Obstructive Sleep Apnea Diagnosis and Treatment - part 10 pot

Legal Implications of Obstructive Sleep Apnea 409
clearly reproduced on a video monitor or a compact printer, the sleep specialist’s
interpretation of the test can occur anytime and at any place. Often the physician’s
diagnosis of OSA occurs without the physician examining or even speaking with
the patient. Questions may arise whether the sleep study patient and the distant
reading physician have established a physician-patient relationship for purposes of
a malpractice action.
The trend in recent case law is for courts to imply the existence of a physician-
patient relationship among physicians unknown to the patient if the physician affir-
matively undertakes to diagnose and/or treat the patient (32). A Texas case,
Dougherty v. Gifford (33), is instructive. There, the patient’s specialist sent a biopsy to
his contracted pathologist who practiced in the regional medical center in Paris,
Texas. The pathologist diagnosed cancer and aggressive treatments ensued, only to
be discontinued when the pathologist admitted to having misread the biopsy (34).
Like most distant readers of sleep tests, the pathologist in Paris never intended
to create a professional relationship with the patient. The pathologist never met the
patient, did not review the patient’s records, and only reviewed the specimen
provided. The pathologist communicated the results to the patient’s treating physi-
cian, who retained primary responsibility for the patient’s care (35).
Nonetheless, the court found on these facts that a physician-patient relation-
ship was created by the acceptance of the pathology work, the conduction of the
tests, the preparation of a lab report, and the acceptance of a fee for the services ren-
dered. The court stated that there could be no doubt that the diagnostic services
f urnished on behalf of the patient constituted the practice of medicine (36). As stated
by the Tennessee Supreme Court in a similar case:
In light of the increasing complexity of the health care system, in which patients rou-
tinely are diagnosed by pathologists or radiologists or other consulting physicians who
might not ever see the patient face-to-face, it is simply unrealistic to apply a narrow
definition of the physician-patient relationship in determining whether such a relation-
ship exists for purposes of a medical malpractice case. Based upon the foregoing
authorities, we hold that a physician-patient relationship may be implied when a

physician affirmatively undertakes to diagnose and/or treat a person, or affirmatively
participates in such diagnosis and/or treatment (37).
Telemedicine Aspects of the Physician-Patient Relationship
The free flow of sleep data to physicians who are not only invisible to the patient but
also reside in a state different from the patient challenges traditional notions of the
physician’s license to practice medicine. All states have adopted laws which define
the types of activity constituting the practice of medicine within their borders. Such
laws generally prohibit persons from engaging in the unlicensed practice of medi-
cine, and further punish physicians for aiding and assisting others in the unlicensed
practice of medicine.
The threshold question is whether the professional interpretation of a sleep
study constitutes the practice of medicine. Although each state defines the practice
of medicine somewhat differently, the recent trend is for states to include the inter-
pretation of diagnostic tests within the practice of medicine definition. Colorado’s
practice of medicine definition, which specifically includes the interpretation of
tests, is representative. In full, the Colorado law provides that:
Practice of medicine In Colorado means holding out one’s self to the public within this
state as being able to diagnose, treat, prescribe for, palliate, or prevent any human
410 Brown
disease, ailment, pain, injury, deformity, or physical or mental condition, whether by
the use of drugs, surgery, manipulation, electricity, telemedicine, the interpretation of
tests, including primary diagnosis of pathology specimens, images, or photographs, or
any physical, mechanical, or other means whatsoever (38) (emphasis added).
At least 14 states have passed legislation specifically restricting the practice of
telemedicine across state lines. For example, the Missouri statute defines the “prac-
tice of medicine across state lines” to mean:
1. The rendering of a written or otherwise documented medical opinion concerning
the diagnosis or treatment of a patient within this state by a physician located
outside this state as a result of transmission of individual patient data by
electronic or other means from within this state to such physician or physician’s

agent; or
2. The rendering of treatment to a patient within this state by a physician located
outside this state as a result of transmission of individual patient data by
electronic or other means from within this state to such physician or physician’s
agent, definition (39).
An Oregon law specifically issues a special purpose license to outside physi-
cians to practice within Oregon by distant communications, but only after the phy-
sician has first personally examined the patient (40). Other states, such as Alabama,
issue a three-year special purpose license (41).
If the interpretation of the sleep study constitutes the practice of medicine, the
next question is “which licensing authority governs?” The general rule in malprac-
tice actions is that the patient’s location at the time of service determines the location
where the treatment occurs (42). As stated by the Ninth Circuit Court of Appeals in
Wright v. Yackley (43):
In the case of personal services focus must be on the place where the services are
rendered, since this is the place of the receiver’s (here the patient’s) need. This need is
personal and the services rendered are in response to the dimensions of that personal
need. They are directed to no place but to the needy person herself.
Although improper licensure may not, by itself, indicate negligence in all
malpractice actions (44), proper licensure can be a condition to the presentation
of a clean, nonfraudulent claim to a government healthcare program for
reimbursement (45).
Physician’s Duties to Diagnose and Treat Obstructive Sleep Apnea
Upon establishment of the physician-patient relationship, a physician owes his
patient the duty of reasonable care present in the community when treating
his patient (31). A 1993 Louisiana case found a hospital and its physicians liable for
the death of patient William Cornett as a result of the defendants’ failure to treat the
decedent’s OSA (6). Mr. Cornett suffered from acromegaly, a generally nonmalig-
nant pituitary tumor causing excessive secretion of growth hormones and the result-
ing enlargement of facial features, limbs, and soft tissues of the body (46). The

condition may cause OSA, from which Mr. Cornett also suffered (46).
In March 1986, a family practice resident at the defendant hospital examined
Mr. Cornett, who complained of chest pains and sleep apnea. The resident referred
the patient to the hospital’s endocrinology clinic for acromegaly. The hospital failed
to schedule the appointment (46).
Legal Implications of Obstructive Sleep Apnea 411
Seven months later, Mr. Cornett presented at the hospital’s emergency room
believing he was in a diabetic coma. He again explained his four- to five-year
history of sleep apnea, and Mr. Cornett fell asleep during his diabetes testing,
which proved negative. Concerned about Mr. Cornett’s somnolence, the emer-
gency room physician ordered arterial blood gas testing, which indicated elevated
carbon dioxide levels and low oxygen levels. The emergency room physician testi-
fied at trial that Mr. Cornett requested treatment for sleep apnea because he had
fallen asleep while driving. The doctor diagnosed acromegaly and sleep apnea. To
confirm the diagnosis of acromegaly, the physician ordered diagnostic tests at the
hospital’s endocrinology clinic. These tests confirmed the diagnosis of the pituitary
condition (47).
Mr. Cornett presented at the endocrinology clinic two weeks later when a dif-
ferent hospital physician confirmed a diagnosis of acromegaly and central hypoxia.
This physician ordered pulmonary function testing at the hospital’s chest clinic, but
Mr. Cornett died before his scheduled appointment date. The cause of death was
documented as cardiopulmonary arrest as a consequence of pituitary tumor (47).
Expert testimony at trial indicated that Mr. Cornett’s death was more likely
caused by sleep apnea and, had the hospital and its physicians provided appropriate
medical treatment for OSA, Mr. Cornett would have survived. The last two hospital
physicians who examined Mr. Cornett acknowledged that OSA is a potentially fatal
condition. Each also testified that they failed to inform Mr. Cornett of the risk of death
presented by untreated sleep apnea. The hospital’s own medical expert acknowl-
edged that sleep apnea may lead to life-threatening cardio-respiratory events and that
the disease is a recognized emergency. The appellate court affirmed the trial court’s

holding the hospital and the physicians liable for professional negligence (48).
Physician’s Duty to Obtain Patient’s Informed Consent for Obstructive
Sleep Apnea Surgery
Physicians have a general duty to provide their patients with sufficient informa-
tion concerning their diagnosis, the nature and reason for the proposed treatment,
the risks or dangers involved, the prospects for success and alternatives methods
of treatment and the risks and benefits of such treatment (49). An unpublished
decision of the Tennessee Court of Appeals discusses a physician’s duty to inform
a sleep apnea patient of CPAP treatment before performing uvulopalatopharyngo-
plasty (UPPP) (50).
The case involved a board-certified otolaryngologist who scheduled a nonur-
gent tonsillectomy for his 49-year-old male patient. The patient asked whether the
procedure would help his snoring. Examining the patient further, the physician
diagnosed mild sleep apnea and recommended surgical treatment. The patient tes-
tified at trial that he heard the doctor say that the doctor would trim his uvula, but
the physician’s notes indicated “surgery discussed, risks, and complications, sched-
ule tonsillectomy, septoplasty, UVPP (uvulopharyngoplasty)” (51). In fact, the
defendant physician performed the UPPP procedure. At no time did the physician
advise his patient as to any nonsurgical alternatives to remedy his snoring.
The patient suffered various neurological disorders following the surgery and
brought a malpractice action against the physician. Plaintiff based his claim on the
physician’s failure to inform his patient of noninvasive alternatives and failure to
inform him of the diagnosis of OSA so that the patient could be properly informed
of risks that stemmed from that diagnosis. In support, Plaintiff’s medical expert
testified that the physician should have informed Plaintiff of noninvasive snoring
412 Brown
treatments, such as CPAP and laser surgery. The expert further testified that the
physician should have ordered a sleep study to determine the presence of sleep
apnea and the severity of the condition. However, on cross-examination, the expert
admitted that even he did not send all of his patients who presented with OSA

symptoms for a sleep study and that a sleep study was not required to identify the
location in the throat that caused the snoring (52).
The physician presented the medical testimony of two fellow otolaryngolo-
gists. These doctors testified that the treating physician informed the patient of the
procedure and risks consistent with the standards of the community. The jury also
considered the broad language of the written consent form signed by the patient.
On the basis of the expert testimony and the patient’s written consent, the
jury determined that the physician properly informed his patient and found for the
physician (53).
What is unknown is a physician’s responsibility to recognize the documented
link between sleep apnea and hypertension, cardiovascular disease, and other dis-
eases (3) when performing routine examinations. The Cornett case discussed above
indicates the risks attendant to physicians who fail to recognize the urgency of the
disease. Increased awareness of sleep medicine and recognition by the American
Board of Medical Specialties of sleep medicine as a subspecialty (54) may bring
minimum sleep inquiries into the community standard of practice for cardiologists,
pulmonologists or family practice physicians whose patients present with typical
OSA markers.
Physician’s Duties and Liabilities to Third Parties for the Acts of Their
Obstructive Sleep Apnea Patients
Duty to Warn and Report Impaired Driving
Because hypersomnolence generally follows untreated OSA, a physician may have
additional legal and ethical duties to the public to inform the patient of the risks of
fatigued driving caused by the failure or refusal to treat the disease. In appropriate
cases, the physician may be required by law to report the patient’s condition to
applicable state motor vehicle agencies.
Although no case found expressly discusses a physician’s duty to third parties
in the context of an OSA patient, under the proper facts, a physician owes a duty to
use reasonable care to protect the driving public if the physician’s negligence in
diagnosis or treatment of his patient contributes to Plaintiff’s injuries (55).

