Identification of patients with sleep disordered breathing: comparing the four-variable screening tool, STOP, STOP-Bang, and Epworth Sleepiness Scales

Validation of the Slovene Version of the Stop-Bang Questionnaire in a Primary Practice Setting

Aim

The aim of our study was to validate the Slovene translation of the STOP-BANG (SBQ) questionnaire for use in the primary practice setting.

Methods

We recruited 158 randomly selected visitors at four primary practice clinics who came to the practice for any reason. Participants completed the Slovene SBQ and underwent type 3 respiratory polygraphy, which was analysed by an experienced somnologist. The SBQ was previously translated in to Slovene and validated for the sleep clinic.

Results

Of 158 participants, 153 had valid recordings. The mean age of the participants was 49.5 years (±13.0 years), and 47.7% were male. OSA was identified in 49.0% of the participants. The questionnaire, with a cutoff of ≥3, demonstrated an area under the curve of 0.823 for any OSA (REI≥5), 0.819 for moderate and severe OSA (REI≥15) and 0.847 for severe OSA (REI≥30). Sensitivity was 65.3%, 81.8%, and 90.0%, and specificity was 87.2%, 73.3% and 65.0% for any, moderate to severe and severe OSA, respectively.

Conclusions

The Slovene translation of the SBQ is a reliable instrument for OSA risk stratification in the primary practice setting.

Slow oscillation-spindle cross-frequency coupling predicts overnight declarative memory consolidation in older adults

Cross-frequency coupling (CFC) between brain oscillations during non-rapid-eye-movement (NREM) sleep (e.g. slow oscillations [SO] and spindles) may be a neural mechanism of overnight memory consolidation. Declines in CFC across the lifespan might accompany coinciding memory problems with ageing. However, there are few reports of CFC changes during sleep after learning in older adults, controlling for baseline effects. Our objective was to examine NREM CFC in healthy older adults, with an emphasis on spindle activity and SOs from frontal electroencephalogram (EEG), during a learning night after a declarative learning task, as compared to a baseline night without learning. Twenty-five older adults (M [SD] age = 69.12 [5.53] years; 64% female) completed a two-night study, with a pre- and post-sleep word-pair associates task completed on the second night. SO-spindle coupling strength and a measure of coupling phase distance from the SO up-state were both examined for between-night differences and associations with memory consolidation. Coupling strength and phase distance from the up-state peak were both stable between nights. Change in coupling strength between nights was not associated with memory consolidation, but a shift in coupling phase towards (vs. away from) the up-state peak after learning predicted better memory consolidation. Also, an exploratory interaction model suggested that associations between coupling phase closer to the up-state peak and memory consolidation may be moderated by higher (vs. lower) coupling strength. This study supports a role for NREM CFC in sleep-related memory consolidation in older adults.

Association between alcohol use disorder and risk of obstructive sleep apnea

Obstructive sleep apnea (OSA) is a common sleep disorder characterised by recurrent upper airway collapse during sleep. Alcohol consumption has been linked to an increased risk of OSA due to its effects on the upper airway and body mass index (BMI). We aimed to investigate the correlation between alcohol use disorders and OSA. We used 11,859 participants data from Korean National Health and Nutrition Examination Surveys. The variable of interest was alcohol use disorder, measured using the Alcohol Use Disorders Identification Test, and the dependent variable was the risk of OSA, measured using the Snoring, Tiredness, Observed apnea, high blood Pressure, BMI, age, neck circumference, and male gender questionnaires. Multiple logistic regression was used to assess the association between alcohol use disorder and OSA risk after adjusted analysis. A significant association was found between alcohol use disorder and OSA (adjusted odds ratio [aOR] 2.14, 95% confidence interval [CI] 1.93-2.37). In the unemployed group, those with alcohol use disorder had the highest odds of being at risk of OSA compared with those who did not have this disorder (aOR 2.45, 95% CI 2.04-2.95). The OSA risk increased as the snoring frequency, amount of alcohol consumed, and frequency of binge drinking increased. This study suggests an association between alcohol use disorders and the risk of OSA. The frequency of alcohol consumption, quantity of alcohol consumed, and snoring frequency were associated with the risk of OSA. Therefore, ceasing alcohol consumption is recommended as an effective approach to enhancing sleep quality.

Comparison of the value of the STOP-BANG questionnaire with oxygen desaturation index in screening obstructive sleep apnea in Germany

PURPOSE

Despite polysomnography being the gold standard method of diagnosing obstructive sleep apnea (OSA), it is time-consuming and has long waiting lists. Alternative methods including questionnaires and portable sleep devices have been developed to increase the speed of diagnosis. However, most questionnaires such as the STOP-BANG questionnaire (SBQ) are limited due to low specificity. This study evaluated the value of SBQ to screen for OSA and compared it with the oxygen desaturation index (ODI) and their combination.

METHODS

This retrospective study included patients who completed the SBQ and underwent a night at the sleep lab or home sleep testing. The ODI was extracted from these sleep study reports. The combination of SBQ with ODI and their individual scores were compared with apnea-hypopnea index (AHI) in terms of their accuracy in diagnosing OSA. Sensitivity, specificity, and area under the curve (AUC) for different severities of OSA were calculated and compared.

RESULTS

Among 132 patients, SBQ showed a sensitivity of 0.9 and a specificity of 0.3 to screen for OSA. As the severity of OSA increased, the sensitivity increased whilst specificity decreased for both measurements. ODI achieved an increased specificity of 0.8 and could correctly diagnose OSA 86% of the time which was better than SBQ's 60%. For all severities of OSA, ODI alone displayed a larger AUC than SBQ and similar AUC to their combination.

CONCLUSION

ODI produced a higher specificity and AUC than SBQ. Furthermore, ODI combined with SBQ failed to increase diagnostic value. Therefore, ODI may be the preferred way to initially screen patients for OSA as an easy-to-use alternative compared to SBQ.

Modified STOP-bang questionnaire incorporating morning dry mouth and BMI adjustment in China: a retrospective study of 590 patients

BACKGROUND

Morning dry mouth (MDM) is a common symptom of Obstructive Sleep Apnea (OSA) yet current OSA screening tools overlook it.

OBJECTIVE

To enhance the specificity of the Stop-Bang questionnaire (SBQ) by adding an MDM symptom.

METHOD

A retrospective analysis on 590 patients from Peking University First Hospital (2013-2018) suspected of OSA was conducted. They underwent polysomnography. The research incorporated the MDM symptom into SBQ and adjusted the body mass index (BMI) threshold to 28 kg/m2. Predictive parameters were then calculated.

RESULTS

83.1% patients were diagnosed with OSA, with 61.4% reporting MDM. Multivariate regression confirmed MDM significantly influenced Apnea-Hypopnea Index (AHI). Adjusted SBQ with MDM showed a slight decrease in sensitivity but improved specificity, especially when using a BMI threshold of > 28 kg/m2. For AHI ≥ 5 events/h and AHI ≥ 15 events/h, adjusted SBQ with MDM (BMI >28 kg/m2) obtained the highest Youden index.

CONCLUSION

Incorporating the MDM symptom into SBQ and adjusting the BMI threshold enhances the diagnostic specificity for OSA.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Revisiting the Epworth sleepiness scale : Is excessive daytime sleepiness still a valid screening tool for obstructive sleep apnea in a population at risk?

