RFT 319: Sleep Apnea

From the FAA:

What is Obstructive Sleep Apnea?
OSA affects a person’s upper airway in the area of the larynx (voice box) and the back of the throat. This area is normally held open to allow normal breathing by the surrounding muscles. When an individual is asleep, these muscles become slack, and the open area becomes smaller. In some individuals, this area becomes so small that breathing and resulting normal oxygenation of the blood is impaired. The person may actually choke. This causes some degree of arousal from normal sleep levels which the individual may or may not be aware of. These people do not get restorative sleep, and wake feeling tired.

OSA has significant safety implications because it can cause excessive daytime sleepiness, personality disturbances, cardiac dysrthythmias, myocardial infarction, stroke, sudden cardiac death, and hypertension, and cognitive impairment such as decreased memory, attention, planning, problem-solving and multi-tasking.

What is the background on the FAA’s actions on OSA?
The FAA’s has always used the special issuance medical certification process to certificate pilots with OSA. In November 2013, the FAA proposed guidance that would have required treatment for pilots with a body mass index (BMI) of 40 or more. It would have grounded those pilots until they successfully completed treatment, if required, and they obtained a Special Issuance medical certificate from the FAA. Key aviation industry stakeholders, as well as members of Congress, expressed concern about this enhanced screening. The FAA has now revised the guidance to address those concerns.

What is the new guidance? 
An AME will not use BMI alone to assess whether the pilot applicant has OSA or as a basis for deferring the medical certificates (except in cases where the OSA risk is extreme). AME’s will screen for the risk for OSA using an integrated assessment of history, symptoms, and physical/clinical findings.  OSA screening will only be done by the AME at the time of the physical examination using the American Academy of Sleep Medicine (AASM) guidance provided in the AME Guide. Pilots who are at risk for OSA will be issued a medical certificate and will then, shortly thereafter, receive a letter from the FAA’s Federal Air Surgeon requesting that an OSA evaluation be completed within 90 days. The evaluation may be done by any physician (including the AME), not just a sleep medicine specialist, following AASM guidelines. If the evaluating physician determines, using the AASM guidelines, that a laboratory sleep study or home study is warranted, it should be done at that time. The pilot may continue flying during the evaluation periodand initiation of treatment, if indicated. The airman will have 90 days (or longer under special circumstances) to accomplish this, as outlined in the Federal Air Surgeon’s letter. The FAA may consider an extension in some cases. Pilots diagnosed with OSA and undergoing treatment may send documentation of effective treatment to the FAA in order to have the FAA consider them for a special issuance medical certificate.

How is OSA treated?
Though several types of treatment are available depending on the severity of OSA, the most effective treatment involves the use of a continuous positive airway pressure (CPAP) or Automatic Positive Airway Pressure device that is worn while sleeping. In fact, there are currently 4,917 FAA-certificated pilots who are being treated for sleep apnea and are flying with a special issuance medical certificate.

When will the new guidance take affect?
The FAA plans to publish the new guidance in the FAA Guide for Aviation Medical Examiners on March 2, 2015.

What are the FAA’s current rules on OSA?
Untreated OSA always has been and will continue to be a generally disqualifying medical condition requiring a special issuance medical certificate. AMEs are advised by the FAA to be alert for OSA and other sleep-related disorders such as insomnia, restless legsyndrome,and neuromuscular or connective tissue disorders, because they could be signs of problems that could interfere with restorative sleep, which are needed for pilots to safely perform their duties.

Is the FAA changing the rules on OSA?
The FAA is not changing its medical standards related to OSA. The agency is revising the screening approach to help AMEs find undiagnosed and untreated OSA.

Have there been any accidents or incidents associated with OSA?
The National Transportation Safety Board (NTSB) determined that OSA was a contributing factor in the February13, 2008 Mesa Airlines (operated as go!) Flight 1002 incident, in which both the captain and first officer fell asleep during the flight. They flew 26 miles past their island destination into open ocean, and did not respond to air traffic controllers for more than 18 minutes. After normal communication was resumed, all three crewmembers and 40 passengers onboard arrived safely at their destination.  The captain was found to have undiagnosed severe OSA. The NTSB has investigated accidents in all modes of passenger transportation involving operators with sleep disorders and believes OSA to be a significant safety risk. The NTSB database lists 34 accidents – 32 of which were fatal – where sleep apnea was mentioned in the pilot’s medical history, although sleep apnea was not listed as “causal” or “contributory” in those accidents. The database includes an additional 294 incidents where some type of sleep disorder was mentioned in the history.

