FAA adds another hoop for medicals

[wsuffa]

Speaking of Obamacare & the "shrug" given to Bruce over the cost. If treatment is mandated, and that includes a CPAP, the equipment will be subject to the new "durable medical device" tax - adds cost to the patient & $$$ revenue to the government. So there is a conflict of interest here somewhere....

 

[Fearless Tower]

So there is a conflict of interest here somewhere....

Of course there is a conflict of interest. Someone likely stands to gain a great deal from this.

This thing stinks of the current administration's big brother programs. It is very much like the new breathalyzer requirements that SECNAV is forcing down our throats (they are going to make all Navy personnel pass a BAC test when coming to the ship in the morning at a ridiculous cost to the govt.....because so many sailors have been coming to work drunk....NOT. An expensive solution to a non problem.

 

[Matthew]

What if you fall into the range that FAA says will require OSA evaluation, but don't have it? Right now the limit is BMI 40, but the plan is to go lower.

So, you go in for your medical, AME checks the chart and says you need a sleep study before he can issue (or you proactively get a sleep study) and it's negative. Great. But unless your BMI changes significantly you are going to have to do it again next time, aren't you?

 

[ifconfig]

Wait until they start testing everyone for ADD. Pilots all be wishing we only had fat guy discrimination.

That's right. Or refer to my earlier one about the number of times you have intercourse!

 

[Art VanDelay]

Looks like LSA's just got a bump up in value !

 

[ClimbnSink]

Looks like LSA's just got a bump up in value !

Do they have LSAs that can lift pilots that are >BMI 40?

 

[Skylane81E]

Yes, there are folks with that BMI that weigh less than I do

 

[denverpilot]

This was for me at least part of the reason along with some really bad posture while sitting that I ended up at the doctor with neck pain=.

When I stopped slouching all the time and sat up straight, stopped sleeping as much on my stomach. My neck pain and any associated other side effects have almost all but gone away.

I'm sure. But last I checked the FAA doesn't care too much that I have a bad shoulder from it. They'd probably like to know if/when I ever get to a point where I have enough pain that a Doc has to go in and fix it.

They would however not appreciate all the air leaking from the Darth Vader mask smashed into the bed or pillow and I probably wouldn't appreciate the times I covered the exhalation port and suffocated myself until I woke up.

Seems like a full face Lexan shield, and I mean FULL face, think "space movies" here, with the input port on TOP with the exhalation port up there off the edge of the pillow too... would sell like hot cakes to face planters. Guess we aren't a big enough demographic to garner any products like that from a quick perusal of the CPAP websites. A quick Google of the best masks for stomach sleepers shows they're all just thinner "jet fighter" masks. No ingenuity at all. But I digress.

 

[DFH65]

I'm sure. But last I checked the FAA doesn't care too much that I have a bad shoulder from it. They'd probably like to know if/when I ever get to a point where I have enough pain that a Doc has to go in and fix it.

They would however not appreciate all the air leaking from the Darth Vader mask smashed into the bed or pillow and I probably wouldn't appreciate the times I covered the exhalation port and suffocated myself until I woke up.

Seems like a full face Lexan shield, and I mean FULL face, think "space movies" here, with the input port on TOP with the exhalation port up there off the edge of the pillow too... would sell like hot cakes to face planters. Guess we aren't a big enough demographic to garner any products like that from a quick perusal of the CPAP websites. A quick Google of the best masks for stomach sleepers shows they're all just thinner "jet fighter" masks. No ingenuity at all. But I digress.

You just need to sleep on a message table.

 

[Art VanDelay]

Do they have LSAs that can lift pilots that are >BMI 40?

Oh heck yeah but not anyone else !

 

[Palmpilot]

BMI assumes that everything over a certain "ideal" weight is fat. That is true in many, but not all, cases. That's why the military and some insurers will do an immersion buoyancy test to determine what's muscle and what's fat.

Not that it would help me, but I wish the FAA would recognize an immersion test as refuting the table. But perhaps that would be too rational.