OBJECTIVE

Obstructive sleep apnea (OSA) is a common medical problem with numerous comorbidities and high costs. Since the introduction of the Epworth sleepiness scale (ESS), excessive daytime sleepiness (EDS) has been considered the most common and prominent symptom of OSA. Aim of this study was to re-evaluate the ESS for detection of OSA in a population at risk compared to the gold standard overnight polysomnography (PSG).

METHODS

A total of 266 patients (mean age 57.9 ± 11.6 years; 189 men and 77 women), referred to our sleep laboratory for probable OSA, were given ESS followed by an overnight PSG. The ESS values were compared to PSG apnea hypopnea index (AHI) with sensitivity (SE), specificity (SP), positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy (DA) calculated for ESS. The positive cut-off value for ESS was ≥ 10 and for AHI ≥ 5.

RESULTS

Only 92 (34.6%) subjects had a positive ESS. An OSA was diagnosed by PSG in 213 (80.1%) subjects: 46 having mild, 37 moderate and 130 severe apnea. Most subjects with positive ESS (88.0%) were found to have OSA but most subjects with a negative ESS (75.9%) were also positive for OSA (42% with AHI ≥ 30). The area under the receiver operating characteristic (ROC) curve for ESS was 0.60 (95% confidence interval, CI 0.54-0.66; p = 0.020) with SE 38.0%, SP 79.3%, PPV 88.0%, NPV 24.1% and DA 46.2%.

CONCLUSION

It was found that excessive daytime sleepiness, measured by ESS, is not a valuable screening tool for OSA, especially when the test is negative. Other screening tests that involve additional parameters, beside daytime sleepiness alone, should be considered.

The Usefulness of Questionnaires in Assessing the Risk of Obstructive Sleep Apnea in Patients in the Managed Care after Acute Myocardial Infarction Program-The Results of a Cross-Sectional Study

Obstructive sleep apnea (OSA) worsens prognosis after myocardial infarction (MI) but often remains undiagnosed. The study aimed to evaluate the usefulness of questionnaires in assessing the risk of OSA in patients participating in managed care after an acute myocardial infarction program. Study group: 438 patients (349 (79.7%) men) aged 59.92 ± 10.92, hospitalized in the day treatment cardiac rehabilitation department 7-28 days after MI. OSA risk assessment: A 4-variable screening tool (4-V), STOP-BANG questionnaire, Epworth sleepiness scale (ESS), and adjusted neck circumference (ANC). The home sleep apnea testing (HSAT) was performed on 275 participants. Based on four scales, a high risk of OSA was found in 283 (64.6%) responders, including 248 (56.6%) based on STOP-BANG, 163 (37.5%) based on ANC, 115 (26.3%) based on 4-V, and 45 (10.3%) based on ESS. OSA was confirmed in 186 (68.0%) participants: mild in 85 (30.9%), moderate in 53 (19.3%), and severe in 48 (17.5%). The questionnaires' sensitivity and specificity in predicting moderate-to-severe OSA were: for STOP-BANG-79.21% (95% confidence interval; CI 70.0-86.6) and 35.67% (95% CI 28.2-43.7); ANC-61.39% (95% CI 51.2-70.9) and 61.15% (95% CI 53.1-68.8); 4-V-45.54% (95% CI 35.6-55.8) and 68.79% (95% CI 60.9-75.9); ESS-16.83% (95% CI 10.1-25.6) and 87.90% (95% CI 81.7-92.6). OSA is common in post-MI patients. The ANC most accurately estimates the risk of OSA eligible for positive airway pressure therapy. The sensitivity of the ESS in the post-MI population is insufficient and limits this scale's usefulness in risk assessment and qualification for treatment.

Validation of the STOP-Bang questionnaire as a preoperative screening tool for obstructive sleep apnea: a systematic review and meta-analysis

BACKGROUND

Obstructive sleep apnea (OSA) is a common disorder that is highly associated with postoperative complications. The STOP-Bang questionnaire is a simple screening tool for OSA. The objective of this systematic review and meta-analysis is to evaluate the validity of the STOP-Bang questionnaire for screening OSA in the surgical population cohort.

METHODS

A systematic search of the following databases was performed from 2008 to May 2021: MEDLINE, Medline-in-process, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PsycINFO, Journals @ Ovid, Web of Science, Scopus, and CINAHL. Continued literature surveillance was performed through October 2021.

RESULTS

The systematic search identified 4641 articles, from which 10 studies with 3247 surgical participants were included in the final analysis. The mean age was 57.3 ± 15.2 years, and the mean BMI was 32.5 ± 10.1 kg/m² with 47.4% male. The prevalence of all, moderate-to-severe, and severe OSA were 65.2, 37.7, and 17.0%, respectively. The pooled sensitivity of the STOP-Bang questionnaire for all, moderate-to-severe, and severe OSA was 85, 88, and 90%, and the pooled specificities were 47, 29, and 27%, respectively. The area under the curve for all, moderate-to-severe, and severe OSA was 0.84, 0.67, and 0.63.

CONCLUSIONS

In the preoperative setting, the STOP-Bang questionnaire is a valid screening tool to detect OSA in patients undergoing surgery, with a high sensitivity and a high discriminative power to reasonably exclude severe OSA with a negative predictive value of 93.2%.

TRIAL REGISTRATION

PROSPERO registration  CRD42021260451 .

SANReSP: A new Italian questionnaire to screen patients for obstructive sleep apnea

Purpose

Obstructive sleep apnea (OSA) is a common, prevalent, and underdiagnosed disorder. Its lack of diagnosis and treatment is associated with increased morbidity and mortality. Previous screening questionnaires investigated parameters including body mass index, age, neck circumference, and sex, in addition to symptoms. This study aimed to validate a new Italian, self-administered, and easy-to-use six-item questionnaire that evaluates only subjective symptoms.

Patients and methods

The present study included 2622 patients (male, 2011; female, 611). Patients who were at least 18 years old, spoke Italian, referred to our sleep clinic for possible OSA, and completed the self-administered SANReSP questionnaire were recruited for the study. The predictive performance of the questionnaire was also evaluated.

Results

Nocturnal study showed 89.9% of OSA patients had apnea-hypopnea index (AHI) ≥ 5/h; 68.7%, AHI ≥ 15/h; and 48.2%, AHI ≥ 30/h. The optimal SANReSP score for AHI ≥ 5/h was >3 with a sensitivity and specificity of 74.76% and 67.92%, respectively, and an area under receiver operating characteristic curve (ROC) of 0.76. For moderate–severe OSA, the optimal SANReSP score was >3 (sensitivity, 78.18%; specificity, 46.53%; ROC, 0.66). For severe OSA, the optimal SANReSP score was >4 (sensitivity, 59.10%; specificity, 64.73%; ROC, 0.65). The probability of OSA increased with higher SANReSP scores (98.7% and 97.9% in men and women, respectively).

Conclusion

The SANReSP questionnaire is a short, easy-to-use, and self-administered screening tool for OSA. Its performance is similar to that of other widely used questionnaires; furthermore, it is advantageous in that it does not require anthropometric measurements.

