Untreated Sleep Apnea in Truck Drivers

The Dangers of Sleep Apnea & Trucks

Obstructive sleep apnea (OSA) is more than a sleeping condition that makes people snore. It is a physiological disorder in which the upper airway repeatedly collapses during sleep, causing brief interruptions of breathing that can last at least 10 seconds and recur hundreds of times over the course of a single night. Because each interruption triggers a partial arousal from sleep, OSA fragments the sleep cycle, preventing deep, restorative sleep that the brain requires to function at full capacity. And because OSA affects an individual's quality of sleep, OSA can make it difficult for individuals to stay awake during the day. Thus, a driver with untreated OSA can spend eight hours in bed and still wake up significantly impaired, functioning much like someone who did not get adequate rest.¹

Obstructive sleep apnea makes it difficult for drivers to stay awake, focus their eyes, and react quickly. In general, studies show that people with untreated OSA have an increased risk of being involved in a fatigue-related motor vehicle crash. A driver does not have to fall asleep to cause a motor vehicle crash, as crashes frequently occur when drivers are inattentive and less alert than they would have been had they slept restfully.²

For commercial drivers, the risks are amplified significantly. Longer routes are often run at night or in the early morning hours, the precise times when the body's circadian rhythm creates its strongest drive toward sleep.³ A driver whose baseline alertness is already degraded by fragmented sleep faces an additional deficit on top of the hours-of-service pressures the federal regulatory system was designed to address. The result is a category of chronic impairment that looks like fatigue but originates in a treatable medical condition, leaves no chemical trace at a crash scene, and is likely undercounted in fatality statistics.⁴

Sleep Apnea Is Common Among Truck Drivers

The prevalence of obstructive sleep apnea in the commercial trucking population is not a contested figure. Sponsored by the Federal Motor Carrier Safety Administration (FMCSA) and the American Transportation Research Institute of the American Trucking Associations, a University of Pennsylvania study found that nearly 28 percent of commercial truck drivers have mild to severe sleep apnea.⁵

Truck drivers are disproportionately affected compared to the general population, as the nature of the job itself lends itself to the development of OSA. Key occupational factors, such as sedentary work, irregular schedules, limited access to healthy food, and poor sleep environments, are also OSA risk factors.⁶ Further, OSA is closely associated with obesity and is more common in middle-aged men, the demographic that makes up the majority of the commercial driving workforce.⁷ Other studies estimate that, of the 14 million U.S. commercial driver's license holders, between 2.4 and 3.9 million have obstructive sleep apnea.⁸

OSA Prevalence in Trucking

28% of commercial truck drivers have mild to severe sleep apnea

14M U.S. commercial driver's license holders

4 occupational risk factors linked to OSA: sedentary work, irregular schedules, limited access to healthy food, poor sleep environments

Source: FMCSA-sponsored research and National Academies of Sciences, Engineering, and Medicine

Current FMCSA regulations pertaining to obstructive sleep apnea depend largely on subjective reporting, which is an unreliable mechanism for identifying the condition.⁹ Drivers who have never been diagnosed with OSA cannot report what they do not know, and self-reported denial of symptoms does not rule out the condition.¹⁰ This creates a structural detection gap that the regulatory system leaves unaddressed.

The Crash Risk Explained

The relationship between untreated OSA and elevated crash risk is among the more robustly supported findings in transportation safety research. Multiple systematic reviews commissioned by FMCSA have examined this question.

A systematic review and meta-analysis commissioned by FMCSA found that drivers with obstructive sleep apnea have a crash risk that is between 21 percent and 489 percent higher than comparable drivers without the condition.¹¹ Research also demonstrates that untreated OSA is associated with a two to seven-fold increase in the risk of motor vehicle accidents among primarily non-commercial drivers,¹² and separate research found a nearly five-fold increase in preventable crashes among commercial truck drivers who did not adhere to mandated OSA treatment.¹³ The commercial driver figures are likely higher than the general population figures because commercial drivers operate heavier vehicles at highway speeds for longer durations, reducing the margin for error that degraded alertness creates.

Obstructive sleep apnea is the most common medical cause of fatigue among commercial motor vehicle operators, and it is estimated that 10 to 20 percent of all large truck crashes are attributable to fatigued drivers.¹⁴ Together, OSA's status as the leading medical cause of fatigue among commercial vehicle operators and the documented role of fatigue in large truck crashes illustrates that untreated OSA substantially contributes to crash risk.

Crash Risk Findings

21 to 489% higher crash risk for drivers with OSA compared to comparable drivers without the condition

2 to 7 fold increase in motor vehicle accident risk among primarily non-commercial drivers with untreated OSA

Nearly 5 fold increase in preventable crashes among commercial truck drivers who did not adhere to mandated OSA treatment

10 to 20% of all large truck crashes are attributable to fatigued drivers

Critically, the evidence also shows that this crash risk is reversible. Drivers with OSA who receive and adhere to treatment with continuous positive airway pressure (CPAP) show meaningful reductions in crash risk.¹⁵ Though the condition is dangerous when untreated, OSA is manageable when addressed. Yet, there is no mandatory screening standard imposed on the trucking industry.

