Sleep Apnea - SI

[My Flight Surgeon]

This is another in the series of condition for which the FAA grants Special Issuance certificates.

As with all other conditions, the FAA will want to review the entire medical record. Your AME or www.faaspecialissuance.com can assist you in preparing your records for submission.

The topic today is Sleep Apnea.
Introduction

Have you been told that you snore loudly? Do you wake up feeling tired after a full night's sleep? Are you sleepy during the day? If so, you may have sleep apnea. In this potentially serious sleep disorder, breathing repeatedly stops and starts during sleep. "Apnea" is Greek for "without breath."
Sleep apnea occurs in two main types: obstructive sleep apnea, the more common form that occurs when throat muscles relax, and central sleep apnea, which occurs when your brain doesn't send proper signals to the muscles that control breathing. Additionally, some people have complex sleep apnea, which is a combination of both obstructive and central sleep apneas.
Obstructive sleep apnea occurs two to three times more often in older adults and is twice as common in men as in women. Treatments for sleep apnea may involve using a device to keep your airway open or undergoing a procedure to remove tissue from your nose, mouth or throat.
Signs and symptoms
The signs and symptoms of obstructive and central sleep apneas overlap, sometimes making the type of sleep apnea more difficult to determine. The most common signs and symptoms of obstructive and central sleep apneas include:

• Excessive daytime sleepiness (hypersomnia)
• Loud snoring
• Observed episodes of breathing cessation during sleep
• Abrupt awakenings accompanied by shortness of breath
• Awakening with a dry mouth or sore throat
• Morning headache
• Difficulty staying asleep (insomnia)

Disruptive snoring may be a more prominent characteristic of obstructive sleep apnea, while awakening with shortness of breath may be more common with central sleep apnea.
Causes

[IMG]file:///C:/DOCUME%7E1/Walt/LOCALS%7E1/Temp/msohtml1/01/clip_image001.gif[/IMG][IMG]file:///C:/DOCUME%7E1/Walt/LOCALS%7E1/Temp/msohtml1/01/clip_image001.gif[/IMG]Obstructive sleep apnea occurs when the muscles in the back of your throat relax. These muscles support the soft palate, the triangular piece of tissue hanging from the soft palate (uvula), tonsils and tongue.
When the muscles relax, your airway narrows or closes as you breathe in, and breathing momentarily cuts off. This may lower the level of oxygen in your blood. Your brain senses this inability to breath and briefly rouses you from sleep so that you can reopen your airway. This awakening is usually so brief that you don't remember it.
You can awaken with a transient shortness of breath that corrects itself quickly, within one or two deep breaths, although this is rare. You may make a snorting, choking or gasping sound. This pattern can repeat itself 20 to 30 times or more each hour, all night long. These disruptions impair your ability to reach those desired deep, re####l phases of sleep, and you'll probably feel sleepy during your waking hours.
People with obstructive sleep apnea may not be aware that their sleep was interrupted. In fact, many people with this type of sleep apnea think they sleep well all night.
Central sleep apnea, which is far less common, occurs when your brain fails to transmit signals to your breathing muscles. You may awaken with shortness of breath or headaches. The most common cause of central sleep apnea is heart disease. People with central sleep apnea may be more likely to remember awakening than people with obstructive sleep apnea are.
Risk factors
Sleep apnea may occur if you're young or old, male or female. Even children can have sleep apnea. But certain factors put you at increased risk:
Obstructive sleep apnea

• Excess weight. Fat deposits around your upper airway may obstruct your breathing. However, not everyone who has sleep apnea is overweight. Thin people develop the disorder too.
• Neck circumference. The size of your neck may indicate whether or not you have an increased risk of sleep apnea. That's because a thick neck may narrow the airway and may be an indication of excess weight. A neck circumference greater than 17 inches is associated with an increased risk of obstructive sleep apnea.
• High blood pressure (hypertension). Sleep apnea is not uncommon in patients with hypertension.
• A narrowed airway. You may inherit a naturally narrow throat. Or, your tonsils or adenoids may become enlarged, which can block your airway.
• Being male. Men are twice as likely to have sleep apnea as women are. However, women increase their risk if they're overweight, and the risk also appears to rise after menopause.
• Being older. Sleep apnea occurs two to three times more often in adults older than 65.
• A family history of sleep apnea. If you have family members with sleep apnea, you may be at increased risk.
• Use of alcohol, sedatives or tranquilizers. These substances relax the muscles in your throat.
• Smoking. Smokers are much more likely to have obstructive sleep apnea than are nonsmokers. Smoking may increase the amount of inflammation and fluid retention in the upper airway. This risk drops after smoking cessation.