A Comparison of the Reliability of Five Sleep Questionnaires for the Detection of Obstructive Sleep Apnea

The aim of this study was to compare the reliability of five sleep questionnaires in detecting the occurrence of obstructive sleep apnea (OSA). The study was conducted on a group of 201 patients. The patients completed five sleep questionnaires: the Epworth Sleepiness Scale (ESS), the STOP-Bang questionnaire, the STOP questionnaire, the Berlin questionnaire (BQ) and the Pittsburgh Sleep Quality Index (PSQI). Subsequently, the patients were examined using limited polygraphy, and the sensitivity and specificity of the questionnaires were evaluated. The STOP-Bang, Berlin and STOP questionnaires had the highest sensitivity for OSA detection (81.6%, 78.7%, and 74.2%, respectively), while the sensitivities of PSQI and ESS were low (50.8% and 34.5%). The ESS, STOP-Bang, STOP and Berlin questionnaires had the highest specificity (82.6%, 75%, 61.9%, and 61.9%). In our sample, we found the STOP-Bang and Berlin questionnaires to be the most suitable for OSA screening with the highest sensitivities (81.6%, 78.7%) and satisfactory specificities (75%, 61.9%). The STOP questionnaire was also relatively reliable, especially given its time-saving nature; though short, it preserved satisfactory sensitivity (74.2%) and specificity (61.9%). The ESS and PSQI were unsuitable for OSA screening.

Biochemical Markers and Obstructive Sleep Apnea Risk in Individuals After Long-Term Bariatric Surgery

BACKGROUND

Individuals who have undergone long-term bariatric surgery may be at increased obstructive sleep apnea (OSA) risk. The purpose of this study was to estimate the frequency of OSA risk and its associations, via biochemical markers, in patients who have undergone long-term bariatric surgery.

METHODS

This cross-sectional study evaluated patients after 5 years or more post Roux-en-Y gastric bypass. Biochemical markers, anthropometrics, and OSA risk, via the STOP-Bang score screening tool, were evaluated. Independent Student t, Pearson's chi-squared, or correlation tests were applied, according to total OSA risk score groups or its isolated components.

RESULTS

Among the 77 patients evaluated (88.3% female; body mass index = 32.7 ± 5.8 kg/ m²; postoperative time = 9.9 ± 3.1 years), 36 were at risk for OSA. OSA risk score was positively correlated to high-sensitivity C-reactive protein levels (r² = 0.270; p = 0.025), triglycerides (r² = 0.338, p = 0.004), total cholesterol (r² = 0,262; p = 0,028), and HbA1c (r² = 0.332; p = 0.005). Compared to each counterpart, basal insulin and triglycerides were higher among those who self-reported witnessed apnea (12.8 ± 6.5 vs 8.1 ± 3.8, p = 0.013; 136.4 ± 41.1 vs 88.5 ± 34.8, p = 0.001, respectively), while levels of total cholesterol and LDL-C were higher in participants who reported tiredness (183.9 ± 27.0 vs 164.8 ± 33.4, p = 0.005; 105.9 ± 24.4 vs 92.0 ± 26.6, p = 0.018). Participants with snoring also had higher levels of triglycerides (107 ± 41.1 vs 83.7 ± 33.9, p = 0.010).

CONCLUSIONS

OSA risk was highly prevalent among patients who had undergone long-term bariatric surgery, as noted via increased STOP-Bang scores, as were isolated components related to inflammatory markers and lipid and glycemic profile.

Obstructive sleep apnea risk and hearing impairment among occupational noise-exposed male workers

This study aimed to investigate the association between obstructive sleep apnea (OSA) risk and hearing impairment among workers exposed to occupational noise. A cross-sectional study was conducted among 607 healthy male workers at a tire-manufacturing factory. The subjects underwent audiometric testing, and their OSA risk was examined based on the STOP-Bang questionnaire. Hearing impairment was defined as a hearing threshold >25 dB hearing level (HL) in any frequency of 1, 2, 3 and 4 kHz in either ear. High OSA risk was defined as a STOP-bang score of ≥3. Hearing thresholds at 1, 2, 3 and 4 kHz in both ears were significantly higher among workers with high OSA risk than among those with low OSA risk after adjusting for confounders. Multiple logistic regression analysis examining the association of OSA risk and STOP-Bang score with hearing impairment revealed an odds ratio of 1.738 (95% confidence interval [CI] 1.113-2.713, p = 0.015) and 1.256 (95% CI 1.031-1.529, p = 0.023), respectively, after adjusting for confounders. In addition, when the hearing impairment was reclassified into high- and low-frequency hearing impairment, a statistically significant OR was seen for high-frequency hearing impairment. In conclusion, high OSA risk was associated with hearing impairment in occupational noise-exposed workers, especially in the high-frequency range of 3 and 4 kHz. More efforts are required to improve the management of OSA and its risk factors to preserve hearing in occupational noise-exposed workers.

Respiratory Muscle Endurance in Obesity Hypoventilation Syndrome

BACKGROUND

An increase in respiratory work load and resistance to respiration cause a decrease in respiratory muscle endurance (RME) in patients with obesity hypoventilation syndrome (OHS). We aimed to evaluate and compare RME in subjects with OHS and a control group using an incremental load test and compare the RME of subjects with OHS in whom noninvasive ventilation (NIV) was and was not used.

METHODS

Forty subjects with OHS (divided according to body mass index [BMI] as group I: 30-40 kg/m²; and group II: ≥ 40 kg/m²) and 20 subjects with obesity (control group: 30-40 kg/m²) were included in the study. RME was evaluated using the incremental load test, and respiratory muscle strength (RMS) was evaluated using mouth pressure measurements. The 6-min walk test, Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI), Fatigue Severity Scale (FSS), EQ-5D Health-Related Quality of Life Questionnaire (EQ-5D), and the Obesity and Weight-Loss Quality of Life Instrument (OWLQOL) were performed.

RESULTS

RME and RMS (%) in group I were lower than the control group (P = .001, P = .005, and P = .001, respectively). No significant difference was found between the 3 groups in terms of 6-min walk distance (6MWD) percentage predicted values (P = .98). RME in the NIV user group was higher than the non-user group (P = .006). ESS, total PSQI, and FSS scores in the control group were less than group I (P = .01, P = .009, and P = .005, respectively) and group II (P = .01, P < .001, and P < .001, respectively). The EQ-5D scores of the control group were higher than group II only (P = .005 and P = .005, respectively). There were no differences in OWLQOL between the groups (P = .053).

CONCLUSIONS

RME was low in subjects with OHS but higher in those who used NIV. The incremental load test could be performed easily and safely in a clinic setting.

Relationship between Severity and Complexity of Coronary Artery Involvement and Obstructive Sleep Apnea Based on STOP-BANG Questionnaire

Background:

Obstructive sleep apnea (OSA), which has a known correlation with cardiovascular disease, is a possible risk factor of coronary artery disease (CAD) that is preventable.

Aims:

We sought to put lights on the relationship between OSA based on the STOP-BANG questionnaire (SBQ) and the severity and complexity of coronary artery involvement.

Methods:

This cross-sectional, single-center, retrospective study was conducted among 145 patients who underwent selective coronary angiography (SCA) between October 2018 and March 2019, admitted to the Tehran Heart Center, Tehran, Iran. OSA risk was assessed in patients based on SBQ categories. Also, the severity and complexity of coronary artery involvement calculated according to SYNTAX and Gensini scores. Analysis performed by statistical software SPSS 25.

