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Sleep Disorders and Safety in the Transportation Industry: An Update - Aneesa M. Das, MD, FCCP, FAASM

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Summary

This on-demand teaching session is presented by Dr. Anisa Das, Professor of Medicine in the Division of Pulmonary and Critical Care at Ohio State University. Dr. Das is a highly accomplished professional who has extensive expertise in the field of medicine, particularly focusing on sleep disorders such as obstructive sleep apnea, and transportation medicine. Her impressive portfolio includes a myriad of academic contributions, numerous awards as a teacher and mentor, and televised medical interviews. Her in-depth discussion revolves around the correlation between sleep disorders and vehicular accidents, the importance of proper sleep tendency, the effects of treating sleep apnea on addressing accident risks, and the complications in healthcare that obstruct effective patient treatment. Dr. Das also presents a comprehensive study on the crucial repercussions of untreated sleep disorders amongst truck drivers, urging medical professionals to take a pivotal role in addressing this important public health issue. Be sure not to miss out on this enlightening session for a more holistic understanding of sleep disorders through the lens of transportation medicine.
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Please note: Only in-person attendees were eligible for CME.

2024 New Jersey Thoracic Society Annual Scientific Meeting

Discussing the Rational and Practical Considerations for Diagnosing and Treating OSA in Transportation Workers

Aneesa M. Das, MD, FCCP, FAASM

Learning objectives

1. To understand the prevalence of sleep apnea in the truck driving population and the associated risks of untreated sleep apnea on traffic accidents. 2. To review the challenges and barriers to diagnosing and treating sleep apnea in high-risk populations, particularly those in the transportation industry. 3. To evaluate different sleep apnea screening tools and their application in identifying high-risk individuals in diverse populations. 4. To analyze potential solutions for improving the access to and efficiency of sleep apnea diagnostic and treatment services for high-risk populations. 5. To understand the potential impact of policy changes on the management of sleep apnea in high-risk populations, particularly focused on mandatory screening in the transportation industry.
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Yeah. So I have the greatest pleasure of introducing Doctor Anisa Das. She holds the position of Professor of Medicine within the Division of Pulmonary and Critical Care at um at Ohio State University. She did her training at University of Virginia where she got her doctorate from and then continued with her academic journey with her internal medicine and pulmonary critical care fellowship at um University of North Carolina. She is an amazing person. Um I've seen her multiple times at chess. She holds has held multiple positions sharing and just like Jonathan said, more positions than I can I can even know about. Um when she's not busy at chess, contributing with um her knowledge and expertise. She's also busy winning awards in her program from her trainees um as the best teacher and best mentor of the year awards. Um She also has significant academic contributions and has published multiple articles. I tried to count them yesterday. It was taking too long. So I just stopped. Um And of course, she also has great media presence and she has been asked to interview for multiple uh different um TV uh televisions including uh MSN. And she's also interviewed for Yahoo and it just list kept going on and I had to stop because Jonathan said I only had two minutes. So it's my greatest pleasure to introduce her. And I can't wait to hear about her expertise in sleep and obstructive sleep apnea and transportation medicine. Yeah. So I didn't even remember a lot of those things. Is this working yet? Ok. I can you guys hear me if I speak loudly? I am so good at that. Awesome. All right. So first of all, welcome uh or welcome and thank you so much for having me have fun. I don't think I've actually ever been to New Jersey before. So this is a new first for me. So I'm excited to be here. Um And I just have m minimal disclosures and like every good storyteller, I thought we would start with a case. So act ironically, I just saw this patient right before I, the first time I gave a talk like this and she had come in to see me right before. She was a 34 year old young woman who was a truck driver um and had let her c convention expire. So I went to the dot to get recertified and because she said, you know, I sometimes am sleepy um and she does snore but she's never sleeping while driving. They said, ok, well, you need to have sleep testing. So they gave her a 90 day credentialing window to get this done once this happened. She said, ok, well, I don't really know where to start because there's no guideline for her. So her next step was to try to get in with her primary care doc. It took 42 days to get into her primary care doc who then said, ok, I'll refer you to sleep and miraculously, I have no idea how she got in to see me within 26 days because our wait time is at least much, much longer. But at this point, she had very little time left. So in between this, she said, I better take things into my own hands. She had