Central sleep apnea

• Sex. Males are more likely to develop central sleep apnea than are females.
• Heart disorders. People with atrial fibrillation or congestive heart failure are more at risk of central sleep apnea.
• Stroke or brain tumor. These conditions can impair the brain's ability to regulate breathing.
• Neuromuscular disorders. Conditions such as amyotrophic lateral sclerosis (Lou Gehrig's disease), spinal cord injuries and muscular dystrophy can affect central nervous system breathing functions.
• High altitude. Sleeping at an altitude higher than you're accustomed to may increase your risk of sleep apnea.

Screening and diagnosis
Your doctor may make an evaluation based on your signs and symptoms or may refer you to a sleep disorder center. There, a sleep specialist can help you decide on your need for further evaluation. Such an evaluation often involves overnight monitoring of your breathing and other body functions during sleep. Tests to detect sleep apnea may include:

• Nocturnal polysomnography. During this test, you're hooked up to equipment that monitors your heart, lung and brain activity, breathing patterns, arm and leg movements, and blood oxygen levels while you sleep. Because treatments for other sleep disorders such as narcolepsy and insomnia differ, this test helps your doctor to arrive at an accurate diagnosis.
• Oximetry. This screening method involves using a small machine that monitors and records your oxygen level while you're asleep. A simple sleeve fits painlessly over one of your fingers to collect the information overnight at home. If you have sleep apnea, the results of this test will show drops in your oxygen level during apneas and subsequent rises with awakenings. If the results are abnormal, your doctor may have you undergo polysomnography to confirm the diagnosis. Oximetry doesn't detect all cases of sleep apnea, so your doctor may still recommend a polysomnogram even if the oximetry results are normal.
• Portable cardiorespiratory testing. Under certain circumstances, your doctor may provide you with simplified tests to be used at home to diagnose sleep apnea. These tests usually involve oximetry, measurement of airflow and measurement of breathing patterns.

If you have obstructive sleep apnea, your doctor may refer you to an ear, nose and throat doctor (otolaryngologist) to rule out any blockage in your nose or throat. An evaluation by a heart doctor (cardiologist) or a doctor who specializes in the nervous system (neurologist) may be necessary to look for causes of central sleep apnea.
Complications
Sleep apnea is considered a serious medical condition. Complications may include:

• Cardiovascular problems. Sudden drops in blood oxygen levels that occur during sleep apnea increase blood pressure and strain the cardiovascular system. About half of people with sleep apnea develop high blood pressure (hypertension), which raises the risk of heart failure and stroke. If there's underlying heart disease, these repeated multiple episodes of low blood oxygen (hypoxia or hypoxemia) can lead to sudden death from a cardiac event.

The more severe the obstructive sleep apnea, the greater the risk for high blood pressure. In contrast, central sleep apnea usually is the result, rather than the cause, of heart disease.
A study published in November 2005 in the New England Journal of Medicine reported that obstructive sleep apnea greatly increases the risk of stroke, regardless of whether a person has high blood pressure. However, effectively treating obstructive sleep apnea can lower blood pressure and the risk of other cardiovascular diseases.

