Cutoff points in STOP-Bang questionnaire for obstructive sleep apnea

ABSTRACT

Background: Obstructive Sleep Apnea Syndrome (OSAS) is a public health problem of high prevalence and impacts on quality of life, anesthetic complications and cardiovascular diseases. In view of the difficulty in accessing the polysomnography, it is necessary to validate other methods for OSAS diagnostic screening in clinical practice in our country, such as the STOP-Bang questionnaire. Objective: To validate the STOP-Bang questionnaire in Brazilians and evaluate optimal cutoff points. Methods: After translation and back-translation, STOP-Bang questionnaire was applied to 71 individuals previously submitted to polysomnography and classified into control, mild, moderate or severe OSAS. Results: The majority of patients was male (59.2%), white (79%), aged 48.9±13.9 years, and with neck circumference >40 centimeters (73.8%). STOP-Bang score was higher in OSAS mild (median/inter-quartis 25-75%: 5/3.5-6), moderate (4.5/4-5) and severe (5/4-6), versus control (2.5/1-4). The receiver operating characteristic (ROC) curve indicate that scores 3, 4 and 6, present the best specificity values (100, 80 and 92.9%) with acceptable sensitivity (60, 66.7 and 50%) in the mild, moderate and severe OSAS subgroups, respectively. In OSAS group analysis (Apnea Hypopnea Index [AHI] ≥5, <15, ≥15 - <30, ≥30), STOP-Bang cutoff point of 6 was optimal to detect OSAS. Conclusion: STOP-Bang Brazilian version identified OSAS patients with lower sensitivity and higher specificity compared to previous studies. Different cutoff points would improve the performance to detect patients with more severe OSAS.

RESUMO

Introdução: A Síndrome da Apneia Obstrutiva do Sono (SAOS) é um problema de saúde pública de alta prevalência e com impacto na qualidade de vida, complicações anestésicas e doenças cardiovasculares. Diante da dificuldade de acesso à realização da polissonografia, é necessário validar outros métodos para a triagem diagnóstica da SAOS na prática clínica no cenário brasileiro, como o questionário STOP-Bang. Objetivos: Validar o questionário STOP-Bang em brasileiros e avaliar os melhores pontos de corte. Método: Após tradução e retrotradução, o STOP-Bang foi aplicado em 71 indivíduos previamente submetidos à polissonografia e classificados em controles e em SAOS leve, moderada e grave. Resultados: A maioria da amostra foi de homens (59,2%), com 48,9±13,9 anos, brancos (79%) e com circunferência do pescoço >40 cm (73,8%). O escore STOP-Bang foi maior na SAOS leve (mediana/interquartis 25-75%: 5/3,5-6), moderada (4,5/4-5) e grave (5/4-6) versus controles (2,5/1-4). A Curva Característica de Operação do Receptor (ROC) indicou que os escores 3, 4 e 6 apresentam os melhores valores de especificidade (100, 80 e 92,9%) e sensibilidade aceitável (60, 66,7 e 50%) nos subgrupos de SAOS leve, moderada e grave, respectivamente. Na análise da amostra com SAOS (IAH ] ≥5, <15, ≥15 - <30, ≥30), o ponto de corte de 6 no STOP-Bang detectou melhor a SAOS. Conclusão: A versão brasileira do STOP-Bang identificou pacientes apneicos com menor sensibilidade e maior especificidade em relação a estudos anteriores. Diferentes pontos de corte melhorariam o desempenho para detectar pacientes com SAOS mais grave.

Keywords:

Obstructive Sleep Apnea - Polysomnography - Surveys and Questionnaires

Palavras-chave:

Apneia Obstrutiva do Sono - Polissonografia - Inquéritos e Questionários

Authors’ contributions:

Neves Junior JAS and Fernandes APA: data acquisition, analysis and interpretation of data, preparation of the article, final approval of the submitted version. Tardelli MA, Yamashita AM, Moura SMPGT, and Tufik S: conception and design of the study, critical review of the article for important intellectual content, final approval of the submitted version. Silva HCA: conception and design of the study, analysis and interpretation of data, preparation of the article, final approval of the submitted version.

Support:

This study was financed in part by the Coordenacção de Aperfeicçoamento de Pessoal de Nióvel Superior - Brasil (CAPES) - Finance Code 001, Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), Associação Fundo de Incentivo à Pesquisa (AFIP) and Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq).

