What is the role of the STOP BANG (Stop-Breathing-Alert-Neck-Group) questionnaire in assessing the risk of obstructive sleep apnea (OSA) in adult patients?

STOP-BANG Questionnaire for OSA Screening

The STOP-BANG questionnaire is a highly sensitive screening tool for obstructive sleep apnea (OSA) that should be used to identify patients requiring diagnostic testing, but it cannot be used alone to diagnose or exclude OSA due to its poor specificity and excessive false negative rate. 1, 2

What is STOP-BANG?

The STOP-BANG questionnaire consists of eight dichotomous (yes/no) items that assess key OSA risk factors: Snoring, Tiredness, Observed apneas, high blood Pressure, BMI >35 kg/m², Age >50 years, Neck circumference >40 cm (men) or >38 cm (women), and male Gender. 3, 4 Each positive response adds one point, with total scores ranging from 0-8. 2, 3

Scoring Interpretation and Risk Stratification

• Score ≥3: Indicates intermediate-to-high risk for OSA and mandates objective diagnostic testing with polysomnography (PSG) or home sleep apnea testing (HSAT). 2, 3
• Score 0-2: Low risk for moderate-to-severe OSA (18% probability). 4
• Score 5-8: High risk for moderate-to-severe OSA (probability increases from 45% to 75% as score rises). 5, 4

The probability of severe OSA increases proportionally with higher scores: 25% at score 3, rising to 75% at scores 7-8 in sleep clinic populations. 5

Diagnostic Performance Characteristics

The STOP-BANG demonstrates excellent sensitivity but poor specificity, which is critical to understand for proper clinical application:

• Sensitivity: 90% for any OSA (AHI ≥5), 93-94% for moderate-to-severe OSA (AHI ≥15), and 96-100% for severe OSA (AHI ≥30). 2, 5, 4
• Specificity: Only 36% at high-risk cutoffs, resulting in substantial false positives. 1, 2
• Negative predictive value: 90% for moderate-to-severe OSA and 100% for severe OSA, making it excellent for ruling out disease when negative. 5, 4

The American Academy of Sleep Medicine explicitly states that STOP-BANG produces 61 false negatives per 1,000 patients at 87% prevalence—a rate deemed "clearly excessive" for standalone diagnostic use. 1, 2

Mandatory Next Steps After Positive Screen

All patients with STOP-BANG scores ≥3 require confirmatory objective testing before initiating treatment. 2, 3

Diagnostic Testing Options:

• Polysomnography (PSG): Gold standard requiring EEG, EOG, chin EMG, airflow, oxygen saturation, respiratory effort, and ECG monitoring. 6
• Home Sleep Apnea Testing (HSAT): Type III portable monitors acceptable for patients with high pretest probability of moderate-to-severe OSA, with manually scored respiratory event index ≥15 events/hour establishing diagnosis. 6

Perioperative Management (Surgical Patients):

For surgical patients with positive STOP-BANG (≥3), implement precautions even before confirmatory testing is completed: 2

• Use regional or local anesthesia when possible
• Provide continuous respiratory monitoring
• Administer supplemental oxygen
• Consider CPAP therapy
• Avoid supine positioning
• Use enhanced postoperative monitoring in telemetry-capable settings

STOP-BANG correctly identified 92.5% and 93.1% of patients with moderate-severe OSA missed by anesthesiologists and surgeons respectively, demonstrating superiority over clinical gestalt. 2

Critical Limitations and Pitfalls

Do not use STOP-BANG as a standalone diagnostic tool or to exclude OSA. 1, 2, 3 The American Academy of Sleep Medicine determined that clinical questionnaires produce too many false negatives to diagnose individual patients. 1, 2

Population-Specific Limitations:

• Reduced accuracy in women: The questionnaire was validated primarily in middle-aged, obese males. 2
• Poor performance in East Asian populations: AUC of only 0.52 compared to >0.80 in other geographic regions for moderate-to-severe OSA. 2, 7
• Lower accuracy in non-obese individuals and younger patients (<40 years). 2

Common Clinical Errors to Avoid:

• Never rely solely on STOP-BANG score for diagnosis without confirmatory PSG or HSAT. 2, 3
• Do not assume negative symptoms exclude OSA: 78% of patients with confirmed OSA denied common symptoms of snoring and sleepiness, and patients with severe OSA often report normal sleepiness scores. 6
• Recognize the low specificity leads to overdiagnosis: Many positive screens will not have clinically significant OSA on objective testing. 1, 2

Comparison to Alternative Screening Tools

STOP-BANG outperforms other questionnaires with higher diagnostic accuracy: 2

• Berlin Questionnaire: Produces large numbers of false negatives with sensitivity 0.93 but specificity only 0.36. 1
• Epworth Sleepiness Scale (ESS): Sensitivity range 0.27-0.72 and specificity 0.50-0.76 for AHI ≥5, with excessive false negatives. 1

The STOP-BANG demonstrates superior AUC (0.74-0.77) compared to these alternatives. 2

Clinical Algorithm

1. Administer STOP-BANG to all patients with suspected OSA symptoms (snoring, witnessed apneas, daytime sleepiness, gasping/choking at night, nocturia). 6
2. Score ≥3: Order PSG (preferred) or HSAT for high pretest probability patients. 2, 3, 6
3. Surgical patients with score ≥3: Implement perioperative precautions immediately while awaiting diagnostic testing. 2
4. Score 0-2: Low risk, but do not completely exclude OSA if high clinical suspicion based on comorbidities (resistant hypertension, cardiac arrhythmias, type 2 diabetes). 6
5. Confirmed OSA on testing: Initiate CPAP for moderate-to-severe OSA (AHI ≥15) and optimize blood pressure control. 6