For many Americans, especially men and those with higher BMIs, sleep apnea is a chronic source of sleep deprivation and poor rest. A lack of sleep is unhealthy enough, but in a pilot, sleep deprivation can lead to errors with deadly consequences.

Untreated sleep apnea can keep an airman from receiving the medical certificate they need to fly. The FAA’s chief concern is the “cognitive impairment secondary to the lack of restorative sleep” that sleep apnea causes. Pilots will be evaluated for the risk factors of sleep apnea during their medical certificate examination. If they appear to be suffering from a sleep disorder, they cannot receive a medical certificate without further evaluation and treatment.

However, an airman undergoing treatment for sleep apnea only needs to demonstrate compliance and improvement. They can qualify for a special issuance for their medical certificate, with the assistance of their aviation medical examiner (AME). For most, this involves sleeping with a machine that creates positive pressure in the airway—a CPAP machine.

Sleep Apnea: The Basics

Sleep apnea is a periodic failure to breathe during sleep. There are two major types of sleep apnea: central (CSA), which is due to faulty nervous system signals, and obstructive (OSA). OSA is the more common type; it arises from airway blockage during sleep. When soft tissue from the palate or tongue obstructs breathing, it disrupts sleep, lowers blood oxygen levels, and reduces the quality of rest.

Common risk factors for OSA include:

  •  A BMI over 35
  •  Congestive heart failure
  • Atrial fibrillation
  • Treatment-refractory hypertension
  • Type 2 diabetes
  • A stroke
  • Pulmonary hypertension
  • Retrognathia (an overbite)

AMEs use guidelines like these from the American Academy of Sleep Medicine to evaluate OSA risk. None of these are definite indicators, and none are necessary for OSA. Any patient who snores or is excessively sleepy during the daytime may be showing symptoms of OSA.

Machines that create positive pressure in the sleeper’s airway can keep the airway clear of obstructions and allow uninterrupted rest. These are often simply called “CPAP machines,” but available devices offer variations according to the patient’s needs:

  • CPAP (continuous positive airway pressure)
  • BIPAP (bilevel positive airway pressure, with different settings for exhalation and inhalation)
  • APAP (automatic positive airway pressure, adjusting to the patient as needed)

Studies have shown that using a CPAP machine improves results on tests for cognitive functioning and daytime sleepiness. However, the masks and hoses are cumbersome, and long-term patient compliance can be poor. As such, the FAA wants assurance that an airman with a prescription for a CPAP machine is using it steadily and frequently.

Guidelines and Documentation for CPAP Use

New Diagnoses

If an AME identifies severe symptoms of OSA presenting an immediate safety risk, they cannot issue a medical certificate. To stay airborne, you will need an AASI—a special issuance from the FAA’s medical division.

Within 90 days, the FAA will require you to undergo a sleep assessment and, when necessary, a sleep study interpreted by a sleep medicine specialist. Where the sleep study shows an AHI (apnea-hypopnea index) of 15 or over, most people will need to use a CPAP.

After a diagnosis of OSA, the FAA requires you to submit the following:

  • “A signed FAA Compliance with Treatment sheet or equivalent;
  • “The results and interpretive report of your most recent sleep study; and
  • “A current, detailed Clinical Progress Note from your treating physician addressing compliance, tolerance of treatment, and resolution of OSA symptoms.”

See the FAA’s spec sheet for OSA assessment for more details.

The FAA wants to see documented use of the CPAP “for at least 75% of sleep periods and an average minimum of 6 hours use per sleep period,” as well as a target AHI of 5 or less. For someone with a new diagnosis, a minimum of 30 days’ use of the CPAP is requested, although two weeks’ use may be enough if compliance is “excellent” and symptoms have resolved.

Ongoing Treatment

You will need to provide your cumulative CPAP data on a yearly basis to have your AASI renewed, together with a report confirming that the treatment is still effective. If you are a new candidate seeking a medical certificate with a history of sleep apnea, you will need to provide this information as well.

You may be able to remove the AASI requirement if you can show that you no longer have OSA. This requires a follow-up sleep study and at least three years of symptom abatement, ideally combined with other interventions to end the condition.

Other Interventions and Treatments

Doctors often prescribe weight loss to relieve sleep apnea, as it can significantly decrease a patient’s AHI. However, persistent sleep apnea may require surgery to enlarge the airway for permanent relief.

Mild cases of sleep apnea may be treated by oral appliances that reposition the jaw, stabilize the tongue, or otherwise prevent the airway from collapse. These are compact and often easier to use than CPAPs. However, the FAA requires PAP machine use for anyone with an AHI of 16 or higher.

Securing Your Certificate

For an airman with a persistent disorder, medical treatment can turn into a matter of FAA regulatory compliance—an embarrassing and frustrating situation. Our Florida aviation attorneys can help you navigate your medical certification process, as well as with any other compliance issues you may need assistance with. Call us today at 954-869-8950 to schedule your free initial appointment.