One principal case holds that a physician who “takes charge” of a patient
whom the physician knew or should have known was likely to cause bodily harm
to others adopts the duty of reasonable care to prevent the patient from causing
harm to others (56). However, courts readily distinguish a physician’s prescribing
narcotic drugs or similar treatment plans from situations in which the physician
“takes charge” of the patient. The courts reason “that whether the patient takes the
medication and then drives is beyond the doctor’s control. In fact, whether the
patient consumes the medication at all is beyond the doctor’s control” (57). This
same result would logically follow upon an injury caused by an OSA patient’s
failure to comply with his or her CPAP treatment.
However, the law requires a physician to warn the patient of the risks flowing
from the use or misuse of the treatment (58). In Gooden v. Tips (59), a physician
prescribed Quaalude tablets for his patient but failed to warn her not to drive under
its influence. The patient’s drug-induced driving injured third parties, who brought
Legal Implications of Obstructive Sleep Apnea 413
suit against the physician. The court ruled that the physician was liable to the injured
third parties not because the physician had a duty to prevent his patient from
driving, but because the physician had the duty to warn the patient not to drive,
which he failed to do (30). A treating physician may have a similar duty to warn an
OSA patient that the disease may cause a risk of drowsy driving if left untreated or
treated improperly.
In addition to legal duties under common law negligence, physicians may have
a statutory obligation to report impaired driving to the department of motor vehicles.
For example, Vermont, Oregon, New Jersey, California, Delaware, Pennsylvania, and
Nevada require physicians to report specific disorders of their patients to appropriate
state agencies, typically the state department of motor vehicles (60). Other states permit
physicians to report their patients’ impaired driving conditions, but do not require
reporting. Still other state laws permit the report to be made anonymously, while some
laws offer physicians complete immunity from liability if they have reported the
patient’s condition to the applicable agency prior to a patient’s injury (61).

According to the American Medical Association’s “Physician’s Guide to
Assessing and Counseling Older Drivers,” patients with a diagnosis of narcolepsy
should cease driving altogether (62). The Guide suggests that patients with sleep
apnea may drive if they do not suffer excessive daytime drowsiness as a conse-
quence of therapy or otherwise (63). Physicians in reporting states should check
with the department of motor vehicles in their states to determine if a sleep disorder
is a specified condition for which reporting is required.
Even if reporting is not required, physicians face legal and ethical dilemmas if
they judge the patient unfit to drive but the patient refuses to comply. In 2000, the
American Medical Association adopted Ethical Opinion E-2.24 to address physicians’
ethical obligations in this regard (63). According to the Opinion, if clear evidence of
substantial driving impairment implies a “strong threat” to patient and public safety,
and if the patient ignores the advice to discontinue driving, then the AMA believes it
is desirable and ethical for the physician to notify the applicable department of motor
vehicles. However, the Opinion clarifies that the physician must follow state law if
reporting is required. The Opinion also advises that physicians should disclose and
explain their responsibility to report to their patients.
Reporting a patient’s impaired driving condition impacts an array of legal
issues, including patient confidentiality. If a state law requires or permits disclosure,
patient authorization may be required prior to the disclosure. The Privacy Standards
applicable to protected health information under the Health Insurance Portability
and Accountability Act of 1996 (HIPAA) will not stand in the way if state law
requires or permits disclosure without authorization. HIPAA permits healthcare
providers to disclose protected health information without individual authorization
as “required by law” (64) or to avert a serious threat to health or safety (65). However,
HIPAAs provisions yield to more stringent state laws. Accordingly, prior patient
authorization may still be required under state law even though HIPAA may permit
an unauthorized disclosure.
LEGAL OBLIGATIONS OF PERSONS EMPLOYING OBSTRUCTIVE
SLEEP APNEA PATIENTS

Because science and the law recognize OSA as an impairment which, if untreated,
may adversely affect work performance and safety, the law imposes distinct legal
duties on employers of OSA patients. These duties include taking reasonable
414 Brown
accommodations to the extent required by federal and state disability laws,
vicarious liability for the acts of drowsy employees, and, in certain industries, the
adoption of fitness for duty standards that recognize the risks posed by employees
with sleep apnea.
Disability Laws
The Americans with Disabilities Act (ADA) (66), along with the Rehabilitation Act
of 1973 (67) and similar state civil rights laws (68), prohibits discrimination by
certain employers against qualified individuals with a disability (69). A “qualified
individual” is one who is capable of performing the essential function of a job with
or without reasonable accommodations (70). For example, if driving is an essential
function of one’s job and if an employee cannot safely drive due to his combined
conditions of severe OSA, narcolepsy and cataplexy, then the employee is not a
“qualified individual” eligible for ADA protections (71). The same holds true if sleep
apnea prevents an employee from working overtime in his job as a power company
lineman when working overtime shifts is an essential function of being a lineman
(72). If the employee is not a qualified individual, then the employer has no obliga-
tion under the ADA to make the employee’s job easier or even to make the job
available at all (73).
Qualified individuals have often claimed OSA is an ADA disability and that
such persons therefore deserve redress for lost employee benefits, promotions or
even their jobs due to their disability. However, the allegation of a particular diag-
nosis, standing alone, is insufficient to establish a disability under the ADA (74). The
answer whether OSA is an ADA disability requires an individualized, case-by-case
approach to evaluate whether the employee’s impairment is severe enough to
constitute a disability for ADA purposes (75). Thus, the proper legal inquiry in such
matters is not whether sleep apnea is a disability for purposes of ADAs protections,

but whether the individual’s sleep apnea substantially limits his or her major life
activities as those terms are defined by the ADA.
1
To establish a prima facie case of discrimination under the ADA, the employee
must show that: (i) he is disabled within the meaning of the ADA, (ii) he is qualified
to perform the essential functions of his job either with or without reasonable accom-
modation, and (iii) he has suffered from an adverse employment decision because
of his disability (76).
To prove the existence of a disability, the employee must show that (i) he suf-
fers from an impairment; (ii) the impairment affects major life activities; and (iii) the
impairment “substantially limits” such major life activities (77).
Although the ADA does not define “impairment,” regulations promulgated
under the ADA by the Employee Equal Opportunities Commission do (78). These
regulations define a physical or mental impairment to include, in part, any physio-
logical disorder or condition affecting a person’s neurological, musculoskeletal,
respiratory or cardiovascular systems (79).
1
Under certain circumstances sleep apnea is considered a disability for some federal benefit
programs, such as Veteran’s Affairs, 38 CFR § 4.97. Persons seeking social security disability
benefits must prove that they have a “disability,” which is defined to mean the “inability to
engage in any substantial gainful activity” due to a “physical or mental impairment” that
could cause death or might reasonably be expected to last continuously for at least twelve
months. See 42 U.S.C. § 423(d) (1) (A).
Legal Implications of Obstructive Sleep Apnea 415
Courts discussing OSA in the context of these ADA regulations routinely
find—and employers routinely concede—that OSA is a physical impairment in
satisfaction of the first prong of the analysis (80). Sleep apnea affects one’s ability to
breathe during sleep. As a consequence, one may not achieve a sound sleep at night
and may drop off to sleep uncontrollably during the work day. This condition could
reasonably be considered a respiratory disorder within the definition of “physical

impairment” (81).
The second prong of the test requires that the impairment affect a major life
activity. The regulations make clear that “breathing” is included in the definition of a
“major life activity” for purposes of meeting the ADA test (78). “Sleeping,” however,
is conspicuously absent from the regulatory list of major life activities. ADA claimants
with OSA can finesse the point by claiming that their sleep apnea substantially limits
their breathing during sleep, thus impacting both activities (82).
In fact, most courts interpret ADA regulations to find that “sleeping” is a
major life activity for ADA purposes (83). “Sleeping is a basic activity that the
average person in the general population can perform with little or no difficulty,
similar to the major life activities” that do appear in the regulations: walking,
seeing, hearing, speaking, breathing, learning, and working (84). Interestingly,
courts have also ruled that staying awake, in and of itself, is not a major life activ-
ity (85), and that general sleeplessness is insufficient to show a significant
impairment to one’s activity of sleeping (86).
Having determined that sleep apnea is an “impairment” affecting a “major
life activity,” the determination whether sleep apnea is a disability under the ADA
depends, in each case, whether the claimant can prove that sleep apnea substan-
tially limits the claimant’s sleep or breathing for purposes of ADA protection. Such
proof must satisfy yet another three part evaluation relative to (i) the nature and
severity of the impairment; (ii) the duration or expected duration of the impairment;
and (iii) the permanent long-term impact, or the expected permanent or long-term
impact of or resulting from the impairment (87). In addition, courts will consider the
measures used by the claimant to mitigate or treat his condition (86), such as, in the
case of sleep apnea, CPAP (82).
The courts recognize that a determination of ADA disability for persons with
OSA depends on the severity of the impairment, which presents in a wide
spectrum:
In general terms sleep apnea can be so severe such that it does impact on the major life
activity of sleep. [Citation omitted]. Sleep apnea, however, is also a condition that varies

