So, so basically this is this is the same thing for every single body system, as long as they haven't had a whatever likely interfere with your ability to control motor vehicle, which is correct. Respiratory diseases can be debilitating. Some motor vehicle tests do require moderate aerobic capacity, and you still have to deal with emergencies you have to take walk back 100 250 feet behind your vehicle to put out a triangle. You have to be able to put snow chains on have to strap your load those are all physically demanding things, probably strapping your load is probably the end although change are pretty hard to. Those are the two things that will increase your oxygen demand. Just if you think about this, when you want to like, oh I don't know across the Rockies or the mountains in California and you need to put chains on, you're not doing it at sea level, you're up some to start with where there's where God didn't give you as much oxygen as they do as much pressure on the oxygen as they do when you're down sea level. So, just kind of think that through that you need to put a change on for the past. It's you're already at six or seven, eight 10,000 feet. So, I want I'm curious if they have adequate oxygenation. They've impaired gas exchange, and we'll talk a little bit about asthma sleep apnea and medication use side effects FMCSA expectation for drivers is six maps. Okay, so as long as they can get do six mats drivings about three mats. The other stuff they do is about seven and a half minutes, if they do it quickly, but you can slow, you can put the chains on slowly get down to about six. They can't do six. That's not enough for FMCSA, whether it's breathing or cardiac. So, you need to secure your load that can be a lot of work, that guy if you look at the guy on the bottom right with a big coal truck or gravel truck. He's got to climb up there, unroll the tarp stretch the tarp climb down the side of the vehicle to stretch the tarp down onto the side. He's got to run around and put straps on to hold bungee cords to hold that strap that tarp down onto the vehicle. It's a fair amount of exercise he's doing right now. So the things I worry about are things like asthma COPD bronchitis and then all the other things listed there and we'll go through some more of them in just a second. So, medications that they're on cognitive difficulties so anti histamines. Okay, I'm going to loop them in here because we don't really have a separate section on allergy. So, there's a sedating antihistamine, which is Benadryl and Zyrtec. Zyrtec is on the evil list do not let people do not think it's not sedating, it is a sedating antihistamine. So, and, and, and, you know, and Adarax and Vistaril a couple other ones that sometimes people use all those are sedating, and you don't want people to use those and drive. They use them for sleep. And just, just so you kind of think about the going back to FAA is way of doing this dosing interval for Benadryl is six hours. Okay, the FAA wants you to be five multiples of the dosing interval to before they consider to be off the medication. So it's 30 hours, so you can't use panel PM to sleep every night and drive the next morning. 30 hours later. Okay, so they're still being impacted their cognitive ability to be impacted by the medication. Liratidine and Allegra which is always been affected. Claritin and Allegra are safe, they do not interfere with your ability to cognitive abilities, the FAA has literally done the testing. They dose people they dose them and then they test to see what happens. And those people are fine. So, you know those things. Okay. I don't know if any medication, any pulmonary medication is going to cause risk of sudden incapacitation I mean albuterol doesn't do that. So, do they have a respiratory disease that might get them in trouble, is the other thing you have to kind of think about. Do they feel like it's bad for you feeling if they if they do you have to ask a little bit more questions about that. There were some recommendations that every smoker got PFTs and stuff that's all evaporated. They feel short of breath when they're driving. Do they, do they cough much they use supplemental oxygen supplemental oxygen actually is a hard no. That's one of the very few hard no's it's left. So if they're using supplemental oxygen while driving. If they're driving on supplemental oxygen. That's a hard no to me know why. Think, think through the process. They can run out of oxygen that's one risk, the bigger risk is they've got a missile inside it's not gonna explode, but they've got a missile they've got a cylinder in a metal cylinder inside the truck, that becomes a missile to have an accident. And you really slow. They can do the duties of the job. Oh, I agree with you. Yeah, I don't worry too much. Some people use supplemental oxygen overnight for sleep apnea that's a thing now. I don't worry too much about those people, but the people that are using supplemental