Tilton Is Right (but he could use a good PR agent)
Unpopular as his crusade may be, Federal Air Surgeon Fred Tilton is right to shine a spotlight on sleep apnea in the pilot community. But the way he broke the news of the proposed screening program surely raised hackles: it did not adhere to rulemaking protocol and to pilots it appears invasive beyond the agency’s charter. The doc got off on the wrong foot, and his stated goal of using body mass index (BMI) as the matrix for unearthing sufferers, while in line with medical opinion that BMI is a leading indicator, has some shortcomings. BMI is one indicator, but it will not weed out everyone struggling with sleep apnea. “Struggling” is no exaggeration for someone trying to cope with severe OSA.
I’m not a fan of reading about other people’s medical problems, and I would have preferred to continue to keep the lid on my own sleep apnea. But Tilton has thrust the condition into the consciousness of pilots, and I feel some duty to share my experience with severe sleep apnea–from which I have to draw one overriding conclusion: untreated, the condition is seriously incompatible with the demands of piloting.
The big relief for me that accompanied a diagnosis of obstructive sleep apnea was that it revealed the cause of the chronic exhaustion that had sapped my enthusiasm for pretty much everything. I had grown steadily more fatigued and exhausted with each passing year for seemingly as long as my declining powers of memory could recall.
In the shower each morning, as I leaned against the tiles wondering why I was so utterly drained after a night in bed, all I wanted to do was curl up on the floor of the enclosure and sleep. I would pull off the road en route to work or returning home to doze for a few minutes and try to fend off the overwhelming urge to sleep. During brief forays into something resembling sleep at night, I would dream I was unable to breathe but told myself it was only a dream, when in fact I was indeed suffocating from lack of oxygen. A core reflex would yank me out of it and restart breathing until the next stoppage. This went on all night, every night, and I was unaware of it.
Activities and pursuits that used to excite me or at least hold my interest lost their luster, including flying. In 2002, although I didn’t know it then, I flew an aircraft for the last time–this after 30 years spent flying something new and exciting every month, photographing it and writing about my impressions of flying it. It had been the dream job for this kid who grew up thinking about little else other than aircraft and flying. What on earth had happened?
There was no conscious decision to quit flying the airplane I had spent three years building and flown for 300 hours, or to quit flying any other aircraft for that matter. Flying was another victim of my declining enthusiasm for anything other than just struggling through the basics: keep the magazine accurate, hold onto my job so I could make the mortgage payments and function as father and husband as best I could. I searched for factors that might explain my condition. Was it the daily round trip of 125 miles on New Jersey’s clogged roads just to get to and from the office, in addition to the often long hours devoted to AIN between the northbound and southbound drives? Was it the exercise I surely needed but couldn’t find the time for or summon the energy for? Was I trying to cram too much into too few hours? Was I just not cut out for the pace of modern life?
In the meantime, supposedly like all Brits, I kept a stiff upper lip and carried on. Eventually my wife, concerned about the periods of nocturnal silence that suggested my usual snoring had taken a more serious turn, persuaded me to undergo a full sleep study (an expensive overnight polysomnography that AIN’s medical insurance covered).
The results of my initial sleep study spelled bittersweet relief. Fewer than five stoppage events an hour–a five on the apnea-hypopnea index (AHI) doctors use–is regarded as normal; anything above 30 on the AHI is classified as severe OSA. My AHI number was 87, meaning a stoppage on average every 42 seconds, severe enough that the medics terminated the test prematurely and slapped a CPAP mask on me for the remainder of the night.
I hadn’t had a good night’s deep sleep for years, maybe even decades, and now I had the evidence for what was causing the debilitating fatigue and utter exhaustion.
Body Mass Index
My six-foot frame and 210 pounds equate to a BMI of 28.5 (officially “overweight” until I drop to 183 pounds/24.8 BMI), so me and my 87 stoppages an hour would slip through not only the FAA’s initial net of 40 BMI (officially “obese class III”) but also its proposed second-stage net of 30 BMI (officially “obese class I”).
To be caught in the first net of 40 BMI, I’d have to weigh 295 pounds. To be caught in the second net of 30 BMI, I’d have to weigh 220 pounds. If I weighed 295 pounds, I’m not sure I’d even fit in most cockpits and would likely be on warning at most corporate operators to slim down or find another line of work.
