AINsight: The FAA and Sleep Apnea

 - August 9, 2018, 11:58 PM

Due to several incidents likely related to fatigue and interrupted sleep in both aviation and the trucking industry, the NTSB and DOT called on the FAA to consider screening for sleep apnea. After a thorough decision pathway analysis and beta test of the FAA’s plan to comply, guidance to aviation medical examiners (AMEs) in regard to sleep apnea screening was issued early in 2015.

As one of only a handful of AMEs who participated in the beta test, I had the opportunity to work directly with FAA physicians in an attempt to make the system somewhat palatable for pilots. While safety is the primary role of the FAA, it is my goal to bring some reason into the system in my daily interface between the FAA and pilots.

If we can avoid having pilots grounded for significant periods of time, they will be a bit more honest and forthcoming from the outset. The FAA understood that point and has been collegial in that aspect in the development of the actual protocol and applicable special issuance process. Yes, pilots with sleep apnea requiring treatment will need a special issuance to keep flying, but there should be no significant period of grounding involved.

Sleep apnea comes in two forms: obstructive and central. The term “apnea” simply means “without respiration.”

Treating sleep apnea is truly one of the best things we do in medicine; it’s a condition where treatment not only lowers risk factors for many serious conditions, but the patient usually feels better right off the bat. On the contrary, prescribing a statin for cholesterol—and to reduce heart attack and stroke risks—doesn’t make a patient feel better along the way. In fact, drug side effects might be rather annoying.

In short, treating sleep apnea is a win-win situation. And while pilots likely are not pleased about yet another cumbersome FAA medical certification process, this newer protocol for sleep apnea keeps nearly 100 percent of pilots flying, even during the evaluation period. Avoiding lengthy grounding periods was something I lobbied strongly for in my interactions with the FAA during the beta test.

In obstructive sleep apnea (OSA), anatomical obstructions in the respiratory pathway cause all sorts of problems, from irregular breathing to long periods without breathing at all. These are typically followed by a loud gasp as the respiratory drive forces the body to begin breathing at all costs.

Risk factors for OSA include obesity, large tonsils, and abnormal size and shapes to the tongue, jaw, and palate, among others. Loud and irregular snoring is often, but not always, part of OSA symptoms.

While obesity is a very strong risk factor, OSA also occurs in people with a normal body habitus. In my practice, I actually have more pilots with OSA who are slim than obese.

So, what’s the big deal? Do we really need to treat sleep apnea, or is this simply more government regulation?

Untreated sleep apnea is clearly contributory in many serious medical conditions. In fact, it increases risks for cardiac disturbances (including irregular heart rhythms such as atrial fibrillation), hypertension, heart attack, stroke, diabetes, headaches, memory loss and other cognitive impairments, attention and problem-solving deficiencies, fatigue and daytime drowsiness (I know pilots who fly “all-nighters” are chuckling right now), and sometimes causes people to be simply irritable and unhappy. Psychiatric problems such as depression can also be exacerbated by sleep apnea. And, for men, these risks significantly exacerbate erectile dysfunction.

Treating OSA usually consists of a continuous positive airway pressure device (CPAP), the nasal mask used during sleep. While earlier versions of these devices were uncomfortable and loud, over time they continue to become more portable, quieter, and less annoying to the patient—and less annoying to the patient’s spouse. In addition, surgery can be curative in some cases. A small subset of pilots is well treated with a simple, although not inexpensive, oral appliance.

Speaking of the spouse, the majority of patients being treated for sleep apnea report that their spouse is not only less concerned about the patient’s health and long-term prognosis, but the near resolution of snoring (along with the quietness of the newer CPAP machines) means that he/she might actually sleep in the same room as the patient once again. Yet another win for sleep apnea treatment.

Central sleep apnea (CSA) is a bit different. The results are similar, with disrupted breathing and potential long-term health risks, but the apneic episodes in this case aren’t caused by anatomical variants.

In CSA, the brain itself is the culprit. This makes it a more difficult “fix,” with a more challenging prognosis. However, over time the FAA has found that pilots with CSA tend to do pretty well with treatment, and so certification is also possible for these pilots.

Sometimes there is a mix of OSA and CSA in the same person. These folks might use CPAP and often simultaneously a small flow of regular oxygen. There are various means to achieve stability, and fortunately most of these pilots return to the cockpit in spite of their slightly increased risks over garden-variety OSA.

There has been concern among pilots that a marginally high body mass index (BMI) would prompt the FAA to mandate formal sleep apnea screening. Fortunately, that is not the case. Typically, the FAA allows the AME to weigh the BMI (and consider if the pilot is very muscular, for example) along with any other risk factors being considered and then recommend whether or not the pilot undergo formal screening.

There are several methods for formal screening, including the “gold standard” of the observed sleep study (you know, in the sterile, cold, noise, and lack of privacy in a formal medical setting). I’m a lousy sleeper at best, and I can promise any medical provider that my chances of getting any sleep in such a setting would be virtually zero. Fortunately, there are now more convenient methodologies to screen for sleep apnea, including user-friendly home testing.

As for BMI, there is no hiding from the fact that those with a very high BMI have a greatly increased risk for sleep apnea. In fact, the morbidly obese person has a 75 percent to 90 percent chance that they have clinically significant sleep apnea. There is, therefore, a verifiable reason to include BMI as part of this protocol.

What happens if the person (obese or not) is diagnosed with sleep apnea? First and foremost, get it treated. As I state in all of my talks to pilot groups, it’s easier to keep you flying if you are still alive.

Once treated, the patient will state, almost without exception, “Wow, this might be a pain, but I feel better than I have in many years!” They usually don’t mind if their spouse lets them sleep in the same room once again, too.

What about the FAA and career implications for the pilot? In my next blog, I’ll discuss the workings of how the AME screens for sleep apnea and assists in the special issuance process. Again, barring some dramatic co-morbid medical condition discovered during the evaluation (that would be grounding in and of itself), most pilots treated for sleep apnea continue to fly without interruption. In most cases, the special issuance is routinely granted. There will be annual follow-up requirements, but these are reasonably simple to comply with.

Dr. Sancetta is a former DC-10 captain with 11,000 flight hours. He has worked as a Senior AME since 1993 and is appointed as AME Consultant to the Federal Air Surgeon.