Sleep Apnea Evaluation Specifications

Sleep Disorders—Sleep Apnea Evaluation Specifications

Obstructive Sleep Apnea

Sleep Apnea Evaluation Specifications

Obstructive Sleep Apnea is a condition that, if undiagnosed, can have significant aeromedical complications such as daytime hypersomnolence, also referred to as Excessive Daytime Sleepiness (EDS), heart rhythm disturbances, stroke, diabetes, high blood pressure, as well as memory and concentration difficulties.  In 2009, a National Transportation Safety Board (NTSB) Safety Recommendation to the FAA resulted in changes to the evaluation requirements for medical certification.

The FAA grants medical certification under a Special Issuance Authorization to pilots who report successful treatment and control of obstructive sleep apnea.  However, medications prescribed to treat symptoms are generally NOT allowed if used on a regular basis. 

Initial evaluation must include:

a.   A sleep evaluation that includes overnight polysomnography. The evaluation should also include a baseline AHI (Apnea/Hypopnea Index) and comments regarding existing cardiovascular or psychological symptoms or complications. The sleep specialist should also include a clinical opinion of the number of    hours of effective sleep the airman should expect under the prescribed treatment plan.

b.  If CPAP (continuous positive airway pressure) therapy is recommended, a follow-up report showing compliance and effective response to treatment will be required.  Documentation should include the airman’s own impressions regarding improved sleep quality and absence of excessive daytime sleepiness

Acceptable treatment includes:

a.   CPAP/biPAP/auto-titrating CPAP: Adequate compliance is indicated by an average of 6 hours sleep per night and at least 75% nightly use, documented by download interrogation report of the machine’s smart card.
b.  ENT Surgery: Surgical procedure to relieve upper airway obstruction with documentation of satisfactory results.  A post-operative polysomnogram should be completed after surgical wounds have healed.  If the results are satisfactory, an annual status report with any other testing deemed necessary will be required for continued certification. 

c. Weight loss or bariatric surgery: A sustained weight loss of greater than 10% from a baseline polysomnogram may provide acceptable relief of sleep apnea symptoms. A follow-up polysomnogram or MWT may be required to document adequate control. Annual status reports will be needed to confirm control.

d. Oral appliances- may be acceptable for treatment of mild OSA (AHI of 5-15). An annual current status report will be required, and periodic sleep study may be necessary.

e. Positional therapy/sleep hygiene: Generally not recommended, but may be acceptable for mild apnea (AHI 5-15) where is there is a clear positional component. MWT may be required to document normal daytime alertness.

Unacceptable treatment includes:

a. Oral appliances and positional therapy if the sleep apnea diagnosis is greater than “mild” or if the obstructive apnea includes any associated co-morbid condition other than well controlled hypertension requiring no more than two medications.
b. Weight loss alone where the BMI (Body Mass Index) remains greater than 35 kg/m2   or the apnea is moderate to severe. 

Required Protocol for MWT:

a. No dietary or medication manipulation is allowed. There must be a drug screen for stimulant drugs and caffeine.

b. The MWT consists of four (4) fort- minute test periods at two hour intervals (e.g., 9:00 a.m., 11:00 a.m., 1:00 p.m., and 3:00 p.m.).  NO napping is allowed between test periods.

c. Patients should be monitored continuously during the nap test period. The standard polysomnographic monitoring (digastrics EMG, eye movement recorder, apnea recorder or ECG) may not be required; however, EEG monitoring will be required in order to detect the various stages of sleep.

d. Patients should be dressed and sitting semi-recumbent on a bed in a dark room.

e. Patients are asked to remain awake, but not to use extraordinary measures such as face slapping or singing.

f. The endpoint of each test period is either sleep (three consecutive 30-s epochs of Stage I or any single 30-s epoch of Stages 2,3,4, or REM) or the end of the forty-minute time period. The patient is then asked to stay awake until the next test.

AASI for Sleep Apnea

After initial certification by FAA staff doctors, subsequent renewals qualify for AME Assisted Special Issuance (AASI), a process that provides examiners the ability to issue an airman medical certificate to an applicant who has a medical condition that is disqualifying under 14 CFR Part 67.
The authorization letter received from FAA, granted in accordance with part 67 (14 CFR Part 67.401), is accompanied by attachments that specify what information the treating physician(s) must provide for the renewal issuance.

Examiners may issue renewal of an airman medical certificate if the applicant provides the following:

• An authorization granted by the FAA.
• Current status letter from treating physician that includes present treatment and its effectiveness, and specific comments regarding daytime sleepiness.

The examiner should defer to the AMCD or Region if:

• There is question concerning adequacy of treatment or airman's compliancy
• The Maintenance of Wakefulness test shows evidence of daytime sleepiness.
• There is evidence of new, associated illness, such as right-sided heart failure.