oxygen during the day. Yeah. Okay. Do an exam, look for clubbing cyanosis so they take hypnotic while they're sitting there in your office, because they left their oxygen in the car because they know they bring the oxygen and they'll fail. I have seen that I've seen them, I've seen blue fingers, same answer, because they know if they brought the oxygen and they failed their exam and they want to pass their exams they left all that in the car. Do they have the bad breath sounds, I mean, this is, this is like your little spider sense goes off like this person can barely breathe right clinically you're going this is a problem. You want to do a good evaluation. So the old guidelines was, if there was any, any evidence of specific lung disease you do pulmonary function test. If they were a smoker over the age of 35 you do pulmonary function tests. That's all gone. And then there's a new guideline. And then the question was who needs pulse oximetry. Well if you have a one was at 65 predicted, then you might get pulse oximetry. Okay, now there was a time when a pulse oximeter was a very expensive instrument that you really wanted to reserve using that for a patient that was really needed it like you'd use that after blood gases. It's 2023. I can buy a pulse ox at Walgreens for $30. Okay, if you don't have one in your clinic, you're deficient. If you don't have one in your doctor bag you're deficient I have one in the bag I'm gonna take on the airplane because I'm, I've treated two people who are epoxy on the airplane and they don't have them. They're $30 and they're $15 you can buy them on eBay. And they don't have one of the airplane where they're taking everybody to 8000 feet intentionally. Just saying. Okay, so the this was the old thing. So, their pulse oximetry had to be over 92 I think that's actually pretty good. I agree with that. If their pulse ox is at less than 92 at rest in your office, we have a problem. Then you might want to, if it's not overnight you might want to think about getting a blood gas. Again, the blood gas thing got a little fuzzy but the 92 is probably still pretty solid, but the right, the pulmonary function tests, then pulse ox then a BG hierarchy is gone. But they said, you know, if the admiral pulse pulse ox they get a blood gas. Now if they have a blood gas. These are okay cut offs. If they're worse than that, they've got problems. This is, this is, I mean a resting blood gas. It's always, it's less than 65. The person should be on supplemental oxygen for their health, let alone everything else. All that's gone. So, now we're back. So, so now that's the, that's the required testing, the 92 for pulse ox appears to still be recommended. They don't recommend we do PFTs and everybody that smokes, and we don't recommend that we do blood gases, but the pulse ox is pretty good test. That concerns you history or physical right can ask for additional information, and that's why those big red X's are on there. Yeah, those are the old record. Yeah. And it would be left up to the decision. Right. So what what I do is most, most mental medical offices now do a pulse ox in the way in the door. If it's less than 92, think about the pulmonary system if it's 98, you can move on you to worry about other systems. So let's talk about a little bit allergic allergic rhinitis. If they can't be controlled, they have conjunctivitis that goes with it. That's all fine. The big thing for these guys to watch out for medications because almost always medication for these is sedating. So just be aware of that. Remember, fire and Allegra are safe. The other ones are not If they're well controlled we're good to go. If they are have continual asthmatic symptoms, or really bad pulmonary function tests, then you might not certify these people. COPD. So, you think about PFTs and people over 35, we're back to that's not really true anymore. COPD is remember is a garbage basket for all bad lung problems and people. It really isn't a diagnosis so just be aware of that. It's useful for treatment, because the insurance will pay for it, but it's really not a diagnosis. Sleep apnea. This used to be the bane of our existence doing these exams, people would. This is where you the other places people would threaten you. And so, the, there were a set of rules. Right now I'm required to let you know the FMCSA has no rules. There are no regulations, you're to use best medical judgment. The NRCME recommends you use best, continues to recommend that. So why is this an issue, people with excessive daytime sleepiness, most all of which are because of sleep apnea are don't drive as well, and make worse decisions. And if you fall asleep while you're driving. It's, you're not a good driver. During that time. So when they've done some testing and found about 20% had mild five 6% had moderate and about 5% had severe sleep apnea. So, there's this line that the that was created between so if you have mild or moderate, there was