SLEEP-APNEA, SLEEPINESS, AND DRIVING RISK

Among patients with sleep apnea, risk for impaired driving is highest among those with both severe excessive daytime sleepiness and historic evidence of an unintended motor vehicle crash or, by history, an equi valent level of concern. The level of apneic activity by itself is not a factor that increases risk. The high-risk individual can be recogni zed by pulmonary physicians who, in turn, are in a position to inform and notify the patient of increased driving risk and to explore immedi ate measures to reduce risk. Effective therapy needs to be instituted promptly and the effectiveness of therapy and compliance with therapy should be monitored on a routine basis. Historic information on sleepi ness and driving impairment are at present the best information for me dical follow-up. Among this group of high-risk patients, what is best for the patient's effective treatment is also best for society. In the opinion of the Committee, there is as yet no compelling evidence to r estrict the driving privileges in apnea patients where there has not b een a motor vehicle crash or an equivalent level of concern for increa sed driving risk. However, it is very appropriate for the physician to warn of potential dangers of driving while sleepy and inform the pati ent of this potential personal and social risk. Whether and under what circumstances patients with sleep apnea should be reported to the lic ensing authority will depend on the laws of the state in which the phy sician practices. in those jurisdictions in which conditions such as e xcessive daytime sleepiness caused by sleep apnea may be construed as reportable events, we recommend reporting to licensing bureaus if: (a) the patient has excessive daytime sleepiness and steep apnea and a hi story of a motor vehicle accident or equivalent level of clinical conc ern; and (b) one of the following circumstances exists: (i) the patien t's condition is untreatable or is not amenable to expeditious treatme nt (within two months of diagnosis); or (ii) the patient is not willin g to accept treatment or is unwilling to restrict driving until effect ive treatment has been instituted. Because of the imprecision of curre nt markers of cognitive or biologic performance to prospectively ident ify patients at foreseeable driving risk, there can be no recommendati ons at this time for objective testing in patients diagnosed with or t reated for sleep apnea or even for those patients presenting with eith er moderate or mild sleepiness. Licensing agencies are challenged to d evelop guidelines and mechanisms to assist in the recognition and trea tment of excessive sleepiness, of which untreated sleep apnea is but o ne cause. The public should be advised of the dangers of driving while sleepy or extremely fatigued and educational materials developed appr opriate for all operators of motor vehicles. Finally pulmonary special ists along with other medical experts familiar with sleep apnea should help formulate public policy and support reasonable regulations and b ehavior that will identify and treat sleepy drivers.