in severity from very mild asymptomatic snoring to severe snoring and extremely
restless sleep with extreme daytime hypersomnolence or excessive sleepiness during
the day (88).
The use of CPAP therapy to correct or mitigate OSA symptoms is a key factor
in determining the severity of the employee’s disease in the determination of ADA
disability. Thus, in a situation where common OSA therapies such as CPAP and sur-
gery failed to alleviate an employee’s fatigue resulting from severe sleep apnea, the
United States District Court of Eastern Pennsylvania permitted the jury to consider
whether the employee’s OSA constituted a severe impairment for ADA disability
purposes (89).
Cases involving successful use of CPAP reach different conclusions (90). The
case of an obese police officer, 46-year-old Ike Mont-Ros, is instructive (82). Officer
Mont-Ros was diagnosed with sleep apnea in 1993. His employer paid for his CPAP
416 Brown
machine to alleviate his symptoms and, when Officer Mont-Ros’ knees became too
brittle for regular police work, accommodated Mont-Ros’ request for light-duty,
daytime dispatch duties. Armed with a physician’s opinion that Officer Mont-Ros
was not qualified to perform police work due to his orthopedic problems, the police
department fired Officer Mont-Ros on grounds that he was hired originally to per-
form police duties at police officer pay, not civilian dispatch duties compensated at
lower rates. Mont-Ros sued the City of West Miami for intentional discrimination
against him due to his sleep apnea disability.
Using the applicable three-part tests, the court held that Officer Mont-Ros
failed to provide sufficient evidence to support his contention that his sleep apnea
constituted a disability under the ADA. While expert testimony showed that OSA is
a severe, potentially life-threatening disease, Mont-Ros failed to show the severity
of the disease in his specific case. Finally, the court noted that because OSA is treat-
able and can be corrected with the use of CPAP at night, Officer Mont-Ros could not
demonstrate that he is substantially limited in any major life activity. As Officer
Mont-Ros’ own medical expert point out, “much like the use of glasses to correct

ones vision, the use of the nasal CPAP machine at night will alleviate Plaintiff’s
condition during sleeping hours and, thus, reduce the daytime drowsiness (91).”
Thus, in the worker’s compensation context, OSA patients using CPAP earn no
impairment ratings because “treated OSA has no permanent disability” (92).
Employers’ Liability for Employee’s Negligence
The application of traditional vicarious liability rules renders employers vicariously
liable for the acts of their employees when performed in the scope of their employ-
ment (93). Thus, when Norman Munnal killed a woman when he fell asleep at the
wheel of a tractor-trailer while driving for his trucking company employer, it was
W.L. Logan Trucking Company that faced liability for its driver’s acts (94). The
trucking company invoked Ohio’s version of the “sudden blackout” doctrine to
defend Munnal’s conduct (95). The employer alleged that it was the driver’s “sudden
unconsciousness” that caused the truck to move left of center, and that Munnal
cannot be liable for losing control under these circumstances (95).
As we have seen, the sudden blackout defense fails if defendant knew that
consciousness loss was likely to occur or was otherwise foreseeable (95). Munnal
testified that he had a propensity to fall asleep at unpredictable times and that he
had fallen asleep at the wheel at least once before (96). A sleep test ordered after the
accident revealed that he suffered from severe OSA (96). At trial, Munnal’s sleep
disorders specialist opined that many sleep apnea patients engage in automatic
behavior, such as driving, while unknowingly unconscious (97). The expert distin-
guished automatic behavior from fainting following a sudden blackout, and opined
that distance truck driving was not the right profession for someone with untreated
sleep apnea (96).
Even though Munnal testified that he had no knowledge of his sleep apnea
before the accident (96), the court ruled that the employee driver was aware of his
excessive fatigue and propensity to falling asleep at inopportune times (98). Because
of this prior knowledge, the court held Munnal negligent for failing to operate the
truck in a safe manner, and further found Munnal’s employer trucking company
liable for the driver’s acts while in the scope of his employment (98). Under the rule

in this case, employers’ risk management programs would likely benefit from an
Legal Implications of Obstructive Sleep Apnea 417
employee OSA screening and therapy compliance program for employees working
at safety-sensitive tasks such as driving.
Employers are also exposed to allegations of direct liability if they negligently
hire persons with OSA and entrust vehicles to them. To prevail on these direct liabil-
ity allegations, the injured party must prove that the employee’s fatigue was due to
the disease, was known to the employer, and proximately caused the accident
leading to damages (99).
Growing awareness of general sleep health and expressions of public policy
against drowsy driving of the kind codified in New Jersey by Maggie’s law and
New York’s Bell Regulations (limiting medical residents’ work hours) (100) sets the
stage for actions against employers brought by unknown third parties injured by
overworked, and likely fatigued, employees.
The legal question in such circumstances is whether the employer owes a duty
to control the off-duty conduct of its employee. Although the general rule is that
employers owe no duty to third parties for the off-duty acts of their employees,
(101) at least one court has re-fashioned tort principles to find an employer liable for
accidents caused by employees presumably fatigued due to over-scheduling by
their employer (102). The same result obtains on similar facts under workmen’s
compensation law (103).
Regulatory Screening for Obstructive Sleep Apnea in
Safety-Sensitive Positions
Because sleep apnea is a relatively common medical condition which, if untreated,
contributes to daytime sleepiness and impaired job performance (2), public policy
suggests that certain industries directly affecting public safety screen employees in
safety-sensitive positions for sleep apnea or other fatigue-enhancing sleep disor-
ders. Thus, each of the air, rail, ferry, distance trucking, and nuclear power indus-
tries have or propose regulatory fitness for duty programs addressing OSA.
The National Transportation Safety Board (NTSB) has issued three investigation

reports finding that the undiagnosed or untreated OSA of a train or ship operator
contributed to the subject incident (104). The latest, in 2004, involved a 2001 collision
of two trains arising from the crewmembers’ fatigue caused primarily by the engi-
neer’s untreated and the conductor’s insufficiently treated OSA (105). The 2004 NTSB
Report recommended that the Federal Railroad Administration (FRA) take remedial
steps regarding employee fatigue (106), and the FRA issued its Safety Advisory
2004-04 on September 21, 2004 in response. The Advisory suggests that railroads
adopt procedures to recognize sleep disorders, screen employees, and permit impaired
persons to perform safety-sensitive tasks only after proper treatment (107).
Federal regulations require that only physically fit persons are eligible to oper-
ate a commercial motor vehicle in interstate commerce (108). Persons are considered
physically fit if they obtain medical certification from a physician certifying that the
applicant does not have an established medical history or clinical diagnosis of,
among other ailments, a respiratory dysfunction or other condition which is likely
to cause loss of consciousness or any other loss of ability to control a commercial
motor vehicle safely (109). The current Medical Examination Form, updated in 2000,
makes specific inquiry whether the applicant suffers from “sleep disorders, pauses
in breathing while asleep, daytime sleepiness, (or) loud snoring (110).”
In 1991, the Federal Motor Carrier Safety Administration published advisory
criteria to assist medical examiners determine a driver’s physical qualifications for
418 Brown
commercial driving. The guidance regarding pulmonary/respiratory disorders
identifies OSA as a condition which, if untreated, renders applicants unqualified to
operate a commercial vehicle:
Individuals with suspected or untreated sleep apnea (symptoms of snoring and hyper-
somnolence) should be considered medically unqualified to operate a commercial
vehicle until the diagnosis has been dispelled or the condition has been treated success-
fully. In addition, as a condition of continuing qualification, commercial drivers who
are being treated for sleep apnea should agree to continue uninterrupted therapy as
long as they maintain their commercial driver’s license. They should also undergo

yearly multiple sleep latency testing (MSLT) (111).
Guidance respecting seizures, epilepsy and interstate commercial driving
reaches a similar conclusion as to chronic sleep apnea:
Patients with sleep apnea syndrome having symptoms of excessive daytime somno-
lence cannot take part in interstate driving, because they likely will be involved in haz-
ardous driving and accidents resulting from sleepiness. Even if these patients do not
have the sleep attacks, they suffer from daytime fatigue and tiredness. These symptoms
will be compounded by the natural fatigue and monotony associated with the long
hours of driving, thus causing increased vulnerability to accidents. Therefore, those
patients who are not on any treatment and are suffering from symptoms related to EDS
should not be allowed to participate in interstate driving. Those patients with sleep
apnea syndrome whose symptoms (e.g., EDS, fatigue, etc.) can be controlled by surgical
treatment, for example, permanent tracheostomy, may be permitted to drive after three-
month period free of symptoms, provided there is constant medical supervision.
Laboratory studies (e.g., polysomnographic and MSLTs) must be performed to docu-
ment absence of EDS and sleep apnea (112).
As to pilots, the Federal Aviation Administration Guide for Aviation Medical
Examiners

provides that any degree of sleep apnea is disqualifying for medical cer-
tification for all classes of pilots (113). However, aviation medical examiners may
reissue a pilot’s medical certificate without administrative appeal if the pilot pres-
ents a current report of a treating physician that the pilot’s OSA treatment therapy
has eliminated symptoms of the disease along with specific comments regarding
the pilot’s daytime sleepiness (114).
In 1989, the Nuclear Regulatory Commission (NRC) adopted its first Fitness
for Duty Program focusing on detection of drug and alcohol impairments on per-
sonnel with access to protected areas of nuclear power reactors licensed by the NRC
(115). Congressmen and others petitioned the NRC to expand the regulations to
expand the program to include screening for sleep apnea and other disorders. The