 

[Palmpilot]

I see that the table puts me at 34%, so it looks like I have some time to get my act together. (And there are certainly plenty of reasons besides this to do so.)

 

[Unregistered]

Not that it would help me, but I wish the FAA would recognize an immersion test as refuting the table. But perhaps that would be too rational.

The combination of BMI 40 or over with greater than 17" neck is a medically sound indicator of high likelihood of OSA, but to go to crudely measured BMI in the 30's is part of a political agenda for sure. After all, flying small airplanes is a rich white man's hobby and Amerika still needs more fundamental transformation.

 

[LDJones]

Oh I agree on overweight being common, but a BMI of 40 is absolutely MASSIVE!

But when they start working their way down to 25...it's going to truly "thin" the herd....

 

[LDJones]

Agreed,

.6 from "overweight"

I do have a 50lb cushion to a BMI of 30 but...

MAN!!! How'd you let yourself go like that??!!

 

[bbchien]

I fly about 150 segments a year and my wild assed guess is that it will hit about 1 in 30.

That's very close to my guess, too Jim....

With the resources CAMI now has, Testing below BMI 30 is never gonna happen. I doubt they can even sustain BMI 40, but the they might). Remember, CAMI is 105 days behind as it is. ]

Eventually what will happen, is OKC will say to DC: "Hey. if you want more, we'll just refer them to you in Washington". And it will stop there. Remember Washington supplies direction. OKC is the crew chief that says, "we'll never make it, sir...".

 

[Unregistered]

Can someone help me out with what exactly a sleep study measures? What happens if one doesn't have apnea but sleeps very little throughout a study? For me, I am not obese, but according to the charts I'm overweight, so I'm not affected right now but could be in the future if the criteria go down. I know I would not sleep well during a sleep study, I'm a 'picky sleeper' you could say. I don't sleep well without some sort of noise and I can't sleep more than 8 hours unless I only slept 3-4 the night prior.

 

[SkyHog]

My BMI is currently 35.5....and while I am overweight, I don't think that I am that close to being so overweight that my neckfat crushes my throat during the night...

 

[weilke]

Can someone help me out with what exactly a sleep study measures? What happens if one doesn't have apnea but sleeps very little throughout a study? For me, I am not obese, but according to the charts I'm overweight, so I'm not affected right now but could be in the future if the criteria go down. I know I would not sleep well during a sleep study, I'm a 'picky sleeper' you could say. I don't sleep well without some sort of noise and I can't sleep more than 8 hours unless I only slept 3-4 the night prior.

The study doesn't care so much about how 'well' you sleep, it measures how often your breathing stops and your oxygen saturation drops below a safe and normal level (apnea events).

A full blown sleep study measures a bunch of different parameters, including electric brain activity, muscle activity, oxygen saturation, breathing motion..... The problem is, once you wire up someone with all the sensors required, there is no way they will fall asleep .

Most commercially offered sleep studies record far fewer parameters, the key is that they monitor for episodes of apnea that last longer than 10 seconds. The measurements get condensed into a 'apnea index' or a 'respiratory disturbance index'.

Here are the diagnostic guidelines from the sleep apnea racket:

http://www.aasmnet.org/Resources/clinicalguidelines/OSA_Adults.pdf



I know everyone is a bit ruffled about this, but OSA is a real problem, and the evidence that that is so is all around us with the rates of heart and lung disease we can see every day. BMI is far from a precise tool, but very few people make it to 40 without a significantly abnormal body fat content.

What tends to cure people off the skepticism on whether this is real is to watch their own video-tape from their sleep study when they can see themselves not breathing for 30seconds with their saturation going down and their ticker starting to create abnormal beats.

If your BMI is 40 or even approaching it, your risk of having OSA is sizeable. It is in your best interest to get your risk for OSA assessed and to possibly undergo a screening study with a take-home recording system.

