1. Determining the Effectiveness of the STOP-BANG Sleep Apnea Questionnaire in
Diagnosing Sleep Apnea in a Community Setting
Nicolette Stasiak
Dr. Leslie Cole
The University of Alabama Capstone College of Nursing
Abstract
Obstructive sleep apnea (OSA) is an obstruction in the upper airway in which a person
stops breathing suddenly and restarts again while sleeping. This disorder affects mostly
middle aged and older adults; however, other risk factors exist that put a person at a higher
probability for developing the disorder. In order to evaluate these risks, the STOP-Bang
questionnaire was developed that consists of eight questions to determine whether a
patient is at high risk by evaluating the client’s Snoring, Tiredness, Observed apneas, blood
Pressure, Body mass index (>35 or >30 kg/m2), Age >50 years, Neck circumference > 40
cm, and male Gender (STOP-Bang). The focus of this study is to discuss the accuracy of
the STOP-Bang questionnaire in predicting the probability the patient has OSA. A
literature search of CINAHL and EBSCO databases was conducted and articles were
retrieved related to the topic. Overall, the success rate of predicting a patient had OSA
through the STOP-Bang questionnaire was shown to be successful. Researchers have
found that by administering this small questionnaire before a sedating procedure, such as
an endoscopy, patients are less likely to show signs of OSA that could further inhibit the
success of the procedure.
What is Obstructive Sleep Apnea (OSA)?
OSA is characterized as a disease caused by complete or partial
upper airway flow restrictions (American Academy of Sleep
Medicine [AASM], 2005). Many times during these periods,
oxygen saturation levels will drop dramatically. In order to be
diagnosed with OSA, a person must have 15 episodes per hour of
sleep. Patients do not realize this is happening and therefore, it
goes unnoticed by many health care providers (HCPs) until
undergoing surgical procedures involving anesthesia.
A patient is diagnosed with OSA so why does it
matter?
It can cause:
-Cardiovascular problems: increases in Blood
pressure can put a strain on the heart
-Daytime fatigue: trouble concentrating and
performing activities of daily living (ADLs)
therefore decreasing quality of life
-Eye problems: links between OSA and glaucoma
-Complications with medications and surgery:
Certain medications along with general anesthesia
relaxes the upper airway therefore worsening
OSA. Risks also increase post sedation when lying
on back. The patient can stop breathing due to a
complete obstruction and go into respiratory
failure.
(Mayoclinic.org, 2013)
What is the STOP-Bang Questionnaire and how is
it related to OSA?
-Questionnaire that evaluates 8 risk factors for OSA: Snoring,
Tiredness, Observed apneas, blood Pressure, Body mass index
>35 or >30 kg/𝑚2
, Age >50 years, Neck circumference >40 cm,
and male Gender
-For each affirmative answer, a point was assigned and zero points
are given for negative answers. 3 or more points means a patient
is at high risk for OSA and should have a sleep study done.
(Vana, Silva, & Goldberg, 2013)
Introduction
Methods
Findings
Conclusions/Significance
Future Directions
References
Research Questions:
1) What is a better score for determining high risk apnea
patients, STOP-Bang score of greater than or equal to 3 or
4?
2) Is the STOP-Bang Questionnaire the most accurate quick
assessment tool to determine if a patient is at risk for OSA
prior to surgery and general anesthesia?
Hypothesis:
I will conduct a study of 200 participants who are scheduled
to undergo surgery with general anesthesia and request they
fill out a STOP-Bang Questionnaire; if a patient scores
greater than 3 they will be referred to a sleep apnea clinic to
determine their risk for OSA prior to undergoing anesthesia.
Methodology:
Prior to undergoing surgery, patient s will be asked to fill out
the STOP-Bang Questionnaire. These patients will have no
prior history of OSA or visits to a sleep clinic. If the patient
has a score of 3 or greater, they will be sent to a sleep clinic
prior to undergoing general anesthesia in order to rule out
OSA. If the client is positive for OSA, the STOP-Bang
Questionnaire will be labeled effective for that client. Overall,
a percentage for the clients who were determined to have
sleep apnea versus not while testing positive on the STOP-
Bang Questionnaire will be determined.
American Academy of Sleep Medicine. (2005). The international classification
of sleep disorders: Diagnostic and coding manual (2nd ed.). West Chester,
IL: Author.