NRC published proposed rules to that effect in August 2005 (116).
LAWS REGULATING DIAGNOSTIC TESTING AND TREATMENT
OF OBSTRUCTIVE SLEEP APNEA
State Certificate of Need and Licensure Laws
The majority of states allocate healthcare resources within their borders through the
Certificate of Need (CON) process. Most CON laws require healthcare facilities,
such as hospitals, magnetic resonance imaging centers and other outpatient diag-
nostic centers, to apply for and receive a CON prior to obtaining a state license or
otherwise operating. Penalties for operating a healthcare facility without a CON
range from civil fines to criminal penalties.
CON laws routinely exempt a variety of healthcare activities from the lengthy
and expensive CON process. These exemptions include the individual or group
Legal Implications of Obstructive Sleep Apnea 419
practice of physicians and, in many cases, facilities requiring equipment or capital
expenditures below a certain dollar threshold. A review of applicable CON laws is
necessary to determine the impact on sleep testing.
States will typically require healthcare facilities such as nursing homes, ambu-
latory surgical centers, and some outpatient diagnostic testing facilities to obtain a
license prior to operating. Because polysomnograms have historically been catego-
rized for reimbursement and other purposes as an extensive electroencephalographic
(EEG)–electrocardiographic (EKG) modality, states do not usually require separate
facility licenses for sleep testing. However, a license may be required for freestanding
sleep testing facilities. Again, review of applicable state laws will be necessary.
Self-Referral Laws
Providers of healthcare must comply with applicable fraud and abuse laws. The risk
most relevant to OSA is the so-called federal “Stark” law prohibition on patient self-
referrals and related state laws (117). The Stark law prohibits a physician from making
a referral for a designated health service to an entity in which the physician (or an
immediate family member of such physician) has a financial relationship—including
a compensation arrangement—if the service is reimbursed by a federal healthcare

program (including Medicaid). Only referrals for designated health services are pro-
hibited. Professional readings for pulmonary function testing, EKGs and EEGs are
not designated health services, unless furnished in a hospital setting (118). For this
reason, polysomnography is also not considered to be a designated health service.
However, items of durable medical equipment, including CPAP and bilevel pressure
and related supplies, are designated healthcare services under the Stark law (119).
Consequently, a physician may not refer anyone to an entity owned, directly or indi-
rectly, by the physician or his immediate family, for CPAP if the entity seeks reim-
bursement from a federal healthcare program for the CPAP.
Many states have their own laws restricting self-referrals. Many are modeled
after the federal Stark law and prohibit referrals for durable medical equipment
regardless of government reimbursement. Some are more restrictive, others are less.
A review of the law applicable to the states in which the physician practices is neces-
sary to determine compliance.
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1. Sassani A, Findley LJ, Kryger M, et al. Reducing motor-vehicle collisions, costs, and
fatalities by treating obstructive sleep apnea. Sleep 2004; 27(d):453, 458.
2. Kryger MH, Roth T, Dement WC, eds. Principles and Practice of Sleep Medicine.
Philadelphia, PA: W.B. Sanders, 1994.
3. Shahar E, Whitney CW, Redline S, et al. Sleep-disordered breathing and cardiovascular
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128(2):624-633.
5. See, e.g., McCall v. Wilder, 913 S.W.2d 150 (Tenn. 1995).
6. Cornett v. State, W.O. Moss Hospital, 614 So.2d 189 (La. App. 3rd Cir. 1993).
7. Guilleminault C, Eldridge FL, Dement WC. Insomnia with sleep apnea: A new syn-
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8. Parks v. Harris, 614 F.2d 83 (5th Cir. 1980).

9. Sullivan CE, Issa FG, Berthon-Jones M, Eves L. Reversal of obstructive sleep apnea by
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420 Brown
10. Results of a March 10, 2006, Westlaw inquiry of all reported and unreported cases for
the mention of “sleep apnea” in any context in any state or federal court.
11. See, e.g., Besaraba v. State, 656 So.2d 441 (Fla. 1995), Edwards v. Edwards, 140 Or. App.
409 (1996).
12. William L. Prosser, Law of Torts, 4th ed, St. Paul: West Publishing Co., 1980:143.
13. William L. Prosser, Law of Torts, 4th ed, St. Paul: West Publishing Co., 1980:324.
14. See, e.g., Cruzan v. Missouri Department of Health, 497 U.S. 261, 110 S.Ct. 2841, 111
L.Ed.2d 224 (1990).
15. Eric L. Schulman, Note, Sleeping with the Enemy: Combatting (sic) the Sexual Spread
of HIV-AIDS Through A Heightened Legal Duty, 29 J. MARSHALL L. REV. 957, 971–
976, 1996.
16. American Law Reports 3d, Liability for Automobile Accident Allegedly Caused by
Driver’s Blackout, Sudden Unconsciousness, or the Like, Section 2(a), 93 A.L.R. 326
(1979), (updated 2006).
17. American Law Reports 2d, Physical Defect, Illness, Drowsiness, or Falling Asleep of
Motor Vehicle Operator as Affecting Liability for Injury, Section 3, 28 A.L.R.2d 12
(1953), (updated 2006).
18. Bushnell v. Bushnell, 103 Conn. 583, 131 A. 432 (1925).
19. Bushnell v. Bushnell, 103 Conn. 583, 591, 131 A. 432 (1925).
20. See, e.g., Estate of Embry v. GEO Transportation of Indiana, Inc., 395 F. Supp 2d 516
(E.D. Ky 2005), McCall v. Wilder, 913 S.W.2d 150 (Tenn. 1995).
21. McCall v. Wilder, 913 S.W.2d 150, 155 (Tenn. 1995).
22. See, Malcolm v. Patrick, 147 So.2d 188 (Fla.Ct.App. 1962); accord Eleason v. Western
Cas. & Sur. Co., 254 Wis. 134, 35 N.W.2d 301 (1948).
23. Howle v. PYA/Monarch, Inc., 288 S.C. App. 586, 344 S.E. 2d 157 (1986).
24. Testimony of Darrell Drobnich before the House Subcommittee on Highways and

Transit, Committee on Transportation and Infrastructure, 4, June 27, 2002,
(accessed
March 2006).
25. Chapter 143, 2003 New Jersey Public Laws.
26. “Maggie’s Law,” N.J.S.2C:11-5(a).
27. See, e.g., Robinson v. Bleicher, 251 Neb. 752, 559 N.W.2d 473 (1997).
28. See, e.g., Gooden v. Tips, 651 S.W.2d 364 (Tex. App. 1983) (as to physician’s failure to
warn a patient not to drive while under the influence of a prescribed drug).
29. See, e.g., U.S. Department of Transportation, National Highway Traffic Safety
Administration, “Strategies for Medical Advisory Boards and Licensing Review,” DOT
HS 809 874 (July 2005), available at />research/MedicalAdvisory/index.html, (accessed March 2006).
30. See, e.g., Gooden v. Tips, 651 S.W.2d 364 (Tex. App. 1983).
31. Kelly v. Middle Tennessee Emergency Physicians, P.C., 133 S.W.3d 587, 592 (Tenn. 2004).
32. Kelly v. Middle Tennessee Emergency Physicians, P.C., 133 S.W.3d 587, 593
(Tenn. 2004).
33. Dougherty v. Gifford, 826 S.W.2d 668 (Tex. App. 1992).
34. Dougherty v. Gifford, 826 S.W.2d 668, 672 (Tex. App. 1992).
35. Dougherty v. Gifford, 826 S.W.2d 668, 674 (Tex. App. 1992).
36. Dougherty v. Gifford, 826 S.W.2d 668, 674, 675 (Tex. App. 1992).
37. Kelly v. Middle Tennessee Emergency Physicians, P.C., 133 S.W.3d at 596 (Tenn.
2004).
38. CRS § 12-36-106(1) (a).
39. Missouri Revised Statutes Section 334.010.
40. ORS § 847.025.0010.
41. Ala. Code § 34-24-502.
42. Wright v. Yackley, 459 F.2d 287 (9th Cir. 1972).
43. Wright v. Yackley, 459 F.2d 287, 289 (9th Cir. 1972).
44. Andrews v. Lofton, 57 S.E.2d 338, 342 (Ga. App. 1950); Irwin v. Arrendale, 159 S.E.2d
719, 725 (Ga. App. 1967).
45. See, e.g., 42 CFR 410.33(e) (requiring the supervising physician of an independent diag-

