FMCSA issues advisory on Sleep Apnea
The Federal Motor Carrier Administration (FMCSA) recently issued an advisory to all medical examiners who conduct DOT physicals on commercial drivers under the National Registry of Certified Medical Examiner (NRCME) program on sleep apnea. The full text of the advisory can be downloaded at
The advisory is in response to a call from Congressmen Buchon and Lupinski to ensure the agency clarified Congress’ mandate on sleep apnea screening and testing from Public Law 113-45 passed and signed by President Obama last November. The advisory was sent to medical professionals certified under the NRCME program to conduct DOT medical exams and training organizations who administer the training.
Points in the advisory sleep medicine professionals should be aware of include:
- There is no requirement for screening for sleep apnea as part of a DOT medical exam.
This was a major reason there were calls for FMCSA to clarify OSA issues. Many of the training organizations giving the training on the NRCME program stressed the contents of the 3 major sets of medical recommendations made to FMCSA. These included various screening protocols.
The advisory stresses that a medical examiner may issue a conditional certification pending completion of additional testing only when in their expert medical opinion the driver has a disqualifying medical condition. This should be done through a combination of reported symptoms and medical history. No specific set of screening criteria of guidelines are required to be used by FMCSA. The advisory stresses that the medical examiner should explain this to the driver and explain the reasons for a conditional certification.
This may ease the push back sleep specialists get from drivers being mandated sleep studies. Issues on this should be referred back to the NRCME medical examiner who issued the conditional certification.
- Home sleep tests for commercial drivers must include “chain of custody”.
“’Methods of diagnosis include in-laboratory polysomnography, at-home polysomnography, or other limited channel ambulatory testing devices which ensure chain of custody.”
There is no clarification available at this time as to what this means. Some vendors who use HST for commercial drivers have developed affidavits the patient/driver signs attesting to the validity of the HST to establish legal chain of custody. Other vendors have proximity sensors that must be applied to the patient/drivers wrist and must be within a certain distance of the HST device.
PSG and in home PSG are also acceptable methods of testing for commercial drivers.
All patients being given HST should be asked if they are a commercial driver before using an HST that does not establish chain of custody. In reality chain of custody would only be an issue in the event of a negative (no need for treatment) sleep study.
- Oral appliances are now acceptable for treating commercial drivers.
All three previous sets of guidance to DOT medical examiners on sleep apnea recommended not to certify drivers treated with oral appliances. This new advisory stresses the methods of treatment and effectiveness of treatment is a professional medical opinion of the treating specialist.
There has been discussion here on Sleep Scholar and in other venues on the use of the new Braebon oral appliance compliance chip technology. The FMCSA did not include language requiring the use of compliance chip technology.
As this advisory is not part of a formal rulemaking the FMCSA did not and normally would not explain its reasons for its decisions or allow public comments seeking clarification.
- For existing drivers CPAP compliance data requirements are not included.
Whether or not drivers will now need to have an annual review of treatment for documentation of effective treatment for the DOT medical examiners is not clear. Whether this review of treatment must be done by an MD Board Certified in Sleep Medicine or any MD is not clear. Also whether or not treatment reviews can be done by RT’s, RPGST’s, RN, PA or other support staff in sleep medicine is unknown. As treatment options have been expanded to include oral appliances whether or not dentists or other Dental Sleep Medicine accreditation would be appropriate is unknown.
- The advisory stresses the FMCSA’s goal is to address AHI>15.
This opens the question on drivers diagnosed with an AHI<15 who are asymptomatic. It appears that a driver with an AHI<15 who in the expert medical opinion of a treating sleep specialist does not require treatment and is not showing symptoms of excessive daytime sleepiness and/or is not suffering from a respiratory dysfunction likely to cause loss of control of a commercial motor vehicle may be certified by the DOT medical examiner without treatment.
Sleep specialists should be ready to be seen by drivers seeking such a medical opinion. Sleep specialists should be familiar with the advisory and the regulatory language it contains. Use of psychomotor vigilance testing (PVT) or other in office testing might be considered. Use of subjective questionnaires such as ESS or FOSQ will be problematic as drivers will be familiar with the questions and answer to show no EDS.
Questions and issues on how sleep apnea will be managed in commercial motor vehicle operators may be an evolving question. If FMCSA proceeds with a formal rulemaking it will allow all stakeholders including professionals in sleep medicine an opportunity to provide input on the details.
This advisory is the result of calls from both Congressmen and groups within trucking to clarify to DOT medical examiners the mandate given by Congress in public law 113-45 that there are no specific sleep apnea screening and testing requirements. Whether or not this advisory will get reactions from trucking groups for violating the congressional mandate to issue no new guidance without a formal rulemaking will be something to watch. The advisory does contain several points wanted by trucking but opposed by medical groups giving recommendations in the past.
Bob Stanton describes himself as “Just a truck driver with sleep apnea”. In addition to being a truck driver with sleep apnea and a writer, patient advocate and campaigner for the transportation industry Bob is also Active in lobbying and educational efforts as they apply to FMCSA medical certification guidelines and truck driver health and wellness.