Publication History

Received: 20 February 2020

Accepted: 20 April 2020

Article published online:
13 June 2023

• References

• 1 No authors listed. Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. The Report of an American Academy of Sleep Medicine Task Force. Sleep. 1999 Aug;22(5):667-89.
• 2 Tufik S, Santos-Silva R, Taddei JA, Bittencourt LR. Obstructive sleep apnea syndrome in the Sao Paulo Epidemiologic Sleep Study. Sleep Med. 2010 May;11(5):441-6. https://doi.org/10.1016/j.sleep.2009.10.005
• 3 Young T, Evans L, Finn L, Palta M. Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women. Sleep. 1997 Sep;20(9):705-6. https://doi.org/10.1093/sleep/20.9.705
• 4 American Academy of Sleep Medicine. International classification of sleep disorders. Diagnostic and coding manual (ICSD-2). 2^nd ed. Westchester, IL: American Academy of Sleep Medicine; 2005.
• 5 Pavarangkul T, Jungtrakul T, Chaobangprom P, Nitiwatthana L, Jongkumchok W, Morrakotkhiew W, et al. The Stop-Bang Questionnaire as a screening tool for obstructive sleep apnea-induced hypertension in asian population. Neurol Int. 2016 Apr;8(1):6104. https://doi.org/10.4081/ni.2016.6104
• 6 Alotair H, Bahammam A. Gender differences in Saudi patients with obstructive sleep apnea. Sleep Breath. 2008 Nov;12(4):323-9. https://doi.org/10.1007/s11325-008-0184-8
• 7 Lux L, Boehlecke B, Lohr KN. Effectiveness of portable monitoring devices for diagnosing obstructive sleep apnea: update of a systematic review. Rockville (MD): Agency for Healthcare Research and Quality (US); 2004. Available from: https://www.ncbi.nlm.nih.gov/books/NBK299250/
• 8 Abrishami A, Khajehdehi A, Chung F. A systematic review of screening questionnaires for obstructive sleep apnea. Can J Anaesth. 2010 May;57(5):423-38. https://doi.org/10.1007/s12630-010-9280-x
• 9 Silva GE, Vana KD, Goodwin JL, Sherrill DL, Quan SF. Identification of patients with sleep disordered breathing: comparing the four-variable screening tool, STOP, STOP-Bang, and Epworth Sleepiness Scales. J Clin Sleep Med. 2011 Oct;7(5):467-72. https://doi.org/10.5664/JCSM.1308
• 10 Chung F, Yegneswaran B, Liao P, Chung SA, Vairavanathan S, Islam S, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008 May;108(5):812-21. https://doi.org/10.1097/ALN.0b013e31816d83e4
• 11 Nagappa M, Liao P, Wong J, Auckley D, Ramachandran SK, Memtsoudis S. Validation of the STOP-Bang Questionnaire as a screening tool for obstructive sleep apnea among different populations: a systematic review and meta-analysis. PLoS One. 2015 Dec;10(12):e0143697. https://doi.org/10.1371/journal.pone.0143697
• 12 Iber C, Ancoli-Israel S, Chesson Jr A, Quan S. The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications. Westchester, IL: American Academy of Sleep Medicine ; 2007.
• 13 Coelho FM, Pradella-Hallinan M, Palombini L, Tufik S, Bittencourt LRA. The STOP-BANG questionnaire was a useful tool to identify OSA during epidemiological study in São Paulo (Brazil). Sleep Med. 2012 Apr;13(4):450-1. https://doi.org/10.1016/j.sleep.2012.01.008
• 14 McGraw KO, Wong SP. A common language effect-size statistic. Psychol Bull. 1992;111(2):361-365. https://doi.org/10.1037/0033-2909.111.2.361
• 15 Dancey DR, Hanly PJ, Soong C, Lee B, Shepard J Jr, Hoffstein V. Gender differences in sleep apnea: the role of neck circumference. Chest. 2003 May;123(5):1544-50. https://doi.org/10.1378/chest.123.5.1544
• 16 Silva HGV, Moreira ASB, Santos VR, Santos SO, Rêgo AFB. Factors associated with obstructive sleep apnea severity: obesity and excessive daytime sleepiness. Rev Bras Cardiol. 2014 Mar/Apr;27(2):76-82.
• 17 Weaver EM, Kapur V, Yueh B. Polysomnography vs self-reported measures in patients with sleep apnea. Arch Otolaryngol Head Neck Surg. 2004 Apr;130(4):453-8. https://doi.org/10.1001/archotol.130.4.453