nostic testing facility to be licensed in each state in which the facility operates); 31 U.
S.C. § 3729.
Legal Implications of Obstructive Sleep Apnea 421
46. Cornett v. State, W.O. Moss Hospital, 614 So.2d 189, 193 (La. App. 3rd Cir. 1993).
47. Cornett v. State, W.O. Moss Hospital, 614 So.2d 189, 194 (La. App. 3rd Cir. 1993).
48. Cornett v. State, W.O. Moss Hospital, 614 So.2d 189,196 (La. App. 3rd Cir. 1993).
49. See, e.g. Shadrick v. Coker, 963 S.W.2d 726, 732 (Tenn. 1998).
50. Russell v. Brown, No. E2004-01855-COA-R3-CV, 2005 WL 1991609 (Tenn.Ct.App.)
(August 18, 2005).
51. Russell v. Brown, No. E2004-01855-COA-R3-CV, 2005 WL 1991609 *2 (Tenn.Ct.App.)
(August 18, 2005).
52. Russell v. Brown, No. E2004-01855-COA-R3-CV, 2005 WL 1991609 *5 (Tenn.Ct.App.)
(August 18, 2005).
53. Russell v. Brown, No. E2004-01855-COA-R3-CV, 2005 WL 1991609 *13 (Tenn.Ct.App.)
(August 18, 2005).
54. See, The American Board of Medical Specialties, 2005 Annual Report & Reference
Handbook, available at />AnnualReport2005.pdf, (accessed March 2006).
55. See, e.g., Wharton Transport Corp. v. Bridges, 606 S.W.2d 521 (Tenn. 1980); Gooden v.
Tips, 651 S.W.2d 364, 396 (Tex. App. Tyler 1983).
56. Tarasoff v. Regents of University of California, 17 Cal 3d 425, 131 Cal. Rptr 14, 551 P.2d
334 (1976).
57. Taylor v. Smith, 892 So.2d 887, 895 (Ala. 2004).
58. See, e.g., McKenzie v. Hawa’i Permanente Med. Group, Inc., 98 Hawai’i 296, 309, 47
P.3d 1209, 1222 (2002) (physician “owes a duty to non-patient third parties” to warn
patients of possible adverse effects of prescribed medication on patients’ driving abil-
ity, “where the circumstances are such that the reasonable patient could not have been
expected to be aware of the risk without the physician’s warning”); Joy v. Eastern
Maine Med. Ctr., 529 A.2d 1364 (Me. 1987) (physician who treated a patient by placing
a patch over his eye owed a duty to motorists to warn the patient against driving while
wearing the patch); Welke v. Kuzilla, 144 Mich.App. 245, 252, 375 N.W.2d 403, 406

(1985) (physician who injected a patient with an “unknown substance” owed a duty to
motorists “within the scope of foreseeable risk, by virtue of his special relationship with
[the patient]”); Wilschinsky v. Medina, 108 N.M. 511, 515, 775 P.2d 713, 717 (1989) (phy-
sicians owe a duty “to persons injured by patients driving automobiles from a doctor’s
office when the patient has just been injected with drugs known to affect judgment and
driving ability”); Zavalas v. State Dep’t of Corr.,124 Ore.App. 166, 171, 861 P.2d 1026,
1028 (1993) (rejecting the argument “that a physician has no duty to third parties… who
claim that the physician’s negligent treatment of a patient was the foreseeable cause of
their harm”). But see Kirk v. Michael Reese Hosp. & Med. Ctr., 117 Ill.2d 507, 513
N.E.2d 387, 111 Ill.Dec. 944 (1987); Rebollal v. Payne, 145 A.D.2d 617, 536 N.Y.S.2d
147 (1988).
59. Gooden v. Tips, 651 S.W.2d 364, 370 (Tex. App. Tyler 1983).
60. See, generally, Massachusetts Medical Society, “Medical Perspectives on Impaired
Driving” (July, 2003), available at />ion=Home&CONTENTID=5027&TEMPLATE=/CM/HTMLDisplay.cfm, (accessed
March 2006).
61. American Medical Association, “Physician’s Guide to Assessing and Counseling Older
Drivers,” Chapter 8 (May 2003), providing a list of all 51 state laws regarding reporting
of impaired drivers. The Guide is available at the American Medical Society Website,
(accessed March 2006).
62. See, American Medical Association, “Physician’s Guide to Assessing and Counseling
Older Drivers,” Chapter 8 (May 2003).
63. See, American Medical Society, Ethics Opinion E-2.24, “Impaired Drivers and
Their Physicians,” (June 2004), available at http:// www.ama-assn.org (accessed
March 2006).
64. See, 42 C.F.R. § 164.512(a).
65. See, 42 C.F. R. § 164.512(j).
66. 42 U.S.C. §1201, et seq.
67. 29 U.S.C. § 791, et. seq.
68. See, e.g., Minnesota Human Rights Act, Minn.Stat. § 363.01, Wisconsin Fair Employment
Act, Wisc. Stats § 111.34, Maine Human Rights Act, 5 M.R.S.A. §§ 4551–4634.

422 Brown
69. See, e.g., Sutton V. United Air Lines, Inc., 527 U.S. 471, 477, 119 S.Ct. 2139 (1999).
70. See, e.g., EEOC v. Amego, Inc., 110 F.3d 135, 144 (1st Cir. 1997).
71. Matewski v. Orkin Exterminating Co., 2003 WL 21516577 *12 (D. Maine, July 1, 2003).
72. Sanders v. Firstenergy Corp., 157 Ohio App. 3d 826, 834 (2004).
73. Calef v. Gillette Co., 322 F.2d 75, 86 (1st Cir. 2003).
74. Tice v. Centre Area Transportation Authority, 247 F.3d 506, 513 (3rd Cir. 2001).
75. Albertson’s, Inc. v. Kirkingburg, 527 U.S. 555, 566 (1999).
76. Dvorak v. Mostardi Platt Assoc., Inc., 289 F.3d 479, 483 (7th Cir. 2002); Bekker v.
Humana Health Plan, Inc., 229 F3d 662, 669-70 (7th Cir. 2000).
77. Bragdon v. Abbott, 524 U.S. 624, 631 (1998).
78. 29 CFR § 1630.02(h).
79. 29 CFR § 1630.02(h)(1).
80. See, e.g., Kolecyck-Yap v. MCI Worldcom, Inc., No. 99 CV 8414, 2001 WL 245531 (N.D.
Ill. 2001), Peter v. Lincoln Technical Institute, Inc., 255 F. Supp 417. 431 (N.D. Ill 2002).
81. Miller v. Centennial State Bank, 472 N.W.2d 349, 351 (Minn. Ct. App. 1991).
82. Mont-Ros v. City of West Miami, 111 F. Supp.2d 1338 (S.D. Fla. 2000).
83. See, Pack v. Kmart Corp., 166 F.3d 1300, 1305 (10th Cir. 1999); McAlindin v. County of
San Diego, 192 F.3d 1226, 1234 (9th Cir. 1999), Bennett v. Unisys Corporation, No.
2:99CV0446, 2000 WL 33126583, at *5 (E.D.Pa. Dec.11, 2000); Reese v. American Food
Service, No. CIV. A.99-1741, 2000 WL 1470212, at *6 (E.D.Pa. Sept.29, 2000), Tedeschi v.
Sysco Foods of Philadelphia, No. CIV. A.99-3170, 2000 WL 1281266, at *5 (E.D.Pa.
Sept.5, 2000); Enforcement Guidance on the Americans with Disabilities Act and
Psychiatric Disabilities, Compliance Manual, COMPLIANCE MANUAL (CCH) P6906,
at 5398 (1998) (“EEOC Compliance Manual”). But See, Sarko v. Penn-Del Directory Co.,
968 F. Supp. 1026, 1034 n. 8 (E.D. Pa. 1997) (the ability to get a sound night’s sleep and
report to work on time and clear-minded was not a major life activity).
84. Sutton v. United Air Lines, 130 F.3d 893, 900 (10th Cir. 1997).
85. See Reberg, 2005 WL 3320780 at *5 (citing Katekovich v. TeamRent A Car of Pittsburgh,
Inc., 36 Fed. Appx. 688 (3rd Cir.2002); Green v. Pace Suburban Bus, No. 02 C 3031, 2004

WL 1574246 (N.D. Ill. July 12, 2004)).
86. Pack v. Kmart Corp., 166 F.3d 1300, 1306 (10th Cir. 1999).
87. 29 C.F.R. § 1630.2(j)(2).
88. Mont-Ros v. City of West Miami, 111 F. Supp.2d 1338, 1355 (S.D. Fla. 2000).
89. Peter v. Lincoln Technical Institute, Inc., 255 F. Supp. 417, 434 (E.D. Pa. 2002) (ADA
claim denied on other grounds).
90. See, e.g., Taylor v. Blue Cross Blue Shield of Texas, 1999 WL 451339 *4 (N.D. Tex. 1999),
Pack v. Kmart Corp., 166 F.3d 1300, 1306 (10th Cir. 1999); Mont-Ros v. City of West
Miami, 111 F. Supp.2d 1338 (S.D. Fla. 2000); Kolecyck-Yap v. MCI Worldcom, Inc., No.
99 CV 8414, 2001 WL 245531 (N.D. Ill. 2001); Wendt v. Village of Evergreen Park, No.
00 C 7730, 2003 WL 223443 (N.D. Ill. 2003).
91. Mont-Ros v. City of West Miami, 111 F. Supp.2d 1338, 1346 (S.D. Fla. 2000).
92. Long v. Mid-Tennessee Ford Truck Sales, 160 S.W.3d 504, 509 (Tenn. 2005).
93. Burlington Industries, Inc. v. Ellerth, 524 U.S. 742, 756 (1998).
94. Dunlap v. W.L. Logan Trucking Co., 161 Ohio App. 3d 51 (2005).
95. Dunlap v. W.L. Logan Trucking Co., 161 Ohio App. 3d 51, 66 (2005).
96. Dunlap v. W.L. Logan Trucking Co., 161 Ohio App. 3d 51, 67 (2005).
97. Dunlap v. W.L. Logan Trucking Co., 161 Ohio App. 3d 51, 68 (2005).
98. Dunlap v. W.L. Logan Trucking Co., 161 Ohio App. 3d 51, 69 (2005).
99. Martinez v. CO2 Services, Inc., No. 00-2218, slip op. at 7, (10th Cir. April 12, 2001).
100. 10 N.Y. Comp. Codes & Regs., tit. 10, § 405.4 (2002). First enacted in 1989, the regula-
tions limit resident scheduling to no more than 80 hours per week, averaged over four
weeks. Shifts are limited to 24 hours with flexibility for certain surgery residents.
Violators face significant monetary fines.
101. Baggett v. Brumfield, 758 So.2d 332, 336 (La. App.3d Cir. 2000).
102. Faverty v. McDonald’s Restaurants of Oregon, Inc., 133 Or. App. 514, 893 P.2d
703 (1995).
103. Snowbarger v. Tri-County Electric Coop., 793 S.W.2d 348 (Mo. 1990) (electric lineman
worked 86 of 100 hour work period during snow emergency and fell asleep at the
Legal Implications of Obstructive Sleep Apnea 423