Results:

Based on SBQ risk assessment categories, 22 (15.2%), 64 (44.1%), and 59 (40.7%) of the patients were low, intermediate, and high-risk for OSA, respectively. By comparing the means of coronary artery involvement, there was no significant difference in SYNTAX score 17.15 ± 13.67 (10.56–23.74) in low, 15.67 ± 9.78 (13.19–18.16) in intermediate, and 16.93 ± 9.21 (14.42–19.45) in high-risk groups; P value: 0.754, and Gensini score 66.4 ± 70.75 (35.04–97.77) in low, 66.21 ± 55.05 (52.45–79.96) in intermediate, 74.61 ± 56.33 (59.93–89.3) iin high risk groups; P value: 0.697 with groups of OSA risks. Also, after adjusting confounding factors, there was still no statistically significant difference in terms of coronary involvement scores.

Conclusions:

There was no statistically significant difference in SYNTAX and Gensini scores of different groups of OSA risk categories based on the SBQ. However, our results can't be extended into the connection between OSA and CAD.

Validity Analysis of Neck Circumference as a Screening Test for Hypoxia Occurrence in Patients Undergoing Sedative Endoscopy

This study was performed to check the validity of and propose a cutoff point for measuring the neck circumference for screening hypoxia occurrence in patients undergoing sedative endoscopy. Data were collected from 168 patients who visited the Endoscopy Center of G University Hospital between 27 April 2020 and 12 June 2020 to undergo sedative endoscopy. Hypoxia occurrences were measured using sleep questionnaires (STOP-BANG and Berlin questionnaires), and the neck circumference measurements of the patients were compared. Neck circumference as a predictor of hypoxia and its sensitivity and specificity according to the cutoff values were high; thus, it is a valid screening test for hypoxia in patients undergoing sedative endoscopy. The most appropriate cutoff values for sitting neck circumference and lying neck circumference in men were 40.5 and 40.3, respectively, and those for women were 35.3 and 35.8, respectively. Hypoxia can be predicted in patients undergoing sedative endoscopy by measuring their neck circumference.

Diagnostic Performance of Machine Learning-Derived OSA Prediction Tools in Large Clinical and Community-Based Samples

BACKGROUND

Prediction tools without patient-reported symptoms could facilitate widespread identification of OSA.

RESEARCH QUESTION

What is the diagnostic performance of OSA prediction tools derived from machine learning using readily available data without patient responses to questionnaires? Also, how do they compare with STOP-BANG, an OSA prediction tool, in clinical and community-based samples?

STUDY DESIGN AND METHODS

Logistic regression and machine learning techniques, including artificial neural network (ANN), random forests (RF), and kernel support vector machine, were used to determine the ability of age, sex, BMI, and race to predict OSA status. A retrospective cohort of 17,448 subjects from sleep clinics within the international Sleep Apnea Global Interdisciplinary Consortium (SAGIC) were randomly split into training (n = 10,469) and validation (n = 6,979) sets. Model comparisons were performed by using the area under the receiver-operating curve (AUC). Trained models were compared with the STOP-BANG questionnaire in two prospective testing datasets: an independent clinic-based sample from SAGIC (n = 1,613) and a community-based sample from the Sleep Heart Health Study (n = 5,599).

RESULTS

The AUCs (95% CI) of the machine learning models were significantly higher than logistic regression (0.61 [0.60-0.62]) in both the training and validation datasets (ANN, 0.68 [0.66-0.69]; RF, 0.68 [0.67-0.70]; and kernel support vector machine, 0.66 [0.65-0.67]). In the SAGIC testing sample, the ANN (0.70 [0.68-0.72]) and RF (0.70 [0.68-0.73]) models had AUCs similar to those of the STOP-BANG (0.71 [0.68-0.72]). In the Sleep Heart Health Study testing sample, the ANN (0.72 [0.71-0.74]) had AUCs similar to those of STOP-BANG (0.72 [0.70-0.73]).

INTERPRETATION

OSA prediction tools using machine learning without patient-reported symptoms provide better diagnostic performance than logistic regression. In clinical and community-based samples, the symptomless ANN tool has diagnostic performance similar to that of a widely used prediction tool that includes patient symptoms. Machine learning-derived algorithms may have utility for widespread identification of OSA.

Obstructive sleep apnea

Obstructive sleep apnea (OSA) is a disease that results from loss of upper airway muscle tone leading to upper airway collapse during sleep in anatomically susceptible persons, leading to recurrent periods of hypoventilation, hypoxia, and arousals from sleep. Significant clinical consequences of the disorder cover a wide spectrum and include daytime hypersomnolence, neurocognitive dysfunction, cardiovascular disease, metabolic dysfunction, respiratory failure, and pulmonary hypertension. With escalating rates of obesity a major risk factor for OSA, the public health burden from OSA and its sequalae are expected to increase, as well. In this chapter, we review the mechanisms responsible for the development of OSA and associated neurocognitive and cardiometabolic comorbidities. Emphasis is placed on the neural control of the striated muscles that control the pharyngeal passages, especially regulation of hypoglossal motoneuron activity throughout the sleep/wake cycle, the neurocognitive complications of OSA, and the therapeutic options available to treat OSA including recent pharmacotherapeutic developments.

Validation of the STOP questionnaire as a screening tool for OSA among different populations: a systematic review and meta-regression analysis

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is a sleep breathing disorder associated with adverse health outcomes, but it remains largely underdiagnosed. The STOP questionnaire is a simple tool for screening OSA and is widely used in various populations. The objective of this study was to determine the predictive parameters of the STOP questionnaire to detect OSA in sleep clinics, medical population, surgical population, commercial drivers, and the general population.

METHODS

Electronic databases were searched from January 2008 to April 2021. Pooled predictive parameters were recalculated using 2 × 2 contingency tables and random-effects meta-analyses were performed. The combined test characteristics at different OSA severities [any OSA (AHI≥5), moderate-to-severe OSA (AHI≥15), severe OSA (AHI≥30)] were used to compare the accuracy of the STOP questionnaire with polysomnography. The quality of the studies was evaluated using Cochrane Methods criteria.

RESULTS

Twenty-four studies met the inclusion criteria: 16 were in the sleep clinic population (n=8,132), four in medical population (n=1,023), two in the surgical population (n=258), and one study each on commercial drivers (n=85) and general population (n=4,770). A STOP score ≥2 showed excellent sensitivity to the different OSA severities for the sleep clinic population (>89%) and to severe OSA for the medical population (85.6%). In both populations, the STOP questionnaire also had excellent discriminative power to exclude severe OSA [negative predictive values (NPV) >84%]. The pooled sensitivity and NPV for the surgical population with moderate-to-severe OSA was 81% and 75%.

CONCLUSIONS

This meta-analysis suggests that the STOP questionnaire is a valid and effective screening tool for OSA among these population.

Validity of the New "Top End Sleepiness Scale" (TESS) against the STOP-Bang Tool in Predicting Obstructive Sleep Apnoea among Indigenous Australian Adults

BACKGROUND

The validity of the newly developed sleepiness assessment tool the "Top End Sleepiness Scale" (TESS) against other established obstructive sleep apnea (OSA) screening tools has not been evaluated.