very limited income. She's on Medicaid, but she said, I'm gonna pay cash and I'm gonna go online and see where I can do it and she could buy a sleep study online for cash. Um, so she did that and she brought her report to me. The report didn't say anything about what type of study was done. If it was a type three or a type four, it didn't describe it. It did not have a signature on it. It just said you have an a of 7.4 and mild sleep apnea and for an additional fee, we can offer consultation and treatment. Um, she didn't have the additional fees. Um, so she came to me and said, hey, could you get me started on therapy? So here's the problem. There's some barriers to care here. Number one on patient, wait time. This is a huge problem in particular for truck drivers who lose time and money. Right. So, if she couldn't get recredential, she has to go out of service and she not only loses her, you know, her income, but she also now has to wait and pay for these testing. The report wasn't signed. I couldn't do anything with it if I wanted to because it's not signed. Number three in the state of Ohio Medicaid does not acknowledge home sleep apnea tests. Um I just recently learned that actually in California, they have just started accepting them. But in the state of Ohio, Medicaid does not end. Medicaid requires a titration which is a whole another conversation we could get into with the Phillips recall and the increased disparity of care. But um right now, all Medicaid patients in most states require a titration study. So she has 22 days left. I don't have a diagnostic study I can use. Um She's gonna need to have a pap titration. So at this point, we were kind of stuck. Fortunately, I was able to get her into our lab. I ordered a mandatory split night if she actually was positive her study was negative, she did not have sleep apnea and she was able to drive, but this is not an atypical scenario. So because of some of these pro I think this is working now or no. OK, because I can lower my voice um because of issues like this. Um and the and the concerns about untreated sleep apnea and driving the American Academy of Sleep Medicine said we are gonna put together a task force to look at all the different stakeholders and really come up with where we're at with things and the stakeholders included the transportation workers themselves, it included the employers, the payers, the um healthcare providers and then the legislators. And so let's start with how do we really care about this so much? Right? Like what's how big of an impact is this really? So if you look at the 2, 2017 reports um by the NH uh sorry N ht SA, they looked at the police reports um and documented like how many police reports, documented driving drowsiness with the accidents and they determined that 91,000 traffic accidents were associated with drowsy driving, including 5 50,000 injuries and 800 deaths. This was in 2017. So that seems like a pretty high number. However, the reality is, is everybody including physicians. Um The government said, well, this is probably underestimated because how many times in an accident do we actually investigate? Were you falling asleep? And is that reported? So it's thought to be massively underestimated. So just recently hot off the press in um this just got published, the um um AAA Foundation for Traffic Safety said we're gonna create a model. So they looked at in depth crash investigations, took the data from these created a model to input drowsiness, the drowsy factor into those that didn't have a report, they then validated it against those studies. And those accidents that actually had known drowsiness said, ok, we're gonna say that this is validated and then applied that, that model to all pa to all accidents between 2017 and 2021 they found. And this is just looking at fatal accidents, not just accidents, 17% of all fatal accidents were associated with drowsy driving. And over that five-year period of time that computed to just under 30,000 fatalities, positive effects. Ok. So, so we talked, that's just drowsy driving. So that's like all comers, drowsy driving. But we also know that one of the biggest factors for drowsy driving, right? A aside from insufficient sleep is obstructive sleep, apnea, and obstructive sleep apnea in its own right has been determined to be a risk for crashes. So, this study is a meta analysis, uh, that was, um, me that was commissioned by the Federal Motor Carrier Safety Administration or the FMC SA. And they said we wanna look at all the studies that have looked at crash risk, um, associated with obstructive sleep apnea versus those who don't have it. And the risk is thought to be between 21% and 489% risk, higher risk than those who don't have sleep apnea, so significant risk factor. And then if you look at truck drivers, truck driver populations have a much higher prevalence. So it's a bigger issue in this population, right. So if you look at all the various studies to the lowest end, they said it was slightly higher than, than their average population, at the highest end studies have shown a greater than 50% of the truck drivers have obstructive sleep apnea. So, somewhere in general between 21 and 50% just a quick aside, because I'm talking predominantly about obstructive sleep apnea. But um, we were just talking about Pen AAC study actually looked at the um, different factors that it can affect crash risk and um, abduct abductive sleepiness and severe obstructive sleep apnea in truck drivers