That said, I believe that there is a fair amount of unethical conduct in the commercial 'sleep center' industry. The relatively good reimbursement for sleep studies and the lure of an ongoing income stream from DME rentals and consumables seems to push some of the practicioners towards a generous interpretation of what is an episode and what isn't. I would feel a lot more confident about the results of many commercial sleep studies if there was not a link between diagnosing someone and profiting off their ongoing equipment needs.

And yes, it's 3:45am and I am posting. That is not because I have insommnia but because I get paid to be up at this time (6'3.5', 204lbs, BMI 25.2, and I could loose a couple of pounds).

 

[Unregistered]

This also applies to controllers. Has anyone from AAM ever been in a radar room? It'll hit 1/4 of that population. Now we get into labor issues (because controllers and their medicals are funded by FAA). Now controllers are paid for sleep studies and overtime must be called in to backfill for them. Now insurance won't cover a CPAP - it was the FAA that wanted it, let them pay for it. This is going to cost ATO millions. In the fight between ATO and AAM...well...

 

[Palmpilot]

What tends to cure people off the skepticism on whether this is real is to watch their own video-tape from their sleep study when they can see themselves not breathing for 30seconds with their saturation going down and their ticker starting to create abnormal beats.

It sounds like anyone with a video camera and video recorder could capture breathing interruptions at home. Or possibly a microphone and a PC would do the job.

 

[Skylane81E]

It sounds like anyone with a video camera and video recorder could capture breathing interruptions at home. Or possibly a microphone and a PC would do the job.

Wouldn't count on AV being enough, I used to think Angie had SA till one night the breath sounds stopped while I had an arm around her. She was still breathing the same, just suddenly and breifly silently.

 

[Matthew]

Can someone help me out with what exactly a sleep study measures? What happens if one doesn't have apnea but sleeps very little throughout a study? For me, I am not obese, but according to the charts I'm overweight, so I'm not affected right now but could be in the future if the criteria go down. I know I would not sleep well during a sleep study, I'm a 'picky sleeper' you could say. I don't sleep well without some sort of noise and I can't sleep more than 8 hours unless I only slept 3-4 the night prior.

Weilke already answered it: a sleep study measures a whole lot of stuff. For a breathing episode to be counted as an apnea event, it has to last beyond a certain amount of time. For a diagnosis of sleep apnea you need a certain number of apneas per hour. A sleep study can differentiate between Obstructive Sleep Apnea (where your throat closes = FAA special issuance) and Central Sleep Apnea (where your nervous system doesn't tell your body to breathe = FAA denial, I think).

For anyone without OSA who's interested: close your throat like you are swallowing. Hold your breath for about 30 seconds, then try to inhale, then open your throat. You'll start breathing with a gasp. You've just simulated an apnea. Now imagine this happening every minute or two throughout the night. It's more than just restless sleep.

 

[Palmpilot]

Wouldn't count on AV being enough, I used to think Angie had SA till one night the breath sounds stopped while I had an arm around her. She was still breathing the same, just suddenly and breifly silently.

Sounds like a video might produce false positives, but not false negatives. The former could be dealt with by asking to have an actual sleep study.

I guess a microphone alone could produce a false negative when more than one person is in the room.

 

[Henning]

Of course there is a conflict of interest. Someone likely stands to gain a great deal from this.

This thing stinks of the current administration's big brother programs. It is very much like the new breathalyzer requirements that SECNAV is forcing down our throats (they are going to make all Navy personnel pass a BAC test when coming to the ship in the morning at a ridiculous cost to the govt.....because so many sailors have been coming to work drunk....NOT. An expensive solution to a non problem.

Someone stands to gain a great deal? No, the numbers involved are miniscule.

 

[Henning]

Interesting... I thought I was fat but the index has me just inside 'normal' at 24.4. As for stomach and side sleepers, is it physically possible to have OSA? It would seem that gravity would prevent the conditions.

 

[weilke]

It sounds like anyone with a video camera and video recorder could capture breathing interruptions at home. Or possibly a microphone and a PC would do the job.