• 18 Peppard PE, Young T, Palta M, Dempsey J, Skatrud J. Longitudinal study of moderate weight change and sleep-disordered breathing. JAMA. 2000 Dec;284(23):3015-21. https://doi.org/10.1001/jama.284.23.3015
• 19 Isono S. Obstructive sleep apnea of obese adults: pathophysiology and perioperative airway management. Anesthesiology. 2009 Apr;110(4):908-21. https://doi.org/10.1097/ALN.0b013e31819c74be
• 20 Vasu TS, Doghramji K, Cavallazzi R, Grewal R, Hirani A, Leiby B, et al. Obstructive sleep apnea syndrome and postoperative complications: clinical use of the STOP-BANG questionnaire. Arch Otolaryngol Head Neck Surg. 2010 Oct;136(10):1020-4. https://doi.org/10.1001/archoto.2010.1020
• 21 Reis R, Teixeira F, Martins V, Sousa L, Batata L, Santos C, et al. Validation of a Portuguese version of the STOP-Bang questionnaire as a screening tool for obstructive sleep apnea: Analysis in a sleep clinic. Rev Port Pneumol. 2015 Mar/Apr;21(2):61-8. https://doi.org/10.1016/j.rppnen.2014.04.009
• 22 Chung F, Yang Y, Brown R, Liao P. Alternative scoring models of STOP-Bang questionnaire improve specificity to detect undiagnosed obstructive sleep apnea. J Clin Sleep Med. 2014 Sep;10(9):951-8. https://doi.org/10.5664/jcsm.4022
• 23 Ha SCN, Lee DLY, Abdullah VJ, van Hasselt CA. Evaluation and validation of four translated Chinese questionnaires for obstructive sleep apnea patients in Hong Kong. Sleep Breath. 2014 Dec;18(4):715-21. https://doi.org/10.1007/s11325-013-0889-1
• 24 Kim B, Lee EM, Chung YS, Kim WS, Lee SA. The utility of three screening questionnaires for obstructive sleep apnea in a sleep clinic setting. Yonsei Med J. 2015 May;56(3):684-90. https://doi.org/10.3349/ymj.2015.56.3.684
• 25 Sadeghniiat-Haghighi K, Montazeri A, Khajeh-Mehrizi A, Ghajarzadeh M, Alemohammad ZB, Aminian O, et al. The STOP-BANG questionnaire: reliability and validity of the Persian version in sleep clinic population. Qual Life Res. 2015 Aug;24(8):2025-30. https://doi.org/10.1007/s11136-015-0923-9
• 26 Boynton G, Vahabzadeh A, Hammoud S, Ruzicka DL, Chervin RD. Validation of the STOP-BANG Questionnaire among patients referred for suspected obstructive sleep apnea. J Sleep Disord Treat Care. 2013 Sep;2(4):10.4172/2325-9639.1000121. https://doi.org/10.4172/2325-9639.1000121
• 27 BaHammam AS, Al-Aqeel AM, Alhedyani AA, Al-Obaid GI, Al-Owais MM, Olaish AH. The Validity and Reliability of an Arabic Version of the STOP-Bang Questionnaire for Identifying Obstructive Sleep Apnea. Open Respir Med J. 2015;9:22-9. https://doi.org/10.2174/1874306401509010022
• 28 Vana KD, Silva GE, Goldberg R. Predictive abilities of the STOP-Bang and Epworth Sleepiness Scale in identifying sleep clinic patients at high risk for obstructive sleep apnea. Res Nurs Health. 2013 Feb;36(1):84-94. https://doi.org/10.1002/nur.21512
• 29 Ong TH, Raudha S, Fook-Chong S, Lew N, Hsu AA. Simplifying STOP-BANG: use of a simple questionnaire to screen for OSA in an Asian population. Sleep Breath. 2010 Dec;14(4):371-6. https://doi.org/10.1007/s11325-010-0350-7
• 30 Farney RJ, Walker BS, Farney RM, Snow GL, Walker JM. The STOP-Bang equivalent model and prediction of severity of obstructive sleep apnea: relation to polysomnographic measurements of the apnea/hypopnea index. J Clin Sleep Med. 2011 Oct;7(5):459-65. https://doi.org/10.5664/JCSM.1306
• 31 Fonseca LB, Silveira EA, Lima NM, Rabahi MF. STOP-Bang questionnaire: translation to Portuguese and cross-cultural adaptation for use in Brazil. J Bras Pneumol. 2016 Jul/Aug;42(4):266-72. https://doi.org/10.1590/S1806-3756201520200086243
• 32 Duarte RLM, Fonseca LBM, Magalhães-da-Silveira FJ, Silveira EAD, Rabahi MF. Validation of the STOP-Bang questionnaire as a means of screening for obstructive sleep apnea in adults in Brazil. J Bras Pneumol. Nov-Dec 2017;43(6):456-63. https://doi.org/10.1590/S1806-3756201720200086139