Sleep Apnea: The 'Silent Killer' Lurking Among Long-Haul Truck Drivers

Bob Stanton drove long-haul (OTR) freight for 20 years. During that time, what nearly took his life was neither bad weather nor reckless drivers.

Stanton says not being able to breathe well at night nearly killed him. He is referring to obstructive sleep apnea, a condition often missed that prevents patients from getting restful sleep and deep dreams.

"If I hadn't been treated in 2002, I probably wouldn't be here today," Stanton said. He recently became a referral coordinator for Dedicated Sleep, a professional sleep medical group.

According to the American Sleep Apnea Association, sleep apnea is the involuntary cessation of breathing that occurs during sleep. When the body detects a problem, it partially awakens the sleeper, and then the process repeats. The association says some patients can be disturbed hundreds of times a night.

This condition prevents the body from entering true sleep where dreaming and full rest can occur, while also depriving the body of normal oxygen levels, creating cascading health effects. It can attack the circulatory and cardiovascular systems. Stanton points out that sleep apnea can therefore become a "slow killer" and increase the risk of truck accidents.

Although the Federal Motor Carrier Safety Administration (FMCSA) has not enacted specific regulations for sleep apnea, it takes the issue seriously. According to Stanton, the Obama administration advocated mandatory screening for all commercial drivers, but former President Donald Trump halted that effort to reduce regulations.

The industry currently operates under what Stanton calls "rules without rules" regarding sleep apnea. The FMCSA treats sleep apnea in the same category as other conditions that could affect safe driving.

The FMCSA website states: "Drivers with any condition or clinical diagnosis that could affect their ability to drive safely cannot be medically certified to operate interstate commercial motor vehicles (CMVs)." However, once treated, drivers can regain "medically qualified to drive" status.

"If I hadn't been treated in 2002, I probably wouldn't be here today."

— Bob Stanton, referral coordinator at Dedicated Sleep

Stanton and other experts say truck drivers generally resist being tested for the condition. "Most drivers don't want to be told they have sleep apnea," Stanton said. "They're afraid of losing their medical card (physical exam certificate)."

However, screening and treating drivers for sleep apnea can save fleets money. A study by the Virginia Tech Transportation Institute found that a trucking company, by implementing a mandatory employer-sponsored screening, diagnosis, and treatment program,saved $441 per driver per month。

Additionally, Stanton notes that drivers often have to cover a deductible of about $1,400 themselves. He therefore urges carriers to reform insurance rules to cover sleep apnea treatment at 100%. This would help eliminate myths circulating among drivers that "sleep apnea is a fake disease" or a "money-making scheme."

The American Sleep Apnea Association says the condition can lead to weight gain, sexual dysfunction, high blood pressure, and cardiovascular disease. For drivers, the risks multiply because the condition can cause daily memory problems, headaches, daytime fatigue, and difficulty focusing on the road.

Common symptoms of sleep apnea

• Loud snoring.
• Morning headaches and nausea.
• Gasping or choking during sleep.
• Decreased libido/impotence.
• Excessive daytime sleepiness.
• Irritability and/or depressed mood.
• Disrupted sleep.
• Attention and memory problems.
• Frequent nighttime urination.

A recent VTTI study found that up to 47% of commercial vehicle drivers are at potential risk for sleep apnea due to weight or neck circumference factors. According to VTTI research scientist Jeffrey Hickman, the institute surveyed about 20,000 drivers.

Hickman believes the actual diagnosis rate of sleep apnea in the general population is between 6% and 17%, while among truck drivers it is about 33%.

"That's higher than the national average, and much higher," Hickman said. "If you treat (sleep apnea), not only do you make drivers healthier, you also make them better drivers."

Trucking companies are therefore wary of undiagnosed drivers, and some carriers have stepped up efforts to eliminate sleep apnea risks in their long-haul fleets. In 2006, Schneider became the first major company to "screen, diagnose, and monitor" for obstructive sleep apnea. According to Schneider's website, in 2019, Schneider received the National Safety Council'sGreen Cross for Safety Innovation Awardand theRobert C. Johns Research Partnership Award。

Most carriers seem to handle this issue behind the scenes, but Schneider has a dedicated webpage and publicly discloses its treatment program. Schneider requires all new drivers to undergo sleep apnea screening. If diagnosed, the truckload carrier arranges the necessary treatment.

Tom DiSalvi, Schneider's vice president of safety and loss prevention, said the initial problem was getting drivers to complete screening, diagnosis, and treatment in a timely manner without delaying their time on the road. DiSalvi said this process could take up to eight weeks in 2006.

"We realized there were a lot of delays in the process," DiSalvi said.

Schneider began to reduce delays and streamline the process, starting with a questionnaire-based screening. Schneider also sought suppliers of CPAP (continuous positive airway pressure) devices—small machines that provide a continuous positive airflow while a person sleeps. Because early CPAP devices required trucks to have inverters and burn diesel while idling, Schneider had to negotiate power supply issues with original equipment manufacturers (OEMs). DiSalvi said inverters and idling are no longer necessary today.

