Obstructive Sleep Apnea Syndrome
In recent years, obstructive sleep apnea syndrome (OSAS) has been identified as a risk factor for motor vehicle accidents [1]. Individuals with moderate or severe OSAS have an increased risk of causing traffic accidents. However, appropriate treatment of OSAS can reduce this risk [2].
OSAS (G47.32 according to ICD-10-AM) is the most common cause of sleep-related breathing disorders [3]. Its exact prevalence is unknown, but it is estimated that approximately 4% of middle-aged men and 2% of middle-aged women in developed countries have this syndrome [4]. The prevalence of OSAS is also increasing alongside rising obesity rates in developed countries, as approximately 70% of affected individuals are overweight [5].
In patients with OSAS, partial or complete collapse of the soft tissues above the glottis during sleep causes pauses in breathing. In an attempt to prevent suffocation, the body triggers arousals or awakenings that interrupt these breathing pauses. As a result, sleep becomes fragmented and of poor quality, leading to daytime sleepiness, impaired attention, and slower reaction times.
Obstructive Sleep Apnea Questionnaire
The regulations governing medical examinations for drivers have been supplemented with an appendix entitled Obstructive Sleep Apnea Questionnaire [6]. This questionnaire was developed in accordance with the European Commission's 2013 recommendations concerning drivers with OSAS [2].
Every individual undergoing a medical examination before obtaining or renewing a driver's license must complete the questionnaire.
It is important to emphasize that the assessment consists of two components: the Obstructive Sleep Apnea Questionnaire and the Epworth Sleepiness Scale. Both components are evaluated together, and the assessment is performed by a physician.
Table 1. Obstructive Sleep Apnea Questionnaire
| No. | Question | Response |
|---|---|---|
| 1 | Sex | Male / Female |
| 2 | Age (years) | |
| 3 | Weight (kilograms) | |
| 4 | Height (meters) | |
| 5 | Do you snore while sleeping? | Yes / No / Don't know |
| 6 | Have you ever been awakened or shaken by a passenger or another person because you were dozing off while driving? | Yes / No / Don't know |
| 7 | Do you sometimes experience shortness of breath at night? | Yes / No / Don't know |
| 8 | Has anyone ever told you that you stop breathing while sleeping? | Yes / No / Don't know |
| 9 | Do you wake up feeling rested after a night's sleep? | Yes / No / Don't know |
| 10 | Have you been diagnosed with high blood pressure, or are you taking medication to lower your blood pressure? | Yes / No / Don't know |
Every physician should consider the possibility of OSAS based on the patient's medical history, anatomical characteristics, and comorbidities. The diagnosis should be confirmed through specialized testing performed in sleep laboratories using respiratory polygraphy and/or polysomnography.
The severity of OSAS is determined according to the results of these examinations. Moderate OSAS is diagnosed when objective testing (overnight respiratory polygraphy and/or polysomnography) confirms between 15 and 29 episodes of apnea and hypopnea per hour. Severe OSAS is diagnosed when the apnea-hypopnea index is 30 or higher, regardless of the presence of excessive daytime sleepiness [1].
An individualized treatment plan is developed according to disease severity and potential causes. Treatment effectiveness is assessed by medical specialists.
Epworth Sleepiness Scale
Please complete the Epworth Sleepiness Scale, which assesses the likelihood of dozing off or falling asleep in the situations listed below, rather than simply feeling tired.
Your answers should reflect your usual recent lifestyle. If you have not experienced a particular situation recently, imagine how you would feel in that situation.
Enter the number that best describes your likelihood of dozing off in each situation:
0 = Would never doze
1 = Slight chance of dozing
2 = Moderate chance of dozing
3 = High chance of dozing
It is important to assess each situation as accurately as possible.
| Situation | Score (0–3) |
|---|---|
| Lying down to rest in the afternoon when circumstances permit | |
| Sitting and talking to someone | |
| Sitting quietly after lunch without alcohol | |
| In a car, while stopped for a few minutes in traffic | |
| Total score |
Evaluation of Responses to the Obstructive Sleep Apnea Questionnaire
A family physician, internist, or pediatrician evaluates the questionnaire by calculating the total score according to the methodology presented below.
If the total score is 10 points or higher, the individual completing the questionnaire may have moderate or severe OSAS. Such individuals must be informed that they should refrain from driving until the diagnosis has been clarified. They must be referred to a healthcare institution licensed and equipped to perform the necessary investigations to confirm or exclude OSAS and assess treatment effectiveness.
Assessment of Fitness to Drive
A driving licence may be issued to applicants or existing drivers who do not have OSAS, have suspected or confirmed mild OSAS, or have been diagnosed with moderate or severe OSAS but possess an official medical certificate from an authorized healthcare institution.
The certificate must confirm that the individual adequately controls the condition, adheres to the prescribed treatment regimen, and has experienced an improvement in daytime sleepiness, if previously present [1].
| Question | Scoring |
|---|---|
| 1. Sex | Female = 1; Male = 2 |
| 2. Age | Under 30 years = 2; Over 31 years = 1 |
| 3–4. Body mass index (BMI) | Below 30 kg/m² = 1; 31–35 kg/m² = 2; Above 36 kg/m² = 3 |
| 5 | Yes = 3; No = 0; Don't know = 2 |
| 6 | Yes = 4; No = 0; Don't know = 3 |
| 7 | Yes = 2; No = 0; Don't know = 1 |
| 8 | Yes = 1; No = 0; Don't know = 0 |
| 9 | Yes = 0; No = 2; Don't know = 1 |
| 10 | Yes = 2; No = 0; Don't know = 1 |
The Epworth Sleepiness Scale score is added to the questionnaire score as follows:
- 0–10 points: add 0 points.
- 11–14 points: add 2 points.
- 15 points or more: add 4 points.
The total score is recorded in the patient's medical record, Form No. 025/a.
Individuals diagnosed with moderate or severe OSAS who wish to obtain or renew a driving licence must undergo regular medical examinations at healthcare institutions licensed and equipped to confirm or exclude OSAS and evaluate treatment effectiveness.
A pulmonologist or neurologist at the designated healthcare institution determines the appropriate investigations, including overnight respiratory polygraphy and/or polysomnography and any other necessary tests. The specialist then provides a medical assessment of the OSAS diagnosis, its severity, the required treatment, and treatment effectiveness.
These examinations must be performed at least once every three years for Group 1 drivers and at least once every year for Group 2 drivers. Their purpose is to assess adherence to treatment, the need for continued treatment, and the maintenance of adequate daytime alertness [1].
Criteria for Recovery
Although OSAS is a chronic condition, some patients may experience a reduction in disease severity, for example, from severe or moderate OSAS to mild OSAS, or the condition may resolve.
In such cases, the patient must undergo a repeat consultation with a pulmonologist or neurologist, who must objectively assess the condition using overnight respiratory polygraphy and/or polysomnography.
Healthcare Institutions Authorized to Diagnose OSAS and Assess Treatment Effectiveness
- Hospital of the Lithuanian University of Health Sciences Kauno Klinikos
- Vilnius University Hospital Santariškės Clinics
- Klaipėda University Hospital
- Republican Klaipėda Hospital
Lithuanian Doctor's Journal: Expert Recommendations, 2016/2017
