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DOT and sleep tests
Hi all. I have a question that I think some of you may be able to answer as I am sure some of you may have dealt with something similar when first diagnosed with apnea.
My husband is a truck driver he is trying to get his health certification for DOT. The DOT Dr said he needs a sleep test (the clinic is contracted with the sleep center and they try to force you to sign an agreement to be seen at the sleep center before you leave there, no matter if you need the test or not) my husbands Dr says he does not need the test. Is the DOT DRs word the final say or are we able to seek another opinion as long as we divulge all info. Can DOT dr.s hold certificates when he decides someone needs a sleep test despite lack of apnea symptoms? Does anyone know the current regulations with department of transportation? Any info would be greatly appreciated.
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Is there a conflict of interest?  What is the basis of the Dr's opinion that your husband needs a sleep test.  Here is an article by http://www.landlinemag.com/Magazine/2014...sting.aspx
Additional resources: https://www.linkedin.com/pulse/can-dot-m...eep-tigges

From what I can tell, if your husband does not have a diagnosis for Sleep Apnea, he cannot be legally required to submit to a sleep test based on screening criteria alone; and his medical certification cannot be held for his refusal to submit to a sleep test.  Once he is diagnosed however, he can be suspended from driving until issued the medical equipment, and for 1-month until compliance and efficacy is demonstrated.  There is currently no ruling by the FMCSA for sleep apnea screening on DOT physicals. 

I would avoid a sleep test under these conditions since it is a lose-lose situation.  If your husband is a risk for sleep apnea, then his regular doctor can ask him some questions and determine if he should have a sleep study.  Following the recommendation of this DOT doctor, would likely result in at least temporary unemployment.  So he should vigorously deny he is affect by SA and if necessary get a letter from his personal physician supporting that claim and refuse the sleep study and demand his medical certification.

So your DOT doc says you ‘have’ to get tested for sleep apnea?
Does FMCSA really have any regs on the books mandating testing for sleep apnea? Many in the industry would like you to believe that it does.

By Jami Jones, managing editor

Let’s start off with a little quiz.

True or false: FMCSA has mandated sleep apnea testing for all CDL holders.

Unfortunately, a lot of people get the answer wrong. Some of those people include motor carriers and medical professionals conducting CDL medical certification tests.

The answer? False.

The Federal Motor Carrier Safety Administration is silent on sleep apnea testing. Many truckers who have been told that the testing is mandatory are probably either very puzzled or very upset right now.

The Federal Motor Carrier Safety Regulations state:

391.41(b) A person is physically qualified to drive a commercial motor vehicle if that person (5) has no established medical history or clinical diagnosis of a respiratory dysfunction likely to interfere with his/her ability to control and drive a commercial motor vehicle safely.

Not a word in there about testing. In order to get the full scoop on what FMCSA expects from the regulations, you must look at the “guidance” the agency issues on various regulations. The agency has established guidance for chronic sleep disorders, including sleep apnea.

In that guidance, the agency lays out the minimum waiting period for certification or recertification of an individual with a chronic sleep condition after starting treatment. There is a minimum one-month waiting period after starting a continuous positive airway pressure device (called a CPAP). Individuals with surgical treatment are to wait a minimum of three months before certification or recertification. Medical examiners are directed by the agency to certify the driver for only one year.

Here is where the “mandated testing” comes in. After someone is diagnosed, the agency’s guidance directs the medical examiner to certify or recertify someone who has started nonsurgical treatment and has had “multiple sleep latency testing values within the normal range.” The guidance does not directly address sleep latency testing for drivers who sought surgical treatment. The guidance merely directs doctors to monitor the resolution of symptoms.

Nowhere in any of that did you read neck size, body mass index or anything of the sort? The sleep industry has come up with those types of criteria. Not FMCSA.

So what is guidance anyway?
That’s a really good question, especially as it is the only thing that actually mentions sleep testing of drivers (those who are already diagnosed, remember).

Read this direct quote from the FMCSA Medical Examiner Handbook closely:

“Regulations/standards are laws and must be followed. Whereas guidelines, such as advisory criteria and medical conference reports are recommendations. While not law, the guidelines are intended as best practices for medical examiners.

“Guidelines have been issued by the Federal Motor Carrier Safety Administration (FMCSA) to provide you with additional information and are based on medical literature. If you choose not to follow the guidelines, the reason(s) for the variation should be documented.”

The agency starts off saying the guidance does not have the weight of law behind it. As the explanation goes on, medical examiners are basically told that if they don’t follow the guidance they better provide a reason why.