No Mandatory Screening Requirements for Obstructive Sleep Apnea

The federal standard governing driver medical qualifications is found at 49 C.F.R. § 391.41(b)(5), which specifies that a person is physically qualified to drive a commercial motor vehicle if that person has no "established medical history or clinical diagnosis of a respiratory dysfunction likely to interfere with his/her ability to control and drive a commercial motor vehicle safely." Though there is no specific reference to OSA in the regulation, there are specific standards for other medical disorders that can increase the risk of sudden driver incapacitation, such as diabetes, epilepsy, and cardiovascular diseases. OSA is only addressed through the general "respiratory dysfunction" clause.¹⁶

All commercial drivers operating in interstate commerce must pass a medical examination at least every 24 months.¹⁷ The medical examiner assesses whether the driver meets the physical qualification standards in § 391.41(b) and, if so, issues a Medical Examiner's Certificate (Form MCSA-5876) authorizing the driver to operate a commercial motor vehicle. The examination is a general physical evaluation and is not a comprehensive sleep study. The adequacy of any OSA screening depends entirely on the individual examiner's judgment and training.

Specifically Regulated Conditions

✓Diabetes

✓Epilepsy

✓Cardiovascular diseases

Obstructive Sleep Apnea's Status

✓No specific reference in 49 C.F.R. section 391.41(b)(5)

✓Addressed only through the general respiratory dysfunction clause

✓Medical exam required every 24 months is a general physical, not a sleep study

A Known Regulatory Gap

FMCSA has been aware of the inadequacy of these regulations for years. In fact, in March 2016, FMCSA and the Federal Railroad Administration issued an Advanced Notice of Proposed Rulemaking to address the obstructive sleep apnea issue in commercial drivers and rail operators. However, the FMCSA and the Federal Railroad Administration later withdrew the notice in 2017.¹⁸ In withdrawing the notice, the agencies stated that current safety programs and fatigue risk management regulations were "the appropriate avenues to address OSA."¹⁹

The withdrawal was significant. In 2013, Congress passed a law mandating that any new requirement regarding the screening, testing, or treatment of commercial motor vehicle operators for sleep disorders must first be subject to the formal notice-and-comment rulemaking procedure.²⁰ As a result, the FMCSA was forced to remove its guidance from the medical examiner website and handbook. To date, the FMCSA cannot simply update its medical examiner bulletin to include standardized screening criteria without completing the mandatory notice-and-comment rule making process.²¹ So, when the advanced notice of proposed rulemaking was withdrawn by the FMCSA in 2017, the FMCSA left no rule in progress, no interim guidance, and no standardized criteria.

Timeline of a Regulatory Gap

2013

Congress passes a law requiring that any new OSA screening, testing, or treatment requirement for commercial motor vehicle operators go through formal notice-and-comment rulemaking.

2016

In March 2016, FMCSA and the Federal Railroad Administration issue an Advanced Notice of Proposed Rulemaking to address OSA in commercial drivers and rail operators.

2017

FMCSA and the Federal Railroad Administration withdraw the notice, stating current safety programs and fatigue risk management regulations were the appropriate avenues to address OSA.

2024

The January 2024 Medical Examiner's Handbook links to the 2016 advisory recommendations from FMCSA's Medical Review Board, recommendations that carry no regulatory force.

What remains, however, is discretion. Again, while the FMCSA has no regulations or specific criteria on screening, testing, and treatment of sleep apnea, it does grant the medical examiner the discretion to determine if an individual is at greater risk for the condition. In screenings that occur during the medical certification process, medical examiners may rely on their medical judgment and may consider the relevant medical best practices and expert recommendations.²² The January 2024 Medical Examiner's Handbook includes a link to the 2016 advisory recommendations from FMCSA's Medical Review Board. But again, those recommendations carry no regulatory force.²³ The practical result is a system in which detection of one of the leading medical causes of commercial truck crashes depends on the alertness, training, and judgment of thousands of individual certified medical examiners, absent uniform protocol, required screening questionnaire, and mandated referral threshold.

Carrier Obligations & Negligence Exposures

The absence of a mandatory screening rule does not mean carriers have no obligations when it comes to obstructive sleep apnea. It simply means their obligations operate under a different legal framework, negligence, instead of per se violations of regulations.

A motor carrier may not require or permit a driver to operate a commercial motor vehicle if the driver has a condition that would affect the driver's ability to safely operate the vehicle, such as OSA.²⁴ That prohibition runs directly to the carrier, independent of the medical examiner's certificate. A driver's valid DOT medical certificate establishes that a certified examiner found no disqualifying condition at the time of the exam. Yet, it does not preclude a carrier from independently knowing, or having reason to know, that the driver has a condition affecting safe operation.

When a carrier has information suggesting a driver may have untreated obstructive sleep apnea (a pattern of fatigue-related incidents, documented drowsiness behind the wheel, a previous medical certificate with an OSA referral that was never followed up) and does nothing with that information, the carrier is not protected by the absence of a federal screening mandate. The regulatory gap tells the carrier what it is not required to do. However, it does not tell the carrier to ignore evidence it already has.

The crash risk for OSA is well-documented and publicly known. During DOT physicals, medical providers consider obesity, snoring, neck circumference, older age, and other objective physical indicators as predictors of sleep apnea that could prompt a referral for a sleep test.²⁵ A carrier whose driver qualification file shows a driver with multiple OSA risk factors, repeated fatigue-related incidents, and no evidence of any OSA evaluation is in a fundamentally different position than a carrier that never had reason to suspect the condition in the first place.

Signs Relevant to Carrier Knowledge

Carrier Knowledge Indicators

✓A pattern of fatigue-related incidents

✓Documented drowsiness behind the wheel

✓A previous medical certificate with an OSA referral that was never followed up

Physical Indicators Considered During DOT Physicals

✓Obesity

✓Snoring

✓Neck circumference

✓Older age