Guideline issued on assessing sleep apnea and driving risk

The American Thoracic Society has issued an updated guideline on assessing sleep apnea, sleepiness and driving risk in noncommercial drivers.

The guideline, which updates the society's 1994 guideline on this topic, was developed by a multidisciplinary panel. Existing evidence was systematically reviewed, and recommendations were made and graded according to the Grading of Recommendations, Assessment, Development and Evaluation approach. Crash-related mortality and real crashes were considered critical outcomes, while near-miss crashes and driving performance were considered important outcomes. The guideline, which is intended for practitioners who encounter patients with sleep disorders, was published in the June 1 American Journal of Respiratory and Critical Care Medicine.

The panel determined that obstructive sleep apnea (OSA) is associated with increased overall risk for motor vehicle crashes compared with non-OSA but that it is difficult to predict risk in an individual. A high-risk driver was defined as someone who has moderate to severe sleepiness in the daytime plus a recent unintended motor vehicle crash or near-miss due to sleepiness, fatigue or inattention.

The panel noted that no compelling evidence supports restriction of driving privileges in patients with sleep apnea who have not had a motor vehicle crash or a similar event. It also noted that treating OSA improves driving simulator performance and could help reduce the risk of drowsy driving and related crashes.

The panel's recommendations to clinicians included the following:

• Patients with a high clinical suspicion of OSA who are high-risk drivers should undergo polysomnography and, if indicated, treatment should be initiated as soon as possible instead of delayed until convenient (weak recommendation, very low-quality evidence). The panel suggested not using empiric continuous positive-airway pressure (CPAP) solely for reducing driving risk (weak recommendation, very low-quality evidence).
• Patients with confirmed OSA who are high-risk drivers should receive CPAP therapy to reduce driving risk rather than no treatment (strong recommendation, moderate-quality evidence).
• Patients with suspected or confirmed OSA who are high-risk drivers should not use stimulant medications solely for reducing driving risk (weak recommendation, very low-quality evidence).

The panel also recommended the following measures to improve clinical practice:

• Clinicians should develop a practice-based plan to inform patients and their families about drowsy driving and other risks of excessive sleepiness, as well as behavioral methods that may reduce risk.
• Clinicians should routinely ask patients with suspected OSA about non-OSA causes of excessive daytime sleepiness (e.g., sleep restriction, alcohol, and sedating medications), comorbid neurocognitive impairments (e.g., depression or neurological disorders), and diminished physical skills, since these factors may contribute to crash risk and affect OSA treatment efficacy.
• Clinicians should know their local and state statutes or regulations about required reporting of high-risk drivers with OSA.