while asleep, daytime sleepiness, or loud snoring [21]. Nevertheless, to date, no regulatory mandates exist for comprehensive OSA risk assessment and stratification for commercial motor vehicle drivers, nor do consolidated recommendations that reflect advances in OSA diagnosis and treatment [28].
Therefore, there is an urgent need to develop and implement strategies, as part of commercial drivers' medical examinations, to identify and treat commercial drivers with OSA through screening, diagnosis, and treatment compliance monitoring, especially for TDDGs. Therefore, the aim of this study was to assess the prevalence of TDDGs at risk, to confirm the suspected diagnosis, and to treat the diagnosed subjects with OSA without interrupting their routine work. The risk of MVAs and near miss accidents (NMAs) was analyzed, and the effect of CPAP therapy on NMAs in drivers diagnosed with severe OSA was evaluated.
Section snippets
Subjects and study procedure
This study was conducted between January 2007 and March 2013 in truck drivers of Ente Nazionale Idrocarburi, S.p.A. (ENI). Fig. 1 illustrates a schematic flow chart of the whole project. The selection covered all ENI employees in the north-west area of Italy (n = 320) and included 283 male subjects (88.5%) who agreed to enter the study. A total of 37 male subjects were non-responders (11.5%): 24 of these did not accept to enter the study because they were working abroad (for the other 13, there
Results
The study included 283 male professional truck drivers, with a mean seniority of 17.9 ± 10.7 years. The mean age was 42.3 ± 8.3 years and the mean BMI was 27.8 ± 4.3 kg/m2.
After the clinical evaluation, the whole sample was divided in two groups: the group with suspicion of OSA, including 139 (49%) subjects, and the group without OSA, including 144 subjects (51%). Table 2 summarizes the main sociodemographic and health characteristics of the two groups.
The two groups showed significantly
Discussion
This study of a large sample of asymptomatic TDDGs showed high prevalence of OSA in this population. Furthermore, drivers with severe OSA showed a near five-fold higher risk of NMAs compared with subjects without OSA. This study demonstrated that CPAP therapy is an effective treatment to reduce NMAs and to improve occupational safety in professional drivers.
In the sample of selected truck drivers, a prevalence of 35.7% with OSA was found. The prevalence of OSA in the Italian general population
Conflict of interest
None.
The ICMJE Uniform Disclosure Form for Potential Conflicts of Interest associated with this article can be viewed by clicking on the following link: http://dx.doi.org/10.1016/j.sleep.2015.12.017.
Acknowledgments
ENI (Ente Nazionale Idrocarburi, S.p.A.) totally financed the study. Dr. Enrico Silva of G & A S.p.A. Directors and employers of ENI cargo-deposits e impiegati dei Depositi di carico ENI. Operativi della G & A S.p.A. ASIA S.r.l. Ferruccio Malvicini of the G & A S.p.A. Particular thanks to all of truck drivers of the G & A S.p.A.
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