So why am I being told that it’s mandatory?
That’s where we go from concrete to somewhat speculative. Explanations vary when talking to medical examiners and motor carriers who insist on the testing, but one common theme is liability.

What got us to this point is twofold. First FMCSA published, very briefly, proposed guidance that would have expanded on sleep apnea testing in April 2012. The proposed guidance was pulled down days later, but that bell wasn’t completely unrung. The cat was out of the sleep apnea bag: FMCSA was looking to regulate it further.

Follow that up with the fact that the agency is in the process of implementing the National Registry of Certified Medical Examiners. This is a registry – basically a database – of medical examiners who have paid a fee and gone through FMCSA’s testing. Drivers will only be able to get DOT medical certification from individuals listed on the registry after May 21. (See related article Page 38.)

FMCSA has been forthcoming about the medical examiners’ responsibilities under the regulations and what the penalties could be if they circumvent those regs and incorrectly certify a driver as medically qualified when the driver actually is not medically qualified. Those fines are pretty steep: $10,000 in one instance, $250,000 – a quarter of a million dollars – in another. We won’t get into the likelihood of such fines being levied; the mere threat seems to be enough.

Toss in an added threat of litigation if a driver with a disqualifying medical condition is in a wreck, and the medical examiner who certified him could be facing some liability issues there as well.

All of that amounts to motor carriers and medical examiners looking to cover their assets – so to speak – and ordering more tests to prove they did all they could.

Has it gone too far?
Many drivers will certainly say yes.

The testing alone is extremely expensive. What amounts to a sleep apnea witch hunt is a very profitable one for the sleep labs, treatment centers and treatment device manufacturers.

Beyond the obvious cash cow incentive that has drivers hemorrhaging thousands for sleep testing, there is the overarching threat of misdiagnosis.

OOIDA Member Tim Begle was misdiagnosed with a severe case of sleep apnea and ordered a CPAP for treatment. The road to his diagnosis was one of missteps and misdiagnosis, threats and intimidation, according to Begle.

He eventually caved to the diagnosis and started sleeping with a CPAP machine.
“That’s when the hell began. I couldn’t ever sleep,” Begle said. “The most I ever slept at a time was two to three hours. I would wake up with the hose wrapped around my neck, the mask pulled off my face. I just rolled around all night wrestling the thing. My wife said it was like I was at war all night.”

The so-called treatment left him exhausted and in dire need of sleep. He turned to sleeping pills just so he could sleep longer.

He went three or four months. He drank more soda and ate more just to try to stay awake and wound up gaining weight – something uncommon for properly treated apnea patients, according to Begle.

“It started messing with my head. I was tired and grouchy, more than normal,” Begle said. “I decided something wasn’t right.

“I called my (family) doctor and told him something has to change or I’m going to end it all. This is screwing with my mind. I can’t think straight, I can’t concentrate, I’m tired all the time.”

Begle’s family doctor dug in and determined he was, in fact, misdiagnosed. The original testing ordered by the DOT medical examiner revealed a mild case of apnea, one that was within an acceptable range not needing treatment from a CPAP.

His personal doctor gave Begle a two-year medical card and ordered him to stop the CPAP.

Sleeping in a correct position, he sleeps fine now.

What can you do?
Last year at the urging of large numbers of angry truck drivers, Congress passed (in what seemed like record time) a bill that prevents FMCSA from proceeding with any regulation of sleep apnea without going through a rulemaking process. That involves public comment periods, legitimate research, cost-benefit analysis, etc.

Soon thereafter, President Obama signed the measure into law.

Without the agency going through that rulemaking process, the current regulations along with the guidance is all there is on the books to regulate, if you will, sleep apnea.

OOIDA Executive Vice President Todd Spencer pointed out that while the issue was being considered in Congress, FMCSA maintained they planned to do the rulemaking all along.

“However, a time frame has yet to be mentioned and the issue doesn’t appear to be an agency priority,” he said. “So who knows when the appropriate level of scrutiny might take place to determine whether the billions in new costs to drivers are justified.”

In the meantime, drivers shouldn’t set themselves up to be victims. While apnea may not play a real role in any crashes, it is a medical condition that should be discussed and evaluated with a trusted and qualified physician, Spencer said.

He said that drivers should take care of this before their current medical certifications expire and the “proverbial gun is at your head.”

