Respiratory

Allergy-Related Life-Threatening Conditions

Insights:

Systemic anaphylaxis and acute upper airway obstruction can be induced by the following conditions:

  • The sting of an insect
  • Hereditary or acquired angioedema due to a deficiency of a serum protein can cause life-threatening airway obstruction or severe abdominal pain
  • Recurrent episodes of idiopathic anaphylaxis or angioedema

Considerations:

  • Is the nature and severity of the condition a risk to the safety of the driver and the public?
  • Are there a treatment and/or prevention regimen in place?
  • If applicable, suggest that the driver carry an epinephrine injection device in the vehible

Waiting Period: There is no waiting period

Certification Interval: FMCSA does not provide a specific interval

Antihistamine Therapy

1st Generation Antihistamines:

  • Diphenhydramine (Benadryl)
  • Have sedating effects
  • ME should inform driver to abstain from driving for 12 hours after taking medication

2nd Generation Antihistamines:

  • Cetirizine, Loratadine
  • Are less sedating and most do not interfere with driving

Considerations:

  • Is the underlying condition and treatment with antihistamines likely to interfere with the driver’s ability to control and drive a CMV safely?
  • Does the driver have complications relating to the respiratory dysfunction and treatment that impairs function?
    • Severe conjunctivitis affecting vision
    • Inability to keep eyes open
    • Photophobia
    • Uncontrolled sneezing
    • Sinusitis associated with severe headaches

Waiting Period: There is no waiting period

Certification Interval: FMCSA does not provide a specific interval

Asthma

Insights:

  • Generally reversible airway obstruction when treated effectively with bronchodilators and corticosteroids

Considerations:

  • Frequency and severity of the asthma attacks
  • Are the asthma attacks likely to interfere with the driver’s ability to drive a CMV safely?
  • Is the prevention/treatment regimen likely to interfere with the driver’s ability to drive a CMV safely?
  • Is there significant impairment of pulmonary function (FEV1 less than 65% of predicted value or PaO2 less than 65mmHg)?
  • Consider using the Asthma Clearance Letter

Waiting Period: There is no waiting period

Certification Interval: FMCSA does not provide a specific interval

Chest Wall Deformities

Insights:

Affect the mechanics of breathing, usually affect the driver’s vital capacity.

Examples:

  • Excessive kyphosis
  • Scoliosis
  • Pectus excavatum
  • Ankylosing spondylitis
  • Massive obesity
  • Recent thoracic/upper abdominal surgery or injury

Considerations:

  • Is the deformity stable?
  • Is the deformity likely to interfere with safe driving?
  • Does the driver also have an unstable medical condition?
    • Hypoxemia at rest
    • Chronic respiratory failure
    • History of continuing cough with cough syncope

Waiting Period: There is no waiting period

Certification Interval: FMCSA does not provide a specific interval

Chronic Obstructive Pulmonary Disease (COPD)

Insights:

  • A group of conditions causing a chronic reduction in expiratory flow
  • Most often caused by chronic bronchitis, emphysema
  • Usually brought on by smoking

Symptoms:

  • Chronic cough
  • Sputum production
  • Dyspnea on exertion

Considerations:

  • Consider a PFT
  • Consider using the COPD Clearance Letter
  • Is severity likely to interfere with safe driving?
  • Is there an unstable medical condition such as:
    • Hypoxemia at rest
    • Chronic respiratory failure
    • History of continuing cough with cough syncope

Waiting Period: There is no waiting period

Certification Interval: FMCSA does not provide a specific interval

Cor Pulmonale

Insights:

  • Enlargement of the right ventricle secondary to pulmonary hypertension or hypoxic pulmonary vasoconstriction.

Symptoms:

  • Dizziness
  • Hypotension
  • Syncope

Considerations:

  • Has treatment with vasodilators been shown to be adequate, effective, safe, and stable?
  • Are side effects likely to interfere with safe driving?

Waiting Period: There is no waiting period

Certification Interval: FMCSA does not provide a specific interval

Cystic Fibrosis

Insights:

  • Requires continuous antibiotic therapy and respiratory therapy to mobilize abnormal secretions
  • May result in limited physical strength

Considerations:

  • Consider using the Cystic Fibrosis Clearance Letter
  • Is the driver able to obtain therapy while working if necessary?
  • Does the driver also have an unstable medical condition?
    • Hypoxemia at rest
    • Chronic respiratory failure
    • History of continuing cough with cough syncope

Waiting Period: There is no waiting period

Certification Interval: FMCSA does not provide a specific interval

Hypersensitivity Pneumonitis

Insights:

  • Immune-mediated interstitial pneumonitis presenting as dyspnea, cough, fever
  • Driver should avoid (repeated) exposure to causative agent (cargo)

Considerations:

  • Does driver have a successful treatment plan to alleviate symptoms?

Waiting Period: There is no waiting period

Certification Interval: FMCSA does not provide a specific interval

Interstitial Lung Disease

Insights:

  • Occupational and environmental exposure are common causes
  • Side effects of treatment with corticosteroids and cytotoxic agents

Considerations:

  • Is the disease stable?
  • Is the disease likely to interfere with safe driving?
  • Does the driver also have an unstable medical condition?
    • Hypoxemia at rest
    • Chronic respiratory failure
    • History of continuing cough with cough syncope

Waiting Period: There is no waiting period

Certification Interval: FMCSA does not provide a specific interval

Narcolepsy & Idiopathic Hypersomnia

Insights:

Narcolepsy:

  • A neurological sleep disorder caused by the brain’s inability to regulate sleep-wake cycles normally
  • Characterized by excessive sleepiness and manifestations of rapid eye movement (REM) sleep during wakefulness
  • Manifests as pervasive drowsiness and sub wakefulness, frequent napping, and unexpected and overpowering sleep attacks occurring almost daily

Idiopathic Hypersomnia:

  • Excessive sleepiness after sufficient or even increased amounts of nighttime sleep without any identifiable cause.
  • Unintended naps are longer than those of narcolepsy and are usually unrefreshing.

