STOP-BANG Questionnaire for OSA Screening
Direct Answer
The STOP-BANG questionnaire is a highly sensitive screening tool for obstructive sleep apnea that should be used to identify patients requiring diagnostic testing, but it cannot diagnose OSA on its own and must be followed by polysomnography or home sleep apnea testing for confirmation. 1
What STOP-BANG Measures
The STOP-BANG consists of 8 yes/no questions with scores ranging from 0-8: 1, 2
- Snoring (loud)
- Tiredness/daytime sleepiness
- Observed apneas
- High blood Pressure
- BMI >35 kg/m²
- Age >50 years
- Neck circumference >40 cm
- Male Gender
Diagnostic Performance
Sensitivity (Ruling Out OSA)
A score ≥3 has excellent sensitivity for detecting OSA: 1, 2, 3
- 93% sensitivity for moderate-to-severe OSA (AHI ≥15)
- 100% sensitivity for severe OSA (AHI ≥30)
- Negative predictive values of 77% and 91% respectively
A score <2 effectively excludes moderate-to-severe OSA with 95% probability. 4
Specificity (Confirming OSA)
The major limitation is low specificity of only 36% at high-risk cutoffs, resulting in substantial false positives. 1 This means many patients will screen positive but not have OSA on formal testing.
Risk Stratification Algorithm
Use the following score-based approach: 2, 3
- Score 0-2: Low risk for moderate-to-severe OSA
- Score 3-4: Intermediate risk (requires additional criteria)
- Score 5-8: High risk for moderate-to-severe OSA
The probability of severe OSA increases proportionally with score: 3
- Score 3: 15-25% probability
- Score 4: 25-35% probability
- Score 5: 35-45% probability
- Score 6: 45-55% probability
- Score 7-8: 65-75% probability
Mandatory Next Steps After Positive Screen
All patients with STOP-BANG ≥3 require confirmatory diagnostic testing before treatment initiation. 1 The screening tool produces too many false negatives to serve as a diagnostic instrument. 1
Diagnostic Testing Options
- In-laboratory polysomnography: Gold standard 5
- Home sleep apnea testing (HSAT): Type III manually scored portable monitor with event index ≥15/hour establishes moderate-to-severe OSA 5
- If HSAT is nondiagnostic (technically inadequate or AHI <5), repeat with either HSAT or in-laboratory PSG 5
Perioperative Management
For surgical patients with positive STOP-BANG screen, implement precautions even before confirmatory testing: 1
- Regional or local anesthesia when possible
- Continuous respiratory monitoring
- Supplemental oxygen
- Consider CPAP therapy
- Avoid supine positioning
- Enhanced postoperative monitoring in telemetry-capable settings
Critical Limitations and Pitfalls
Population-Specific Performance
The questionnaire is validated primarily in middle-aged, obese males in surgical settings, which reduces accuracy in: 1
- Women
- Younger patients
- Non-surgical populations
Geographic variation exists, with notably lower performance in East Asian populations compared to other regions. 1, 6 The diagnostic accuracy (AUC) in East Asia is only 0.52 compared to >0.80 in other regions. 6
Common Errors to Avoid
- Never use STOP-BANG alone to diagnose OSA - it is a screening tool only 1
- Do not skip confirmatory testing even with high scores 5, 1
- Do not assume negative screen rules out OSA in high-risk populations - 61 false negatives per 1,000 patients can occur 1
Comparison to Alternative Tools
STOP-BANG outperforms other screening questionnaires: 1
- Superior to Berlin Questionnaire (AUC 0.74-0.77 vs lower)
- Superior to Epworth Sleepiness Scale
- Better diagnostic accuracy overall
The simpler 4-item STOP questionnaire (without Bang components) has similar sensitivity and was recommended by VA/DoD guidelines as an acceptable alternative. 5