actually if you read the old regulations no requirement for treatment. Once you got to severe you had to have treatment. That's the old regulations, which is defined as more than, and this these numbers have changed several times, whether this is more than whether severe is more than 20 or more than 30 depends on which set of recommendations you believe. And the, I'm going to get this wrong, the sleep medicine people, and the pulmonologist have different cut offs, just to make your brain hurt. So there's different ways to write to met their different criteria for what's a HR. That's why they have different cut offs. So use whatever cut off goes with the way that your sleep lab does sleep studies. Okay. That's why that's again that's the difference because I was like, I was 20, and I'm typing into stuff and I realized, sleep medicine and they have different criteria for what's an HR. That's why they're different. So I want to diagnose this in lab is preferred, it costs a fortune at home is just fine, although we'd really prefer it was with some sort of. If it was required if you required it there'd be some sort of verification. The theory was you would put this like you put a wristband on the person that's got some chip in it. And then that has to be part of when they pull this hardware on because we're worried about the substituted human. So the 350 pound truck driver puts the thing on his hundred and 20 pound wife, and, and the machine says that there's no sleep apnea, but it was just on the wrong person. So sleep tests do much less well they're they're really good at it and find sleep apnea, not as good as some of the other things like restless leg and central sleep apnea and stuff like that, which is not as good a test that the test of that. So we want to see that specialists involved. And then we'll keep going decide with the CDN but I still get to decide if I think there was an adequate test and what the outcome is that's that's still all falls back to you. So, if they have a diagnosis of sleep apnea so they've already been diagnosed. Then we still want to follow it. these people all know they need to bring in a report from the chip thing that's in their CPAP machine, and you will monitor treatment. Okay? And so that's still in place. If they have the diagnosis, we want you to monitor that. I like the FAA has a form that I really like, and I use it with my drivers sometimes. If they're using an oral appliance, I'll get them to sign this form that says that they use their oral appliance. Yes, ma'am. They have an oral appliance that has a chip. Yeah, but that doesn't backfill everybody's $30 oral appliance or $200 one. She said they have one that has a chip. It does exist, but I'm just telling you that people aren't going to go throw them out to buy a $4,000 oral appliance instead of the $35 one that they boil themselves at the, from the drug store. But I at least get the drivers certify that they use it. And the FAA form is exactly for that purpose. Yes, sir. I've had several people, not necessarily for the DOT exam, but say that, you know, they don't tolerate CPAP and they're trying to get Inspire and they think everything's all good. Then Inspire some implantable device. Well, Inspire is actually, it's like a pacemaker for the, for the muscles in the back of your throat. So if they get one, that's fine. And I'm not the, the, the, at the end of the day, the efficacy data is better for everything. It's not a CPAP machine. Okay. Because people will wear it all every night. They'll put their, their bike guard in, or they'll put their, the click the button on their Inspire machine. And so the, the, the CPAP has the lowest efficacy of treatment rate, but we kind of like it because it's got a chip, right? Some people tolerate CPAP just fine. And there's no problems. And that's why I mentioned it also, some people on oxygen overnight for, you know, for when they're sleeping as an, is a backup treatment that some, some, in some areas and with some insurances, I got to say that way, cause it's not everybody can do that, but some people can. So it's just something to, there are lots of treatments. I want them to be using the effective treatment for that. That makes sense. And it's what everyone there, them and their doctor have worked out as the effective treatment, but I wanted to actually use it. Does that, does that make sense? Okay. So threshold, I mentioned, there are lots of different AHI thresholds. I met a guy the other day who was on, was using CPAP, was a new pilot who was trying to use, he was using CPAP for an AHI of six. It's not, it's okay, but it just throws them into a whole compliance thing that he would have avoided if he didn't go on a CPAP. So you can encourage people to see treatment if it's between five and 20. If they have a history of fatigue related crash, that's that we've now have clinical evidence that pushes me the other way. A single, a single vehicle crash in the middle of