The thing with obstructive apnea is that your chest is still moving, but no air is going in and out. During a polysomnogram, you have a little tube in your nose that records and temperature of the air going in and out and a sensor on your chest that records chest wall movement. An obstructive episode is when your chest wall moves but the nasal probe doesn't record air moving. It also records pulse-oximetry which documents the result of no air getting into the lungs.

Many OSA patients don't have their spouses reporting apneic episodes yet on a recording they still have many of them.

 

[Matthew]

Interesting... I thought I was fat but the index has me just inside 'normal' at 24.4. As for stomach and side sleepers, is it physically possible to have OSA? It would seem that gravity would prevent the conditions.

I was just above the lower limit of an OSA diagnosis on my side, and way over the top on my back. It depends on your throat anatomy. At the time I was probably at a BMI of about 25 (my weight has crept up a little since then,)

 

[Palmpilot]

...The worst part is they appear to be doing this by bureaucratic fiat rather then following the rules and amending the regs. If they tried to do it right there would be a comment period so the more stupid parts of this would get cleaned up...

I thought about that too, but then I started reading part 67, and noticed that 67.113(b}, 67.213(b). and 67.313(b) amount to a virtual blank check.

 

[Fearless Tower]

Someone stands to gain a great deal? No, the numbers involved are miniscule.

Not as they start expand it below 40.

 

[Henning]

Not as they start expand it below 40.

Even if they get 10% of all active pilots (ones with current medicals) that would be what, 50k?

 

[Palmpilot]

The thing with obstructive apnea is that your chest is still moving, but no air is going in and out. During a polysomnogram, you have a little tube in your nose that records and temperature of the air going in and out and a sensor on your chest that records chest wall movement. An obstructive episode is when your chest wall moves but the nasal probe doesn't record air moving. It also records pulse-oximetry which documents the result of no air getting into the lungs.

Many OSA patients don't have their spouses reporting apneic episodes yet on a recording they still have many of them.

How about just a microphone then, for those who sleep alone in a quiet room? As mentioned previously, it might miss shallow breathing, but if it did pick up breath sounds, wouldn't that be conclusive that air was going in or out at that moment?

I haven't experimented with this, so I don't know how feasible it would be to pick up breath sounds. (I had a little bit of bio-engineering experience in the ancient past, so this kind of problem is interesting to me.)

 

[Matthew]

You'll still need to prove it's OSA and not CSA. And I don't think you can do that without an EEG.

 

[JimNtexas]

Yes. The prevalence is so overwhelming. This is supposed to be one-time only (as I was told). Dr. Lomangino opted AGAINST the overnight home screening as they have no idea who really wore the device overnight.
....

At some point the FAA has to have an innocent until proven guilty approach to these things.

For example, for those of us with diagnosed OSA are supposed to provide CPAP machine data showing that we used the machine at least 6 hours for most nights in a 31 day period.

Anyone with decent scripting skills could write a program to alter the data on the SD card to meet that requirement. But it's just better to wear the damn mask in the long run anyway, and very few pilots will go to the trouble of cheating themselves and the FAA to this extent.



I've said this before, but it's worth repeating. Based on my experience having been diagnosed with OSA in August 2012:

If you suspect you have OSA you probably do. If your BMI is over 30 something you probably have OSA.

Talk to your family doctor. If she suggests a sleep study, get it. If the sleep says to use CPAP, do it.

When I got my sleep study I was at a BMI of 38! A year latter I had lost over 70 pounds and am now merely 'overweight' at 28.5. When I had OSA I found it impossible to lose weight. Once I got treatment I started losing weight. I started sleeping better. I had more energy, so I spent more time doing physical things and less time sitting. It was like slow moving chain reaction, in a good way.

I'm at the point now where I may not even need the CPAP machine anymore, and after I lose another ten or fifteen pounds I may have another study to confirm or deny that theory.

In any case, I'm still using my CPAP, and if you need one (and in your heart you know if you do), get one!

If you have untreated OSA your life will the shorter and a lot less fun!

 

[weilke]

At some point the FAA has to have an innocent until proven guilty approach to these things.

