Asleep at the Wheel
Lifesavers 4/23/18
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Asleep at the WheelUnderstanding and Preventing Drowsy Driving
aasm.org
EVOLVING SAFETY PRIORITIES AND SOLUTIONS
LIFESAVERS ● April 23, 2018 ● San Antonio, TX
2:15 – 3:45 PM
Room 214 D
Conflict of Interest Disclosures for Speakers
1. I do not have any potential conflicts to disclose.
2. I wish to disclose the following potential conflicts of interest:
Type of Potential Conflict Details of Potential Conflict
Grant/Research Support
Consultant
Speakers’ Bureaus
Financial support
Other
3. The material presented in this lecture has no relationship with any of these potential conflicts, OR
4. This talk presents material that is related to one or more of these potential conflicts, and the following objective references are provided as support for this lecture:
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Asleep at the Wheel: Understanding and Preventing Drowsy Driving
Healthy sleep, sleepiness and sleep disorders: role in motor vehicle accidents (35 min)
Shift work and crash risk (25 min)
Sleep deprivation and crash risk (25 min)
Sleepiness and Accidents: A Crash Course
Occupational Sleep Health and Wellness
Presidential Committee
Healthy sleep, sleepiness and
sleep disorders: role in motor
vehicle accidents
Sleepiness and Accidents: A Crash Course
Director, Occupational Sleep Medicine
Perelman School of Medicine
University of Pennsylvania
Director, Sleep Disorders Clinic
VA Medical Center
Philadelphia, PA
Indira Gurubhagavatula, MD, MPH
Associate Professor of Clinical Medicine
American Academy of Sleep Medicine
(AASM)
• 11,000 physicians, scientists, allied health professionals, accredited sleep centers
• leader in setting standards and promoting excellence in sleep medicine health care
• 2014 –Sleep and Transportation Safety Awareness Task Force (STSATF)
• 2017 –Occupational Sleep Health and Wellness Presidential Committee
Mission
• Engage occupations and populations at risk for sleep deprivation
• Provide education– Effects of sleep deprivation
– Fatigue management strategies
• Monitor regulatory agencies’ actions related to sleep health and safety risks in employees– safety-sensitive positions, have sleep
disorders
Asleep at the Wheel
Lifesavers 4/23/18
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Some of our activities
Position statement about addressing sleepiness
and accidents in EMS and ride hailing industry
Educational materials on sleep apnea, shift work,
insomnia, sleep hygiene, drowsy driving, fatigue
management
Response to withdrawal of Notice of Proposed
Rulemaking on sleep apnea
Outline
• What is the difference between healthy sleep and disordered sleep?
• What determines alertness?
• What are some sleep disorders that can impact driving safety?
– Obstructive sleep apnea
– Shift work
– Sleep deprivation
Normal sleep architecture
HOURS OF SLEEP
What determines alertness?HOMEOSTATIC DRIVE FOR SLEEP
CIRCADIAN DRIVE FOR WAKEFULNESS
Reducedbehavioral
capability
Increased behavioral
capabilityInternal Factors
• Stress/anxiety
• Urgency
• Motivation
External Factors
• Alcohol, caffeine
• Medications
• Noise
• Physical activity
Disorders that cause sleepiness
Quality of sleepLength of time awake
Time of day
Duration of sleep
Conditions associated with daytime
sleepiness
• Sleep disorders– Obstructive sleep apnea
– Other sleep disorders (e.g., periodic limb movements, restless legs syndrome, narcolepsy)
• Some medical disorders
• Some psychiatric disorders
• Some medications
• Some behaviors (sleep hygiene)
Asleep at the Wheel
Lifesavers 4/23/18
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Obstructive Sleep Apnea
• What is obstructive sleep apnea?
• Who is likely to have it?
• How common is it?
• What are the usual symptoms?
• What are the consequences?
• Can we diagnose it quickly and at low cost?
• Can it be treated?– Does treatment help?
– Does treatment make sense economically?
Sleep apnea: what actually happens?
http://content.revolutionhealth.com/contentimages/ n5551303.jpghttp://www.thetmjcenter.com/sleep_a pnea.jpg
AWAKE ASLEEP
www.thoracic.org
sleep architecture during sleep apnea
Sleep fragmentation
No N3, REM
Desaturation
EXAMPLE OF AN APNEA
OSA AND OXYGEN LEVEL DURING
SLEEP
Why are some people at risk for
sleep apnea?
