Transcript 20110622 Center for Research on Management of Sleep Disturbances, UW Drowsy Driving: The Problems & Possible Solutions Rayleigh Chiang, M.D., M.M.S. Chairman, Dept.

20110622 Center for Research on Management of Sleep Disturbances, UW
Drowsy Driving:
The Problems & Possible Solutions
Rayleigh Chiang, M.D., M.M.S.
Chairman, Dept. Otolaryngology H&N Surgery, School of
Medicine, Fu-Jen Catholic University. Taipei
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Director, Sleep Technology SIG, INSIGHT Center, National
Taiwan University
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Sleep Center and Dept. Otolaryngology H&N Surgery,
Shin-Kong Memorial Hospital, Taipei
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Board of Directors, Taiwan Society of Sleep Medicine
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Conflict of Interest
None
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Higher Prevalence of SDB
in Truck Drivers
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Sleep-disordered breathing (SDB) affects more than 4% of the
adult population.
Young T, NEJM 1999
With certain groups, such as commercial truck drivers,
demonstrating a much higher prevalence.
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Stoohs R, Guilleminault C, Dement W. Sleep apnea and hypertension in
commercial truck drivers. Sleep 1993;16:S11-S14.
Howard ME, Desai AV, Grunstein RR, et al . Sleepiness , sleep - disordered
breathing, and accident risk factors in commercial vehicle drivers. Am J
Respir Crit Care Med. 2004;170:1014-1021.
Moreno CR, Carvalho FA, Lorenzi C, et al. High risk for obstructive sleep
apnea in truck drivers estimated by the Berlin Questionnaire: prevalence
and associated factors. Chronobiol Int. 2004;21:871-879.
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Prevalence of OSAS
in Commercial Drivers
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In FMCSA (Federal Motor Carrier Safety Administration) study of 4,826
commercial truck drivers
Mild OSAS: 17.6%
Moderate OSAS: 5.6%
Severe OSAS: 4.7%
Edinberg, UK: 10% of 598 bus drivers have OSA (Engleman, ATS 2005)
In our series (Liu et al, 2008)
751 bus drivers screened by
1. SOS (Snoring outcome score): 12.5% with severe snoring
2. 4% ODI (Oxygen desaturation index) >= 10 counts/hr & SpO2 < 88%:
11.5% with OSA
Prevalence closely related to age and obesity, also dependent on
average duration of sleep over consecutive nights at home.
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SDB Related Sleepy Drivers
Incur High Frequency of Crashes
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OSA accounts for up to 2.5 million traffic
accidents per year in U.S.
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Am J Respir Crit Care Med. 2000; 162: 1407–1412.
OSAS: 2 ~ 11 fold risk of accident
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Teran-Santos, NEJM 1999; 340: 847-51
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National Sleep Foundation
Video of Drowsy Driving
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Potential Risk of Accidents
Related to OSA
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More than 80% of OSAS have not yet been medically
identified.
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Mackay T, 2008
Much could be done to identify those at risk of accidents
related to OSA.
Chronic sleep restriction and deprivation related to work
schedules may coexist with OSA and have a multiplying
effect on fatigue.
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OSA Patients are
Dangerous Drivers
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Steering Errors
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Control
Ethanol
OSA
Even more dangerous than the
drunken driver
21 OSA patients vs 21 normal people
with age and gender matched.
Divided attention driving test,
(DADT): higher score means more
steering errors with poor
performance:
1. OSA group (average AHI = 73 +/29) poor performance than normal
control.
2. More than 50% in OSA group
performed worse than normal control,
even worse than the drunken group.
(Blood alcohol concentration = 95 +/25 mg/dl, far above the upper limit of
regulation, 52.5mg/dl )
8 154:175-81
George AJRCCM 1996;
Sleep Apnea
Doubles Car Crash Risk
A Canadian study examined data from insurance companies.
Settings: The Vancouver Coastal Health Research Institute ran the study in
cooperation with the University of Beitish Columbia. The Insurance Corporation of
British Columbia provided the data, which included 1,600 files of people with and
without sleep apnea symptoms.
Results.
1. People with OSA are twice as likely to be in a car accident than normal.
2. The car crash is also likely to be more serious
3. The rate of personal injury amongst people with OSA is 3 ~ 5 times normal.
4. In the general population, men are more at risk of being involved in a car
accident than women. When OSA is a factor, the risk of a car crash is the same
for both men and women.
5. Sleep apnea symptoms did not have to be severe to increase the risk of a
serious car crash. Even "fairly mild sleep apnea" increased the risk of "serious
crashes."
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Thorax 2008
Canadian Research
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Traffic accident rate for OSA patients: 0.18 times/person/year
= 3 times more than people without OSA
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After cPAP treatment, Traffic accident rate reduced to
0.06 times/person/year
From Database of Ministry of Transportation of Ontario, Canada
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Yet to be Found
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In addition to OSA and sleep deprivation, there
are several sleep and fatigue related conditions
may increase the risk of accident.
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Narcolepsy, periodic movements in sleep, chronic
