Mandatory FAA Sleep Apnea Screening for Obese Pilots Deferred
FAA Diverts Course for 2014: High BMI Will not Automatically Trigger Additional Workup during Flight Physical
Dec 20, 2013
by John Ogle, MD, MPH, FACEP
Commercial Pilot / USAF Flight Surgeon
Untreated obstructive sleep apnea is a disqualifying condition for airmen and air traffic control specialists.
— FAA Federal Air Surgeon
Pre Flight Summary Briefing:
Don't ignore sleep apnea symptoms whether you are at ideal weight or not. This article focuses on flight physicals and obesity as a a highly predictive risk factor for OSA, but pilots of any BMI can be affected. Seek personalized medical advice if you:
- snore loudly,
- experience morning headaches,
- suffer restless leg syndrome, or
- notice excessive daytime sleepiness
Every pilot must take command of their own health. Prepare thoroughly for your next personal preflight inspection. Find a trusted AME. Whether you believe the FAA is overstepping their mandate or not, you retain a personal duty to stay fit. Resist denial. Deliberate actions and keen judgment have and always will be required of professionals in the flying business.
According to Federal Air Surgeon, Dr Fred Tilton, the US Federal Aviation Administration (FAA) will not immediately implement their obstructive sleep apnea policy in January 2014 as they had previously proposed. This postponement offers breathing room for time-pressured pilots and AMEs, but it's only temporary relief for obese airmen who are at the threshhold of their own "max gross weight". If you're a heavy-weight aviator, don't use this delay as an excuse to bypass the elliptical trainer, gym or jogging track.
Airline travel is incredibly safe, but most aviation accidents are due to pilot error. Some errors are due to inattention, and trying to predict who will most likely have vigilance problems in the cockpit is an emotionally charged issue.
The health policy debate about obesity (and it's affect on alertness) is intense among flight doctors who evaluate military or civilian aviators, but diagnostic and therapeutic decisions need not be irrational. There are well documented correlations between excess body fat, poor sleep and daytime drowsiness. I advise my pilots (and myself) to log readings from the bathroom scale in addition to the Hobbs meter.
"Corpulence profiling" of portly pilots is contentious in the US Air Force and Civilian Aeromedical communities alike. Nevertheless, the prevailing regulatory winds aloft are strengthening with the obesity epidemic. The news is not all bad, though; 2014 trends reflect improved detection algorithms and better treatment options for obstructive sleep apnea (OSA) patients. Diverging political viewpoints in the U.S. suggest we're in for choppy aeromedical debates about obesity, screening and who pays for it all.
As an insidious and under-diagnosed condition, Obstructive Sleep Apnea (OSA) is similar to glaucoma and hypertension. Failing to detect and correct is medically inexcusable. Once recognized, OSA is treatable. Long term problems can be averted, and there is one highly-predictive, easy measurement that facilitates accurate risk stratification.
Body Mass Index (BMI) has been proven to quickly and easily isolate the "at risk" subset of pilots. A 2008 study from the American Academy of Otolarynology--Head and Neck Surgery reveals that BMI at or above 32 has an 89% postive predictive value for identifying OSA. Pilots with higher BMI are at even greater risk.
The FlightPhysical.com staff monitors these emerging policy considerations, and even though our staff pilots and physicians seldom agree amongst ourselves on regulatory issues, we concur on the long term health implications of unidentified and untreated OSA. Pilots and pilot employers should be proactive in screening for this clinical problem.
Despite the obligatory uproar about an overly-intrusive "Nanny State", fatigue and inattention remain appropriate concerns for doctors, especially Aviation Medical Examiners (AMEs) and Flight Surgeons. Those who certify pilots and air traffic controllers as "fit for duty" are reminded that sleep apnea affects over 200,000 Americans and is largely undiagnosed. Obstructive sleep apnea is increasingly recognized as an independent cause of medical morbidity and mortality. OSA causes systemic and pulmonary hypertension, cardiovascular disease, stroke, and abnormal glucose metabolism. Fortunately, this common affliction can be managed once identified.
The announcement to defer obesity screening was unexpected because earlier this month ( Dec 12, 2013) the FAA announced they were pressing forward with enhanced screening techniques for high-BMI pilots. The proposed FAA policy for 2014 would have required pilots with a body mass index (BMI) greater than 40 to be tested, and, if needed, treated for obstructive sleep apnea. Dr Tilton outlines upcoming strategy in the Federal Air Surgeon's Medical Bulletin (Vol 51, No 4):
OSA is almost universal in obese individuals who have a Body Mass Index (BMI) over 40 and a neck circumference of 17 inches or more, but [in addition to this group] up to 30% of individuals with a BMI less than 30 [also] have OSA...We [the FAA] have purposely moved slowly because we wanted to give everyone an opportunity to learn about some of the issues before we added major changes to the medical certification process. We [ the FAA] began by publishing educational OSA pamphlets, talking about the issues at flying safety meetings, and adding an OSA session to the curriculum of aviation medical examiner (AME) seminars.
The next step will be to require AMEs to calculate the BMI for every examinee (both airman and ATCS) by using a formula that is located in the examination techniques section of the AME Guide and to record the results in Block 60 of FAA Form 8500-8. Airman applicants with a BMI of 40 or more will have to be evaluated by a physician who is a board certified sleep specialist, and anyone who is diagnosed with OSA will have to be treated before they can be medically certificated. Once we have appropriately dealt with every airman examinee who has a BMI of 40 or greater, we will gradually expand the testing pool by going to lower BMI measurements until we have identified and assured treatment for every airman with OSA. Note: We plan to implement the same assessment and treatment protocol for ATCSs, but we have to finalize some logistical details before we can proceed.
Some pilot groups argue OSA screening is excessive, and they advocate relaxation of certain medical standards for pilots. Lenient standards make sense sometimes, like for young pilots without risk factors. In retrospect, extending the mandatory FAA Class 3 Flight Physical interval to 5 years for pilots under 40 years of age was a good call. That change was not universally applauded in 2008, but six years later, most acknowledge that change was thoughtful, timely and cost-effective. From a safety perspective too, the relaxed flight physical interval appears to have been an acceptable statistical decision.
Contemporary liberalization proposals sit on the legislative table today. Congress recently introduced the General Aviation Pilot Protection Act, which (if passed) would allow pilots to use their driver's license as a medical certificate for certain VFR (noncommercial) operations. Turbulent dialog continues into 2014 as the FAA and industry stakeholders seek an acceptable balance between pilot concerns and public safety. For those of us with the aerial genes, flying is highly demanding but even more rewarding. Stay fit, stay healthy, stay airborne, stay tuned...