Chung, F., Yang, Y., & Liao, P. (2013). Predictive performance of the STOP-bang
score for identifying obstructive sleep apnea in obese patients. Obesity Surgery,
23(12), 2050-2057. doi:10.1007/s11695-013-1006-z
Nagappa, M., Liao, P., Wong, J., Auckley, D., Ramachandran, S. K.,
Memtsoudis, S., . . . Chung, F. (2015). 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,
10(12), 1-21. doi:10.1371/journal.pone.0143697
Obstructive sleep apnea. (2013). Mayoclinic.org. Retrieved from
http://www.mayoclinic.org/diseases-conditions/obstructive-sleep
-apnea/basics/complications/con-20027941
Sadeghniiat-Haghighi, K., Montazeri, A., Khajeh-Mehrizi, A., Ghajarzadeh, M.,
Alemohammad, Z. B., Aminian, O., & Sedaghat, M. (2015). The STOP-BANG
questionnaire: Reliability and validity of the persian version in sleep clinic
population. Quality of Life Research: An International Journal of Quality of Life
Aspects of Treatment, Care & Rehabilitation, 24(8), 2025-2030. doi:10.1007/s11136-
015-0923-9
Toshniwal, G., McKelvey, G. M., & Wang, H. (2014). STOP-bang and prediction of
difficult airway in obese patients. Journal of Clinical Anesthesia, 26(5), 360-367 8p.
doi:10.1016/j.jclinane.2014.01.010
Vana, K., Silva, G., & Goldberg, R. (2013). Predictive abilities of the STOP-Bang
and Epworth Sleepiness Scale in identifying sleep clinic patients at high risk
for sleep apnea. Research in Nursing & Health 36, 84-94.
doi:10.1002/nur.21512
An integrative literature review was conducted using CINAHL and EBSCO databases by searching words and phrases such as
“STOP-Bang Questionnaire,” “STOP –Bang Questionnaire and Obstructive SleepApnea,” and “Effectiveness of STOP-Bang
Questionnaire.” Articles were chosen based on recent publication (within last 5 years January 2011-March 2016), validity of
the source, and relevance to research in question.
Title, Author (s),
year
Purpose Method Sample Instruments Results/findings
Predictive Abilities of the
STOP-Bang and Epworth
Sleepiness Scale in Identifying
Sleep Clinic Patients at High
Risk for Obstructive Sleep
Apnea
Kimberly D. Vana, Graciela E.
Silva, Rochelle Goldberg
2013
to determine the effectiveness of
the STOP-Bang questionnaire, as
well as determine whether it was
more effective than the ESS
questionnaire in determining
whether a patient had obstructive
sleep apnea (OSA).
-convenience sample was used
-patients completed a demographic questionnaire, the
ESS, and the first four items of the STOP-Bang
-measurements such as blood pressure, neck
circumference, weight, and height were collected by
clinic staff member.
-new adult patients referred to a sleep
clinic (18 yoa+) were used in
consecutive order until a sample of 60
was obtained.
-STOP-Bang Questionnaire
-1 point was assigned for each affirmative
answer and zero points for negative answers
(high risk being >3 affirmative answers)
-predictive abilities was then validated by
polysomnographic results
-SB30 had a statistically higher AUC when
identifying patients with OSA and SDB than
the ESS but not the SB35.
-SB30 and ESS both identified OSA patients’
risk 77% (positives) and 38% (negatives) of
the time.
Providers want to identify as many cases of
OSA as possible therefore the SB30 is the
better choice due to its higher sensitivity.
-The ESS should only be used to screen
patients for their degrees of sleepiness and
not OSA.
-SB30 classified twice as many patients as the
ESS did into high and low risk OSA
categories
Predictive Performance of the
STOP-Bang Score for
identifying Obstructive Sleep
Apnea in Obese Patients
Frances Chung, Yiliang Yang,
& Pu Liao
2013
The purpose of this article was to
validate whether the STOP-Bang
questionnaire is a good predictor of
an obese or morbidly obese patient
having an operative adverse event
due to undiagnosed obstructive
sleep apnea (OSA).
First two years of the study, overnight
polysomnography was used; subsequent two years, a
portable polysomnography with 10 channel portable
device was used at home.
Patients 18 or older who were
undergoing an elective procedure in
general surgery (gynecology,
orthopedics, urology, plastic surgery,
ophthalmology, or spinal surgery.