the night, single vehicle, like they find themselves in a little farm field, or they hit a tree at five at three 30 in the morning is almost always sleep deprivation related. Same thing can occur during the day. They just find themselves in a little farmer field. That's not where they were going. That's where they didn't make a corner. That's almost always, you know, sleep related. Okay. So if they have the diagnosis, that's annual recertification, and we want all that stuff to make sure that they're actively taking care of themselves. If they're using a CPAP machine that has a chip, I want four hours a day on 70% of days. Okay. That's something I would want to know for a test maybe. More is better, but that's the minimum. Don't certify if they admit to excessive daytime sleepiness or sleepiness during their major awake period, if they've had a single vehicle crash or non-compliant with treatment. You don't check the AHI-2 on the report? If I get it, yes. If it's, and I, again, if it's six, I don't know if I'm, I'm not necessarily require them to have be on any kind of active treatment. If it's 35, I want them on treatment. I have a question. So driver falls asleep during the exam. That's an FAA thing. It comes from the FAA. On the FAA side, the only way that the person is going to get a hard fail is if they literally fall asleep during the examination. If they, so if they do that on my truck drivers, they're, they're done. I've had one guy that, that fell asleep, talk. I mean, it was, he was the, he, he was, everything was classic and he fell asleep talking. He fell asleep like between elements of the exam. Like I turn around to put the stuff in the computer and he's snoring. Okay. Like that's, that's a no. If you can't stay awake while you're in the doctor's office, we've got a problem. Okay. So I have a couple of things here. When you say request to monitor the driver's sleep apnea, do you mean they need to show each physical with a 30 day report? So the, the CDME is responsible for what I call ongoing use. And so it's not that a 90 day is someone, some person respond to be requesting a 90 day report. That's fine. Three, you don't need a 365 day report. If they've ever been doing good the last 90 days, you're fine. Because that shows that they're compliant and they're, they're doing just what they're supposed to be doing. I've had run into, I've run into some of the machines that have the chips, the chips, not forever. It will eventually get full, especially if they use it every day, like they're supposed to. So 90 days, 120 days, or even 60 days of reliable use. I'm happy with, because I don't want to say, well, you need to go buy a new $8,000 machine, our own back order, because they've, Phil's has been recalled again. I don't want to push them that way. I want them to keep using the machine they've got. And some of the machines have cell technology. As long as they set up an account every day, uploads, and then you can print your own report. Yeah. Some of them, some of them go, are connected to the cloud by magic. And if that's the case, that's fine. I don't care where the report comes from as long as I get a report. So medical review board. So these are the old recommendations for when you might think about, this is the screening recommendations for sleep apnea. So what I want you to notice is that it's, if their BMI is over 40, worry a lot, just BMI, I don't care about anything else. If their BMI is between 33 and 40, then they've got to have at least three of those things that are listed. Keep in mind that by being a 50 year old male, the last two, you're already got two. So it needs one more. So if, and you've got diabetes, you're already, you're done. You've now got three. That recommendation is why this fell apart. The screening thing, why Congress demanded that we do not screen drivers for sleep apnea and directed FMCSA to make that happen. Yes, ma'am. You also mentioned some electronic medical records. When you're doing a DOT exam, won't let you go on until you put those things in, but it's not because we were expecting it to be required. It was required for a while. Well, and then it fell apart. And then Congress said, no, they, they couldn't fund the government, but they decided we in 2017, the government was on shut. This is like 45 day government shutdown that saved us all zero because every federal employee was paid to have not worked for those 45 days. So yeah, this is, this is, but that, that it was during that time, they passed the rule that said, FMCSA can't do this for sleep apnea specifically. But you see it in some of the EHRs. Yeah, you may, you may find systems that are not keeping up with the times. So a single risk factor, they may, they emphasize single risk factor. So if their neck's over 17 inches, that does not necessarily infer risk. You need a bunch of them. You could, if you were concerned, give somebody a short card. Now I will tell you that if you're going to