• Daytime fatigue. The repeated awakenings associated with sleep apnea make normal, restorative sleep impossible. People with sleep apnea often experience severe daytime drowsiness, fatigue and irritability. They may have difficulty concentrating and find themselves falling asleep at work, while watching TV or even when driving. Children and young people with sleep apnea may do poorly in school or have behavior problems.
• Complications with medications and surgery. Obstructive sleep apnea also is a concern with certain medications and general anesthesia. People with sleep apnea may be more likely to experience complications following major surgery because they're prone to breathing problems, especially when sedated and lying on their backs. Before you have surgery, tell your doctor that you have sleep apnea. Undiagnosed sleep apnea is especially risky in this situation.
• Sleep-deprived partners. Loud snoring can keep those around you from getting good rest and eventually disrupt your relationships. It's not uncommon for a bed partner to sleep in another room, or even on another floor of the house, to be able to sleep. Many bed partners of people who snore are sleep deprived as well.

People with obstructive and central sleep apneas may also complain of memory problems, morning headaches, mood swings or feelings of depression, a need to urinate frequently at night (nocturia), and impotence. Gastroesophageal reflux disease (GERD) may be more prevalent in people with sleep apnea.
Treatment

For milder cases of sleep apnea, your doctor may recommend lifestyle changes such as losing weight or quitting smoking. If these measures don't improve your signs and symptoms or if your apnea is moderate to severe, a number of other treatments are available. Certain devices can help open up a blocked airway. In other cases, surgery may be necessary.
Treatments for obstructive sleep apnea may include:
Therapies
·Continuous positive airway pressure (CPAP). If you have moderate to severe sleep apnea, you may benefit from a machine that delivers air pressure through a mask placed over your nose while you sleep. With CPAP (SEE-pap), the air pressure is somewhat greater than that of the surrounding air, and is just enough to keep your upper airway passages open, preventing apnea and snoring.
Although CPAP is a preferred method of treating sleep apnea, some people find it cumbersome or uncomfortable. With some practice, most people learn to adjust the tension of the straps to obtain a comfortable and secure fit. You may need to try more than one type of mask to find one that's comfortable. Some people also benefit from using a humidifier along with their CPAP system.
Don't just stop using the CPAP machine if you experience problems. Check with your doctor to see what modifications can be made to make you more comfortable. Additionally, contact your doctor if you are still snoring despite treatment or begin snoring again. If your weight changes, the pressure settings may need to be adjusted.
·Oral appliances. Another option is wearing an oral appliance designed to keep your throat open. CPAP is more effective than oral appliances, but oral appliances may be easier for you to use.Some are designed to open your throat by bringing your jaw forward, which can sometimes relieve snoring and mild obstructive sleep apnea.
A number of devices are available from your dentist. You may need to try different devices before finding one that works for you. Once you find the right fit, you'll still need to follow up with your dentist at least every six months during the first year and then at least once a year after that to ensure that the fit is still good and to reassess your signs and symptoms.
Surgery or other procedures
The goal of surgery for sleep apnea is to remove excess tissue from your nose or throat that may be vibrating and causing you to snore, or that may be blocking your upper air passages and causing sleep apnea. Surgical options may include:

• Uvulopalatopharyngoplasty (UPPP). During this procedure, your doctor removes tissue from the rear of your mouth and top of your throat. Your tonsils and adenoids usually are removed as well. This type of surgery may be successful in stopping throat structures from vibrating and causing snoring. However, it may be less successful in treating sleep apnea because tissue farther down your throat may still block your air passage. UPPP usually is performed in a hospital and requires a general anesthetic.

• Maxillomandibular advancement. In this procedure, the upper and lower part of your jaw is moved forward from the remainder of your face bones. This enlarges the space behind the tongue and soft palate, making obstruction less likely. This procedure may require the cooperation of an oral surgeon and an orthodontist, and at times may be combined with another procedure to improve the likelihood of success.

• Tracheostomy. You may need this form of surgery if other treatments have failed and you have severe, life-threatening sleep apnea. In this procedure, your surgeon makes an opening in your neck and inserts a metal or plastic tube through which you breathe. You keep the opening covered during the day. But at night you uncover it to allow air to pass in and out of your lungs, bypassing the blocked air passage in your throat.