Schneider requires all new drivers to undergo sleep apnea screening. If diagnosed, the truckload carrier arranges the necessary treatment. (Image source: Schneider)

Schneider also offers free treatment to insured drivers. Today, the results show up as $440 per driver per month in health cost savings. When a third-party study first reported this figure to the company, DiSalvi said it must be a mistake—the report must have meant "per year."

Schneider also reports improved driver retention. Drivers diagnosed with sleep apnea have a 30% higher retention rate.

What some industry officials call "fatigue management" is taking root in trucking. According to Mary Convey, vice president of corporate health and safety programs at SleepSafe Drivers, a fatigue management company focused on transportation companies, several fleets including Marten, Maverick, Old Dominion, Saia, and Southeastern Freight have implemented sleep apnea and fatigue management programs.

Unable to breathe

Richard Bren, a board member of the American Sleep Apnea Association, has worked in the risk and insurance sector of the trucking industry for over 25 years. This issue is particularly important to him because he also has sleep apnea and has used a CPAP device for 18 years.

"My father had (sleep apnea). It's in our genes," Bren said. He says sleep apnea is caused by airway constriction at night, and weight and neck circumference can be contributing factors.

For Bren, now 58, the condition means his airway constricts about every 40 seconds during sleep. His sleeping body gasps for air, partially waking him, and then he falls back into one to two minutes of deep sleep.

"You never get into deep sleep," Bren said.

Today, Bren wears a CPAP mask when he sleeps, joking that he looks a bit like a jet fighter pilot. He says the device's intrusion into sleep patterns is exactly why many people eventually give up on CPAP. But he adds that the technology is very effective.

"The first time I was treated, my wife thought I was dead," Bren said. But in reality, he was in deep sleep and no longer gasping. The CPAP forces airflow into his airway, allowing him to sleep peacefully. The next day, Bren felt refreshed and energetic.

"I felt like I'd had a Red Bull," Bren said.

Common risk factors for sleep apnea

• Family history of sleep apnea.
• Narrow upper airway.
• Being overweight.
• Receding chin, small jaw, or severe overbite.
• Large neck circumference (17 inches or more for men, 16 inches or more for women).
• Smoking and alcohol use.
• Age 40 or older.
• Race.

Dr. Jordan Stern, a practicing physician in New York, treats sleep apnea and has provided care for transportation industry workers. Stern says these workers are reluctant to be tested, but he has been exploring various treatment options for patients.

"CPAP is just one treatment for sleep apnea," Stern said. "70% of our patients don't want to use CPAP."

Stern says he offers patients CPAP devices and medical oral appliances, and conducts testing via telemedicine. His sleep tests can be done at the patient's home. Stern calls in-clinic sleep testing a "dinosaur experience" and says more advanced technology has existed for 15 years. Stern's clinic mails disposable diagnostic devices to patients for use while they sleep.

"I felt like I'd had a Red Bull."

— Richard Bren, board member of the American Sleep Apnea Association

Stern notes that more transportation companies are requiring employees to undergo testing. In New York City, the Metropolitan Transportation Authority requires employees with a body mass index (BMI) over 30 or an oversized neck (17 inches for men, 16 inches for women) to undergo sleep apnea testing.

Some MTA employees come in for testing with resistance, Stern says. He can usually detect this resistance when adults claim they are never sleepy during the day. Anyone referred who insists they have no sleep problems raises his suspicion. In the face of resistance, Stern's response is simple.

"I say: 'Listen, I'm going to fix you,'" Stern said.

FMCSA's "catch-all clause"

Stanton says the FMCSA needs to improve its rules on sleep apnea, with the first step being to explicitly mention the condition in regulations. Currently, obstructive sleep apnea falls under a "catch-all" category for conditions that, if untreated, reduce safety. The FMCSA is a member of the North America Fatigue Management Program, which aims to "develop guidelines and materials that enable motor carriers to implement comprehensive fatigue management programs (FMPs) and provide FMP implementation approaches to motor carriers across North America."

Stanton believes that if the FMCSA explicitly mentions sleep apnea in its rules, it can then establish testing formats and treatment guidelines.

Bren compares the condition to high blood pressure: if untreated, it worsens and affects other organs and conditions.

"These problems start to pile up," Bren said.

Many long-haul drivers have already been confirmed to have other conditions such as type 2 diabetes, high blood pressure, being overweight, and heart problems. Stanton says obstructive sleep apnea only makes these conditions worse.

Bren says he would like to see more carriers openly discuss sleep apnea. He says the condition needs to be publicized and handled properly internally so it doesn't become a major issue that forces the FMCSA to regulate strictly.

Convey says she doesn't think federal regulations will be enacted, but believes the sleep apnea problem can be solved without legislation and congressional intervention.

"It takes everyone, including your healthcare provider," Bren said. "The trucking industry had better solve this problem itself rather than let federal regulators get too deeply involved."