fatigue and idiopathic hypersomnolence may
increase individual susceptibility to accidents.
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Major Disasters Worldwide
 Space shuttle
Challenger accident
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Presidential Commission. Report of the
Presidential Commission on the Space
Shuttle Challenger Accident, vol. 2,
Appendix G. Washington, DC, U.S.
Government Printing Office, 1986
 Three Mile Island
Nuclear Accident
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Moss TH, Sills DL: The Three Mile Island
nuclear accident: Lessons and implications.
Ann N Y Acad Sci 1981;365:1-341
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Painful Price with
Untreated Sleep Disorders
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U.S. National Highway Traffic Safety
Administration
With registration, >10,000 Traffic accidents
/ year were due to sleepy driving and nodding,
causing 76,000 injured,15,000 death.
More than US$ 100,000,000,000 of medical
cost & working impairment each year was caused
by sleep disorders.
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Japan, 新幹線 Shinkansen
Driver Fell Asleep When
Driving
A Shinkansen driver fell asleep for 8
minutes when driving at the speed of
300 km/hour with more than 800
passengers.
This driver was proved to have no
sleep deprivation and no alcohol
drinking around driving.
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Air Crash of
KAL 801 in 1997
From Seoul to Kuan
1997/08/06
228 dead
NTSB (National Transportation
Safety Board) proved due to
sleepy pilot
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China Airline
006
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1985/02/19, Taipei to
LA
One engine failed.
Spinning and decline for
9000 feet
Pilot didn’t get sleep
during resting period
2 a.m. of Taipei time
when accident occurred
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Sleepy Driver causes Disasters
in Taiwan
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SDB Related Traffic Accidents
in Taiwan
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疲勞駕駛致許瑋倫車禍
+
2007年02月28日 13:05:31
來源：中新網 www.chinanews.com
臺灣女藝人許瑋倫車禍，電腦動畫還原經過。
許瑋倫和助理駕駛的白色MINI車，先是擦撞護欄，彈向外側車道，接著車速逐漸降低，最後斜停
在路肩和車道中間，這時開在外側車道的大貨車尾隨而來，直接從車尾撞上，向前推了大約60公
尺左右，貨車和MINI才停了下來。
逢甲大學車禍鑒定中心主任葉名山：“先撞上護欄，左前輪破裂，然後往前約40公尺停下來，在爆
胎之前沒有刮地痕，初步分析，應該是疲勞駕駛。”
葉名山說：“他(貨車駕駛)在看到狀況時，他要踩煞車。反應時間就在彈指之間，就0.8秒了。”
依據許瑋倫坐車被往前推了60公尺左右，推算出當時大貨車車速已經減慢至6、70公里，但反應時
間太短，才會直接追撞，與警方調查結果相吻合。
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Sleepy Driver Caught
on the Street
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Regulations about
Drivers with OSA
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U.S.: Those who cause traffic accidents are forced to receive
overnight sleep study in Sleep Lab to make sure the existence of OSA
and the necessity for treatment.
Before appropriate treatment, OSA patients are not supposed to
drive commercial vehicles.
In CA, physicians are obligate to inform DMV to suspend the
driving licenses of the OSA patients. Many people lost their jobs
because of this.
Maggie's Law: National Drowsy Driving Act of 2003
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Named for a 20 year-old college student, Margaret McDonnell.
Penalty as high as 100 thousands US$ 100,000. Same penalty
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for the sleep deprived driver as the drunken driver.
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Regulations about
Drivers with OSA
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Canada: OSA is a medical condition which must
be reported to the Ministry of Transportation
(MOT). Pursuant to section 177 of the highway
traffic act. All patients with sleep apnea must be
reported to
the Ministry of Transportation and
Communications and physicians who do not
comply are breaking
the law.
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http://www.silentpartners.org/sleep/sinfo/news/sleep
_driving.htm
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Concept of “Near-misses”
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It will be too late when “accident” occurs.
In our study (Powell et al, Sleep 2007),
statistically
significant dose-response was seen between
numbers of self reported sleepy near-miss
accidents and an actual accidents.
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Near-Miss Strategy Systems
 Near- Miss Defined: detected event, that has not caused harm
hence, a limited immediate impact
 Requires: systematic reporting of all near-misses that might be
associated with a defined accident outcome
 Findings: provides insight to early detection of a systems weakness
 Outcomes: to recognize and identify “precursor” conditions that may
lead to a serious accident
 Countermeasures: limit precursors
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Rationale
Investigate Near-Miss Strategy
 Intuitively near-miss accidents are likely to be associated with actual
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accidents
 Very little focus on sleepy Near-Miss accidents in sleep research
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(3 papers)* ancillary data, no clear association to actual accidents
 Near-Misses effectively used in industry to limit accidents
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airlines
railroads
petrochemical
nuclear power
medicine (blood banks)
* Krieger et al, Engleman et al,Turkington et al
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Phimister* Safety Pyramid
accidents
serious injury
minor injuries
near-misses
incidents with property damage
incidents without damage or loss
unsafe/hazardous conditions
Phimister et al. Risk Analysis,Vol.23,No.3,2003
Wharton School of Management, University of Pennsylvania
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The National DATELINE NBC Driving Test
"SELECT YOUR ANSWERS AND SAVE YOUR LIFE"
1 hour special on sleepy driving