“That way you have options for testing and appropriate treatment that won’t break the bank,” Spencer said.
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The DOT examiners in our area are pushing sleep apnea testing based on BMI and neck circumference. Whether it is actually a regulation or not I don't know. The company I work for sent out a memo in late 2015 stating that it was in fact a regulation. Like Sleeprider, I can't find anything by web search stating the regulation was ever implemented. A search of the U. S. Department of Transportation website has a lot of information on testing requirements for pilots, but I could find nothing about commercial drivers.

When it became evident to me that I had sleep apnea, I had my testing done and got my 30 day compliance period out of the way before my next DOT medical certification was due so I wouldn't have to miss work during the compliance period.

Will his doctor give him a medical card based on his diagnosis? If not, you may want to consult an attorney to find out just what your husband needs to do.
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This article at Trunkinginfo may answer some of your questions.

Sleep Apnea in Truckers Continues to Confuse
Are doctors going overboard in sending drivers for expensive sleep studies?
September 25, 2015

I've known people, including truckers, who were diagnosed with sleep apnea and reported feeling an amazing, life-changing difference after they started using a C-PAP machine at night

That wasn't the case for Joey Romero, an owner-operator in Fargo, ND. He finds the mask on his AutoPAP machine "highly uncomfortable" and says he doesn't feel any different, according to Forum News Service.

The story says local truckers have been far more likely to be sent for sleep testing following last year's implementation of the National Medical Examiner Registry.

A North Dakota Motor Carriers representative said he believes many of these doctors are recommending the expensive sleep tests (which are not always covered by insurance) based solely on the driver's neck size.

"A number of factors increase the likelihood of someone having sleep apnea," not just neck size, Arik Spencer, executive vice president of the association, was quoted as saying in the article. "Unfortunately, I think a lot of clinics are using the training to try to generate additional profit."

A large neck size and body mass index do make one more likely to have sleep apnea, but they should not be the only criteria. Rather, they should be an indication for doctors to delve a little deeper to see if patients should be sent for a sleep study.

At the moment, however, there's no federal law or regulation stating that.

About sleep apnea

If you're not familiar with sleep apnea, the Greek word "apnea" literally means "without breath." In obstructive sleep apnea, the most common type, the sleeping patient's tongue falls back against his or her soft palate, and the soft palate and uvula fall back against the back of the throat, effectively closing the airway. When the sleeper expands the chest to inhale, no air enters the lungs.

People with untreated sleep apnea stop breathing repeatedly during their sleep, sometimes hundreds of times during the night and often for a minute or longer. In most cases the sleeper is unaware of these breath stoppages because they don't trigger a full awakening. But they do keep you from getting the restful sleep you need.

The National Heart, Lung and Blood Institute (part of the government's National Institute of Health) says doctors diagnosing sleep apnea "will ask you questions about how you sleep and how you function during the day."

For instance, a common sign of sleep apnea is fighting sleepiness during the day, at work, or while driving. You may find yourself rapidly falling asleep during the quiet moments of the day when you're not active.

"Your doctor also will want to know how loudly and often you snore or make gasping or choking sounds during sleep. Often you're not aware of such symptoms and must ask a family member or bed partner to report them.

"Your doctor will check your mouth, nose, and throat for extra or large tissues... Adults who have sleep apnea may have an enlarged uvula (U-vu-luh) or soft palate. The uvula is the tissue that hangs from the middle of the back of your mouth. The soft palate is the roof of your mouth in the back of your throat."

Others signs and symptoms of sleep apnea include:
  • Morning headaches
  • Memory or learning problems and not being able to concentrate
  • Feeling irritable, depressed, or having mood swings or personality changes
  • Waking up frequently to urinate
  • Dry mouth or sore throat when you wake up
Confusion over rules and guidelines

In 2000, 2008 and 2012, the Medical Review Board made recommendations to the FMCSA about screening, diagnosis, treatment and monitoring for commercial drivers with obstructive sleep apnea. As Edward D. Michaelson wrote earlier this year in Sleep Review, these guidelines have been inconsistently applied. 

In 2013, in response to industry concerns about the confusion over sleep apnea diagnosis and commercial driver medical certification, a law was passed requiring the FMCSA to follow a formal rulemaking process allowing industry comment, rather than allowing guidance to become a "de facto" regulation. (FMCSA said it would propose such a rule, but there's no sign of it yet.)

In 2014 came the National Registry of Certified Medical Examiners.

But all that didn't solve the problem. Last fall, due to trucking industry complaints, two U.S. representatives stated in a letter to the FMCSA that some training facilities were skirting the law by telling examiners to test for sleep apnea.

