Knowledge hub for Authorised Health Professionals.
Obstructive Sleep Apnoea (OSA) and STOP-BANG
Credit: Chief Medical Officer, Dr Stuart Turnbull
Acknowledgement: Chief Medical Officer, Dr Graeme Edwards
Four months into the 2024 National Standard for Health Assessment of Rail Safety Workers, the biggest change by far is the STOP-BANG tool for identifying Category 1 and 2 workers who are at risk of suffering from obstructive sleep apnoea (OSA). We have long recognised the limitations of the Epworth Sleepiness Score and that ‘awareness’ is a relatively late clinical feature of sleep disordered breathing.
OSA is an insidious condition that may eventually result in a worker suffering from impaired judgement and even excessive day-time sleepiness. It is not a condition that necessarily manifests as microsleeps. Its onset can be much more subtle.
A STOP-BANG score of 3 or more indicates the person has at least a 2.5-fold increased risk of asymptomatic OSA. The higher the score, the greater the risk. Under the Standard these workers are required to undertake at least a home-based Level 2 (usually 7 channels) sleep study irrespective of their Epworth score. In the past, a trigger for a sleep study was primarily based on BMI. With the introduction of STOP-BANG, a male over the age of 50, needs only one other risk factor to cross the threshold.
Chief Medical Officers (CMOs) oversight many AHPs and it appears many may be missing the objective of the STOP-BANG. A fundamental purpose of the Standard is to identify those individuals who will benefit from intervention before their medical condition contributes to a “serious incident”. Many of our older workers will qualify simply based on elevated blood pressure, BMI ≥35, or a neck circumference ≥ 40cm. So be vigilant and remember, unless the worker manifests an Epworth Score greater than 15, or the workplace has flagged a concern, they remain “Fit” for duty but subject to review.
What do you do when the sleep study result comes back
If the Apnoea-Hypopnoea Index (AHI) is 30 or more events per hour, the worker has “severe sleep apnoea” and is temporarily unfit for rail safety work (Category 1 or 2). While the rail transport operator may be able to accommodate the worker in non-safety critical activities, the focus should be on establishing a satisfactory response to treatment under the care of their usual medical practitioner. CPAP use is the quickest and easiest way to experience the benefits of treatment and demonstrate a satisfactory response to and compliance with treatment; criteria necessary before they can return to rail safety critical work. Renting an auto-titrating CPAP machine means they could return to work after 1-2 weeks, even before they have been assessed by their treating sleep physician. Their CPAP usage data also provides valuable information for when they see their sleep specialist. Once stabilised and reviewed, annual review is appropriate.
If the AHI is 15-29 events per hour, moderate OSA, the worker may remain “fit” subject to review while awaiting the advice of their sleep physician. Once information is received, further follow-up will depend on the recommended treatment (eg-weight loss, mandibular splint, CPAP etc).
Workers with mild OSA (AHI >5 – <15) do not need to comply with specific Rail Standard requirements. But they do have OSA and should be directed to follow the advice of their medical practitioner. The specifics of their case may mean you schedule a ‘triggered review’ to appropriately monitor their modifiable risk factors.
If a worker has an AHI <15, they do not need a repeat study with subsequent medicals unless there has been a significant change in their risk profile – such as weight gain of 10% or more, increased neck circumference, or a worsening of their STOP BANG score.
The STOP-BANG is a powerful tool but remember the score does not predict the severity of OSA, only the likelihood of its presence. We have seen a young man with a STOP BANG score of 3 with severe OSA (AHI 133); and an older gentleman with a score of 5, that had an AHI <5.
Please contact a CMO if you have any questions. The list of CMOs can be found on the RISSB webpage.
Obstructive Sleep Apnoea (OSA) and STOP-BANG
Credit: Chief Medical Officer, Dr Stuart Turnbull
Acknowledgement: Chief Medical Officer, Dr Graeme Edwards
Four months into the 2024 National Standard for Health Assessment of Rail Safety Workers, the biggest change by far is the STOP-BANG tool for identifying Category 1 and 2 workers who are at risk of suffering from obstructive sleep apnoea (OSA). We have long recognised the limitations of the Epworth Sleepiness Score and that ‘awareness’ is a relatively late clinical feature of sleep disordered breathing.
OSA is an insidious condition that may eventually result in a worker suffering from impaired judgement and even excessive day-time sleepiness. It is not a condition that necessarily manifests as microsleeps. Its onset can be much more subtle.
A STOP-BANG score of 3 or more indicates the person has at least a 2.5-fold increased risk of asymptomatic OSA. The higher the score, the greater the risk. Under the Standard these workers are required to undertake at least a home-based Level 2 (usually 7 channels) sleep study irrespective of their Epworth score. In the past, a trigger for a sleep study was primarily based on BMI. With the introduction of STOP-BANG, a male over the age of 50, needs only one other risk factor to cross the threshold.
Chief Medical Officers (CMOs) oversight many AHPs and it appears many may be missing the objective of the STOP-BANG. A fundamental purpose of the Standard is to identify those individuals who will benefit from intervention before their medical condition contributes to a “serious incident”. Many of our older workers will qualify simply based on elevated blood pressure, BMI ≥35, or a neck circumference ≥ 40cm. So be vigilant and remember, unless the worker manifests an Epworth Score greater than 15, or the workplace has flagged a concern, they remain “Fit” for duty but subject to review.
What do you do when the sleep study result comes back
If the Apnoea-Hypopnoea Index (AHI) is 30 or more events per hour, the worker has “severe sleep apnoea” and is temporarily unfit for rail safety work (Category 1 or 2). While the rail transport operator may be able to accommodate the worker in non-safety critical activities, the focus should be on establishing a satisfactory response to treatment under the care of their usual medical practitioner. CPAP use is the quickest and easiest way to experience the benefits of treatment and demonstrate a satisfactory response to and compliance with treatment; criteria necessary before they can return to rail safety critical work. Renting an auto-titrating CPAP machine means they could return to work after 1-2 weeks, even before they have been assessed by their treating sleep physician. Their CPAP usage data also provides valuable information for when they see their sleep specialist. Once stabilised and reviewed, annual review is appropriate.
If the AHI is 15-29 events per hour, moderate OSA, the worker may remain “fit” subject to review while awaiting the advice of their sleep physician. Once information is received, further follow-up will depend on the recommended treatment (eg-weight loss, mandibular splint, CPAP etc).
Workers with mild OSA (AHI >5 – <15) do not need to comply with specific Rail Standard requirements. But they do have OSA and should be directed to follow the advice of their medical practitioner. The specifics of their case may mean you schedule a ‘triggered review’ to appropriately monitor their modifiable risk factors.
If a worker has an AHI <15, they do not need a repeat study with subsequent medicals unless there has been a significant change in their risk profile – such as weight gain of 10% or more, increased neck circumference, or a worsening of their STOP BANG score.
The STOP-BANG is a powerful tool but remember the score does not predict the severity of OSA, only the likelihood of its presence. We have seen a young man with a STOP BANG score of 3 with severe OSA (AHI 133); and an older gentleman with a score of 5, that had an AHI <5.
Please contact a CMO if you have any questions. The list of CMOs can be found on the RISSB webpage.