wheel); Van Devander v. Heller Electric Co., 405 F.2d 1108 (D.C.Cir. 1968) (an electrical
equipment installer worked twenty-six consecutive hours on the job and fell asleep
from fatigue).
104. Maryland Transit Administration Light Rail Vehicle Accidents at the Baltimore-
Washington International Airport Transit Station near Baltimore, Maryland, February
13 and August 15, 2000, Railroad Special Investigation Report NTSB/SIR- 01/02
(Washington, D.C: NTSB, 2001); and Grounding of the Liberian Passenger Ship STAR
PRINCESS on Poundstone Rock, Lynn Canal, Alaska, June 23, 1995, Marine Accident
Report NTSB/MAR-97/02 (Washington, D.C: NTSB, 1997).
105. National Safety Transportation Board Report No. RAR-02/04, 27, “Railroad Accident
Report, Collision of Two Canadian National/Illinois Central Railway Trains Near
Clarkston, Michigan, November 15, 2001,” (November 19, 2002).
106. National Safety Transportation Board Report No. RAR-02/04, 28 (November 19, 2002).
107. Department of Transportation, Federal Railroad Administration, “Notice of Safety
Advisory 2004-04; Effect of Sleep Disorders on Safety of Railroad Operations,” 69 Fed.
Reg. 190, 58995, 58996 (October 1, 2004).
108. 49 CFR § 391.41.
109. 49 CFR § 391.41(b)(5), (8).
110. 49 CFR § 391.43; Final Rule, Department of Transportation, Federal Motor Carrier Safety
Administration, “Physical Qualification of Drivers; Medical Examination; Certificate,”
65 Fed. Reg. 194, 59363-59380 (October 5, 2000).
111. Federal Motor Carrier Safety Administration, Advisory Criteria, The Conference on
Pulmonary/Respiratory Disorders and Commercial Drivers, FHWA-MC-91-004, at 5
(1991), (accessed March 2006).
112. Federal Motor Carrier Safety Administration, Advisory Criteria; Conference on
Neurological Disorders and Commercial Drivers at: />regs/medreports.html “Seizures, Epilepsy and Interstate Commercial Driving,” http://
www.fmcsa.dot.gov/documents/neuro2.pdf.
113. Electronic Guide for Aviation Medical Examiners, />org/headquarters_offices/avs/offices/aam/ame/guide/media/sec3.pdf, 61, (July 31,
2005) (accessed March 2006).
114. Electronic Guide for Aviation Medical Examiners, “AASI For History of Sleep Apnea,”

(January 16, 2006), />offices/aam/ame/guide/media/aasisleep.pdf (accessed March 2006).
115. 10 CFR Part 26, 54 Fed. Reg. 24468.
116. Nuclear Regulatory Commission, Proposed Rule, “Fitness for Duty Programs,” 70 Fed.
Reg. 165 50442-50620 (August 26, 2005).
117. 42 U.S.C. § 1395nn.
118. 66 Fed. Reg. 3; 880 (January 4, 2001).
119. 42 U.S.C. § 1395nn(h)(6)(F).

425
A Concluding Note and Future Directions
William C. Dement
Stanford Sleep Research Center, Palo Alto, California, U.S.A.
Obstructive sleep apnea (OSA) and other sleep-related breathing disorders are argu-
ably the number one health problem in the United States if not the entire world.
Given the high prevalence, it is amazing that this problem was completely unknown
to the general public as well as health professionals as recently as 1965 and mostly
unknown until the late 1970s. In addition to the actual obstructive sleep disorder
itself, there are strong associations with cardiovascular disease, fatigue, mental
impairment, diabetes, obesity, and probably a host of other less well-documented
associations.
All of the above receives a detailed description in these two volumes. It is
worth noting that early on, Stanford sleep specialists realized the high prevalence of
OSA. We also realized that a standard model to deal with the condition should be
established. Finally, we knew it would be necessary to start training other physi-
cians to diagnose and treat OSA. This led directly to the establishment of the formal
clinical practice specialty of sleep medicine, which deals exclusively with the diag-
nosis and treatment of sleep disorders.
As with anything else, there are those who insist on only the most high-tech
approaches. This is no longer appropriate. I have always said probably 90% of vic-
tims can be identified by asking two questions: (i) Do you snore loudly or does the

bed partner, if there is one, complain? and (ii) Are you unusually tired when you are
awake throughout the daytime with no apparent cause? If the answers to both
the foregoing questions are “yes,” OSA is highly likely. Keep in mind that indi-
viduals often do not seem to be aware of their fatigue, and among other individuals
there is often a misapprehension that the tiredness is caused by depression, anemia,
or some other esoteric problem. Any time there is loud snoring, check it out. As I
have indicated, checking it out could not be easier. In fact, an educated bed partner
can easily assess the implications of the snoring.
One of the problems we have encountered is that this area of human behavior
is strange and frightening to many people. Some years ago, we showed a film clip
of patients being treated with continuous positive airway pressure (CPAP) to a
group of burly, tough, long-haul truck drivers. They were visibly shaken by the
strangeness of patients sleeping with CPAP machines. Therefore, bestowing the
benefits of the diagnosis of OSA on most individuals will certainly require extra
efforts of persuading and convincing.
All of this is very ambitious, but clearly, as the large-scale clinical trials such as
the Apnea Positive Pressure Long-term Efficacy Study (APPLES) now being con-
ducted demonstrate, there is a pressing need for additional research in the service
of prevention and diagnostic methodologies for all potential patient populations,
including infants and children. There is promise of meeting some of this need in the
near future, as less expensive and more accessible diagnostic tools, such as portable
monitoring, are now being evaluated as a reasonable alternative to the in-laboratory
polysomnogram. Above all, there is an even greater need for research in the service
of the development of new treatment modalities and conclusive testing of those
25
426 Dement
currently available. Partnerships between academia and industry, once frowned
upon but now viewed as almost a codependent relationship, can help to foster the
development of these newer treatment technologies. It is important to realize that
the field of apnea treatment has made significant advances since the development

of CPAP a little over a quarter of a century ago, but much more needs to be accom-
plished in sleep apnea patient care and research to develop treatments that are more
palatable and accessible to those with this debilitating condition.
I have taught “Sleep and Dreams,” which is the largest undergraduate course
at Stanford, for over 30 years. During this time, I have witnessed countless personal
stories in which students have learned about sleep apnea through my course and
then subsequently educated and encouraged their family and friends suspected of
having sleep apnea to obtain professional help for their condition. Based on this
experience, there is a need to promote more education about sleep apnea and other
sleep disorders not only at the medical or graduate student, resident, and practicing
physician levels, but also at the undergraduate student levels. Only in doing so can
we increase the awareness of this condition within the general public as well as to
encourage others to enter the field to find better diagnostic and treatment options
for sleep apnea sufferers.
There have been strong efforts in the public awareness and advocacy sectors,
notably the National Commission on Sleep Disorders Research which issued its
final report “Wake Up America: A National Sleep Alert” in 1993 after its two-year
study, and more recently, the Institute of Medicine’s report, “Sleep Disorders and
Sleep Deprivation: An Unmet Public Health Problem,” which was released in 2006.
Given the existence of the National Center on Sleep Disorders Research in the
National Heart, Lung and Blood Institute and the scope of the problem, it is abso-
lutely essential that this center be accorded a much higher priority and a much
larger budget from its parent institute and/or the US Congress, or perhaps it should
be a freestanding entity. At the moment, the will to strongly advocate such improve-
ments does not seem to exist among patients and practitioners, but the professional
organizations representing this field, to wit, the American Academy of Sleep Medicine,
the Sleep Research Society, the American Association of Sleep Technologists, and the
National Sleep Foundation must respond to the challenge. There are also patient orga-
nizations, in particular the American Sleep Apnea Association as well as smaller local
organizations. The moral imperative, however, is that we can and therefore we must

deplore the diminished health, quality of life, and shortened-life expectancy of human
beings afflicted with OSA and because we can, we must work as hard as possible to
change their lives for the better.
427
ACE. See Angiotensin-converting enzyme
inhibitors
Acetazolamide (Diamox), 239, 297, 298
nonhypercapnic CSA, 328
Acid maltase deficit
NIPPV, 176
Acoustic reflection
upper airway, 67–68
Acromegaly, 237, 398
CSA, 326
Actigraphy, 29–30
ADA. See Americans with Disabilities Act
Adaptive servo-ventilation, 125, 134. See also
Bilevel pressure and adaptive
servo-ventilation
Adenotonsillectomy
pediatric SDB, 272
ADHD. See Attention deficit/hyperactivity
disorder
Adherence
adaptive servo-ventilation, 129–130
CPAP, 111–113
nasal CPAP, 255
oral appliances, 223
positive pressure therapy, 160,
161–164

dependent variable, 161–162
Aerophagia
positive pressure therapy, 159
Aggressive disorders, 267
Aging, CSA, 324
AHI. See Apnea/hypopnea index (AHI)
Air leakage
positive airway pressure therapy, 159
Airway bypass surgery, 210
tracheotomy, 210
Alcohol, 233, 253, 300, 302
GER, 396
geriatric OSA, 282
OSA, 8–9
Alertness, 89–100
Allergies, 9
Almitrine, 239
Alprazolam (Xanax, Niravam), 301
ALS. See Amyotrophic lateral sclerosis
Alveolar hypoventilation
clinical features, 176
Alzheimer’s disease, 285, 370–371
Ambien
®
, 234, 302
Ambulatory diagnostic system, 30
Americans with Disabilities Act (ADA), 414
Aminorex (Menocil), 236
Amlodipine (Norvasc), 299
Amyotrophic lateral sclerosis (ALS),