do this for sleep apnea, you need to have some patience here because sleep apnea right now is this black hole. It's hard to get people tested because there's no machines to put them on because of the whole Phillips thing. They're still recovering from that and they just disqualified a bunch of them again. So it's a mess getting people because they don't want the, the free testing comes from the pulmonary companies. They're going to sell you a machine, but they have no machines to sell. So they don't want to really, they don't, they don't want to do the work until there's ready to sell a machine. They figure you might just die between now and when they get machines in. So why should they bother to do the work until they've got a machine to sell you? So this is, this is actually hard. Malampati scores, just so we've covered it. These are the, you ask them to just open their mouth, don't do anything else. And when you look back there, if you can see their whole uvula, you're good. If you can't see the uvula at all, that's malampati four, that suggests that increases the risk of having obstruction. Testing is good. You might want to get a new test if they're having more risk factors or things change. If they get, if they're, if they've been tested and they were negative, they recommend waiting for about three years before you retest them. Unless something else changes, like they gained a hundred pounds or something. Cert, there are lots of treatment effects. There are treatment approaches that are effective. Surgery, CPAP, BiPAP, dental stuff, any of them are fine. We, we prefer, we, we, the, the CDME community prefer ones that have some verification system. But as an, I use the FM, the FAA form for drivers that use a non-chip version of something. All, by this point, pretty much all the CPAP machines have chips in them, but the other things don't. I mean, the, the, the, the simulator, I'm sure the answer is yes, but I don't know what it is. I've not met anybody that went to the extent of getting one of those that doesn't use it. Yeah. I know people who have it and absolutely always use it. They put the box where they put a pacemaker box usually because it's basically a pacemaker box and they just run it over. No, it's, it's, it's to do the muscles in your neck to keep the airway open. It's for OSA, not central sleep apnea. They also do what you're talking about for central sleep apnea. They'll sometimes stimulate the diaphragm directly, but that's different. They've been doing that for a long time too. So waiting periods, we want to, the theoretical thing is we want a month after they start on CPAP, three months from after, but not with surgical stuff. Again, it's what you feel comfortable with. And it's when the sleep, the sleep apnea treater says, Hey, they're okay. So, and this is a one-year certification. If you're happy with everything that's going on the minimum for the minimum for the records, they bring you to show that they're using their CPAP is 30 days. Cause that question was asked in the chat. And, and as the mentioned, somebody said, it's rough to play the bad guy when previously I'm nurse haven't flagged them. So what I do is flag them. Okay. Flag them early, let them know this is going to be a problem. They need to look into this. You may not give them a shorter card, but scare them. I found it very helpful. If you will let the driver know that compliance is four hours because sometimes they, they think they're going to fill automatically because about in the middle of the night, they'll take it off. So it's really helpful to them to let them know you will be considered compliant if you do it most nights, at least four hours. And then they, I think they are much more likely to be open. Yeah. And, and I, I point out, this is when you're asleep. I've had people when, when, when this was being really strict, I watched, I saw a guy on the, on 70 driving across Ohio, wearing his CPAP mask while he's driving. Yeah. He got his four hours in. Probably asleep. I hope he wasn't asleep cause he was driving. He wasn't in the passenger seat. He was driving with the, I saw the big mask and the hose coming up. I'm like, oh, that's not the way this is supposed to work. So, and you can give them a shorter card to get them onto the system. If you need to, that is an option. This goes to all the, you know, nine day cards, 30 day cards, and all those things you can do if you need to. So again, the, the, you, this is the summary is that if they're going to interfere with driving, you need to stop. Best practice is to make sure that everything's safe and we move on. So I'm going to skip the scenarios right now, because you may have noticed, if you look at these things, I've X'd out almost all the answers. And we, Bridget, we're ready for the last one, which is musculoskeletal. And then we're done.

respiratory diseases

aerobic capacity

antihistamines

sleep apnea

CPAP machine shortage

driver certification