QUESTION #1 PICK ONE ANSWER:
A. You rarely get sleepy after any meal
B. You often get sleepy or drowsy after breakfast or dinner
C. You often get sleepy or drowsy after lunch
QUESTION #2 PICK ONE ANSWER:
A. You usually take about 9-10 minutes to fall asleep after going to bed
B. It takes you longer than 10 minutes to fall asleep
You usually
to sleep
soon as your
theTechnology
pillow, in 5 minutes or less
CenterC.
of INnovation
andgo
Synergy
foras
IntelliGent
Homehead
and hits
Living
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Sleepy Driving Questionnaire
 Only
32/99 questions were extracted & analyzed for this
investigation
 Accident history over last 3 years
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number of accidents
accidents related to sleepiness
number of near-miss accidents
Demographics
Current habits of ETOH, sleep disturbances & driving
Epworth Sleepiness Scale (ESS)
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Sleepy Driver
NBC – Dateline, Stanford University, General Motor & Sleep
Education Research Foundation
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Relationship Between Near-Miss Accidents
Associated with Sleepiness and Both Actual
Accidents and the Epworth Scale
Number of
Near-Miss
Accidents Due
to Sleepiness
Number
of
Subjects
% of Subjects
with at least 1
Actual
Accident
Epworth Scale Score
Summary
Single item:
Score:
Doze While in a
Entire Scale Car, Stopped for
Traffic
0
28479
23.2%
6.57 + 3.4
0.06 + 0.31
1
3705
28.2%
8.41 + 3.5
0.19 + 0.47
2 or 3
2068
31.6%
9.56 + 3.9
0.36 + 0.62
4 or more
631
44.5%
12.1 + 5.3
0.79 + 0.98
P value
<0.0001
<0.0001
<0.0001
Epworth Scale summary score had an independent association with having an actual
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accident after adjusting for age, sex, marital status, the number of miles driven
per
week, the percent of miles driven at night, and alcoholic drinks per week.
Results Summary
 Risk of at least one accident increases monotonically from 23.2% if
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no near-misses to 44.5% if ≥ 4 near-misses (p<0.0001)
 After covariate adjustments, subjects with one near-miss accident
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were 1.13 (95% CI,1.01 to 1.16) likely to have at least one actual
accident VS subjects with no near-miss sleepy accidents
 Odds of at least one actual accident associated with ≥ 4 N-Misses
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VS no near-miss sleepy accidents was 1.87 (95% CI,1.64 to 2.14)
 After adjustments the summary ESS had an independent association
with having a near-miss or actual accident
 An increase of one unit of ESS associated with a covariate adjusted
4.4% increase of having at least one accident (p<0.0001)
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Conclusion
 We are unaware of any other study of this nature or
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any adequately powered study with the emphasis on near-miss
sleepy accidents
 Statistically significant dose-response seen between numbers
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of self reported sleepy near-miss accidents and an actual
accident
 Near-miss sleepy accidents occur 14 times more than normal in
actual sleepy accidents (18.3% vs. 1.3%)
 This study suggests that sleepy near-misses may be a
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dangerous precursor to an actual accident
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I’m not Drunk!
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Strategies for
Solution
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Treatment of OSAS
& Coexistence of Other
Sleep Disorders
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Application of
Sleep Technology
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Research Rationale：
Development of
Rapid Screening
Modules
Efficacy
validation &
Criteria
establishment
Evidences for
policies of
government
Rapid =>
Real Time
Precision
Portable
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Current Test Batteries
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Current Test Batteries
1. Physiological Assessment
2. Cognitive Function Assessment
3. Executive Function Assessment
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Example 1: Pupillometry
Objective measurement of size
of pupil for individual sleep
tendency
www.amtech.de/en/products/cip
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Example 2 : Paced Auditory Serial
Addition Test (PASAT)
Examinee is required to add the
newly heard number to the
previously heard one.
Gronwall DM: Paced auditory serial-addition task: a measure of recovery
from concussion. Paced auditory serial-addition task: a measure of