For example, for those of us with diagnosed OSA are supposed to provide CPAP machine data showing that we used the machine at least 6 hours for most nights in a 31 day period.

Anyone with decent scripting skills could write a program to alter the data on the SD card to meet that requirement. But it's just better to wear the damn mask in the long run anyway, and very few pilots will go to the trouble of cheating themselves and the FAA to this extent.



I've said this before, but it's worth repeating. Based on my experience having been diagnosed with OSA in August 2012:

If you suspect you have OSA you probably do. If your BMI is over 30 something you probably have OSA.

Talk to your family doctor. If she suggests a sleep study, get it. If the sleep says to use CPAP, do it.

When I got my sleep study I was at a BMI of 38! A year latter I had lost over 70 pounds and am now merely 'overweight' at 28.5. When I had OSA I found it impossible to lose weight. Once I got treatment I started losing weight. I started sleeping better. I had more energy, so I spent more time doing physical things and less time sitting. It was like slow moving chain reaction, in a good way.

I'm at the point now where I may not even need the CPAP machine anymore, and after I lose another ten or fifteen pounds I may have another study to confirm or deny that theory.

In any case, I'm still using my CPAP, and if you need one (and in your heart you know if you do), get one!

If you have untreated OSA your life will the shorter and a lot less fun!

There in a nutshell is why this FAA policy change is maybe not such an evil thing.

 

[Palmpilot]

You'll still need to prove it's OSA and not CSA. And I don't think you can do that without an EEG.

I'm not thinking of it as proof. I'm thinking of it as an inexpensive means of determing whether it would be worthwhile asking for a sleep study. Hopefully the latter would then provide a definitive diagnosis.

 

[denverpilot]

This also applies to controllers. Has anyone from AAM ever been in a radar room? It'll hit 1/4 of that population. Now we get into labor issues (because controllers and their medicals are funded by FAA). Now controllers are paid for sleep studies and overtime must be called in to backfill for them. Now insurance won't cover a CPAP - it was the FAA that wanted it, let them pay for it. This is going to cost ATO millions. In the fight between ATO and AAM...well...

The controllers will be fine. Their NATCA will buy politicians to fix whatever they need fixed.

 

[weilke]

I'm not thinking of it as proof. I'm thinking of it as an inexpensive means of determing whether it would be worthwhile asking for a sleep study. Hopefully the latter would then provide a definitive diagnosis.

The inexpensive way is a recording pulse-oximeter. Doesn't catch all of them, but if you are apneic enough to drop your oxygen saturation, it will pick it up.

There is a reason both the techs who record the studies and the docs who interpret them have to be trained. It's not quite as trivial as it sounds.

 

[Matthew]

I'm not thinking of it as proof. I'm thinking of it as an inexpensive means of determing whether it would be worthwhile asking for a sleep study. Hopefully the latter would then provide a definitive diagnosis.

The inexpensive way is a recording pulse-oximeter. Doesn't catch all of them, but if you are apneic enough to drop your oxygen saturation, it will pick it up.

There is a reason both the techs who record the studies and the docs who interpret them have to be trained. It's not quite as trivial as it sounds.

What would be nice is a cheap, easy, way of screening to decide if you should get a sleep study.

FAA just did that by deciding the screening criteria should be BMI >= 40 and neck >=17".

 

[DFH65]

The inexpensive way is a recording pulse-oximeter. Doesn't catch all of them, but if you are apneic enough to drop your oxygen saturation, it will pick it up.

There is a reason both the techs who record the studies and the docs who interpret them have to be trained. It's not quite as trivial as it sounds.

This is the problem with our current health care system. In this case the solution IS fairly trivial, a CPAP machine. So if you suspect the person has OSA put the pulse-ox on them if they show reduced O2 levels then give them an autopap with a fairly wide range say 5-12cm. Unless they are sever and need the machine cranked up (pulse-ox + CPAP would tell you this) then problem solved for 1/3 of the price. Of course the sleep centers don't make money that way.