look is about four per 4.7% right in their study. And if you look at sleep duration, those sleeping less than five hours, that was actually 13.5% and it had the same impact on sleepiness. So even though I'm talking about obstructive sleep apnea today, I wanna at least, and you'll see me come back to this, making sure you're getting adequate sleep hours is important in pa in particular in this state. We'll talk about laws that are particular to New Jersey, um, regarding that, but ensuring that drivers are getting adequate sleep is important as well. So we know that treating sleep apnea, actually, we have data that shows it actually improves crash risk, right. So this is a meta analysis of nine case control studies. So what they did is they identified when patients got um were diagnosed with obstructive sleep apnea anywhere between one and five years later. And then they asked some questions with us corresponding time beha before diagnosis about crash incidents. And when you look at that, there was a significant increase in um sleep apnea before being treated versus after. And so it significantly reduced it with treatment to the point. And then three of those studies actually, compared to those who've never had sleep apnea and so treated sleep apnea. Those three studies had the same level of risk of crash to those who did not have sleep apnea. So this is all commerce, right? This is not looking at truck drive in general. So then they said, well, what if we made screening mandatory for truck drivers? Cause that's certainly not the case right now. Would it work? And could this work? And could it work financially? Well, Schneider actually did that. They went through a nonpunitive screening testing and treatment plan, right. And they said we're gonna, we're, and this is how they went about it and then they wrote it up and they published it. So they use soda stage, which is a questionnaire that uses both subjective and objective data. And it puts patients into four different categories ranging from low risk to high risk. And then they said, ok, if you're high risk, you have to, you, you have to get tested that, that was our mandatory. So everyone who's considered high risk has to be tested based on this. And every single one of their employees had to get this questionnaire. And then the low priority were considered their controls and they went forward and they separated them out based on adherence. They did not mandate adherence in this trial so that they could actually sort it out. That's probably not the same anymore. So basically what they did is they first gave them a period when the, when their drivers applied, they said we're gonna do education. They really focused on education about the importance of obstructive sleep apnea and the outcomes associated with it. And then they also committed that it once you're diag, once you decide you're, we determined that you're at risk, we are gonna get your diagnostic testing and everything done within 12 hours. We're only keeping you out of driving for 12 hours. So they committed to them that they weren't gonna hurt their livelihood, right? So that's p that's piece two. And then the third part is they offered an optional insurance plan with their trucking company, which not all trucking companies do if you were in their optional insurance plan. They said all diagnosis and treatment is 100% covered by insurance. You pay no copays. So they said we're, we're gonna come up to this part if you're offering it and then they looked at their outcomes. So the control again with the people who are at low risk and then they had the patients who were considered high risk but were negative studies and then full adherence, partial adherence and no adherence. And when you look at that, the crash rate was five times higher in the no adherence group. And if you look at that over years, so what they did is they said, we're gonna look at it in 12 years. They took all their new drivers and then they went up at 26 weeks and they said, we're gonna say we're gonna look at the new drivers who got to 26 weeks, um, and had similar driving accident risks. And they, and then they said, and now we're gonna look at the, all of those who had a polysomnogram at that time and we're gonna pass out their cumulative risks over two years. And if you look at it, I keep, this is my pointer. The red line is those who did not adhere to CPAP but had sleep apnea. And the other lines are either they didn't have sleep apnea or they at least partially used some, some pap, right? So trauma dramatic difference over to your time period. And then the A sm said, well, let's look at the finances of this, right? Because what talks in the United States money talks. So, www, what is the real financial impact of this, if you look at one year. So they said we're gonna look at 2015 and they determined that the cost of untreated obstructive sleep apnea was 100 and $49 billion. That was from workplace accidents. 26.2 were from auto accidents. So that's the piece that we're talking about today. 