Asleep At the Controls: Obstructive Sleep Apnea & What Pilots Need to Know

Obstructive sleep apnea is the most common sleep-related breathing disorder.  The term sleep apnea means ‘without respiration’ and people with obstructive sleep apnea repeatedly stop and start breathing multiple times each night while they sleep.

Obstructive sleep apnea occurs when the throat muscles relax and block the airway.  The result is that breathing stops during sleep often for prolonged periods of time throughout the night.  The person sleeping almost never notices and it is often reported to them by others who observe the events.

The statistics are alarming:
   - 10-15% of females and 20-30% of males have OSA; with up to 90% undiagnosed

Additionally, an OSA diagnosis is found in:
   - 70% of all morbidly obese patients
   - 70% of patients with Type II diabetes
   - 40% of patients with hypertension

What’s Going On In the Body With OSA
OSA is characterized by repetitive upper airway obstruction during sleep, causing a cascade of repetitive physiologic responses to these ‘breathing arrest’ episodes.  At the root of these changes is the decrease in blood oxygen levels that accompany these events.

When these events happen repeatedly, every night, over time:
   - blood pressure rises; ultimately remaining chronically elevated (hypertension)
   - the heart muscle is subjected to a chronic and abnormal workload leading to heart failure
   - the circulatory system responds to decreased oxygen levels in a way that increases risk of heart attack, stroke
   - chronic decreased oxygen to the brain increases risk of neurocognitive decline
   - diabetes risk increases while those who are already diabetic find it more difficult to control their blood glucose levels

Ultimately, untreated OSA can manifest in pilots as:
   - memory loss and task processing difficulties
   - pulmonary (lung) hypertension
   - cerebrovascular events (stroke)
   - cardiovascular events (heart attack, heart failure, heart arrhythmia)
   - hypertension
   - diabetes
   - chronic drowsiness and fatigue
   - excessive daytime sleepiness
   - chronic headache
   - obesity

Symptoms of obstructive sleep apnea during the night include:
   - loud snoring
   - pauses in breathing during sleep, often noticed by a partner.
   - waking during the night gasping or choking.
   - needing to urinate often.

Symptoms of obstructive sleep apnea during the day include:
   - excessive daytime sleepiness.
   - waking in the morning with a dry mouth or sore throat.
   - morning headaches
   - trouble concentrating, focusing and processing
   - mood changes, including depression
   - persistent/uncontrolled high blood pressure
   - decreased libido in men and women, and erectile dysfunction in men

Consult a healthcare professional if you have, or if your partner notices, any one or more of the following:
   - snoring loud enough to disturb your sleep or the sleep of others.
   - waking up gasping or choking.
   - pausing in your breathing during sleep.
   - excessive daytime drowsiness. You may fall asleep while working, watching television, operating heavy machinery, driving a vehicle and operating an aircraft.

OSA and Flight Safety
It is estimated that 2.6% of aircrew have OSA, with the numbers rising considerably to as high as 70% in higher risk cohorts, like those with obesity.

Data also suggest that pilots with untreated OSA have a 6-fold increase in the risk of aircraft crashes and other flight-related mishaps.

In 2008, during a daytime flight, both the Pilot and the First Officer were found to have fallen asleep in the cockpit resulting the aircraft overflying its destination airport.  Though the aircraft did land safely,  the incident was attributed to a combination of sleep-related factors including the Pilot’s undiagnosed OSA.

By 2015, the NTSB identified OSA as one of its ‘Most Wanted’ Transportation Safety Improvements.

In fact, when sleep-related impacts on pilot performance are linked to substance impairment, pilots with mild-to-moderate OSA consistently show performance degradation similar to those operating an aircraft (simulated) with a blood alcohol concentration (BAC) of 0.06% to 0.08%.  

