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Table of Contents
Year : 2021  |  Volume : 24  |  Issue : 3  |  Page : 313-314
A simple and validated test for detecting patients with OSA: STOP-BANG questionnaire

Department of Anesthesiology and Reanimation, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Istanbul, Turkey

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Date of Submission09-Sep-2020
Date of Decision14-Sep-2020
Date of Acceptance11-Sep-2020
Date of Web Publication09-Jul-2021

How to cite this article:
Nurgul Y. A simple and validated test for detecting patients with OSA: STOP-BANG questionnaire. Ann Card Anaesth 2021;24:313-4

How to cite this URL:
Nurgul Y. A simple and validated test for detecting patients with OSA: STOP-BANG questionnaire. Ann Card Anaesth [serial online] 2021 [cited 2022 Dec 2];24:313-4. Available from:

Obstructive sleep apnea (OSA) is a syndrome characterized by episodes of respiratory arrest during sleep, oxygen desaturation, and increased daytime sleepiness due to recurrent obstructions in the upper airway. It is classified by the number of apneas and/or hypopneas per hour of sleep, known as the apnea–hypopnea index. Although the incidence of OSA has been reported to be 9–25% in the adult population, the incidence is 13.2–78% in patients who underwent cardiac surgery.[1]

Many risk factors are associated with OSA, including male gender, advanced age, higher body mass index (BMI), greater waist-to-hip ratio and neck circumference, illiteracy, smoking, and alcohol intake.[2] OSA is associated with endothelial dysfunction, inflammation, oxidative stress, and blood pressure fluctuations, which increase cardiac and vascular complications in these patients.[3] Obesity, coronary artery disease, and diabetes mellitus are seen frequently in OSA patients. A positive correlation was found between the severity of OSA and the incidence of type 2 diabetes, independent of obesity.[4] OSA is not only an independent risk factor for perioperative complications in noncardiac surgery; it is also associated major adverse cerebrovascular and cardiovascular events after coronary artery bypass graft surgery (CABG). General anesthesia, inflammatory response to the extracorporeal circulation, and the use of sedative and narcotic drugs that contribute to airway obstruction in OSA patients undergoing CABG pose a risk for postoperative complications. The incidence of postoperative desaturation, postoperative cardiac events, respiratory failure, and ICU transfers was higher in patients with OSA. Nagappa et al. demonstrated that odds of major adverse cardiac or cerebrovascular events and newly documented postoperative atrial fibrillation after cardiac surgery in OSA patients were 33.3% and 18.1% higher, respectively, compared to non-OSA patients.[5] Therefore, it is important to diagnose these patients in the preoperative period in order to reduce the complications of both coronary surgery and OSA.

There are ethnic differences in the sleep study findings, clinical presentation, and OSA-related morbidity. Although most Asian patients undergoing CABG are younger and not obese, they are affected more by the presence of OSA due to their craniofacial structure and have higher prevalence of risk factors such as diabetes and hypertension, compared to the Western population. It is difficult to diagnose OSA in patients in the Asian continent living in aconcentrated and underdeveloped environment compared to the Western population.[2] Therefore, reliable, cost-effective, and practical methods for diagnosing OSA preoperatively could be useful in these populations.

As shown in many studies, a significant proportion of OSA patients are undiagnosed and untreated during the perioperative period.[1] The Society of Anesthesia and Sleep Medicine Guidelines strongly recommend identification and screening for OSA patients in the preoperative period. The gold standard for diagnosis of OSA is overnight polysomnography (PSG). However, PSG may not be applicable in all patients because it is time consuming, may not be available in many centers, requires trained personnel, and is costly. For these reasons, alternative methods have been developed to diagnose OSA, such as the Berlin Questionnaire, The American Society of Anesthesiologists checklist, and the STOP-BANG Questionnaire.[6]