89 billion from lost productivity and 30 billion from comorbid disease. So then you say, ok, well, if that's, that's the burden of undiagnosed, how much would it actually cost to diagnose and treat all of those? And they said, ok, we're gonna look at that. It would cost 49 billion to diagnose and treat all of them. And that's just one time, right? You only have to diagnose them and get them the PAP once and this is a one year cost. So that's a projective $100 billion savings. So financially it makes sense. Ok, so now that's sort of our rationale. So now let's say, let's let's really dig into all the different stakeholders and how they're looking at all these things, right? So the payers, employers, the legislators, the transportation personnel themselves and the healthcare providers. So from the payer standpoint, the insurance companies, we need them to acknowledge that, you know what not every patient is gonna come in saying they're sleepy. So where I work, if you don't have hypersomnia, documented or observed apneas, you probably can't get a sleep study. Do you guys have another diagnosis or symptom that will qualify for a sleep study in the state of New Jersey or prior diagnosis? F, fragmented sleep works for you guys. So that has not worked for us. So that's helpful, right? But, but there's lots of symptoms that aren't covered or if somebody has a stop being of, let's say they have a stop being of five, right? They have everything but observed apneas and sleepiness. They're pretty high risk risk. Um they're considered very high risk but they don't have those two symptoms. So we run into this problem. So we need to get payers to acknowledge that objective symptoms are important and that some of these risk assessment sales um risk assessments should be considered for determining whether or not a study would be covered. And then we need to remove some of the barriers. Many insurance companies require a two week turnaround time just to get it prior authorized. Well, these guys are under, under the gun, right? Two weeks, out of, out of driving is lots of lot of income for them. And then finally, we need to broaden the coverage for clinical support. Other than saying, if you're not using it for a 30 day period within the 1st 90 days, maybe we need to increase the financial support for visits and for some of the other options um including like the desensitization protocols that we have that aren't currently covered. We have things to help adherence. We just don't get reimbursed. And then what about the employer? So right now, and I'm gonna say this over and over, there's no federal mandate for screening or testing, but employers could do something right. We just saw with Schneider that it actually works. Um And then they really need to at least focus on education and the importance of addressing O SA because they have to get their drivers and their high-risk transportation workers to buy in so that they're very transparent about what their symptoms are. And we'll acknowledge that while there are some large companies like Snyder, the majority of the companies are much, much smaller, they don't have 10,000 drivers, right? So we need to look at at the finances on that piece of things. So Frost and Sullivan actually published a white paper looking at exactly this. They created a model looking at all the data that I've given you so far. They said, ok, we're gonna assume that 99% of accidents in the trucking industry are not fatal semi-trucks, right? Those are, those are the minority, the large majority are the medium to small size trucks. They're gonna have a couple of trailers, that's the majority of them. So let's first acknowledge that. And then we're gonna say small tracking companies are 1000 LA. The large ones are like 11,000 and we're gonna assume the prevalence of obstructive sleep apnea is 19%. So that assumption. And then they said, we know the prevalence of risk for treated and untreated. So they inputted that and then they went down based on all those numbers and said, we're gonna figure out how much it's gonna cost, um, to, to not have these patients treated versus having them treated. And even in the small trucking groups in one year, there was a $19.1 million savings in having them all on Pap. And in the large ones, it was 1.2 billion. This is an annual savings. So financially it makes sense. All right, important current case outcome. So what legal things are out there as physicians, we always care about what legal things are out there. So number one, there are no, there are some guidance um documents that are available to the medical examiner and to us. But it's not, again, it's not mandated. Um We have records that an effort to sue their employer who required a pre higher sleep study um evaluation was overthrown. So it is absolutely legal for them to mandate sleep study testing. Um Decisions have gone against employers who did not mandate testing in patients who were found to be high risk, right? So the driver gets in an accident is found subsequently to have um obstructive sleep apnea. They were never mandated or asked to be tested. The employer was at risk. So that's important to know employers are not required to pay for the testing, they just have to say they have to get it done. This is the widening gap of the problem, right? And then the following thing is, is if you're using CPAP and you're treated adherence to CPAP actually can be used in your defense to prevent negligence. So my first, actually, I was a fellow, it seems like a lifetime ago. One of my first sleep patients was actually a truck driver who drove his semi into a restaurant and killed the owner, son. And after that, his attorneys had him come see us and he had severe sleep apnea, had an H I over 100. It wasn't treated, it wasn't diagnosed, he was convicted of vehicular manslaughter. So that, that's what I tell my patients when they come in to me to see me. I'm like, look, this is only