Sleep apnea scrutiny falls on pilots

Pilots impacted by the FAA’s proposed new obstructive sleep apnea (OSA) policy can expect to pay some $2,000 to more than $5,000 for testing and, if needed, equipment for treatment, according to AOPA research. Meanwhile, the trucking industry was successful through legislation in October in forcing the federal government to use rulemaking when it considers the impact of sleep apnea on commercial drivers.

On Oct. 15, President Barack Obama signed into law a bill that requires any policies on sleep disorders or sleep apnea for commercial truck drivers first to go through the rulemaking process—a move that AOPA and Congress are asking be afforded to the aviation industry. The Federal Motor Carrier Safety Administration confirmed to AOPA that it “does not mandate testing for obstructive sleep apnea.”

The aviation community has been up in arms since Federal Air Surgeon Fred Tilton announced that the FAA would be releasing a new policy that would require aviation medical examiners to calculate a pilot’s body mass index (BMI), and require those with a BMI of 40 or greater to get tested for OSA by a physician who is a board-certified sleep specialist and treated, if diagnosed, before being issued a medical certificate. Tilton stated that obstructive sleep apnea is almost universal in individuals with a BMI of 40 or greater and neck size of at least 17 inches. However, he said the agency would continue ratcheting down the BMI number “until we have identified and assured treatment for every airman with OSA.” He said the policy would later extend to air traffic controllers as well.

AOPA’s online reports on the policy generated more than 200 comments from readers, and forums across the Web lit up with pilots speculating on what the full policy may look like. While the complete policy has not yet been made public, AOPA has researched members’ questions about the current policy on medical certification when diagnosed with OSA, the testing and cost involved, and preventive measures.

Policy, without input, is not the way to go

AOPA quickly weighed in on the FAA announcement, opposing the way in which the agency plans to roll out this new policy without going through the rulemaking process to gather comments from pilots and the aviation industry. In a Nov. 20 letter to FAA Administrator Michael Huerta, AOPA President Mark Baker said, “We believe this policy inappropriately bypasses the rulemaking process; overlooks potentially more effective and efficient solutions; provides no clear safety benefit; and imposes unjustified costs on the user community.”

The AOPA Foundation’s Air Safety Institute analyzed two decades worth of fatal general aviation accidents and found that sleep apnea has not been listed as a causal factor in any of them.

Using the recent efforts of the trucking industry as a model, Congress took action within a matter of days of learning of the FAA’s intent and released legislation that would require the agency to go through the rulemaking process before making policy changes on sleep apnea. They are seeking the same courtesy that was extended to truck drivers.

This isn’t the first time sleep apnea policy has been the focus of attention in aviation. The NTSB in August 2009 recommended that the FAA change the airman medical application form to “elicit specific information about any previous diagnosis of obstructive sleep apnea and about the presence of specific risk factors for that disorder.” AOPA pointed out that sleep apnea already must be reported on the online airman medical application in item 18x, “other illness, disability, or surgery.”

Sleep apnea is a medically disqualifying condition

Sleep apnea is a serious medical condition that is medically disqualifying for pilots. If untreated, OSA can have significant medical complications: excessive daytime sleepiness, heart rhythm disturbances or sudden cardiac death, high blood pressure, cognitive impairment, and personality disturbances.

Pilots who have been diagnosed with OSA must obtain treatment and get an authorization for the special issuance of a medical from the federal air surgeon to return to flying as pilot in command. The FAA routinely grants special issuance authorizations to pilots who are successfully treating their OSA, but the process can take significant time and expense. 

What’s involved with sleep apnea testing?

OSA testing involves an overnight sleep study and a follow-up maintenance of wakefulness test after treatment has been initiated. Some acceptable treatments, according to the FAA, are surgery, use of continuous positive airway pressure (CPAP), or use of an oral appliance. After receiving treatment, either a maintenance of wakefulness test or a 30-day download of a programmable chip from a CPAP will be needed. (Those who use an oral appliance will need to complete the maintenance of wakefulness test.) AOPA offers details on the documentation required when applying for a special issuance medical with sleep apnea and information on AME-assisted special issuance.

According to American Sleep Apnea Association Executive Director Edward Grandi, an in-lab sleep study, called an overnight polysomnography (PSG), runs $2,000 to $3,000. Many insurers, he said, require pre-authorization for in-lab testing. Current FAA policy regarding sleep apnea requires the in-lab study for initial evaluation when applying for a special issuance medical. The American Society of Sleep Medicine said that Medicare will reimburse “about $550 for the technical component of in-lab polysomnography and $90 for the professional fee. Private carriers’ payments for in-lab PSG range from about $600 - $2,000.” Even with insurance coverage, pilots could be left with a sizable bill. For those required to get the testing, who show no other signs of sleep apnea and are found not to have it, the cost could be a deterrent to continuing to fly.

CPAPs range from $600 to $2,000 or $3,000, Grandi said, based on the functionality of the machine. While it is becoming standard for all of the machines to have data collection capability—even those at the lower end of the price range—a wireless machine that automatically uploads information to a doctor’s office is more expensive.

Custom-made oral appliances cost upward of $1,500 “and may be covered by medical insurance and Medicare if you’ve been diagnosed with sleep apnea by a sleep physician,” according to the American Academy of Dental Sleep Medicine, which also said that “virtually all medical insurers in the U.S. now cover oral appliance therapy as they would a CPAP.” It can be used by those with mild or moderate sleep apnea who can’t use a CPAP. The custom-made appliance fits like a sports mouth guard or orthodontic retainer. Pilots who use an oral appliance must complete a maintenance of wakefulness test for initial and recurrent special issuance medical applications.

The American Sleep Apnea Association and American Society of Sleep Medicine both said that surgery is not always effective, requiring some patients who have had it to continue with a CPAP.

Avoiding and eliminating sleep apnea

Grandi said that it is possible, though difficult, for a person who has been diagnosed with sleep apnea to eliminate it. He said some individuals who have used a CPAP, lost significant weight, and adopted a better diet to maintain a healthy weight, were able to discontinue using the CPAP. However, pilots should note that, according to the FAA, “weight loss alone where BMI remains greater than 35, may be unacceptable treatment for moderate to severe sleep apnea.”

Grandi recommends that individuals who are concerned about their daytime sleepiness first keep a sleep diary for two weeks to document the number of hours in bed each night and the number of hours of sleep. A person might find he isn’t allowing enough time for sleep.

Being careful with diet is also important, he explained. Those who don’t sleep well often eat more carbohydrates to get a sugar rush to help them feel more awake, which can lead to weight gain. He said those who sleep better typically eat healthier. Limiting alcohol and medications that can make one sleepy during the day are also helpful. As pilots know, they cannot fly within eight hours of having alcohol or a blood alcohol concentration of 0.04 or greater, and medications that cause drowsiness are not approved by the FAA to take while flying.