Earlier this year, FMCSA issued a bulletin on sleep apnea to medical examiners and training organizations. The stated purpose is to "remind healthcare professionals on FMCSA's National Registry of Certified Medical Examiners of the current physical qualifications standard and advisory criteria concerning the respiratory system, specifically how the requirements apply to drivers that may have obstructive sleep apnea."

The document emphasizes that "it is clear that FMCSA has considered OSA a respiratory dysfunction that interferes with oxygen exchange. And the agency recommends that, if a medical examiner believes the driver's respiratory condition is in any way likely to interfere with the driver's ability to safely control and drive a commercial motor vehicle, the driver should be referred to a specialist for further evaluation and therapy."
The bulletin says, "Medical examiners may exercise their medical judgment and expertise in determining whether a driver exhibits risk factors for having OSA and in determining whether additional information is needed before making a decision whether to issue the driver a medical certificate and the duration of that medical certification."

It specifically says its "advisory criteria do not include screening guidelines," but it "encourages medical examiners to consider ... common OSA symptoms such as loud snoring, witnessed apneas, or sleepiness during the major wake periods, as well as risk factors and consider multiple risk factors such as body mass index (BMI), neck size, involvement in a single-vehicle crash, etc."

So while the FMCSA "encourages" doctors to consider these things, ultimately it's totally up to the examiner's discretion. From my reading of the bulletin, apparently if he or she believes the best practice is to automatically send drivers with a certain BMI or neck size to get a sleep test, that's perfectly legitimate.

Yes, sleep apnea is a serious condition. Daytime sleepiness obviously is a danger for drivers behind the wheel. And from a personal standpoint, sleep apnea puts you at higher risk for heart problems, high blood pressure and stroke, and the lack of oxygen can cause cognitive problems. If you have these symptoms and your doctor hasn't talked to you about sleep apnea, bring it up at your next exam. The National Heart, Lung, and Blood Institute suggests keeping a sleep diary for a couple of weeks beforehand and bringing it to your appointment. (You can find a sample diary by downloading the Institute's Guide to Health Sleep.)

But if your doctor is sending drivers for expensive sleep testing based solely on neck size or BMI – especially if that practice has any ownership in a sleep-testing clinic – I would look for a different physician.
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The original question was regarding getting a second opinion. Lots of information on that. https://www.google.com/search?q=FMSCA+ex...pinion&*
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Thank you all for your help. His neck circumference is a bit over as is his BMI but they are right on the cusp. His Dr says there is no cause for the test since his breathing is fine he has normal BP (on a low dose of pills for that) he was put on a low carb diet so he doesn't gain any more weight and he has lost 7lbs. His primary DR is extremely happy with his results. The DOT clinic we use has a contract with the sleep center and is constantly trying to get people to test.
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Angilar, if anyone would know, it's you.
Does he snore at night?
Have you observed him not breathing at night, or awakening with a gasp or snort?
Does he get up at night to go the bathroom?
Is he routinely fatigued?
Does he need a nap during the day?
Has he had any microsleeps while driving?
Fall asleep quickly in a quiet environment?
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Sleeprider: He has none of those symptoms. Otherwise I'd understand the request for a study. The Dr went by BMI and neck circumference only. I thank you guys for the quick response the links have been so helpful
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(03-15-2017, 04:31 PM)pupcamper Wrote: The DOT examiners in our area are pushing sleep apnea testing based on BMI and neck circumference. Whether it is actually a regulation or not I don't know. The company I work for sent out a memo in late 2015 stating that it was in fact a regulation. Like Sleeprider, I can't find anything by web search stating the regulation was ever implemented. A search of the U. S. Department of Transportation website has a lot of information on testing requirements for pilots, but I could find nothing about commercial drivers.

FAA, a subset of DOT, has been pushing for OSA testing for the last couple of years.  Starting sometime last year, FAA medical examiners began using screening (BMI and neck circumference are part of the criteria).  Any pilot meeting certain scores was told to get an OSA screening (not a complete sleep lab).  If the results of the screening showed probable OSA, then a full sleep test would be required.  They did relax the way they enforce this.  It used to be that you were grounded until you had all the paperwork and reports showing you were being effectively treated.  Now, you are allowed to fly during that period.  That change makes a big difference.  It encourages pilots to get the OSA treated rather than try to live with the symptoms and not report them.
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Hi angilar77,
WELCOME! to the forum.!
I hope your husband can get his problem with DOT straightened out, good luck to both of you.
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