• OBESITY
• OBESITY
• OBESITY
• Airway crowding
–Large tonsils
–Large tongue
–Small jaw
• Heredity
• Middle age/older
• Male gender
• Female gender, after menopause
• Nasal congestion
• Alcohol, sedatives, narcotics
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As obesity becomes more common, so does sleep apnea
Prevalence of moderate to severe apnea
Men Women
1994 (Young et al)
(state employees, age 30-60 years)
9% 4%
2007-2010 (Peppard et al)
30-49 years 10% 3%
50-70 years 17% 9%
Peppard, Am J Epidemiol, 177 (9):1006-1014; 2013
prevalence data from 1994 was used to model current prevalence rates, based on
recent age, sex, BMI data from NHANES
Studies have linked OSA to crashes
Research studies that were
evaluated
Odds of crash
18 studies in car drivers;
2 in truck drivers
1.21-4.89
http://www.fmcsa.dot.gov/facts-research/research-technology/report/FMCSA-RT-04-008.pdf
Tregear et al, JCSM 2009, Dec 15 5(6); 573-581.
Life with sleep apnea
APNEAS, HYPOPNEAS
(observed by others)
Snoring
Choking, Gasping
Frequent urination
ADRENALINE
LOW OXYGEN
• Sleepiness
• ↑Crash risk
• ↓ mood, memory,
concentration,
attention, decision-
making
• ↑ reaction time
• Morning headache
• Impotence
• ↓producLvity
• Absenteeism
• Hypertension
• Heart disease
• Stroke
• Pre-diabetes
• Death
NIGHTTIME
DAYTIME
LONG-TERM
AROUSALS
worse with weight gain
Costs of crashes due to undiagnosed OSA
(2015, U.S.)
AASM, 2016
In-lab sleep study
• Brain waves
• Eye movement
• Chin, leg muscles
• Chest and abdomen
effort
• Airflow, snoring
• Oxygen level
85% of cases remain undiagnosed
Brain waves
Eye movement
Chin, leg muscles
• Chest and abdomen
effort
• Airflow, snoring
• Oxygen level
http://www.fette-thimm.de/img/embletta400.jpg
Portable sleep study
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Is sleep apnea treatable?
http://amysorrells.files.wordpress.com/2012/06/flat_bicycle_tire.jpg
http://www.everettclinic.com/crs/aha/cpap.jpg
Continuous positive airway pressure (CPAP)
http://www.sleepwise.com.au/images/D912193040.gif
http://www.resmed.com/uk/images/cpap_treatment.jpg
Continuous positive airway pressure
(CPAP)
In addition to improving oxygen level and sleep quality, what are the benefits of CPAP?
� CPAP lowers � crash risk1
� blood pressure2,3
� heart disease, stroke5,6,7
� mortality7,8
� health care costs9,10
� CPAP improves
� alertness1
� performance on
driving
simulator1
� quality of life4
1Tregear, Sleep, 20102Haentjens, Archives Int Med, 20073Bazzano, Hypertension, 20074Sanner, Eur Respir J, 20005Buchner, AJRCCM, 20076Marin, Lancet, 20087Yaggi, NEJM, 20058Martinez-Garcia, AJRCCM, 20099Albarrak, Sleep, 200510Ronald, Sleep Res Online, 1998
How do we know if patients are using
CPAP?
https://www.respshop.com/images/DreamStation-CPAP-Machine-2.jpg
https://sleepright.com.au/wp-content/ uploads/2012/05/Resmed-S10-CPAP-300x226.png
http://www.1800cpap.com/images/ products/detail/iconautoplussensea wakecpa p.jpg
Monitoring therapy
http://www.cpapxchange.com/cpap-machines-bipap-machines/sleepmapper-screens.png
Did they wear it?
Did the mask leak?
Is apnea still present?
http://www.cpaptalk.com/in-house-cpap-news/images/encorepro/ComplianceScreen.jpg
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Sleep apnea
– is common
– causes sleepiness
– is linked to crashes, as well as major economic and health outcomes
– can be diagnosed in the home/berth
Summary
CPAP treatment
• is inexpensive
• is accessible
• lowers crash risk
• improves many health conditions
• lowers health care costs
• can be tracked in real-time
Occupational Sleep Health and
Wellness: Dream Team
Omer Ahmed, MD
Michael Berneking, MD
Jacob Collen, D
Binal Kancherla, MD
Shannon Sullivan, MD
Indira Gurubhagavatula, MD, MPH (Chair)
Questions?