Obese driver w/BMI 33. How often to re-test by somnography?

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docrja

Obese driver w/BMI 33. How often to re-test by somnography?

Post by docrja » Thu May 15, 2014 10:25 am

Obese, BMI 33-plus, Past Expired Polysomnograms show mild (AHI<20) or negative (AHI <5)

Does anyone have any experience with obese CDL drivers previously screened by polysomnography and luckily resulting negative or mild who insist they never have to re-screen by polysomnography because they passed before? How old is too old if they continue to deny somnolence (which is subjective anyway)? Is every two years reasonable for repeat polysomnography?

Can anyone site any literature?

We at our Municipal Government Agency have an epidemic of obese CDL drivers who nearly 100% deny EDS/fatigue or noisy sleep (and we do not have the lab-and must outsource the Study to their Health Plan HMO/PPOS) There are several of those BMI 33-plus who lucked out even on In House Polysomnography and refuse to lose weight. On re-certification for CDL medical certificate, they push back and say they already screened by Polysomnography and therefore never have to do the test again.(never because they scored AHI <20 or rarely <5 two years prior).

How do you all approach this ? No Sleep Doctor I contacted about this (Dr. Charles Anderson, Pacific Sleep Medicine Los Angeles)(Dr. Manthena, P of Kaiser Los Angeles Sleep Lab) returns my calls when I ask how often do we re-screen the negatives/milds who are re-certifying and still obese (33+) and older.

Any comments would be appreciated. The stakes are very high now that we know the pre-test likelihood in our group (over 300 screened since 2009) exceeds 50% for AHI 20 if you mandate the Polysomnograms at BMI 33+ with no other risk factors/symptoms.

THANKS TO ALL



markrainey

Re: Obese driver w/BMI 33. How often to re-test by somnogra

Post by markrainey » Fri May 16, 2014 10:57 am

I don't think you can force a truck driver to have a sleep test because he is fat.

occmedpac

Re: Obese driver w/BMI 33. How often to re-test by somnogra

Post by occmedpac » Mon May 19, 2014 8:50 am

I share your concerns about obese drivers that initially "pass" the PSG, and then feel they no longer need follow-up testing on their recertification exams. I would suggest following the OSA medical studies that recommend PSG if BMI >35 + neck circumference > 17/16, or Hypertension (new, uncontrolled, control w/2 meds) etc.

I would repeat Epworth and measurement screening at each exam, and if follow-up PSG's are not indicated, then perhaps a medical clearance letter from a pulmonologist would be appropriate. Following the above screening criteria, 95% of our DOT driver PSG referrals have been positive for OSA and C-pap has been prescribed.

FYI - We are not comfortable with the home sleep studies as they are less reliable, and we require a chain-of-custody device on the machine to prove that it is the driver being tested (not a friend or family member).

DOTexaminer

Re: Obese driver w/BMI 33. How often to re-test by somnogra

Post by DOTexaminer » Mon May 19, 2014 4:30 pm

I repeat sleep studies on my high risk patients every 4 years unless they drop their BMIs. This is based on Medicare guidelines of when patients with OSA can upgrade their CPAP machine. Of course, if the trucker gains significant weight, I wouldn't hesitate do to an overnight pulse oximetry to check before the 4-year term. And, home studies are fine by me as long as they have chain of custody because they have been shown to be comparable to in-lab testing for catch uncomplicated OSA based on Pittman and Zou's studies.

markrainey

Re: Obese driver w/BMI 33. How often to re-test by somnogra

Post by markrainey » Thu May 22, 2014 3:55 pm

I can understand requesting sleep studies on patients who have some combination of risk factors for sleep apnea such as a history of choking and snoring at night with thick necks and hypertension. In last year's Journal of the American Medical Association article "Does this patient have sleep apnea?", predictive value of signs and symptoms is discussed. Obesity cannot be the sole reason for requesting initial and repeated sleep test. Claims of 95% of drivers over a certain BMI having sleep apnea are hard to believe. We need some science here!

drjchill

Re: Obese driver w/BMI 33. How often to re-test by somnogra

Post by drjchill » Wed Jul 23, 2014 2:04 pm

This not a study; however, 100% of my truck drivers with a BMI >= 35 and a neck >=17 for males have OSA on sleep study. All were at least moderate based on AHI and 4 were "severe." I guess it give me confidence in the guidelines.

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