gonna protect you right? Knowing that you're doing everything and showing that you're being, you're avoiding negligence by trying to address everything is actually gonna protect you legally. All right. So what about legislators and regulators again? O SA is not named in the FMC SA medical standards at all. The words O SA are not in there. It's sort of underneath respiratory diseases. Um, and all they say is the medical examiner should evaluate it. However, in 2016, they did commission, um the medical board to come up with a statement and recommendation. So there is, and that's what we're gonna talk about there's a 2016 report in bulletin that they gave to us and that's what we all use along with the A sm one current law. So we did try to enact law in 2013. They said, ok, if you're gonna mandate anything, this is the government, you have to um basically first go through a formal rulemaking procedure, you can't just do this. Ok? That's fair. So in March of 2016, the um the current um the, the current government officials at the time um said along with the FMC SA and the Federal Railroad administration, we are acknowledging that we are gonna put this in and we are going to start, we want to say that we are gonna support mandating this. But again, you had to have this, this lead, lead time to do it and then the um politics changed and different politicians came into effect and the FMC SA withdrew their proposed rule making. So they said, never mind we're not gonna do any mandated screening. So that's were at 2017, um establishing regulations on a federal level could provide national benefits, right? That would resolve everything. But even on the state level, it could improve organizational and public health and safety and education. So where are we at? New Jersey. New Jersey does not have any mandated um screening screening laws. They do have several um laws pertaining specifically to um safety and driving. So I learned this when I was a fellow. It was Maggie's law specifically, this was actually when I was a fellow in Chapel Hill, we talked about the, the New Jersey law. So Maggie's law, um, a 20 year old woman was driving and a gentleman swerved across three lanes and hit her and killed her. He acknowledged he's like, oh my gosh, I was exhausted. Um, I haven't slept in 30 hours and his fine was $200 for reckless driving. So because of that, her family worked with the local government and now there is Maggie's law in the state of New Jersey. And the statute states that if you are driving while knowingly fatigued, it's reckless and can be vehicular homicide and knowingly fatigued is considered s um, driving after you've got 24 hours without sleep. So, driving without 24 hours without sleep is 100% illegal in the state. You, if you didn't know that you should know that, tell your patients that. Um, so that's one thing and then you can't use cellphones in New Jersey and you're not alone. So the orange, all the bright orange states have banned, uh, cell phone use. It doesn't mean that you can't use it wirelessly. Like if you're ca you can't hold it, but you can't, you have the phone in your hand. And then Doctor Greenstein actually, thank you for making sure that I was aware of this. I was bringing up that you guys are a mandatory um a mandatory reporting state. But it's unless I'm missing something, I think it's coming from this law. II searched hard this morning for the law. It's based on epilepsy law. So like in Ohio, we don't have mandatory reporting debt to our motor vehicle accident, folks for um for a patient having epilepsy. But you do in this state. If a patient has epilepsy, you have to report it And the way they wrote it is a seizure or recurrent periods of unconsciousness or uh for impairment or loss of motor coordination. So, absolutely, narcolepsy is reportable. That's, that's a no brainer. Those patients should be reported and potentially any patient who tells you that they're regularly falling asleep while driving. It's probably reportable. Is that what you were getting at as good? So, what about the transportation personnel themselves? So part of the problem is that they have this lack of awareness about the finances. My poor patient who came to me didn't know that with Medicaid, she could have come straight to me. She wasted 42 days trying to get into her primary care doctor just to get a referral. Um And so had she known all this, she even told me she's like, I would have just lied and never told them that I was tired and then I would have had to worry about all this, right? So that's the problem is that people are underreporting because they're so afraid of, of the outcomes that we haven't made it easy for them. So we need to fix that problem. Right. Because in addition to that, we talked about the sleep deprivation. So not only are they potentially tired from untreated sleep apnea, they have extended or nontraditional work hours, they're working in the early morning hours. So their circadian clocks are aligned, right. And we're driving at the most sleepy time. Um, so that can compound the problem. They also have to be taught to appropriately document their symptoms, right? They have to not hide it. And there's lots of beautiful studies that show if you look at the average upward for a given A I, if you look at truck drivers, it's about eight points lower, right? So if you, I'm just making this number up now, right? So if you say that the average person with severe obstructive sleep apnea has an upward of 