AIMS

To compare the utility and validity of the culturally safe and clinically relevant subjective daytime sleepiness assessment tool the "TESS" for use among Indigenous Australians against STOP-Bang screening tool in predicting OSA in a regional and remote Indigenous Australian cohort.

METHODS

The TESS questionnaire consisting of pictorial representations of six items representing daily activities that would induce daytime sleepiness specific for Indigenous Australians was assessed for its correlation in predicting moderate to severe OSA according to apnea hypopnea index (AHI, ≥15) against STOP-Bang screening tool.

RESULTS

Eighty Indigenous Australian patients (51% male, mean age 45.1 ± 11.5 years were included in this study with the majority (n=70, 88%) having OSA of which 65 (93%) had an AHI ≥15. AUC statistics for overall scores showed no significant difference between TESS or STOP-Bang in the prediction of OSA (p=0.16). A moderate risk score of TESS (≥3) was superior to the STOP-Bang (score 3-4) in sensitivity (84% vs. 33%) and specificity (39% vs. 30%). The sensitivity for a high risk score for the STOP-Bang (≥5) was superior to the TESS (≥8) (60% vs. 33%), though specificity was comparable (83% vs. 91% respectively).

CONCLUSIONS

The TESS screening tool could be a useful standalone or could be adopted alongside STOP-Bang OSA screening tools in the clinical assessment of sleep disorders among Indigenous Australians. This article is protected by copyright. All rights reserved.

Predictive Value of Clinical and Questionnaire Based Screening Tools of Obstructive Sleep Apnea in Patients With Type 2 Diabetes Mellitus

Background

Obstructive sleep apnea (OSA) is a major health problem for people with type 2 diabetes mellitus (DM2) and is associated with poorer glycemic control. Early detection is critical to proper management. In this study, we planned to assess and compare the diagnostic accuracy of various OSA screening tools in patients with DM2.

Methods

In this cross-sectional study, we consecutively recruited 58 patients with DM2, presenting to the endocrinology department of Services Hospital Lahore between February 2020 to March 2021. Along with demographic and anthropometric measurements, including BMI and neck circumference, participants answered the snoring, tiredness, observed apnea, high blood pressure - BMI, age, neck circumference, and gender (STOP-BANG) questionnaire, Berlin questionnaire, and Epworth sleepiness scale. All participants then underwent an overnight, level 3 polysomnography.

Results

The overall prevalence of OSA, diagnosed by overnight polysomnography, was 65.5% in type 2 diabeticDM2 patients. The STOP-BANG questionnaire had the highest sensitivity for mild, moderate, and severe OSA i.e., 84.2%, 90.3%, and 100% respectively. Berlin questionnaire also had 100% sensitivity for severe OSA and was most specific for mild and moderate OSA (70% and 63% respectively) whereas the Epworth sleepiness scale had the highest specificity of 53.3% for severe OSA.

Conclusion

This study shows that OSA is highly prevalent in DM2 patients in Pakistan. The STOP-BANG and Berlin questionnaire proved to be effective screening tools, especially for severe OSA. Results of our study should encourage the routine use of these questionnaires in clinical practice, to help in the early identification of OSA in diabetics.

Comparison of six assessment tools to screen for obstructive sleep apnea in patients with hypertension

Background

Obstructive sleep apnea (OSA) is often accompanied by other complications, especially hypertension.

Hypothesis

The purpose of this study is to compare the application value of six tools in the screening of OSA in patients with hypertension. Compared with other questionnaires, we hypothesized that Berlin performed better in screening hypertensive patients suspected of OSA.

Methods

In this study, we collected the basic data and polysomnography (PSG) data of patients diagnosed with hypertension who underwent PSG at the Sleep Medicine Center of the First Affiliated Hospital of Guangzhou Medical University from April 2012 to March 2021. The sensitivity, specificity, positive predictive value, negative predictive value, area under the curv (AUC) and diagnostic odds ratio (DOR) of the six screening tools were then calculated, and their correlation with the sleep apnea hypopnea index (AHI) analyzed.

Results

There were 303 males (303/398, 76.1%) out of 398 hypertension patients suspected of OSA. The area under the curve of the Berlin questionnaire's receiver operating characteristic (ROC) curve reached 0.753 (95%CI: 0.707–0.794). When the AHI was 5, 15 and 30 times/h as the cut‐off points, the sensitivity and negative predictive value of Berlin were the highest at 0.947 and 0.630, 0.970 and 0.851, and 0.988 and 0.957 respectively, while the specificity and positive predictive value of the Epworth Sleepiness Scale (ESS) were the highest at 0.696 and 0.729, 0.750 and 0.887, and 0.674 and 0.575 respectively. The DOR value of the Berlin questionnaire could reach 18.333 when the AHI cut‐off point was 30 times/h. Berlin had the largest rank correlation coefficient with AHI at 0.466.

Conclusion

The Berlin questionnaire can be considered a priority for the screening and stratifying of hypertensive patients suspected of OSA.

Predictive ability of the International Classification of Sleep Disorders-3 in identifying risk of obstructive sleep apnea among recently unemployed adults

BACKGROUND

The International Classification of Sleep Disorders (ICSD)-3 was developed to aid in the identification of these disorders. The core criterion A (ICSD-3A) to identify obstructive sleep apnea (OSA) requires the presentence of specific signs and symptoms. This study explores the predictive ability of the ICSD-3A for OSA as compared with objective measures of respiratory event index (REI).

PARTICIPANTS

A total of 291 participants who completed a home sleep apnea test (HSAT) during the screening evaluation of the Assessing Daily Activity Patterns through occupational Transitions (ADAPT) study were included.

METHODS

Participants were classified as having mild OSA (REI ≥ 5 and < 15), moderate (≥ 15 to < 30), or severe OSA (> 30). Predictive parameters identifying participants as having OSA by the ICSD-3A criteria were assessed using REI classifications as the reference standard and further compared with a subsample using the STOP-Bang questionnaire.

RESULTS

The ICSD-3A had a sensitivity of 19.2% for identifying participants as having moderate to severe OSA and specificity of 84.4%. The ICSD-3A had a receiver operating characteristics (ROC) = 0.53. On the subsample of participants, the STOP-Bang questionnaire's ROC is 0.61. Results were similar when examining the classification of participants with mild compared with no OSA.

CONCLUSION

In this population, the ability of the ICSD-3A in detecting moderate to severe OSA as well as mild OSA was low. The ROC for the ICSD-3 did not differ significantly from the STOP-Bang questionnaire's ROC in this research population.

The Future of Sleep Measurements: A Review and Perspective

This article provides an overview of the current use, limitations, and future directions of the variety of subjective and objective sleep assessments available. This article argues for various ways and sources of collecting, combining, and using data to enlighten clinical practice and the sleep research of the future. It highlights the prospects of digital management platforms to store and present the data, and the importance of codesign when developing such platforms and other new instruments. It also discusses the abundance of opportunities that data science and machine learning open for the analysis of data.

BASAN index (Body mass index, Age, Sex, Arterial hypertension and Neck circumference) predicts severe apnoea in adults living at high altitude

OBJECTIVES

Obstructive sleep apnoea (OSA)/hypopnoea syndrome is associated with serious and major multiorgan morbidities, particularly in its most severe forms. However, no severe OSA screening instruments are available for high altitude residents that enable adequate identification and clinical prioritisation of such patients. We aimed at developing a severe OSA prediction tool based on the clinical characteristics and anthropometric measurements of a clinical referral cohort living at 2640 m.a.s.l.

