Sleep apnea: traffic and occupational accidents--individual risks, socioeconomic and legal implications

Obstructive sleep apnea has been associated with a high risk for motor vehicle accidents, probably the highest of all risks due to medical conditions. Treatment of sleep apnea with nasal continuous positive airway pressure appears to reduce the risk of traffic accidents to the one of the general population. The risk for accidents may also be increased in untreated patients in the home and work environment. The increased risk seems unrelated to the symptom of daytime excessive sleepiness, and in many studies lacks a clear dose-response relationship with respect to the severity of apneas and hypopneas. The association of sleep apnea, chronic sleep deprivation and consumption of hypnotics or alcohol has not been thoroughly studied, although alcohol has been considered as a confounding variable in some studies. The cost of traffic accidents due to sleep apnea has been estimated to be so high that diagnosing and treating all drivers with sleep apnea in the USA would be cost saving and result in a decrease in society costs related to the disease. Driving licenses are delivered according to national legislations. These are all but uniform, especially concerning sleep apnea. Even within the European Union, where a minimum set of rules is mandatory for all countries, sleep apnea is not included in the minimum. Therefore, drivers are left in a very uncomfortable position, behaving according to the law in one country but being unlawful once the border with the neighbor country is crossed. Physicians are also in a very difficult position if they have to counsel their patients on the best attitude when travelling by car. The situation is even worse for commercial drivers, for whom the legislation is more severe but leaves sleep apnea uncovered in many countries. This is all the more disturbing if one considers that sleep apnea can be suspected, screened and diagnosed with relative ease, and that once diagnosed the adequate treatment allows for safe driving. The inclusion of sleep apnea in the European traffic license regulations would represent a step forward towards safe routes for patients and healthy people alike.