Drowsy Driving: The Problems

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Drowsy DrivingThe Problems Possible Solutions
20110622 Center for Research on Management of
Sleep Disturbances, UW
Rayleigh Chiang, M.D., M.M.S. Chairman, Dept.
Otolaryngology HN Surgery, School of Medicine,
Fu-Jen Catholic University. Taipei a Director,
Sleep Technology SIG, INSIGHT Center, National
Taiwan University a Sleep Center and Dept.
Otolaryngology HN Surgery, Shin-Kong Memorial
Hospital, Taipei A 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

• 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.
• Stoohs R, Guilleminault C, Dement W. Sleep apnea
  and hypertension in commercial truck drivers.
  Sleep 199316S11-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.
  20041701014-1021.
• 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.
  200421871-879.

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Prevalence of OSAS in Commercial Drivers

• 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) gt 10
  counts/hr SpO2 lt 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 DriversIncur High Frequency
of Crashes

• OSA accounts for up to 2.5 million traffic
  accidents per year in U.S.
• Am J Respir Crit Care Med. 2000 162 14071412.
• OSAS 2 11 fold risk of accident
• Teran-Santos, NEJM 1999 340 847-51

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National Sleep FoundationVideo of Drowsy Driving
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Potential Risk of Accidents Related to OSA

• More than 80 of OSAS have not yet been medically
• identified.
• 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

• 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 )

Steering Errors
Control
Ethanol
OSA
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George AJRCCM 1996 154175-81
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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." Thorax 2008
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Canadian Research

• Traffic accident rate for OSA patients 0.18
  times/person/year
• 3 times more than people without OSA
• 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

• In addition to OSA and sleep deprivation, there
  are several sleep and fatigue related conditions
  may increase the risk of accident.
• 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
• 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
• Moss TH, Sills DL The Three Mile Island nuclear
  accident Lessons and implications. Ann N Y Acad
  Sci 19813651-341

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Painful Price with Untreated Sleep Disorders

• U.S. National Highway Traffic Safety
• Administration
• With registration, gt10,000 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, ??? 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

• 1985/02/19, Taipei to
• LA
• One engine failed.
• Spinning and decline for 9000 feet
• Pilot didnt 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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• 2007?02?28? 130531 ????? www.chinanews.com
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Sleepy Driver Caught on the Street
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Regulations about Drivers with OSA

• 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
• Named for a 20 year-old college student, Margaret
  McDonnell. Penalty as high as 100 thousands US
  100,000. Same penalty
• for the sleep deprived driver as the drunken
  driver.

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Regulations about Drivers with OSA

• 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.
• http//www.silentpartners.org/sleep/sinfo/news/sle
  ep_driving.htm

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Concept of Near-misses

• 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
• accidents
• Very little focus on sleepy Near-Miss accidents
  in sleep research
• (3 papers) ancillary data, no clear
  association to actual accidents
• Near-Misses effectively used in industry to limit
  accidents
• - 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
incidents with property damage
near-misses
incidents without damage or loss
unsafe/hazardous conditions
Phimister et al. Risk Analysis,Vol.23,No.3,2003 Wh
arton 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
• C. You usually go to sleep as soon as your head
  hits the pillow, in 5 minutes or less

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Center of INnovation and Synergy for IntelliGent
Home and Living Technology
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Sleepy Driving Questionnaire

• Only 32/99 questions were extracted analyzed
  for this investigation
• Accident history over last 3 years
• 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 DriverNBC 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 Epworth Scale Score
Number of Near-Miss Accidents Due to Sleepiness Number of Subjects of Subjects with at least 1 Actual Accident Summary Score Entire Scale Single item Doze While in a 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 P value lt0.0001 lt0.0001 lt0.0001
Epworth Scale summary score had an independent
association with having an actual 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.
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Results Summary

• Risk of at least one accident increases
  monotonically from 23.2 if
• no near-misses to 44.5 if 4 near-misses
  (plt0.0001)
• After covariate adjustments, subjects with one
  near-miss accident
• 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
• 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 (plt0.0001)

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Conclusion

• We are unaware of any other study of this nature
  or
• any adequately powered study with the emphasis
  on near-miss
• sleepy accidents
• Statistically significant dose-response seen
  between numbers
• 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
• dangerous precursor to an actual accident

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Im not Drunk!
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Strategies forSolution
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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
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Current Test Batteries
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1. Physiological Assessment2. Cognitive Function
Assessment3. Executive Function Assessment
Current Test Batteries
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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 5-The 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
19976142-145. 2.Priest B, Brichard C, Aubert
G, et al Microsleep during a simplified
maintenance of wakefulness test A validation
study of the OSLER test. Am J Respir Crit Care
Med 20011631619-1625.
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Eye Monitoring System

• Eye monitoring system
• obtains data by visual
• measurements relative to
• eye blink
• percent of eye closure
• visual distraction
• gaze-fixation pauses

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Visual Ocular Measuresof Impaired Driving
Behavior

• Drowsiness
• PERCLOSE percent of eye closure measured by
• cameras aimed at face
• Driver Distraction
• Vision analysis of glance direction monitor
• Tunnel vision of search and scan patterns
• Glances inside the vehicle instead of on the
  roadway
• Alcohol Impairment
• 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?
Clinical Symptoms
Polysomnography
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Statistically Significant
Human Factors!
VS
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 Pasteur,
France
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.
Kannan Ramar, M.D., Mayo Clinic, U.S.A.
Claudio L. Bassetti, Prof. Dr. med. President,
European Sleep Research Society, Switzerland
Christian Guilleminault, M.D., BioD., Stanford
Sleep Disorders Research Center, U.S.A.
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
• 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, Asia-Pacific

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