DESIGN

Cohort-nested cross-sectional study.

SETTING

Sleep laboratory for standard polysomnography (PSG) in Colombia.

PARTICIPANTS

A predictive model was generated from 8718 participants referred to the PSG laboratory. Results were subsequently validated in a second cohort of 1898 participants.

PRIMARY OUTCOME

To identify clinical and anthropometric variables associated with severe OSA (>30 events/hour) and to include them in a binary logistic regression model.

RESULTS

The significant variables that were retained with the presence of severe OSA included Body mass index (BMI), Age, Sex, Arterial hypertension and Neck circumference (BASAN). The area under the receiver operating characteristic curvefor the BASAN index was 0.69 (95% CI: 0.68 to 0.70) in the derivation cohort and 0.67 (95% CI: 0.65 to 0.69) in the validation cohort, whereby a BASAN index ≥2 had a sensitivity of 95% and a specificity of 17% to detect severe OSA.

CONCLUSION

An objectively based approach to screen for the presence of severe OSA, the BASAN index, exhibits favourable sensitivity characteristics that should enable its operational use as a screening tool in a Hispanic population with a clinical suspicion of OSA and living at high altitude.

The association between high risk of sleep apnea, comorbidities, and risk of COVID-19: a population-based international harmonized study

PURPOSE

Obstructive sleep apnea (OSA) may increase the risk of severe COVID-19; however, the level of potential modulation has not yet been established. The objective of the study was to determine the association between high risk of OSA, comorbidities, and increased risk for COVID-19, hospitalization, and intensive care unit (ICU) treatment.

METHODS

We conducted a cross-sectional population-based web survey in adults in 14 countries/regions. The survey included sociodemographic variables and comorbidities. Participants were asked questions about COVID-19, hospitalization, and ICU treatment. Standardized questionnaire (STOP questionnaire for high risk of OSA) was included. Multivariable logistic regression was conducted adjusting for various factors.

RESULTS

Out of 26,539 respondents, 20,598 (35.4% male) completed the survey. Mean age and BMI of participants were 41.5 ± 16.0 years and 24.0 ± 5.0 kg/m², respectively. The prevalence of physician-diagnosed OSA was 4.1% and high risk of OSA was 9.5%. We found that high risk of OSA (adjusted odds ratio (aOR) 1.72, 95% confidence interval (CI): 1.20, 2.47) and diabetes (aOR 2.07, 95% CI: 1.23, 3.48) were associated with reporting of a COVID-19 diagnosis. High risk for OSA (aOR 2.11, 95% CI: 1.10-4.01), being male (aOR: 2.82, 95% CI: 1.55-5.12), having diabetes (aOR: 3.93, 95% CI: 1.70-9.12), and having depression (aOR: 2.33, 95% CI: 1.15-4.77) were associated with increased risk of hospitalization or ICU treatment.

CONCLUSIONS

Participants at high risk of OSA had increased odds of having COVID-19 and were two times more likely to be hospitalized or treated in ICU.

Translation and validation of the STOP-Bang questionnaire into Slovene

Purpose

To translate, culturally adapt and evaluate the Slovene version of the STOP-Bang questionnaire (SBQ) for use in the sleep clinic.

Methods

Standard forward–backward translation and harmonisation of the Slovene translation of the SBQ were performed. Test–retest reliability was performed on a sample of healthy subjects. A cross-sectional study was performed with patients referred for a sleep study. Patients filled out the Slovene translation of the SBQ before undergoing sleep study.

Results

The validation group consisted of 256 patients, of which 237 (92.6%) were included. Mean age was 52.5 ± 14.6, 63.3% of patients were male. Obstructive sleep apnoea (OSA) (apnoea–hypopnea index (AHI) ≥ 5) was present in 69.6% of patients, of whom 22.4% had mild (AHI ≥ 5 and < 15), 21.9% moderate (AHI ≥ 15 and < 30), and 25.3% severe (AHI ≥ 30) OSA. A SBQ score of 3 had a sensitivity of 92.1 (86.9–95.7), specificity of 44.4 (32.7–56.6), PPV of 79.2 (75.5–82.4) and AUC of 0.757 (95% CI 0.692–0.823; p < 0.001) for all OSA (AHI ≥ 5). Each increase in the SBQ score was associated with an increase in the probability of OSA.

Conclusion

This study shows that the Slovene version of the SBQ is a valid tool for evaluating the risk of OSA in a sleep clinic.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40001-021-00503-z.

Predictors of At-Home Arterial Oxygen Desaturation Events in Ambulatory Surgical Patients

OBJECTIVES

Little is known about the early recovery phase occurring at-home after anesthesia and surgery in ambulatory surgical patients. We studied quantitative oximetry and quality-of-life metrics in the first 48 hours after same-day orthopedic surgery examining the association between the recovery metrics and specific patient and procedural factors.

METHODS

We used the STOP-Bang score to quantify patient risk for obstructive sleep apnea in 50 adult patients at 2 centers using continuous portable oximetry and patient journaling. Parametric statistical procedures were used to assess relationships among patient and procedural factors and desaturation events.

RESULTS

Higher STOP-Bang scores were predictive of the number and duration of desaturation events below mild and severe thresholds for arterial oxygen saturation during their first 48 hours after discharge from ambulatory surgery. Older patients and patients with higher BMI in particular were at an increased risk of mild and severe arterial oxygen desaturation. Using a home CPAP reduced the number of desaturation events. Of interest, taking opiate analgesics decreased the number of desaturation events.

CONCLUSIONS

Given the absence of systematic research of early ambulatory anesthesia/surgery recovery at home and concerns of postoperative respiratory events, our results have clear implications for patient safety. Our results imply that screening based on noninvasive STOP-Bang scores may allow for suggestions for recovery from ambulatory surgery, such as encouraging patients with high scores to use home CPAP and aggressive education regarding use of opiates.

Using anthropometric measures to screen for obstructive sleep apnea in the Sleep Heart Health Study cohort

STUDY OBJECTIVES

To evaluate predictions of moderate-to-severe-obstructive sleep apnea (MS-OSA) by the neck circumference height ratio (NHR) and waist circumference height ratio (WHR) and compare to the derived STOP-Bang Questionnaire (dSBQ) prediction.

METHODS

Included were 6,167 participants from the Sleep Heart Health Study (SHHS) baseline evaluation who completed polysomnograms, had anthropometric measurements, and data to compute proxy dSBQ item answers. The sample was divided randomly into derivation (n = 2,035) and validation (n = 4,132) subsets. The derivation sample was used to estimate the NHR and WHR cut points to detect MS-OSA; the validation sample was used to evaluate sensitivity (SN) and specificity (SP).

RESULTS

Mean age was 63.1 years, and 47.2% were male for the overall sample. In the derivation sample, a cut point ≥ 0.21 for NHR yielded a SN of 92.0% and SP of 25.0%; a cut point ≥ 0.52 for WHR yielded a SN of 91.2% and SP of 25.0% for MS-OSA. Using the validation sample, the NHR, WHR, and dSBQ areas under the receiver operator curves (AUCs) were 69.8%, 65.2%, and 70.5% respectively for MS-OSA. There was no statistical difference with listwise comparison of the NHR and dSBQ AUCs (p = 0.997); however, there was a significant difference between the WHR and dSBQ AUCs (p = 0.015) for MS-OSA.