378–379
NIPPV, 176
Androgens, 234
Anesthetics, 301
Angina, nocturnal, OSA, 7
Angiotensin-converting enzyme
inhibitors, 299
ANN. See Artificial neural networks
Antacids, GER, 396
Antiepileptic drug side effects, 349
Antihypertensive medications, 296
Antipsychotics, 300
Anxiolytics, 300
APAP. See Auto-positive airway pressure (APAP)
Apert’s syndrome, 271–272
Apnea. See also specific apnea
genioglossus, 63
tensor palatine, 63
Apnea/hypopnea index (AHI), 43, 66
epilepsy, 340
insomnia, 350–351
OSA portable monitoring, 51–53
pediatric OSA, 269–270
Apnea Positive Pressure Long-term Efficacy
Study (APPLES), 425
Apneas, 2–3. See also specific apnea
pons, 368
APPLES. See Apnea Positive Pressure
Long-term Efficacy Study
ARES Unicorder, 28

Arnold Chiari malformations, 377
Arousal disorders, 359
Arrhythmias, cardiac, diagnosis, 38–39
Artificial neural networks (ANN), 23
Index
428 Index
Asthma, 390–392
bronchial
vs. OSA, 342–343
CPAP, 391–392
Ataxic breathing, medulla, 368
Ativan, 301
Attention deficit/hyperactivity disorder
(ADHD), 268
Australia
CPAP cost and reimbursement, 116–117
Auto-positive airway pressure (APAP),
137–150, 163
auto-titration, 140–144
technique, 142–144
BPAP, 140, 147
Cheyne-Stokes central apnea, 139
chronic treatment, 144–148
technique, 147–148
vs. CPAP, 145–146
device characteristics, 137–138
efficacy, 141–142
EPAP, 140
IPAP, 140
mask/mouth leak, 138

portable monitors, 144
potential uses, 138
reimbursement, 148
repetitive apneas, 139
statistics, 145
AutoSet T, 138
Baclofen (Kemstro), 234
Barbiturates, 301, 374
Bariatric surgery, 236, 256
upper airway, 80–81
Bedwetting, 267
Behavioral treatment
OSA, 233–234, 241
UARS, 314
Benzodiazepines, 233–234, 300, 301, 372, 374
Beta-blockers, 299
Bi-Flex device, 129–130, 140
Bilevel PAP (BPAP), 125, 154
APAP, 140, 147
pediatric SDB, 274
Bilevel pressure and adaptive servo-ventilation,
125–136
adherence, 129–130
central apnea, 130
Cheyne-Stokes respiration, 130
complex sleep apnea, 130–131
historical, 125–126
[Bilevel pressure and adaptive
servo-ventilation]
hypercapnia, 128–129

patient selection, 127–128
reimbursement criteria, 131–133
severe obesity, 127–128
titration, 126–127
Bisphosphonates
GER, 396
Blood pressure
CPAP, 115–116
OSA, 10
BMI. See Body mass index
Body mass index (BMI), 22, 235
geriatric OSA, 282
Bötzinger complex, 369
BPAP. See Bilevel PAP
Bromocriptine (Parlodel), 239
Bronchial asthma vs. OSA
quality of life, 342–343
Bronchiectasis, NIPPV, 176
Bullying, 267
Bupivacaine (Marcaine), 234
Bushnell v. Bushnell, 406–407
Butalbital, 301
C-Flex, 110, 140
CAD. See Coronary artery disease
Caffeine, GER, 396
Calcium channel blockers, 299
GER, 396
Canadian CPAP Trial for Congestive Health
Failure Patients with Central Apnea
(CANPAP), 116, 328

Cardiac arrhythmia diagnosis, 38–39
Cardiac failure, CPAP, 116
Cardiac medications, 299
Cardiorespiratory monitoring, 35–60
Cardiovascular disease, 398–400
Cardiovascular outcomes, CPAP,
115–116
Cardiovascular risk factor reduction,
OSA, 235
Cataplexy, 4
Catapres, 299
Central hyperventilation,
midbrain, 368
Central nervous system (CNS)
disorders, 368, 370–375
Central sleep apnea (CSA), 38, 301,
321–332
acromegaly, 326
Index 429
[Central sleep apnea (CSA)]
aging, 324
bilevel pressure and adaptive
servo-ventilation, 130
cerebrovascular disease, 325
congestive heart failure, 325
continuous positive airway pressure therapy,
153–154
CPAP, 103
gender, 324–325
hypercapnic, 321

management, 327
NIPPV, 327
hypothyroidism, 326
idiopathic, 326
management, 327–328
metabolic disorders, 326
nonhypercapnic, 322
management, 327–329
pharmacological therapy, 328–329
supplemental oxygen, 328–329
NREM, 322
pathogenesis during sleep, 322–323
pathophysiologic classification, 321–322
REM, 322
risk factors, 323–326
sleep state, 324
Cephalometry
mandibular advancement splints, 225
upper airway, 67, 194
Cerebral cortex
Cheyne-Stokes, 368
Cerebrovascular disease, CSA, 325
Certificate of need (CON) and licensure
laws, 418–419
Charcot-Marie-Tooth (CMT), 379
Cheyne-Stokes respiration (CSR),
53, 324, 369
APAP, 139
bilevel pressure and adaptive
servo-ventilation, 130

cerebral cortex, 368
continuous positive airway pressure
therapy, 153–154
geriatric SDB, 284
NIPPV, 176
Child Behavioral Checklist, 267
Children. See Pediatric
Choking, 2–3
Choline esterase inhibitor, 372
Chronic hypercapnic respiratory failure
NIMV, 340
Chronic hypoxemia, 379
Chronic obstructive pulmonary disease
(COPD), 333–337, 392–394
airflow limitation, 334
diagnosis and management, 339–340
diaphragm, 336
gas exchange during sleep, 333–334
hypertension, 393
long-term oxygen therapy, 334–335
NIPPV, 394
nocturnal desaturation, 335
nocturnal hypoxemia, 334
treatment, 340
nocturnal oximetry, 339–340
noninvasive mechanical ventilation
(NIMV), 340–341
physiological variables, 334
positive airway pressure therapy, 154
respiratory muscles, 336

SDB, 337–338
sleep quality, 338–339
sleep studies, 340
Claustrophobia
positive airway pressure therapy, 159
Cleveland Family Study, 9
Clonazepam (Klonopin), 301, 372
Clonidine (Catapres), 299
CMT. See Charcot-Marie-Tooth
CNS. See Central nervous system
Cognition
geriatric SDB, 284–285
pediatric SDB, 268
Computed tomography (CT)
upper airway imaging, 65–66
CON. See Certificate of need (CON) and
licensure laws
Congenital craniofacial syndromes, 14
Congestive heart failure
CSA, 325
geriatric SDB, 284
Conners Parent Rating Scale-Revised:Long, 267
Continuous positive airway pressure
(CPAP), 101–124, 255
adherence, 111–113
Alzheimer’s disease, SRBD, 371
vs. APAP, 145–146
assessment, 104
asthma, 391–392
baseline indicators, 113

benefits, 151–152
blood pressure, 115–116
cardiac failure, 116
430 Index
[Continuous positive airway pressure (CPAP)]
cardiovascular disease, 399–400
cardiovascular outcomes, 115–116
central apnea, 103
Cheyne-Stokes respiration, 153–154
CHF, 400
cost and reimbursement, 116–117
CSA, 153–154
decompensated patients with
cardiorespiratory failure, 106–107
ESRD, 397
failure, 114
first night, 104–106
geriatric SDB, 288
health outcomes, 114–115
home setting, 107–108
indications, 152–155
interface, 109
left-to-right cardiac shunt (LRS), 115–116
mode of action, 102–103
motivation, 113
MRI, 79
nasal congestion, 108–109
vs. oral appliances, 222–223
OSA, 101, 152–153
upper airway imaging, 77

vs. other treatments, 110–111
pediatric SDB, 272–275
practical aspects, 103–104
preeclampsia, 115–116
pressure level and airflow, 109–110
side effects, 108–109
split-night study, 107
UARS, 153, 314
COPD. See Chronic obstructive pulmonary
disease
Coronary artery disease
OSA, 8
Cortisol, 252
Cost effectiveness
portable monitor, 55–56
CPAP. See Continuous positive airway
pressure
Craniofacial features
OSA, 11–12
Craniofacial morphology
upper airway, 72–73
Craniofacial syndromes
congenital, 14
Criminal responsibility
recklessness, 407–408
Crouzon’s syndrome, 271–272
CSA. See Central sleep apnea
CSR. See Cheyne-Stokes respiration
CT. See Computed tomography
Cycrin, 238, 297

Cystic fibrosis
NIPPV, 176
Daytime sleepiness, 53
ESRD, 397
Delta sleep, children, 264
Dementia
geriatric SDB, 284–285
Lewy body, 371
Dementia Rating Scale (DRS), 285
Demerol, 301
Depression
OSA, 8
sleep apnea, 352–354
Dermatomyositis, 382
Desyrel, 299
Dexfenfluramine (Fen-Phen
®
), 236
Diabetes mellitus, 379
Diamox, 239, 297, 298
nonhypercapnic CSA, 328
Diaphragm
COPD, 336
Diazepam (Valium), 301
Diet, weight loss, 235
DigiTrace Home Sleep System, 25
Dilaudid, 234
Disability laws, 414–415
DMD. See Duchenne muscular
dystrophy

