- Automobile crashes are the fifth leading cause of death and injury in the United States.
- The number of crashes and severity of injury by distance driven are highest in young drivers (15-25 yr) and in those >65 yr.
- Crashes due to sleepiness typically involve running off the road or into the back of another vehicle.
- Sleepiness is most commonly caused by insufficient sleep, which is associated with prolonged wakefulness or chronic sleep restriction due to long hours of work or play, shift work (comprising 7.4% of all those employed), or a variety of medical and neurological disorders.
- Fatality reduction currently targets increasing seat belt use and reducing speeding and alcohol. However, inattentiveness, fatigue, and sleepiness are increasingly recognized as contributing, and possibly primary, factors.
- Obstructive sleep apnea (OSA) is the most common medical disorder that causes excessive daytime sleepiness, increasing the risk for motor vehicle crashes two to three times.
- Sleepiness may account for up to 20% of crashes on monotonous roads, especially highways.
- A high-risk driver is defined as one who has moderate to severe daytime sleepiness and a recent unintended motor vehicle crash or a near-miss attributable to sleepiness, fatigue, or inattention.
- There is no compelling evidence to restrict driving privileges in patients with sleep apnea if there has not been a motor vehicle crash or an equivalent event.
- Treatment of OSA improves performance on driving simulators and might reduce the risk of drowsy driving and drowsy driving crashes.
- Timely diagnostic evaluation and treatment and education of the patient and family are likely to decrease the prevalence of sleepiness-related crashes in patients with OSA who are high-risk drivers.
- All patients being initially evaluated for suspected or confirmed OSA should be asked about daytime sleepiness, especially falling asleep unintentionally and inappropriately during daily activities, as well as recent unintended motor vehicle crashes or near-misses attributable to sleepiness, fatigue, or inattention. Patients with these characteristics are deemed high-risk drivers and should be immediately warned about the potential risk of driving until effective therapy is instituted.
- Additional information that should be elicited during an initial visit for suspected or confirmed OSA includes the clinical severity of the OSA and therapies that the patient has received, including behavioral interventions. Adherence and response to therapy should be assessed at subsequent visits. The drowsy driving risk should be reassessed at subsequent visits if it was initially increased.
- For patients in whom there is a high clinical suspicion of OSA and who have been deemed high-risk drivers:
- The ATS suggests that polysomnography be performed and, if indicated, treatment initiated as soon as possible, rather than delayed until convenient (weak recommendation, very low–quality evidence).
The ATS recognizes that the duration that constitutes “as soon as possible” will vary according to the resources available, but ATS favors the goal of less than 1 month. For appropriately selected patients (e.g., no comorbidities, high clinical suspicion for OSA), at-home portable monitoring is a reasonable alternative to polysomnography.
- The ATS suggests NOT using empiric continuous positive airway pressure (CPAP) for the sole purpose of reducing driving risk (weak recommendation, very low–quality evidence).
- For patients with confirmed OSA who have been deemed high-risk drivers, the ATS recommends CPAP therapy to reduce driving risk, rather than no treatment (strong recommendation, moderate-quality evidence).
This suggestion is for CPAP because only its effects on driving performance have been well studied. Other treatments that could accomplish the same goal have not been evaluated.
- For patients with suspected or confirmed OSA who have been deemed high-risk drivers, the ATS suggests NOT using stimulant medications for the sole purpose of reducing driving risk (weak recommendation, very low–quality evidence).
- Opportunities to improve clinical practice include the following:
- 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 those risks.
- Clinicians should routinely inquire in patients suspected with 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. Such factors may additively contribute to crash risk and affect the efficacy of sleep apnea treatment.
- Clinicians should familiarize themselves with local and state statutes or regulations regarding the compulsory reporting of high-risk drivers with OSA.