Anyone can develop obstructive sleep apnea. however, certain factors put you at increased risk, including:

   - Excess Weight: Most but not all people with obstructive sleep apnea are overweight. Fat deposits around the upper airway can obstruct breathing. Medical conditions that are associated with obesity, such as hypothyroidism and polycystic ovary syndrome, also can cause obstructive sleep apnea.
   - Older Age:  The risk of obstructive sleep apnea increases as you age but appears to level off after your 60s and 70s.
   - Male Sex: In general, men are 2 to 3 times more likely than premenopausal women to have obstructive sleep apnea. However, the risk of obstructive sleep apnea increases in women after menopause.
   - Family History:  Having family members with obstructive sleep apnea might increase your risk.
   - Narrowed Airway:  Your tonsils or adenoids might become enlarged and block your airway, increasing your risk of obstructive sleep apnea. Enlarged tonsils are an important risk factor for obstructive sleep apnea in children. A narrowed airway also can be passed down in families.
   - Chronic Nasal Congestion:  OSA occurs twice as often in those who have consistent nasal congestion at night, no matter what causes it.
   - Smoking:  People who smoke are more likely to have obstructive sleep apnea.
   - Other Health Conditions:  OSA is associated with other health conditions, including high blood pressure, heart attack, stroke, irregular heartbeat, diabetes, chronic lung disease and depression.

Treatment Options
There are a number of effective treatments for OSA with most medical professionals recommending less invasive and non-surgical interventions as the first-line.

All non-surgical and surgical treatments for OSA must be reported to the FAA in order to maintain lawful medical certification.

Behavioral Changes
   - Change in sleeping position (sleeping on side or stomach)
   - Change in sleep environment (matress type, light level, room temperature)
   - 0% weight loss in obese/morbidly obese patients can reduce risk by up to 25%

Dental Appliances
   - these appliances reposition the mandible (jawbone)

Continuous Positive Airway Pressure (CPAP)
   - considered to be the ‘gold standard’ and most effective non-surgical treatment for OSA
   - found to decrease daytime sleepiness and increase cognitive function
   - CPAP provides continuous positive air pressure by ‘blowing’ air toto the respiratory system through a mask in order to keep the airways open during sleep

Surgical Interventions
   - Surgical interventions include nasal airway procedures, palate implants, uvulopalatopharyngealplasty (UPPP), tongue reduction procedures, genioglossus (tongue) advancement procedures and maxillomandibular (upper and lower jaw) advancement.

OSA and Your Medical Certificate
OSA screening is a part of every aviation medical examination (flight physical)—every time.  

   - Pilots who already have an OSA diagnosis and who have already reported PSA to the FAA, will require regular-interval evaluation of data and will require a Special Issuance.

   - Pilots with known OSA and who have not yet reported their OSA to the FAA and for those pilots at high risk for OSA will be DEFERRED and will be required to undergo additional testing and evaluation before being issued an medical certificate in any class.

The Final Analysis
OSA is a common but highly treatable medical condition.  If left untreated, it can contribute to a host of chronic and potentially dangerous medical conditions.
Untreated and non-monitored OSA is an absolute threat to pilot health and flight safety.

Pilots who fly with untreated, undiagnosed and unmonitored OSA assume an unnecessary risk to self, flight crew, passengers and the general public.

Please contact your Aviation Medical Examiner for more guidance.

You may also want to click HERE to review the current FAA guidance to Aviation Medical Examiners regarding OSA.

Christopher T. Conti, MD is the Founder and Owner of Steel City Direct Care., a Pittsburgh, PA-based medical practice specializing in the care of athletes and aviators.  He is an emergency medicine physician with additional training in sports and concussion health.  He is currently a Team Physician for the US Soccer Federation (USSF), U14-U17 Youth National Team player pools, Medical Advisor for the PA West Soccer Association, a local affiliate of the United States Youth Soccer Association and the Medical Advisor for the Woodland Hills School District in suburban Pittsburgh, PA.  Dr. Conti serves as Medical Advisory Board Member for  SportGait and is also a Credentialed ImPACT Consultant (CIC) for sports concussion care.  Dr. Conti is a designated Senior Aviation Medical Examiner (AME) for the Federal Aviation Administration (FAA)

Disclaimer  
The information, opinions and content presented do not necessarily represent the policies or opinions of USSF, the FAA, PA West Soccer, USYS, FIFA, ImPACT, SportGait, the Woodland Hills School District or Steel City Direct Care, LLC.  

None of the information presented should be construed as formal medical advice, nor should it be considered an acceptable substitute for a formal virtual or in-person encounter with an appropriately trained and licensed healthcare professional.  None of the above-listed entities, including Steel City Direct Care, LCC, are responsible for any adverse outcome associated with this content.  

If you would like to schedule a virtual or in-person visit with Dr. Conti, please contact Steel City Direct Care

Steel City Direct Care is a Direct Patient Care (DPC) practice that provides targeted & specialized in-person and virtual care for aviators and athletes of every age and level of skill and participation.