For more information on medical certification, go to: http://www.faa.gov/licenses_certificates/medical_certification/

From the Mayo Clinic:

Obstructive sleep apnea

Factors that increase the risk of this form of sleep apnea include:

• Excess weight. Obesity greatly increases the risk of sleep apnea. Fat deposits around your upper airway can obstruct your breathing.
• Neck circumference. People with thicker necks might have narrower airways.
• A narrowed airway. You might have inherited a narrow throat. Tonsils or adenoids also can enlarge and block the airway, particularly in children.
• Being male. Men are two to three times more likely to have sleep apnea than are women. However, women increase their risk if they're overweight, and their risk also appears to rise after menopause.
• Being older. Sleep apnea occurs significantly more often in older adults.
• Family history. Having family members with sleep apnea might increase your risk.
• Use of alcohol, sedatives or tranquilizers. These substances relax the muscles in your throat, which can worsen obstructive sleep apnea.
• Smoking. Smokers are three times more likely to have obstructive sleep apnea than are people who've never smoked. Smoking can increase the amount of inflammation and fluid retention in the upper airway.
• Nasal congestion. If you have difficulty breathing through your nose — whether from an anatomical problem or allergies — you're more likely to develop obstructive sleep apnea.

Central sleep apnea

Risk factors for this form of sleep apnea include:

• Being older. Middle-aged and older people have a higher risk of central sleep apnea.
• Being male. Central sleep apnea is more common in men than it is in women.
• Heart disorders. Having congestive heart failure increases the risk.
• Using narcotic pain medications. Opioid medications, especially long-acting ones such as methadone, increase the risk of central sleep apnea.
• Stroke. Having had a stroke increases your risk of central sleep apnea or treatment-emergent central sleep apnea

https://youtu.be/z12MEPiG4cg

Complications

Sleep apnea is a serious medical condition. Complications can include:

• Daytime fatigue. The repeated awakenings associated with sleep apnea make normal, restorative sleep impossible, making severe daytime drowsiness, fatigue and irritability likely.You might have difficulty concentrating and find yourself falling asleep at work, while watching TV or even when driving. People with sleep apnea have an increased risk of motor vehicle and workplace accidents.You might also feel quick-tempered, moody or depressed. Children and adolescents with sleep apnea might perform poorly in school or have behavior problems.
• High blood pressure or heart problems. Sudden drops in blood oxygen levels that occur during sleep apnea increase blood pressure and strain the cardiovascular system. Having obstructive sleep apnea increases your risk of high blood pressure (hypertension).Obstructive sleep apnea might also increase your risk of recurrent heart attack, stroke and abnormal heartbeats, such as atrial fibrillation. If you have heart disease, multiple episodes of low blood oxygen (hypoxia or hypoxemia) can lead to sudden death from an irregular heartbeat.
• Type 2 diabetes. Having sleep apnea increases your risk of developing insulin resistance and type 2 diabetes.
• Metabolic syndrome. This disorder, which includes high blood pressure, abnormal cholesterol levels, high blood sugar and an increased waist circumference, is linked to a higher risk of heart disease.
• Complications with medications and surgery. Obstructive sleep apnea is also a concern with certain medications and general anesthesia. People with sleep apnea might be more likely to have complications after major surgery because they're prone to breathing problems, especially when sedated and lying on their backs.Before you have surgery, tell your doctor about your sleep apnea and how it's being treated.
• Liver problems. People with sleep apnea are more likely to have abnormal results on liver function tests, and their livers are more likely to show signs of scarring (nonalcoholic fatty liver disease).
• Sleep-deprived partners. Loud snoring can keep anyone who sleeps near you from getting good rest. It's not uncommon for a partner to have to go to another room, or even to another floor of the house, to be able to sleep.

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