14 on the studies they showed. Yeah, but if they're a truck driver, it was much lower, which suggests there's some underreporting, right? Um And then ultimately, they need to know it's, it's their, their responsibility to report this if they get in an accident and it's documented that they said they had no symptoms and it turns out that they did that, that is gonna actually ultimately reflect on their, their risk level. So let's talk about our risk level, right? So, as health care providers, what do we do? So, all Right. There's not great recommendations. We don't wanna get sued, but we wanna make sure that we don't keep them out of driving. We wanna make sure that we can get them tested efficiently. We wanna make sure that they're safe. How do we do this? So, healthcare providers include the primary care docs, right. We have to refer referring clinicians, us, the sleep providers and then the health examiners, the medical examiners. So the number one thing is is we need to use objective data and not just subjective data. Again, selfreported, denial of daytime sleepiness or snoring ha does not rule out obstructive sleep apnea in that group that has been shown over and over. Um And then we need to engage in the current evidence and guidelines that we have. So where are we at? There's two most up to date um guidelines that we have. One is that bulletin that I referred to. Um that was by the medical board to the medical examiners. And the other one that came out just the very next year was the A sm Sleep and Transportation Safety Awareness task force. So I'm gonna show you guys these back to back. Um and I'll pause and I'll try to let you know because they're a little bit different, right? And there's no rule about which one, which one you have, you have to sort of decide based on the patient, but I wanna give you both guidelines. So the FM CSA guideline says, what's for when to test is they said anyone over a, with a BMI of 40 or greater should be tested without symptoms. Uh, regardless of symptoms, I should say, right. And then with a BMI between 33 and 40 they said if you have three of these symptoms, so any of those three and that includes a lot of the stop being criteria, right? Plus some additional untreated hypothyroidism. Um But a but a lot of so basically symptoms of sleep apnea, three of them plus obesity, they should be treated so relatively objective. And then they also recommend PSG versus HSA because I don't know if you guys have Google, but there's all kinds of things on how to beat your home, sleep apnea test out there. Um So a a definitive test, right? We know that ruling out sleep apnea is not as good on a home study, ruling out sleep apnea is better on a phd. So that's their, their weighted recommendation and again, still same guideline, immediate disqualification. So this is to the medical examiner when you should take them out of driving, if they say they have any daytime sleepiness, if they had a sleep related crash or near crash, if they have known sleep disorder breathing and they have documented non adherence and they're felt to be or if they're just felt to be extremely high risk. So those guys are taken out until things are fixed and then there's the conditional certification. So the 90 day, which I don't know about you guys, but that's probably what we get most often. So that's if you just did that screening test that we just talked about, right. And they are determined to be at risk, then you can give them a 90 day to get things sorted out. Um And then if they have, and this is how they define it, mild sleep apnea by this guideline, it does not mandate any therapy unless you're symptomatic, right? But moderate to severe sleep apnea. So that's their criteria to cut off of 15. So 15 should be recertified based on effective adherence and we'll, and then we'll and treatment. So we'll talk about that. So now we're gonna switch gears. Now, the A sm what did they have to say about that? So their immediate disqualification is daytime sleepiness during your day, during your safety sensitive duties. If you've had an accident due to drowsiness, no brainer, right? Um If they fell asleep during a safety sensitive um duty or if they have a known a of 20. So here, that's another subtle difference. So their a cut off was 20 as opposed to 15 and the other one and they're non adherent with therapy conditional, they recommended 60 days. Um if they screened positive, meaning their screening assessment was for, for sleep apnea is um at rest, they said a 60 day. And then again, if they're, once they're on therapy, they recommended that initially you give them a 30 day, right? So after 30 days, they can get a 60 day and then after 60 days of adherence, you can give them the year. So we just talked about that. So untreated sleep apnea with a, a less than 20 with no daytime sleepiness, they said could be unrestricted or an a um width of 20 or greater um has to have that documentation. The FM CSA actually went through all treatment therapies and they actually have guidelines for any kind of treatment, right? So they talked about pap bariatric surgery, oral appliance, or uh oropharyngeal surgery and tracheostomy. What they don't have is inspire because inspire is too new for that. Um But based on this, we can kind of infer what we should be doing. Um So for PAP, for the one year again, they, they recommend you do a 30 60 90 day consecutive and that's not necessarily on us. So what I usually do is I will, I will never