The FAA is targeting pilots with a 17-inch neck circumference as well as a BMI of 40 then 30. Medical studies show that overweight people are more prone to suffer from sleep apnea because the structure of their neck and throat encourages the airway blockage that causes OSA, but is the FAA also using sleep apnea as a lever to eject seriously obese people out of cockpits because of the long list of health risks their weight poses? If the agency is intent on weeding out every last sleep apnea sufferer, it’s not going to execute a full purge by focusing on BMI and neck size. On the other hand, it might purge cockpits of morbidly obese pilots.
The Civil Aviation Medical Association (which represents aviation medical examiners) had this to say in a letter to FAA Administrator Huerta objecting to the agency’s proposed policy on OSA: “The FAA is not tasked to provide long-term prognoses, but rather to determine the likelihood of pilot incapacitation for the duration of the medical certificate.”
“Pilot incapacitation” suggests a sudden, unanticipated, disabling event such as a heart attack, which is why a professional pilot’s physical includes an EKG to provide the FAA some guidance in determining the likelihood of cardiac incapacitation during the validity of the medical certificate sought. OSA presents a more subtle type of incapacitation, so the FAA could argue that by targeting OSA it is trying to identify existing, chronic, undiagnosed and subtle incapacitation of the human condition most difficult to evaluate and too prevalent in accidents: judgment.
Some of aviation’s lobby groups have been quick to claim that not one flying accident has ever been attributed to a pilot’s sleep apnea, but the logic of that assertion, in the context of my experience with OSA, is lost on me. There are plenty of accidents that cause pilot readers of the NTSB’s final report to shake their heads and say, “Why on earth did he do that? What was he thinking?”
It is entirely within the realm of possibility that a pilot’s thinking was warped by the relentless exhaustion of severe undiagnosed or undisclosed sleep apnea. Sleep apnea cannot be dismissed as a possible accident cause simply because it has never been cited specifically in an accident report. It’s incontrovertible that fatigue clouds judgment, witness all the studies of circadian rhythm and flight and duty times as they relate to safety. What’s more, those studies assume that a tired pilot sinks into deep, restorative sleep when he finally enters the land of nod at the end of the duty day. That is not the case for a pilot living with untreated OSA.
Unlike many readers of this magazine who might find themselves in this predicament, I was fortunate in that I was able to quietly quit flying, don a CPAP mask every night, hold onto my livelihood and enjoy the prospect of someday flying my (sufficiently light) airplane again on the strength of my driver’s license alone–no requirement to undergo, and possibly fail, an FAA third-class physical. If I took and failed an FAA physical, the driver’s-license route would be shut off. So I never underwent an FAA physical since I quit flying.
In this preliminary stage of sleep apnea screening for the professional pilot population, the fallout from a diagnosis of OSA is a big question: will the OSA sufferers weeded out by the FAA physical have an income safety net for the time they are out of the cockpit, whether that be six weeks or permanently? Will they go to the bottom of the list of 55,000 pilots already awaiting special-issuance medical recertification? Clear answers at this stage are elusive. With a waiting list already that long, the FAA is clearly ill equipped to deal swiftly with the OSA sufferers it banishes from cockpits.
In my case, connecting to a CPAP machine every night has been a passport back to the land of nod, with a commensurate improvement in my outlook on life and my ability to function. But the process is a royal pain in the rump, and I look back fondly on the time I could go to bed in short order rather than spend the requisite 15 minutes to clean the mask, clean my face of any oils for an airtight night-long fit and top up its humidifier reservoir with distilled water. That tiresome routine never changes. Fortunately, the alien sensation of hitting the hay with a mask and air hose strapped to my face became familiar quite quickly.
Does CPAP work? For me it does, and I am reminded how well it works if I succumb to the temptation not to wear it and wake up feeling, once more, as if I haven’t slept all night. OSA has not gone away, but at least the CPAP, its Hobbs now headed for 9,000 hours, keeps it at bay.
What Is Obstructive Sleep Apnea (OSA)?
OSA is a condition marked by pauses in breathing during sleep, despite efforts to breathe, and it usually reduces blood oxygen saturation, introducing the potential for organ damage in the long term. The obstruction to normal breathing is caused by relaxation of the muscle tone in the neck and throat, which leads to collapse of the soft tissue into the airway at the back of the throat. These pauses in breathing typically last between 20 and 40 seconds.
Doctors treat OSA either by having the patient sleep with a dental mouth-guard device inserted at bedtime that moves the lower jaw down and forward, or they prescribe some variant of CPAP/VPAP/APAP (continuous/variable/automatic positive airway pressure) device, which pumps a measured flow of air at a pressure chosen by the doctor into a mask worn over the nose or mouth or both to keep the airway open. A weight-loss and physical exercise program can also be part of the treatment. Medication and surgery are not generally regarded as effective.