Recommendations for the NTSB for Improved Safety in Transportation Industries Related to Fatigue, Daytime Sleepiness, Poor Sleep Hygiene, Undiagnosed and Untreated OSA, as well as Improvement in Technological Utilization

RECOMMENDATIONS FOR THE NTSB FOR IMPROVED SAFETY IN TRANSPORTATION INDUSTRIES RELATED TO FATIGUE, DAYTIME SLEEPINESS, POOR SLEEP HYGIENE, UNDIAGNOSED & UNTREATED OSA, AS WELL AS IMPROVEMENT IN TECHNOLOGICAL UTILIZATION

Neal Seltzer, DMD, FAGD, D. ABDSM, D. ACSDD, D. ASBA

History:

1.   There is overwhelming historical evidence, both medically and anecdotal, of an increase in sleep disorder related illness affecting individuals health, morbidity and mortality as well as the effect these conditions have on learning, job performance and personal and public safety in all fields. Nowhere more is this evident than in the transportation industry. The Federal Aviation Administration, The Federal Motor Carrier Safety Administration, The US Coast Guard, the Federal Railroad Administration, and National Highway Safety Administration, to name a few, have over a decade of recorded accidents and disasters shown to be related to human error caused by fatigue resulting from poor sleep, overwhelming caused by undiagnosed and untreated Obstructive Sleep Apnea. (OSA)

2.   There are many sleep related illnesses that lead to the above-mentioned issues, however the most prevalent disease due to an increase in sedentary life styles and poor diet, as well as underlying genetic factors, is Obstructive Sleep Apnea.  It is estimated that 30 million Americans suffer from some level of this condition.  This is a condition in which an individual's airway collapses during sleep, preventing airflow and decreased oxygenation.  The results of this stress on the body lead to, or contribute to, many medical conditions such as cardiovascular disease, increased risk of stroke, increased risk of diabetes, erectile dysfunction in men, weight gain, and poor sleep quality from repeated awakenings secondary to gasping, choking and drops in blood level oxygen.  In addition, OSA is highly associated with load snoring that impacts the sleep quality and lives of others sleeping in the vicinity of the person in question and subsequently these other individuals suffer secondary consequences of their interrupted sleep leading to their own personal issues and public effects.

3.   As serious as the medical conditions related to OSA are, and as widespread as their impact is, the remarkable truth is that this disease is easily diagnosed and in most cases completely treatable.

4.   The medical advancement in this field over the last 30 years has been incredibly successful in developing sophisticated sleep studies capable of diagnosing a myriad of sleep related illnesses including OSA.  Just as impressive are the advancement in treating these problems.  In the case of OSA just about anyone suffering from this condition can be helped if they are treated by a knowledgeable medical /dental team who are well versed in the etiology and treatment options available today.

Education & Awareness:

1.  First and foremost, there is a lack of education in both the medical world and the public at large in identifying and recognizing signs and symptoms that would suggest a sleep related illness. Sadly, very little time is spent training physicians about sleep related illnesses, their effects on the body, tests available, and even more so, up to date cutting edge treatment options.  Individuals who suffer from many sleep related conditions are either not aware they have these issues or deny the severity of the effects they have on the body.  Also, most people are uninformed as to how easily most of these conditions can be cured or treated.
2.  Lack of awareness has lead to a public safety issue of undiagnosed OSA on an epidemic scale. This same lack of awareness and understanding of the ease of diagnosis & treatment has created a fear amongst many industries that identifying these problems will lead to people losing their jobs. On the contrary, identifying sleep related issues such as OSA and treating them properly is actually a win for all involved.

–  Individuals will be healthier, feel better, and perform tasks more effectively and more safely.

–  Industries will find improved work performance, decrease in safety related accidents, cost

Savings in production and insurance.

– The Public will reap the benefit of safer conditions in all industries, cost reduction secondary to

savings from effective production and decreased financial  losses and insurance costs.

Diagnosis:

1.  The number of patients who suffer from OSA and remain undiagnosed is staggering.
2.  This is due to lack of education on the part of the medical community and the realization that the public at large does not recognize the signs and symptoms related to OSA.
3.  There is need for better screening and understanding of the impacts of OSA
4.  Sleep testing via sleep studies called polysomnography (PSG) are reliable in diagnosing most sleep disorders and must be mandated in all industries that effect public safety. There is no room for error in this situation or excuse for bypassing it. The missed diagnosis and hence lack of treatment could be the next industrial or transportation accident waiting to happen.  It is imperative that a mindset of prevention should be the mantra of every industry.  If we recognize that most fatigue related accidents can be avoided with proper testing,  diagnosis, and treatment, there is no excuse for not having them done.
Treatment Options:

1. For many sleep related issues, a treatment as simple as more hours of sleep may be the solution. In other cases it could be as simple as positional therapy ( changing and maintaining a new sleep position; side vs back), or medication may be the answer.  A simple sleep study could show the results of this.

2. For OSA , there are now more treatment options than ever.  Depending on the severity of an individual's obstructive sleep apnea ( based on diagnosis from a sleep study called a  polysomnography or PSG) treatment may be:

A. CPAP – continuous positive air pressure- provided by wearing a mask that is connected to a small air pump that delivers air under pressure to assure that one's airway does not collapse during sleep.