say they are safe to drive. This is the an do I think what she does? I'll once they have adherence at 30 days, I send that to the medical examiner and then they can determine if they ask me to. Then I'll say at this point, there are um they are obstructive sleep apnea is controlled, they deny sleepiness with continued regular use. They are at no increased risk beyond somebody without sleep. Apnea because that's all factually based. Right. So that's personally how I write it as opposed to they are cleared to drive. So that, that's how I would document it. Um And again, adherence is defined on that archaic four hours or greater 70% of the time. We all know that 676 and seven hours actually has better outcomes. But four hours is, is the number that they use for an oral appliance. All you have to do for moderate to severe sleep apnea is a repeat sleep study showing that it's controlled a is less than 20 no report of sleepiness. Currently as you may or may not know there's numerous brands of adherence, monitors for oral appliances and they use, they're micro sensors for temperature and basically, it showed like when you start using it versus the endpoint of taking it out. So the temperature, they're not mandated right now that you have to use it because there's nothing mandated. Um But for truck drivers who want additional protection, I actually I have several who asked me for it. They're like if I'm gonna use this, I want proof that I'm using it so that I can show people that I'm using it. Um So anyway, oral appliances you can recommend and you can choose to recommend or not recommend they get a microsensor put in for bariatric surgery. The recommendation is that they use their PAP for at least six months regardless postoperatively at POSTOP. S um, six months, POSTOP, they can get a repeat assessment. Um And actually, so that's actually my clinical niche is bariatric surgery patients. And that II run up the jobs of how we practice because at six months, POSTOP, you're losing approximately 80% of the weight you're gonna lose give or take. So that's a reasonable time. If you wait a year, you might have a higher yield. But I've found that you have a higher drop off of patients showing up to come back. So six months is sort of the sweet spot. And then for oropharyngeal surgery and traches, we don't have a whole lot of tricks. I think I've had one trached patient for sleep apnea in my entire career. Um Those patients basically are supposed to continue use PAP using PAP if they wanna stay driving for the first month and then one month, POSTOP, they can have a repeat assessment. Ok? I just said a lot. So I said a lot and at the same time, I'm like, we've got nothing. So where are you really at? So at the end of the day when we did the report with the A sm the, the, the statement is ok, there's no federal regulations, but we do have data to support what we're doing and we do have guidelines to recommend what we should be doing. We know that obstructive sleep apnea is at a very high pre prevalence among transportation workers. We know that it contributes to high costs around the country. Um And that it, there's a cost benefit to potentially treating it and that it's identifiable, it's treatable and overall it can improve uh the public safety. Um And I apologize to the people who are online because this is a very US centric talk because I didn't realize it at the time. But transportation affects everyone, but a lot of the legislation is very US centric. So, and that's it with that. I say thank you. Yeah. Yes. As far as the symptoms are concerned, I think, um, you highlighted most problems we are facing. So, um, when I had zero symptoms, so I cannot get an app in that because they look at the symptoms. Um, so it's, we have been doing a home test but you were able to get the home sleep test covered. Yes, you should well finish your, I have a question about that. Ok. Um, so like sometimes you get the, um, the question I have with the test, there are so many out there. Um, uh, I just want to get your, um, opinion about, uh, is there equipment which is better one versus the one which is like a watch or, um, patients are using because I feel like the wash is not like, and if somebody in with it, um, so how do you, how are you getting for the in lab studies? Um, because that's a struggle um, that we have. So our criteria for in lab at home is exactly the same. So I went to in that patient that you described, I wouldn't have even been able to get a home study. Um, so I was like, wow, you can even get the home studies done. That's fantastic. Um So the i it's sim, so the approach is similar to how I do bariatric patients because it's a very similar problem actually. Um We don't just ask if you're sleepiness. We have, uh we use a lot of the validated questionnaires. So when we ask sleepiness, we ask with a leer scale which helps, I think you get a lot better. Sometimes you'll still get all zeros, right? But it helps tease out some things that you can say that you have documented sleepiness. Um I think the like scales help two if they absolutely say no to everything. Um, and they say they have zero symptoms and they're talking to you like that, right? As they're in clinic, then if I can't get any because for me, I can't get any study, then I'll do an over oximetry. Um And I'll say they report no symptoms but, and then if they get an ODI that's over 10 or something that's elevated, we can say, then, then we use that actually to justify our sleep