Considerations:

  • The diagnosis of narcolepsy or idiopathic hypersomnia is disqualifying

Waiting Period: There is no waiting period

Certification Interval: Disqualification

Obstructive Sleep Apnea (OSA)

Insights:

  • If left untreated, moderate-to-severe OSA may contribute to fatigue, deficits in attention, concentration, situational awareness, and memory.
  • If multiple risk factors are observed, consider a sleep study referral.

Risk factors:

  • History of a small airway
  • Loud snoring
  • Daytime sleepiness
  • Self-reported or witnessed apneas
  • Obesity, high body mass index (BMI)
  • Large neck circumference (men-17”, women-16”)
  •  Diabetes
  •  HTN
  • History of stroke, coronary artery disease, arrhythmias
  • Retrognathia (recessed chin/overbite)
  • Mallampati Score indicating sleep apnea risk (class 3 or 4)

When is treatment required?

  • Treatment is required whenever the OSA test result indicates an Apnea/Hypopnea Index (AHI) of 15 or more
  • If the driver’s AHI is <15 but >5, and they have a comorbidity such as diabetes, hypertension, untreated hypothyroidism, CVD, or arrhythmia, treatment is required

What are acceptable forms of therapy to treat sleep apnea?

  • Any therapy that adequately treats the sleep apnea is acceptable provided the individual remains compliant
  • The most common form of therapy is the use of a CPAP or APAP device
  • Inspire is a device that is surgically implanted to keep the tongue forward by delivering electrical impulses at the base of the tongue. It must be turned on by a handheld remote before falling asleep and therefore, it can measure compliance by amount of usage.
  • Oral devices are acceptable if the individual can demonstrate compliance

Once therapy has started, what is needed to be compliant?

  • The driver must demonstrate use of the assistive device for at least 4 hours per night, 70% of nights, and relate no excessive daytime sleepiness
  • For initial certification after beginning use of assistive device, the driver must show compliance during the last 30 days
  • For recertification, the driver should produce documentation that demonstrates compliance from the time they were last certified (1 year)

When is treatment considered effective?

  • Treatment is deemed effective if their AHI while using the device is resolved to below 15

Waiting Period: There is no waiting period

Certification Interval: 1 year

For further guidance, view the Sleep Apnea Algorithm based on the 2016 MRB recommendations

Pneumothorax

Insights:

  • Air within the pleural space surrounding the lungs
  • This may occur spontaneously or secondary to an underlying disease

Traumatic Pneumothorax

  • The medical history and physical exam will provide details of the event that caused the traumatic pneumothorax

Spontaneous Pneumothorax

  • The underlying disease is the determining factor for certification

Considerations:

  • Has there been complete recovery confirmed by x-ray documented by the treating provider? (No air in pleural space or in the mediastinum.)
  • Is the driver asymptomatic?
  • For a spontaneous pneumothorax, what is the underlying disease? Is this disease likely to interfere with safe driving?
  • Consider disqualification if history of two or more spontaneous pneumothoraxes on one side & no successful surgical intervention
  • Consider using the Pneumothorax Clearance Letter

Waiting Period: There is no waiting period

Certification Interval: FMCSA does not provide a specific interval

Pulmonary Function Tests (PFT)

A pulmonary function test should be obtained when any of the following are present:

  • History of any specific lung disease
  • Symptoms of shortness of breath (especially at rest), cough, chest tightness, or wheezing
  • Cigarette smoking in drivers 35 years or older
  • Clubbing of the fingers usually associated with pulmonary or cardiovascular disease

Acceptable PFT Values:

Pulse Oximetry:

  • SpO2 > 92% on room air

Spirometry:

  • Forced expiratory volume in one second (FEV1) > 65% of the predicted value
  • Forced vital capacity (FVC) > 60% of the predicted value
  • FEV1/FVC ratio > 65%

Arterial Blood Gases:

Do not certify if PaCO2 > 45mmHg at any altitude.

  • Driver lives less than 5000 feet above sea level and has PaO2 > 65mmHg
  • Driver lives more than 5000 feet above sea level and has PaO2 > 60mmHg

Tuberculosis

Atypical Tuberculosis

  • Noninfectious
  • Medications generally not needed
  • If progressive, respiratory insufficiency may develop with cough, mild hemoptysis, or sputum production

Pulmonary Tuberculosis

  • Advanced TB may cause respiratory insufficiency
  • Treatment is extremely successful
  • Only persists in individuals while on therapy (streptomycin)
    • Streptomycin can cause hearing loss

Considerations:

  • What is the nature and severity of the disease and symptoms?
  • Are there symptoms that are likely to interfere with the ability to control and drive a CMV safely?
  • Has the treatment has been completed and no longer contagious?
  • Did treatment affect hearing/balance?
  • Consider using the Tuberculosis Clearance Letter

Waiting Period: There is no waiting period

Certification Interval: FMCSA does not provide a specific interval

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