Patients diagnosed with OSA and
patients expected to have abnormal
electroencephalic findings were
excluded.
-170 had a BMI between 30-34
-140 had a BMI 35 or greater
-7,013 patients were approached and
667 successfully answered the
questionnaire.
Patients underwent a overnight
polysomnography study or a portable
polysomnography at home
In the 310 obese patients, 253 had OSA, 149
had moderate/severe OSA, and 80 had
severe OSA. It was higher in men (60 vs 39)
in moderate/ severe OSA and in severe OSA
(40 v 16)
The STOP-BANG
Questionnaire: reliability and
validity of the Persian Version
in a sleep clinic population
Khosro Sadeghiniiat-Haghighi,
Ali Montazeri, Ahmad Khajeh-
Mehrizi, Mahsa Ghajarzadeh,
Zahara Banasheh
Aleomohammad, Omid
Aminan, Mojtaba Sedaghat
2015
The purpose was to test the
reliability of the STOP-Bang
questionnaire in predicting mild,
moderate, or severe OSA in a
Persian sleep clinic population.
Cross-sectional multicenter design conducted in three
sleep clinics between September 2008 and August 2012
All patients who attended the clinic were asked to
complete the questionnaire
A sample of 603 who were admitted to
the sleep clinic were used
The Bang score was calculated by technicians
and a polysomnography was used for OSA
diagnosis
The questionnaire was translated into Persian
using a standard forward-backward
translation. Two physicians translated it
from English to Persian and then back
translated to English using two blind
translators. 8 experts evaluated the content
validity and then it was translated and 15
patients tested it out an were debriefed
following
438 had a form of OSA
While the form classified 502 as high risks,
after testing 438 were. The form classified
101 at being low risk and 135 were
Validation of the STOP-Bang
Questionnaire as a screening
tool for obstructive sleep apnea
among different populations: a
systematic review and meta
analysis
Mahesh Nagappa, Pu Liao,
Jean Wong, Dennis Auckley,
Satya Krishna Ramachandran,
Starvros Memtsoudis, Babak
Mokhlesi, & Frances Chung
2015
This systematic review and meta-
analysis looks to determine the
effectiveness of the STOP-Bang
Questionnaire for screening patients
suspected of having OSA and to
predict its accuracy in determining
the severity of OSA in the different
populations.
Literature search was done
Criteria: 1) studies where participants were 18+ years
of age 2) validated by polysomnography 3) OSA was
defined as an apnea or respiratory disturbance 4)
publicized in English language
17 studies including 9,206 patients STOP-Bang and polysomnography in the sleep clinic population, the sensitivity
was 90, 94, and 96% to detect any OSA,
moderate-severe OSA, and severe OSA
-the probability with a score of 3 was 25%, 4
was 35%, 5 was 45%, 6 was 55%, and 7/8
was 75% in the sleep clinic population
-in a surgical population, the probability of
OSA with a score of 3 was 15%, 4 was 25%,
5 was 35%, 6 was 45%, 7/8 was 65%
STOP-Bang and prediction of
difficult airway in obese
patients
Gokul Toshniwal, George M.
McKelvey, & Hong Wang
2014
o determine if a high score (greater
than or equal to three) on the
STOP-Bang Questionnaire predicts
whether obese patients are at a high
risk for OSA due to risk of difficult
airway
Patients were divided into three groups 1) patients with
previous history of OSA, 2) patients with no history
but a high STOP-Bang score, 3) patients with no
history of OSA and a low risk STOP-Bang score
127 patients scheduled for elective
bariatric surgery on the STOP-Bang
questionnaire determines whether
obese patients are at high risk for OSA
and increased risk of difficult airway
Frequency of difficult airway, difficult mask
ventilation with or without muscle relaxation,
poor visualization of vocal cords, difficult in
blade insertion, and difficult intubation were
compared
The patients in group 1 and 2 showed the
highest risk for difficult airway due to OSA
compared to group 3
This integrative literature review found that the STOP-Bang questionnaire was an effective determination of a
patient’s risk for obstructive sleep apnea using the score of at least 3 positive answers out of 8. Using this
questionnaire before patients have any elective procedure such as surgeries, endoscopies, or colonoscopies will
greatly reduce the complications of undiagnosed obstructive sleep apnea.