study. Um And for that one, I think we've, we've used sleep apnea otherwise specified because it will be like, they have an oximetry that's consistent with it. So they need a study. Um And then the patient has a home study, then you could probably do the in lab study, correct if you had a negative home study. So then you could, it's just additional testing, right? And then oftentimes if you're very transparent with patients, you know, like we could do the home test, but if it's negative, then we're gonna have to do the in lab one. And oftentimes they're like, but I'm like, but if you're sleepy, you know like, ok, well, fine, you am sleepy sometimes. So, so all of a sudden their tooth comes out, right? Um I do still do home studies though for them. I because that's the reality of of insurance for us, it's mandated by insurance what you have to do whether you're sleepy or not. So we often do still do home studies. Um And then you had another question that I wanted to comment on. Oh, the yeah, so there's there's not a recommended specific type but there is and I, as you said that I was trying to remember the term. Um It's Yes, thank you. Thank you. It's exactly the term I was trying to remember. So it's not so much what device but chain of custody is recommended, right? So meaning, you know, exactly when the patient is getting it and when they're getting it back so that it's not being done on another patient that has been recommended by several guidelines as well. Um There is not a recommendation of a specific type. I can tell you we don't have any watch pads at our institution, whatever that tells you. Um we use a type three device, we actually with two belts. Um so that I can use um the summation when my flow is off if the flow comes off. Uh but, but there, but there isn't, there is not a guideline right now. Um And then, and there's growing data for the, the ones that use um heart rate variability. So I'm gonna head you on that one since there's keep my own personal opinions out of it. The same. Yeah, where it's not higher than the, I don't know. II because I said the exact same thing, I don't know cause that wasn't done by this. I, that came from their medical board. Um I can tell you personally II don't use that number because I'm like there's a, there's that gap. So I have a hard time telling a patient. Um without, with a so and remember any sleepiness and, and a you should treat them but without symptoms, it's ahi of 15 and my issue with that was, it goes against all of our guidelines for health recommendations. This was just for, um for safety. I think part of it was trying to find some middle ground to get drivers on the road. It's, it's trying to be practical is what it came down to, but I don't know any. Are there any people in this room that are using a cut off of 20 to treat patients? Yeah, I don't need that ice 15. So you mentioned that most of the accidents are these, uh, small to medium size drugs? Those are the trucks that are being rented by common of the public which, so it's not just truck companies but rather than rider. Uh, like if I want to rent a truck, right? Is there any type of approach to truck rental or um, you know, just use of the common public? Yeah, I, so I think that data would be with the general public passenger data because for passenger car because it's one time use. So the risk is, is the same as passenger cars. So there's not and there some of the original data, I don't, I can't go back through my slides actually included passing passenger cars for the desk for drowsiness that was passenger cars as well. Um There is no specific guidelines for rental or for consumer drivers using trucks separately. The they do notice I didn't say that right. Yeah, they do have very detailed and part of it is, is because they have more passengers in their cars, right? Like it, an an error would cause a higher, a higher number of death, but they do FAA has different ones. Um I don't have any pilots who I have not treated any sleep apnea. So, thank you so much, eh? Yeah, hi everyone. So, uh the next speaker I have, uh it's my absolute pleasure to re uh to introduce, um, cause he's from my own institution from Robert Wood Johnson Medical School doctor. Um, he is really a giant in the field of pulmonary medicine, specifically in asthma, um asthma translational research specifically and to give you an idea of how much uh of the type of impact that he's had um on our field. Uh My CB is probably like six or seven pages in total. Um His original publications alone were 25 pages like 25 II counted it out like multiple times because I was like, I don't know if I'll ever get there. But anyway, um he's served additionally on uh numerous national grant review panels, major committees as an editor on a number of journals, including the co editor in chief of the journal Respiratory Research. He's mentored and advised. Well, over over 100 trainees, I saw the list of names. Unbelievable. Um And at our institution, Robert Wood, he's the Vice Chancellor for Translational Medicine and Science and the director of the Rutgers Institute for Translational Medicine and Science. And I really could go on and on and I really thought this is gonna be simple but it, it wasn't um um because there was just so much on there. Uh but to get to the point he's really offered uh generously offered his time to discuss how monoclonal antibodies uh improve the management of patients with severe asthma. So please welcome me in. Welcome doctor.