DME. See Durable medical equipment
providers
DMERC. See Durable medical equipment
regional carrier
Dolophine, 234
Donepezil, 372
Dougherty v. Gifford, 409
Down syndrome, 272, 372
Driving, impaired
physicians duties, 412–413
DRS. See Dementia Rating Scale (DRS)
Dry mouth
positive airway pressure
therapy, 159
Duchenne muscular dystrophy (DMD),
272, 381–382
NIPPV, 155, 176
Index 431
Duobloc mandibular advancement splints,
218, 227
Durable medical equipment (DME)
providers, 148
Durable medical equipment regional carrier
(DMERC), 131–132
Dynacirc, 299
Edema, upper airway, 71
Eden Trace II Recording System, 25
EDS. See Excessive daytime sleepiness
Elderly. See Geriatric
Embletta Recording System, 26

Employer legal obligations, 413–418
Enbrel, 239–240, 241
End-stage renal disease (ESRD), 396–398
CPAP, 397
daytime sleepiness, 397
PLMD, 397
RLS, 397
Enuresis, 267
EPAP. See Expiratory PAP
Epilepsy, 373–375
sleep apnea treatment, 349–350
Epworth Sleepiness Scale (ESS), 91–92
Esophageal motility agents, 396
Esophageal reflux, 379
ESRD. See End-stage renal disease
ESS. See Epworth Sleepiness Scale
Estrogen, 251, 252, 296, 299
Etanercept (Enbrel), 239–240, 241
Ethnicity
geriatric OSA, 282
upper airway, 72–73
Examination. See Physical examination
Excessive daytime sleepiness (EDS), 2, 281, 307
Exercise, weight loss, 235
Expiratory PAP (EPAP), 126
APAP, 140
Eye irritation
positive airway pressure therapy, 159
Family history
geriatric OSA, 282

OSA, 9
Federal Aviation Administration Guide for
Aviation Medical Examiners, 418
Federal Motor Carrier Safety Administration,
417–418
Federal Railroad Administration (FRA), 417
Fen-Phen
®
, 236
Fiberoptic nasopharyngolaryngoscopy
upper airway surgery, 193–194
Fluoxetine (Prozac, Sarafem), 298
FRA. See Federal Railroad Administration
Fujita classification, 198
Functional Outcomes of Sleep
Questionnaire, 222
Gasping, 2–3
Gastroesophageal reflux (GER), 394–396
OSA vs. bronchial asthma, 342–343
GBAT. See Genial bone advancement
trephine system
Gender
CSA, 324–325
OSA, 247–260, 253–255
upper airway, 71–72
Genetics, upper airway, 72–73
Genial bone advancement trephine
system (GBAT), 208
Genioglossus, apnea, 63
Genioglossus advancement hyoid

myotomy, 208–209
GER. See Gastroesophageal reflux
Geriatric obstructive sleep apnea, 281–295
epidemiology, 281–282
risk factors, 282–283
upper airway, 282
Geriatric sleep-disordered breathing
Alzheimer’s disease, 285
Cheyne-Stokes respiration, 284
clinical assessment and management, 287–288
clinical features, 283–284
cognition, 284–285
CPAP, 288
dementia, 284–285
diagnosis, 287–288
hypertension, 283
mortality, 286–287
oral appliances, 288
Parkinson’s disease, 285–286
snoring, 283
surgery, 289
treatment, 288–289
Glaucoma, OSA, 8
Glossectomy, midline, 209
Growth hormone, 252
Guillain-Barré syndrome, 368, 379–380
Halcion, 234
Hallucinations, hypnagogic, 4
432 Index
Headaches, 375–376

Health Insurance Portability and Accountability
Act of 1996 (HIPAA), 413
Health outcomes
CPAP, 114–115
HIPAA. See Health Insurance Portability
and Accountability Act of 1996
Histamine H2 receptor antagonists
GER, 396
History
OSA, 1–20, 6–7, 7–8, 9
pediatric OSA, 13–14, 264–265
Hormone replacement therapy, 254–255,
296, 299
Hydromorphone (Dilaudid, Palladone), 234
Hyoid myotomy and suspension, 201–202
Hypercapnia
bilevel pressure and adaptive
servo-ventilation, 128–129
Hypercapnic central sleep apnea, 321
management, 327
NIPPV, 327
Hypercapnic respiratory failure
chronic, NIMV, 340
Hypersomnolence
oral appliances, 220
Hypertension, 299, 373
COPD, 393
geriatric SDB, 283
OSA, 8
Hyperventilation

central, midbrain, 368
Hypnagogic hallucinations, 4
Hypnotics
sedative, 233–234, 301
Hypoglossal nerve, 239
Hypopharynx
anatomy and physiology, 61–62
obstruction, 208–209
Hypotension, 299
orthostatic, UARS, 313
Hypothyroidism, 237, 398
CSA, 326
OSA, 8
Hypoventilation
alveolar, clinical features, 176
neuromuscular junction, 368
Hypoxemia
chronic, 379
nocturnal
COPD, 334
treatment, 340
ICAM-1. See Intracellular adhesion molecule-1
IL-6. See Interleukin-6 (IL-6)
IL-8. See Interleukin-8 (IL-8)
ILD. See Interstitial lung disease
Imipramine (Tofranil), 297
Imovane, 234
Impaired driving
physician duties, 412–413
Inflammation, 389–390, 392, 399

Informed consent
physicians duties, 411–412
Inhibace, 299
Injection snoreplasty, 207
Insomnia, 3, 6–7
defined, 350
prevalence, 350
sleep apnea, 350–352
Inspiratory PAP (IPAP), 126
APAP, 140
Institute of Medicine, 426
Interleukin-6 (IL-6), 389, 392
Interleukin-8 (IL-8), 389, 392, 399
Interstitial lung disease (ILD)
PAP, 155
Intracellular adhesion molecule-1
(ICAM-1), 389, 392, 399
Introspective sleepiness, 91–92
IPAP. See Inspiratory PAP (IPAP)
Isradipine (Dynacirc), 299
K-ABC. See Kaufman Assessment Battery
for Children (K-ABC)
Karolinska sleepiness scale, 91, 92
Kaufman Assessment Battery for
Children (K-ABC), 268
Kemstro, 234
Klonopin, 301, 372
Kyphoscoliosis
NIPPV, 176
PAP, 155

Lambert-Eaton syndrome, 380–381
Laser-assisted uvulopalatoplasty (LAUP),
68, 207
LAUP. See Laser-assisted uvulopalatoplasty
Laws
disability, 414–415
self-referral, 419
Left-to-right cardiac shunt (LRS)
CPAP, 115–116
Legal duties
physicians, 408–409
Index 433
Legal implications
OSA, 405–424
Legal obligations
employers, 413–418
Leptin, 252
LES. See Lower esophageal sphincter (LES)
Lewy body dementia, 371
Liability for employee’s negligence
employers, 416–417
Lingualplasty, 209
Lorazepam (Ativan), 301
Lower esophageal sphincter (LES), 395
LRS. See Left-to-right cardiac shunt (LRS)
Magnetic resonance imaging (MRI)
CPAP, 79
upper airway, 64–65, 73
Maintenance of wakefulness test (MWT),
96, 97

Mallampati classification system, 12
Mandibles
bite depth, 227
Mandibular advancement splints (MAS),
217–218
cephalometric radiograph, 225
duobloc, 218, 227
monobloc, 218
MRI, 219
Mandibular osteotomy with genioglossus
advancement, 200–201
Manifest sleepiness, 95–97
observation scales, 96–97
Marcaine, 234
MAS. See Mandibular advancement
splints (MAS)
Mask leak
APAP, 138
positive pressure therapy, 159
Maxillary osteogenic distraction device
children, 275
Maxillomandibular advancement osteotomy
(MMO), 203–205
MCP-1. See Monocyte chemoattractant
protein-1 (MCP-1)
MD. See Myotonic dystrophy (MD)
Mebaral, 301
Medical disorders, 389–404
Medications
effects, 295–304

side effect checklists, 91, 92
Medroxyprogesterone (Cycrin, Provera),
238, 297
Medulla
ataxic breathing, 368
Men
OSA, 247–248
Menocil, 236
Menopause, 254–255
Mentally handicapped individuals, 372
Meperidine hydrochloride (Demerol), 301
Mephobarbital (Mebaral), 301
Meridia, 236
MESAM IV, 27
Methadone (Dolophine, Methadose), 234
Methadose, 234
Metoclopramide
GER, 396
Metoprolol (Inhibace), 299
MG. See Myasthenia gravis
Mibefradil (Posicor), 299
Micrognathia, 13
Midazolam (Versed), 301
Midbrain
central hyperventilation, 368
Midline glossectomy (MLG), 209
Mirtazapine (remeron), 299
MLG. See Midline glossectomy
MMO. See Maxillomandibular advancement
osteotomy (MMO)

Modafinil (Provigil), 240, 241–242, 295–297
adverse effects, 297
mechanism of action, 296
pharmacokinetics, 296–297
Monobloc mandibular advancement
splints, 218
Monocyte chemoattractant protein-1
(MCP-1), 389, 392, 399
Morbidity
clinical features, 283–284
Mortality
clinical features, 283–284
Motivation
CPAP, 113
Mouth leak
APAP, 138
MRI. See Magnetic resonance imaging
MSLT. See Multiple sleep latency test
Muller maneuver, 68, 80
Multiple sclerosis, 376–377
Multiple sleep latency test
(MSLT), 92, 94
pediatric OSA, 269
Muscular dysfunction/sensory neuropathy
upper airway, 71