Decision Considerations Disease Protocols - Obstructive Sleep Apnea (OSA)

Sleep apnea has significant safety implications due to cognitive impairment secondary to the lack of restorative sleep and is disqualifying for airman medical certification. The condition is part of a group of sleep disorders with varied etiologies. Specifically, sleep apneas are characterized by abnormal respiration during sleep. The etiology may be obstructive, central or complex in nature. However, no matter the cause, the manifestations of this disordered breathing present safety risks that include, but are not limited to, excessive daytime sleepiness (daytime hypersomnolence), cardiac dysrhythmia, sudden cardiac death, personality disturbances, refractory hypertension and, as mentioned above, cognitive impairment. Certification may be considered once effective treatment is shown.

This protocol is designed to evaluate airmen who may be presently at risk for Obstructive Sleep Apnea (OSA) and to outline the certification requirements for airmen diagnosed with OSA. While this protocol focuses on OSA, the AME must also be mindful of other sleep-related disorders such as insomnia, parasomnias, sleep-related movement disorders (e.g. restless leg syndrome and periodic leg movement), central sleep apnea and other hypersomnias, circadian rhythm sleep disorders, etc., that may also interfere with restorative sleep. All sleep disorders are also potentially medically disqualifying if left untreated. If one of these other sleep-related disorders is initially identified during the examination, the AME must contact their RFS or AMCD for guidance.

Risk Information

The American Academy of Sleep Medicine has established the risk criteria (PDF) (utilizing Tables 2 and 3) for OSA. When applying Table 2 and 3, the AME is expected to employ their clinical judgment. Educational information for airmen can be found in the FAA Pilot Safety Brochure on Obstructive Sleep Apnea (PDF).

Persons with physical findings such as a retrograde mandible, large tongue or tonsils, neuromuscular disorders, or connective tissue anomalies are at risk of OSA requiring treatment despite a normal or low BMI. OSA is also associated with conditions such as refractory hypertension requiring more than two medications for control, diabetes mellitus, and atrial fibrillation. Over 90% of individuals with a BMI of 40 or greater have OSA requiring treatment. Up to 30% of individuals with OSA have a BMI less than 30.

AME Actions - On every exam, the Examiner must triage the applicant into one of 6 groups:

  • If the applicant is on a Special Issuance Authorization for OSA (Group/Box 1 of OSA flow chart (PDF)), select Group 1 on the AME Action Tab:

  • If the applicant has had a prior sleep assessment (Group/Box 2 of OSA flow chart (PDF)), select Group 2 on the AME Action Tab:
    • If the airman is under treatment, provide the requirements of the AASI and advise the airman they must get the Authorization of Special Issuance;
    • Give the applicant Specification Sheet A (PDF) and advise that a letter will be sent from the Federal Air Surgeon requesting more information. The letter will state that the applicant has 90 days to provide the information to the FAA/AME;
    • Notate in Box 60;
    • Issue, if otherwise qualified

  • If the applicant does not have an AASI/SI or has not had a previous assessment, the AME must:

  • If the applicant is at high risk for OSA, the AME must (Group/Box 5 of OSA flow chart (PDF)), select Group 5 on the AME Action Tab:
    • Give the applicant Specification Sheet B (PDF) and advise that a letter will be sent from the Federal Air Surgeon requesting more information. The letter will state that the applicant has 90 days to provide the information to the FAA/AME;
    • Notate in Block 60; and
    • Issue, if otherwise qualified

  • If the AME observes or the applicant reports symptoms which are severe enough to represent an immediate risk to aviation safety of the national airspace (Group/Box 6 of OSA flow chart (PDF)), select Group 6 on the AME Action Tab.
    • Notate in Block 60
    • THE AME MUST DEFER

AASM Tables 2 and 3 (PDF)

Obstructive Sleep Apnea (OSA) Flow Chart (PDF)

Specification Sheet A - Information Request (PDF)

Specification Sheet B - Assessment Request (PDF)