Removing tissues in the back of your throat with a laser (laser-assisted uvulopalatoplasty) or with radiofrequency energy (radiofrequency ablation) are procedures that doctors sometimes use to treat snoring. However, these procedures aren't recommended for treating obstructive sleep apnea.
Other types of surgery may help reduce snoring and sleep apnea by clearing or enlarging air passages:

• Nasal surgery to remove polyps or straighten a crooked partition between your nostrils (deviated nasal septum)
• Surgery to remove enlarged tonsils or adenoids

Treatments for central sleep apnea are more limited and may include:

• Treatment for associated medical problems. Possible causes of central sleep apnea include heart or neuromuscular disorders, and treating those conditions may help. For example, optimizing therapy for heart failure may eliminate central sleep apnea.

• Supplemental oxygen. Using supplemental oxygen while you sleep may help if you have central sleep apnea. Various forms of oxygen are available as well as different devices to deliver oxygen to your lungs.

• Continuous positive airway pressure. This method, also used in obstructive sleep apnea, involves wearing a pressurized mask over your nose while you sleep. The mask is attached to a small pump that forces air through your airway to keep it from collapsing. CPAP may eliminate snoring and prevent sleep apnea. As with obstructive sleep apnea, it's important that you use the device as directed. If your mask is uncomfortable or the pressure feels too strong, talk with your doctor so that adjustments can be made.

• Bilevel positive airway pressure (bilevel PAP). Unlike CPAP, which supplies steady, constant pressure to your upper airway as you breathe in and out, bilevel PAP builds to a higher pressure when you inhale and decreases to a lower pressure when you exhale. The goal of this treatment is to boost the weak breathing pattern of central sleep apnea. Some bilevel PAP devices can be set to automatically deliver a breath if the device detects you haven't taken a breath after so many seconds.

• Adaptive servo-ventilation (ASV). This more recently approved airflow device is designed to treat central sleep apnea and complex sleep apnea. The device learns your normal breathing pattern and stores the information into a built-in computer. After you fall asleep, the machine uses pressure to normalize your breathing pattern and prevent pauses in your breathing.

Along with these treatments, you may read or hear about different treatments for sleep apnea, such as implants. However, while a number of medical devices and procedures have received FDA clearance, sleep doctors aren't currently recommending them because there's not yet enough evidence to support their use.
FAA Special Issuance
AME Assisted Special Issuance (AASI) is a process that provides Examiners the ability to re-issue an airman medical certificate under the provisions of an Authorization for Special Issuance of a Medical Certificate (Authorization) to an applicant who has a medical condition that is disqualifying under Title 14 of the Code of Federal Regulations
(14 CFR) part 67.

An FAA physician provides the initial certification decision and grants the Authorization in accordance with 14 CFR 67.401. The Authorization letter is accompanied by attachments that specify the information that treating physician(s) must provide for the re-issuance determination. If this is a first time issuance of an Authorization for the above disease/condition, and the applicant has all of the requisite medical information necessary for a determination, the Examiner must defer and submit all of the documentation to the AMCD or Regional Flight Surgeon for the initial determination.

Examiners may re-issue an airman medical certificate under the provisions of an Authorization, if the applicant provides the following:

• An Authorization granted by the FAA; and
• A current report (performed within last 90 days) from the treating physician that references the present treatment, whether this has eliminated any symptoms and with specific comments regarding daytime sleepiness. If there is any question about response to or compliance with treatment, then a Maintenance of Wakefulness Test (MWT) will be required.

The Examiner must defer to the AMCD or Region if:

• There is any question concerning the adequacy of therapy;
• The applicant appears to be non-compliant with therapy;
• The MWT demonstrates sleep deficiency; or
• The applicant has developed some associated illness, such as right-sided heart failure.

[Doug Taylor]

Kristie swears I have sleep apnea, I really don't think so, but I do snore like a Harley-Davidson at times.

Excessive daytime sleepiness (hypersomnia)

Nope

Loud snoring

Often

Observed episodes of breathing cessation during sleep

No idea.

Abrupt awakenings accompanied by shortness of breath

Nope.

Awakening with a dry mouth or sore throat

Sometimes

Morning headache

I get about a headache every 36 months, they're unnaturally rare. But "forum headaches", lord have mercy, often!

Difficulty staying asleep (insomnia)

Nope! Well, domestically at least.