recovery from concussion. 1977: 44(2): 367-373.
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Example 3:
Purdue Pegboard Dexterity Test
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Example 4 Psychomotor Vigilance Test, PVT
Hand-held device
Currently used in the sleep lab.
Quantify the time delay of the
response of examinee
Dinges DF, Kribbs NB: Performing while sleepy: Effects of experimentally
induced sleepiness. In Monk TM (ed): Sleep, Sleepiness and
Performance. Chichester, England, John Wiley & Sons, 1991, pp 97-128.
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Example 5The Oxford Sleep Resistance
(OSLER) Test
Examinee is required to press
different buttons in response to the
LED signals. The whole procedure
takes 40 min.
It has been validated with MWT.
1.Bennett LS, Stradling JR, Davies RJ: A behavioural test to assess
daytime sleepiness in obstructive sleep apnoea. J Sleep Res 1997;6:142145.
2.Priest B, Brichard C, Aubert G, et al: Microsleep during a simplified
maintenance of wakefulness test: A validation study of the OSLER test.
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Am J Respir Crit Care Med 2001;163:1619-1625.
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Eye Monitoring System
Eye monitoring system
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obtains data by visual
measurements relative
to
eye blink
percent of eye closure
visual distraction
gaze-fixation pauses
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Visual & Ocular Measures
of Impaired Driving Behavior
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Drowsiness
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PERCLOSE: percent of eye closure measured by
cameras aimed at face
Driver Distraction
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Vision analysis of glance direction monitor
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Tunnel vision of search and scan patterns
Glances inside the vehicle instead of on the roadway
Alcohol Impairment
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Horizontal gaze nystagmus
Pupil response to light
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Eyes, Mouth and Facial
Monitoring System
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Eyes, Mouth and Facial
Monitoring System
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Take Home Messages
Daytime Sleepiness related to
poor sleep, such as OSA, sleep
deprivation, narcolepsy,
PLM...etc. is prevailing drivers,
esp. in professional drivers.
Tragedy prevention will never
be too early
Accurate diagnosis and proper
management are always the
key.
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Sleepy or Not?
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Statistically
Significant
HumanVSFactors!
Clinically
Significant
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José Haba-Rubio, M.D.,
Centre d'Investigation et de
Recherche sur le Sommeil
(CIRS), Switzerland
Michael Vitiello, Ph.D.,
University of Washington,
Seattle, U.S.A.
Jean Krieger, M.D., Ph.D.,
Professeur Honoraire, Faculte
de Medecine, Universite Louis
Kannan Ramar, M.D., Pasteur, France
Mayo Clinic, U.S.A.
Christian Guilleminault, M.D., BioD.,
Stanford Sleep Disorders & Research
Center, U.S.A.
Claudio L. Bassetti, Prof. Dr. med.
President, European Sleep Research
Society, Switzerland
Sung Wan Kim, M.D., Ph.D.,
Kyung Hee University, South
Korea
Chol Shin, M.D., Ph.D.,
Korea University Ansan
Hospital, University of
Hawaii.
Michael Sarte, M.D.
President of Philippine
Society of Sleep Medicine
Nelson Powell, M.D., D.D.S.,
Stanford University Sleep
Disorders and Research Center,
U.S.A.
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Journal of Sleep Technology

Academic Journal (under planning) : “Journal of Sleep Technology”,
contract with Springer, the Netherlands. The first academic journal in this
brand new field


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Launching Schedule:

Launch the first issue from November 2011

First call for paper will be in June 2011, from “SLEEP 2011 25th Anniversary
Meeting of the Associated Professional Sleep Societies, LLC (APSS)” which
will be held June 11 – 15, 2011 in Minneapolis, Minnesota, U.S.
Editorial Board:
§ EDITOR IN CHIEF: RAYLEIGH CHIANG, M.D., M.M.S. (TW)

Deputy Editors: M Vitiello, Ph.D (Elderly sleep, psychology US)., J Krieger,
M.D., Ph.D. (Sleep medicine, FR), T Penzel, M.D. (Sleep medicine, DE), M
Tafti, Ph.D. (Basic science, CH), R Grunstein (Sleep medicine, AU), M Kyng
(Computer science, DK), Z Ding, Ph.D. (Industrial design, CN), HH Chou,
M.Sc. (Management, TW)

Editorial Board: Fields of Sleep medicine, Engineering, Design,
Management, Industry from 18 countries across Europe, America, AsiaPacific