Obstructive sleep apnea screening, diagnosis, and treatment in the transportation industry.

Obstructive sleep apnea (OSA) is a common, identifiable, and treatable disorder with serious health, safety, and financial implications-including sleepiness- related crashes and incidents-in workers who perform safety-sensitive functions in the transportation industry. Up to one-third of crashes of large trucks are attributable to sleepiness, and large truck crashes result in more than 4,000 deaths annually. For each occupant of a truck who is killed, 6 to 7 occupants of other vehicles are killed. Treatment of OSA is cost-effective, lowers crash rates, and improves health and well-being. A large body of scientific evidence and expert consensus supports the identification and treatment of OSA in transportation operators. An Advanced Notice of Proposed Rulemaking regarding the diagnosis and treatment of OSA in commercial truck and rail operators was issued by the Federal Motor Carrier Safety Administration and Federal Railroad Administration, but it was later withdrawn. This reversal of the agencies' position has caused confusion among some, who have questioned whether efforts to identify and treat the disorder are warranted. In response, we urge key stakeholders, including employers, operators, legislators, payers, clinicians, and patients, to engage in a collaborative, patient-centered approach to address the disorder. At a minimum, stakeholders should follow the guidelines issued by a medical review board commissioned by the Federal Motor Carrier Safety Administration in 2016 alone, or in combination with the 2006 criteria, "Sleep Apnea and Commercial Motor Vehicle Operators," a Statement from the Joint Task Force of the American College of Chest Physicians, the American College of Occupational and Environmental Medicine, and the National Sleep Foundation developed by a joint task force. As research in this area continues to evolve, waiting is no longer an option, and the current standard of care demands action to mitigate the burden of serious health and safety risks due to this common, treatable disorder. CITATION: Das AM, Chang JL, Berneking M, Hartenbaum NP, Rosekind M, Gurubhagavatula I. Obstructive sleep apnea screening, diagnosis, and treatment in the transportation industry. J Clin Sleep Med. 2022;18(10):2471-2479.

Enhancing public health and safety by diagnosing and treating obstructive sleep apnea in the transportation industry: an American Academy of Sleep Medicine position statement.

Obstructive sleep apnea (OSA) may lead to serious health, safety, and financial implications-including sleepiness-related crashes and incidents-in workers who perform safety-sensitive functions in the transportation industry. Evidence and expert consensus support its identification and treatment in high-risk commercial operators. An Advanced Notice of Proposed Rulemaking regarding the diagnosis and treatment of OSA in commercial truck and rail operators was issued by the Federal Motor Carrier Safety Administration and Federal Railroad Administration, but it was later withdrawn. This reversal has led to questions about whether efforts to identify and treat OSA are warranted. In the absence of clear directives, we urge key stakeholders, including clinicians and patients, to engage in a collaborative approach to address OSA by following, at a minimum, the 2016 guidelines issued by a Medical Review Board of the Federal Motor Carrier Safety Administration, alone or in combination with 2006 guidance by a joint task force. The current standard of care demands action to mitigate the serious health and safety risks of OSA. CITATION: Das AM, Chang JL, Berneking M, et al. Enhancing public health and safety by diagnosing and treating obstructive sleep apnea in the transportation industry: an American Academy of Sleep Medicine position statement. J Clin Sleep Med. 2022;18(10):2467-2470.

Obstructive sleep apnea and stroke.

Obstructive sleep apnea (OSA) is a common disorder that has been associated with many cardiovascular disease processes, including hypertension and arrhythmias. OSA has also been identified as an independent risk factor for stroke and all-cause mortality. OSA is highly prevalent in patients with transient ischemic attacks and stroke. Routinely screening patients with transient ischemic attacks or stroke for sleep apnea is becoming more common. In stroke patients with OSA, treatment with continuous positive airway pressure may prevent subsequent cardiovascular events and improve neurologic outcomes. This review explores the pathophysiology of the association between OSA and stroke, and the clinical implications of identification and treatment of OSA in patients with stroke.