STOP-BANG Questionnaire was first developed in general surgical patients in 2008 and it is easy, reliable, and practical. It consists of eight questions (snoring (S), tiredness (T), observed stopped breathing during sleep (O), pressure (P), BMI, age older than 50, neck circumference male >43 cm, female >41 cm, and male gender). A score of 0–2 indicates low risk, 3–5 moderate risk, and 6–8 indicates high risk for OSA.[6] STOP-BANG Questionnaire has the highest methodologic validity and indicates moderately high sensitivity and best negative predictive value for assessing the risk of moderate/severe OSA.[7] A score of ≥3 has shown 93% sensitivity, 43% specificity for detecting moderate OSA, 100% sensitivity, and 37% specificity for severe OSA.[1] Although high sensitivity in low scores (0–2) excludes OSA, low specificity in scores >3 is associated with false positivity.[8]

As the STOP-BANG score increases incrementally (score of 4, 5, 6, and 7/8), severe OSA probability increases significantly (25%, 35%, 45%, and 65%). It has been reported that the two-step strategy can be applied when the STOP-BANG score is 3 or 4. A combination of a STOP score at least 2 + BMI more than 35 kg/m2 or STOP score at least 2 + male or STOP score at least 2 + neck circumference more than 40 cm indicates a higher risk of moderate-to-severe OSA. These can be easily applied during patient interviews for early diagnosis of OSA and help clinicians avoid postoperative complications by identifying moderate-to-high-risk patients.

In conclusion, the STOP-BANG test is the most convenient, validated, and an effective screening tool that can be easily applied in the diagnosis of moderate-to-high-risk OSA patients. This test can be applied in patients undergoing cardiac surgery, particularly in resource-poor countries.

   References Top

Mason M, Hernandez-Sanchez J, Vuylsteke A, Smith I. Usefulness of the STOP-bang questionnaire in cardiac surgical population. J Cardiothorac Vasc Anesth 2018;32:2694-9.  Back to cited text no. 1
Mirrakhimov AE, Sooronbaev T, Mirrakhimov EM. Prevalence of obstructive sleep apnea in Asian adults: A systematic review of the literature. BMC Pulm Med 2013;23;13:10.  Back to cited text no. 2
Uchôa CHG, Danzi-Soares NJ, Nunes FS, de Souza AAL, Nerbass FB, Pedrosa RP, et al. Impact of OSA on cardiovascular events after coronary artery bypass surgery. Chest 2015;147:1352-60.  Back to cited text no. 3
Muraki I, Wada H, Tanigawa T. Sleep apnea and type 2 diabetes. J Diabetes Investig 2018;9:991-7.  Back to cited text no. 4
Nagappa M, Ho G, Patra J, Wong J, Singh M, Kaw R, et al. Postoperative outcomes in obstructive sleep apnea patients undergoing cardiac surgery: A systematic review and meta-analysis of comparative studies. Anesth Analg 2017;125:2030-7.  Back to cited text no. 5
Nagappa M, Wong J, Singh M, Wong DT, Chung F. An update on the various practical applications of the STOP-Bang questionnaire in anesthesia, surgery, and perioperative medicine. Curr Opin Anaesthesiol 2017;30:118-25.  Back to cited text no. 6
Chiu HY, Chen PY, Chuang LP, Chen NH, Tu YK, Hsieh YJ, et al. Diagnostic accuracy of the Berlin questionnaire, STOP-BANG, STOP, and Epworth sleepiness scale in detecting obstructive sleep apnea: A bivariate meta-analysis. Sleep Med Rev 2017;36:57-70.  Back to cited text no. 7
Chung F, Abdullah HR, Liao P. STOP-bang questionnaire: A practical approach to screen for obstructive sleep apnea. Chest 2016;149:631-8.  Back to cited text no. 8

Correspondence Address:
Yurtseven Nurgul
Sinpas Aqua Manors Sitesi, 23/A Yukari Dudullu, Umraniye, Istanbul
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aca.ACA_205_20

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