Worth a check ya think?

[My Flight Surgeon]

Probably worth a check.

[swingwise]

I am a 26 year-old graduate student. At 24 I was diagnosed with moderate sleep apnea. With a tiny dose of melatonin at least an hour before bed and my cpap, I now sleep great. I am only tired during the day when I get less than 7 or so hours of sleep. (I hear that's normal - it's a miracle for us with apnea.) I am considering ending this graduate school fiasco and becoming a pilot.
With the sleep apnea comes the question of how to get the Special Issuance Certificates, or whatever I need, and when I would need to do it. Would places like Delta hire me, or would my apnea be a stigma for passenger airlines? Would I need the MWT test to even get my pilot's license? I haven't begun (no hours yet) and so I want to do it right if I do it. Thanks for any help.

[Hacker15e]

I was diagnosed with moderate apnea, and it was a very big deal in the USAF. I lost my medical clearance, and had to have surgery (Uppp) to fix it.

After a long process and an additional sleep study, I was cleared to fly again, but I have to go back every couple years and get checked on.

I was a loud snorer my entire life, and still snore post-surgery, but it is nowhere NEAR what it was before (used to be a 10+ and is now a 4 or so). I went through a VERY detailed physical and cognitive study both pre and post operation, and lo and behold, post op I actually had significantly improved cognitive and memory skills. The apnea was actually having an affect on my abilities and I didn't even know it.

[My Flight Surgeon]

Originally Posted by swingwise

I am a 26 year-old graduate student. At 24 I was diagnosed with moderate sleep apnea. With a tiny dose of melatonin at least an hour before bed and my cpap, I now sleep great. I am only tired during the day when I get less than 7 or so hours of sleep. (I hear that's normal - it's a miracle for us with apnea.) I am considering ending this graduate school fiasco and becoming a pilot.
With the sleep apnea comes the question of how to get the Special Issuance Certificates, or whatever I need, and when I would need to do it. Would places like Delta hire me, or would my apnea be a stigma for passenger airlines? Would I need the MWT test to even get my pilot's license? I haven't begun (no hours yet) and so I want to do it right if I do it. Thanks for any help.

You will need to get a Special Issuance with your first medical. They will require the following: Submit all pertinent medical information and current status report. Include sleep study with a polysomnogram, use of medications and titration study results. A MWT is only required in isolated circumstances.

I have several airline pilots who see me and have sleep apnea. They work for major carriers.

[nathanw]

Originally Posted by My Flight Surgeon

You will need to get a Special Issuance with your first medical. They will require the following: Submit all pertinent medical information and current status report. Include sleep study with a polysomnogram, use of medications and titration study results. A MWT is only required in isolated circumstances.

I have several airline pilots who see me and have sleep apnea. They work for major carriers.

What about for ATC? I am in the application process and I have sleep apnea. I currently use a CPAP and have zero problems.

[My Flight Surgeon]

You will still need a special issuance.

[nathanw]

Thanks for the quick response. I just want to make sure I won't be denied an initial medical before I get hired. Should I bring my medical records to the initial medical interview?


Thanks!

[My Flight Surgeon]

I would.

[aloft]

Originally Posted by nathanw

Thanks for the quick response. I just want to make sure I won't be denied an initial medical before I get hired.

If Sleep Apnea requires a special issuance, I'd think that means you'll be initially denied. Or is it simply deferred? All these nuances....

[My Flight Surgeon]

You can get a SPecial Issuance without either. For example, someone with an active medical can develop a disqualifying condition, submit the request for Special Issuance while self-grounding and never have it denied or deferred.

A denial is final so that does not come into play.

[nathanw]

I have a Class 3 already, should I request the SI now? And would it be effective for when I have to do whatever medical is required for ATC?

[My Flight Surgeon]

Yes and yes.

[scongdon]

This is all rather disturbing... my first polysomnography four years ago at age 21 was wretched. Even though I'm well treated with CPAP, will severe OSA (and I mean severe) be a possible bar from any ATC offers?

I suppose if I make 101% on the AT-SAT it could be overlooked, eh?