CONCLUSIONS

The NHR is a viable OSA screening tool comparable to the dSBQ, independent of witnessed apneas and BMI, that can be used for different body types.

Validation of the STOP-Bang questionnaire as a screening tool for obstructive sleep apnoea in patients with cardiovascular risk factors: a systematic review and meta-analysis

Introduction

Obstructive sleep apnoea (OSA) is highly prevalent in patients with cardiovascular risk factors and is associated with increased morbidity and mortality. This review presents the predictive parameters of the STOP-Bang questionnaire as a screening tool for OSA in this population.

Methods

A search of databases was performed. The inclusion criteria were: (1) use of the STOP-Bang questionnaire to screen for OSA in adults (>18 years) with cardiovascular risk factors; (2) polysomnography or home sleep apnoea testing performed as a reference standard; (3) OSA defined by either Apnoea–Hypopnoea Index (AHI) or Respiratory Disturbance Index; and (4) data on predictive parameters of the STOP-Bang questionnaire. A random-effects model was used to obtain pooled predictive parameters of the STOP-Bang questionnaire.

Results

The literature search resulted in 3888 articles, of which 9 papers met the inclusion criteria, involving 1894 patients. The average age of the included patients was 58±13 years with body mass index (BMI) of 30±6 kg/m², and 64% were male. The STOP-Bang questionnaire has a sensitivity of 89.1%, 90.7% and 93.9% to screen for all (AHI ≥5), moderate-to-severe (AHI ≥15) and severe (AHI≥30) OSA, respectively. The specificity was 32.3%, 22.5% and 18.3% and the area under the curve (AUC) was 0.86, 0.65 and 0.52 for all, moderate-to-severe and severe OSA, respectively.

Conclusion

The STOP-Bang questionnaire is an effective tool to screen for OSA (AHI≥5) with AUC of 0.86 in patients with cardiovascular risk factors.

Validation of the NoSAS score for screening sleep-disordered breathing: A sleep clinic- based study in Turkey

Background/aim

The NoSAS score is a new tool for the identification of high-risk patients for sleep-disordered breathing (SDB). The aim of this study was to validate the NoSAS score in a sleep clinical population in Turkey and compare its performance with the Epworth Sleepiness Scale (ESS), STOP-Bang, and Berlin questionnaires for high-risk SDB.

Materials and methods

This was a retrospective study. Patients who had a full-night PSG examination between 01.03.2017 and 01.01.2018 at the sleep center of our hospital were included in the study. Demographic characteristics, anthropometrics measurements, ESS, STOP-Bang, and Berlin scores were collected from the existing data of the patients. The NoSAS score was subsequently calculated based on available data. Predictive parameters for each screening questionnaires were calculated to compare the discriminative power of those for high-risk SDB. 

Results

A total of 450 patients were included in the study. The sensitivity, specificity, PPV, and NPV of the NoSAS score were 81%, 51.2%, 88.2%, and 37.5% for an AHI (apnea–hypopnea index) ≥ 5 event/h and 84.5%, 38.2%, 66%, and 63.4% for an AHI ≥ 15 event/h, respectively. AUC percentages for the NoSAS score, STOP-Bang questionnaire, Berlin questionnaire, and ESS were 0.740, 0.737, 0.626, and 0.571 for an AHI ≥ 5 events/h and 0.715, 0.704, 0.574, and 0.621 for an AHI ≥ 30 events/h. The NoSAS score had a false negative rate of 2.9% for severe SDB.

Conclusion

The NoSAS score had a good degree of differentiation for SDB and can be used as an easily applicable, subjective, and effective screening tool in a sleep clinical population in Turkey. Not only in moderate to severe SDB but also in mild SDB, the NoSAS score performed better than the other 3 screening tools.

Salivary Inflammatory Molecules as Biomarkers of Sleep Alterations: A Scoping Review

Poor sleep quality and sleep disorders are the most common problems in people, affecting health-related quality of life. Various studies show an association between sleep disorders and altered levels of stress hormones and inflammatory cytokines measured in saliva. The main objective of this article is to provide an analysis of the current evidence related to changes in inflammatory markers in the saliva and their associations with sleep quality measurement (both objective and subjective methods) in healthy subjects and in sleep-related disorders. To that end, a scoping review was carried out, following the PRISMA criteria in the bibliographic search in several databases: PubMed, EBSCO, and SCOPUS. Eleven of the articles are from the adult population and two from the child-youth population. They mainly measure the relationship between sleep and interleukin-1β (IL-1β), interleukin-6 (IL-6), and tumor necrosis factor alpha (TNFα) alpha, as well as other inflammatory markers such as myeloperoxidase (MPO) and prostaglandin-endoperoxide synthase 2. An analysis shows the relationship between these salivary biomarkers and sleep quality, especially in the case of IL-6 in both healthy subjects and several pathologies associated with sleep-disorders. The results for TNFα and IL-1β measurements are still inconclusive and the difference with IL-6 was assessed. Two studies reported interventions that result in sleep improvement and are accompanied by the normalization of inflammatory changes detected in the saliva. As it is an easy-to-apply and non-invasive method, the measurement of salivary cytokines can be very useful in chronobiology studies. Further studies are required to determine the sensitivity of salivary inflammatory markers in monitoring biological rhythms and acting as biomarkers in the detection of sleep disorders and sleep interventions.

Validation of the STOP-Bang questionnaire for screening of obstructive sleep apnea in the general population and commercial drivers: a systematic review and meta-analysis

Purpose

Obstructive sleep apnea (OSA) is a critical occupational health concern, but is often undiagnosed in the general population and commercial drivers. The STOP-Bang questionnaire is a simple, reliable tool to screen for OSA, which could improve public health in a cost-effective manner. The objective of this systematic review and meta-analysis is to assess the validity of the STOP-Bang questionnaire to detect OSA in these key populations.

Methods

We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PsycINFO, Journals @ Ovid, Web of Science, Scopus, and CINAHL for relevant articles from 2008 to March 2020. The quality of studies was appraised using Cochrane Methods criteria. To calculate pooled predictive parameters, we created 2 × 2 contingency tables and performed random-effects meta-analyses.

Results

Of 3871 citations, five studies that evaluated STOP-Bang in the general population (n = 8585) and two in commercial drivers (n = 185) were included. In the general population, prevalence of all OSA (AHI ≥ 5), moderate-to-severe OSA (AHI ≥ 15), and severe OSA (AHI ≥ 30) was 57.6%, 21.3%, and 7.8% respectively. In commercial drivers, the prevalence of moderate-to-severe OSA was 37.3%. The trends of high sensitivity and negative predictive value of a STOP-Bang score ≥ 3 illustrates that the questionnaire helps detect and rule out clinically significant OSA in the general population and commercial drivers.

Conclusion

This meta-analysis demonstrates that the STOP-Bang questionnaire is a valid and effective screening tool for OSA in the general population and commercial drivers.

Trial registration

PROSPERO No. CRD42020200379; 08/22/2020

Supplementary Information

The online version contains supplementary material available at 10.1007/s11325-021-02299-y.