B. Surgical intervention – There are various surgical procedures depending on severity that can help to open an airway and prevent collapse

C. Oral Appliance Therapy -These are essentially custom fit devices that a person wears in their mouth , that positions the jaw and prevents collapse of the airway when muscles relax in sleep. NOTE- these devices must be FDA cleared and should be fabricated by a knowledgeable & credentialed dentist

D. Other-There are a few additional treatment modalities that have evolved including : positional therapy to help pts sleep in optimal positions to reduce OSA,  weight loss, EPAP ( nasal expiratory air pressure)  , glossal nerve stimulation ( to keep the tongue from relaxing  too much at night). These  are devices that are similar to pacemakers and are considered surgical.

E. Combination Therapy – combinations of any of the above.
For years the treatment options were limited and unfortunately both the medical profession and the public are not aware that many simple, easy, and  reliable solutions that  are now available. The greatest hindrance  perhaps,  was that with few choices, patients were unable to be compliant with treatment.  One example was the fact that , although capable of treating OSA, CPAP machines were and still are difficult for people to adapt to and long term use was rare as people could not tolerate them. With the advent of Oral Appliance Therapy ( OAT) , these extremely successful and well tolerated devices have proven to be far more compliant.  As a matter of fact, this is the most prevalent treatment of OSA in Europe used far more successfully than CPAP.   Even some of the inventors and original researchers  of CPAP have acknowledged and welcomed OAT as a better , more compliant, and successful treatment.

These factors are not well known.  Plus , oral appliances are optimal for conditions prevalent  in most transportation industry environments. They do not require electricity, they are small and easy to transport, they take up little room in tight quarters, they require very little maintenance.
Monitoring Compliance:

1.  Even more important than diagnosing a sleep disorder such as OSA, is the ability to ensure that the proper treatment solution is effective and well tolerated. Compliance is the key to delivering a healthy result and ultimately a result that provides increased public safety for industries.
2.  For years only CPAP use could be monitored utilizing recording devices that communicated with physicians as to the amount of hours the device was worn. However, due to the difficulty of using CPAP due to discomfort , many patients would tamper with the device to  "fool" it or "trick" it to show compliance when in actuality there was none.
3.  Oral Appliances have proven to be extremely successful, well tolerated, and the most compliant treatment option, yet they are still not utilized to their potential due to lack of education amongst physicians and insurance companies. There are miniature compliance recorders that can be embedded within an oral appliance to now prove compliance. Studies are showing oral appliances to be better tolerated and hence more compliant than CPAP,  yielding equal results in mild and moderate OSA.
Guidelines and Recommendations;

1.  Evidence suggests that sleep related illnesses and conditions must be diagnosed and treated to insure improved health of individuals and public safety, especially in the transportation industry.
2. This should not be left to discretionary judgment.   Similar to other types of mandated testing , it should be a requirement for people who have occupations potentially effecting the safety and well being of the public at large to be mandated  that they be tested for sleep related illnesses.  (every state department of motor vehicles requires a vision test,  there is mandatory drug testing in many industries) . The tests are simple, reliable, and cost effective when compared to the industrial accidents caused by fatigue.  More over industries should be rewarded and given insurance premium reductions
3.  These tests should be conducted by qualified individuals. Preferably, physicians well trained and credentialed in sleep medicine.
4.  Treatment must be offered and delivered by trained and credentialed physicians & dentists.
5.  Individuals must prove that their treatment is effective with follow up testing and must show compliance in treatment.  There are reliable methods that will show that treatment options are working and that individuals are following treatment recommendations properly.
6.  Follow up testing must be consistent and frequent. Unfortunately, unlike vision that changes slowly over time in most cases, sleep disorders can change for better or worse in short periods of time. Simple weight gain of as little as 10 pounds can negatively affect obstructive sleep apnea. So guidelines must be in place to account for these possible changes.
Other  Areas of Discussion , Concern,  and   Technological Advancement:

In addition to advancements in diagnosis and treatment of sleep related illnesses leading to fatigue, it is suggested that the NTSB also look into other  technologies to prevent  "falling asleep at the wheel" such as devices that alert drivers, pilots, engineers etc that they are off course or drifting out of a normal pathway.  There should be investigation into fail-safe systems and computer assisted systems that react when , despite our best efforts as human beings to avoid fatigue related or health related disasters , the unavoidable occurs.

Despite all efforts and best intentions,  there are intangible concerns that can contribute to fatigue related accidents  that will require human beings to use honesty and use good judgment .  These can include such simple issues as just not getting enough sleep and/or  having an poor night's sleep due to illness or stress. in these cases we still need  more education and conversation to make people aware of the potential issues that can arise from their fatigue.

 

Conclusion:

An overwhelming amount of transportation & industrial accidents are documented to be related to fatigue caused by undiagnosed and untreated Obstructive Sleep Apnea. The science of detecting and treating this disease has advanced to the point where very few people should still be suffering from its effects.  In turn, our understanding of how, when left untreated, it can cause personal life threatening health issues and public safety issues of massive proportions, it should be required that insurance companies pay for testing and there should be industry wide mandates for treatment when the public safety is at risk.

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