Hypertension in obstructive sleep apnea: risk and therapy.

Obstructive sleep apnea (OSA) is a common form of sleep-disordered breathing that occurs due to recurrent collapse of the upper airway with inspiration. Large epidemiologic studies have established that OSA is a risk factor for developing hypertension. The pathophysiologic mechanism of this relationship is due to the distinctive pattern of intermittent hypoxia seen in OSA. This pattern increases sympathetic tone, oxidative stress, inflammation and endothelial dysfunction. These processes can all lead to persistent elevation of blood pressure beyond the obstructive events. OSA should be considered as part of the workup of patients with hypertension. Treatment of OSA with continuous positive airway pressure has an effect on hypertension control and risk reduction of cardiovascular diseases. This review discusses the pathophysiology and causal relationship between OSA and hypertension, along with the cardiovascular effects of treatment of OSA.

Development of a triage protocol for patients presenting with gastrointestinal hemorrhage: a prospective cohort study.

INTRODUCTION: Many patients presenting with acute gastrointestinal hemorrhage (GIH) are admitted to the intensive care unit (ICU) for monitoring. A simple triage protocol based upon validated risk factors could decrease ICU utilization. METHODS: Records of 188 patients admitted with GIH from the emergency department (ED) were reviewed for BLEED criteria (visualized red blood, systolic blood pressure below 100 mm Hg, elevated prothrombin time [PT], erratic mental status, and unstable comorbid disease) and complication within the first 24 hours of admission. Variables associated with early complication were reassessed in 132 patients prospectively enrolled as a validation cohort. A triage model was developed using significant predictors. RESULTS: We studied 188 patients in the development set and 132 in the validation set. Red blood (relative risk [RR] 4.53, 95% confidence interval [CI] 2.04, 10.07) and elevated PT (RR 3.27, 95% CI 1.53, 7.01) were significantly associated with complication in the development set. In the validation cohort, the combination of red blood or unstable comorbidity had a sensitivity of 0.73, a specificity of 0.55, a positive predictive value of 0.24, and a negative predictive value of 0.91 for complication within 24 hours. In simulation studies, a triage model using these variables could reduce ICU admissions without increasing the number of complications. CONCLUSION: Patients presenting to the ED with GIH who have no evidence of ongoing bleeding or unstable comorbidities are at low risk for complication during hospital admission. A triage model based on these variables should be tested prospectively to optimize critical care resource utilization in this common condition.

Utilization of bronchodilators in ventilated patients without obstructive airways disease.

OBJECTIVE: To examine physician practice in, and the costs of, prescribing inhaled bronchodilators to mechanically ventilated patients who do not have obstructive lung disease. METHODS: This was a prospective cohort study at 2 medical intensive care units at 2 tertiary-care academic medical centers, over a 6-month period. Included were the patients who required > or = 24 hours of mechanical ventilation but did not have obstructive lung disease. Excluded were patients who had obstructive lung disease and/or who had undergone > 24 hours of mechanical ventilation outside the study intensive care units. RESULTS: Of the 206 patients included, 74 (36%) were prescribed inhaled bronchodilators without clear indication. Sixty-five of those 74 patients received both albuterol and ipratropium bromide, usually within the first 3 days of intubation (58 patients). Patients prescribed bronchodilators were more hypoxemic; their mean P(aO(2))/F(IO(2)) ratio was lower (188 mm Hg versus 238 mm Hg, p = 0.004), and they were more likely to have pneumonia (53% vs 33%, p = 0.007). The mean extra cost for bronchodilators was 449.35 dollars per patient. Between the group that did receive bronchodilators and the group that did not, there was no significant difference in the incidence of ventilator-associated pneumonia, tracheostomy, or mortality. The incidence of tachyarrhythmias was similar (15% vs 22%, p = 0.25). CONCLUSION: A substantial proportion of mechanically ventilated patients without obstructive lung disease received inhaled bronchodilators.