Machine and Deep Learning in Molecular and Genetic Aspects of Sleep Research

Epidemiological sleep research strives to identify the interactions and causal mechanisms by which sleep affects human health, and to design intervention strategies for improving sleep throughout the lifespan. These goals can be advanced by further focusing on the environmental and genetic etiology of sleep disorders, and by development of risk stratification algorithms, to identify people who are at risk or are affected by, sleep disorders. These studies rely on comprehensive sleep-related data which often contains complex multi-dimensional physiological and molecular measurements across multiple timepoints. Thus, sleep research is well-suited for the application of computational approaches that can handle high-dimensional data. Here, we survey recent advances in machine and deep learning together with the availability of large human cohort studies with sleep data that can jointly drive the next breakthroughs in the sleep-research field. We describe sleep-related data types and datasets, and present some of the tasks in the field that can be targets for algorithmic approaches, as well as the challenges and opportunities in pursuing them.

Assessment of Quality of Life and the Risk of Obstructive Sleep Apnea in Individuals with Chronic Rhinosinusitis who are Candidate for Functional Endoscopic Sinus Surgery

BACKGROUND

Chronic rhinosinusitis is associated with changes in quality of life (QoL). The present study intended to evaluate the QoL and risk of obstructive sleep apnea in individuals with chronic rhinosinusitis who were candidate for functional endoscopic sinus surgery. To determine the Quality of Life and the risk of sleep apnea in cases with chronic Rhinosinusitis.

MATERIALS AND METHODS

A total of 100 patients with drug-resistant chronic rhinosinusitis candidate for functional endoscopic sinus surgery referred to the ENT clinic of Masih Daneshvari Hospital, Tehran, Iran were recruited. SNOT-22 and STOP-BANG questionnaires were filled before the surgery.

RESULTS

The mean SNOT-22 score was 40.44, with a standard deviation of 19.27 (ranged from 1 to 94). Also, according to the STOP-BANG questionnaire, 62% of participants were at increased risk of OSA. Based on the cut-off point of 30 for the SNOT-22 score (either larger or lower than 30), patients were categorized into two groups. Sixty-eight percent of participants were categorized in ≥ 30 SNOT-22 score. Age below 50, female gender, and those at high risk of OSA were associated with lower QoL.

CONCLUSION

Most patients with chronic rhinosinusitis had a low QoL and were mostly at increased risk of OSA. Being women younger than 50 years and the presence of OSA probably are associated with lower QoL in these patients.

The Top End Sleepiness Scale (TESS): A New Tool to Assess Subjective Daytime Sleepiness Among Indigenous Australian Adults

PURPOSE

To illustrate the utility of a newly developed culturally safe and clinically relevant subjective daytime sleepiness assessment tool "Top End Sleepiness Scale" (TESS) for use among Indigenous Australians.

PATIENTS AND METHODS

The TESS questionnaire consists of pictorial representations of 6 items representing daily activities that would induce daytime sleepiness specific for Indigenous Australians living in the regional and remote Australia. Consecutive adult Indigenous patients who consented to pilot the TESS questionnaire prior to undergoing a diagnostic polysomnography (PSG) at the Top End Health Service region, Northern Territory of Australia were assessed. The TESS questionnaire was evaluated for its correlation in predicting obstructive sleep apnea (OSA) according to apnea-hypopnea index.

RESULTS

Eighty-two patients were included. The majority (70%) had moderate to severe OSA (AHI ≥15). Patients were aged in their mid-40's (45.47 95% CI (42.9, 48.05)) with a tendency to obesity (median BMI 33.67 IQR 30.86, 38.95) and a high prevalence of chronic conditions (72%) (hypertension, diabetes or heart disease). The TESS showed high internal consistency (Split half Spearman correlation=0.71, Cronbach's α =0.81), and a cut-off value ≥3 resulted in sensitivity 84%, specificity 38%. Comparison of area under the curve for TESS to Epworth Sleepiness Scale (ESS) in this sample showed the TESS to have greater sensitivity and specificity overall, which approached significance (p=0.072) when cut-off values of ≥3 and ≥8 (TESS & ESS respectively) were used. The sensitivity and specificity for TESS was also comparable to the other currently used questionnaires, such as the Berlin Questionnaire, STOP-BANG and OSA 50.

CONCLUSION

Currently, there are no subjective daytime sleepiness assessment toll available specifically for Indigenous population. The proposed TESS sleepiness screening tool represented in this study can potentially complement or adopted alongside other existing questionnaire, which may offer greater utility in the assessment of sleep disorders among Indigenous people.

Cutoff points in STOP-Bang questionnaire for obstructive sleep apnea

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.

Predictors of Intraprocedural Respiratory Bronchoscopy Complications

PURPOSE

Sleep apnea can increase adverse outcomes during ambulatory surgery but not during gastrointestinal endoscopy. We hypothesize that STOP-BANG is associated with intraprocedural bronchoscopy respiratory complications.

METHODS

Consecutive patients undergoing bronchoscopy under moderate sedation were prospectively administered the STOP-BANG questionnaire. Participants were assessed for intraprocedural complications including hypoxemia (oxygen saturation≤85%), bradypnea (respiratory rate<8), premature procedure cessation as well as the use of nonrebreather mask, bag-mask ventilation, jaw lift/chin tilt, nasal/oral airway, and naloxone administration. Associations were assessed via logistic regression. Least absolute shrinkage and selection operator was used for multivariable model variable selection.

RESULTS

The 223 participants-mean age 61.1±15.5 years, body mass index 25.4kg/m (interquartile range: 22.4 to 30.7), 50.7% female, and 45.3% inpatient-had a high rate of respiratory complications (37.7%). There were no associations between STOP-BANG score and respiratory complications [odds ratio (OR)=1.07, 95% confidence interval (CI): 0.92-1.25]. Asthma was protective in univariable models (OR=0.26, 95% CI: 0.04-0.98), whereas endobronchial ultrasound (OR=2.34, 95% CI: 1.35-4.10) and the number of procedure types (OR=1.24, 95% CI: 1.01-1.51) was associated with increased complications. The following factors were associated with respiratory complications in both multivariable and univariate analyses: increasing age (OR=1.28/decade, 95% CI: 1.03-1.61), baseline oxygen use per each liters per minute (OR=1.57, 95% CI: 1.21-2.09), and bronchoscopy duration (OR=1.20/10 min, 95% CI: 1.08-1.33).

CONCLUSION

Bronchoscopy respiratory complications are common. STOP-BANG was not associated with increased immediate bronchoscopy complication risk. Increasing age, oxygen use, and bronchoscopy duration were associated with respiratory complications; increased vigilance in these circumstances may prevent complications.

Are Sleep Questionnaires Valid in All Adult Age Groups as Screening Tools for Obstructive Sleep Apnea?

Background and Objectives: Evaluation of Epworth Sleepiness Scale (ESS), Berlin, STOP, and STOP-Bang questionnaire validities for obstructive sleep apnea (OSA) screening among various adult age groups.Materials and Method: Results for each of those questionnaires were compared with diagnostic overnight polysomnography (PSG) data obtained for 396 patients suffering either insomnia, sleep apnea, excessive daytime sleepiness, or chronic snoring who had been divided into three age groups (20-39, 40-59, or ≥60 years). For each questionnaire, the sensitivity, specificity, accuracy, and area under the curve (AUC) were calculated.Results: Among the OSA group [apnea hypopnea index (AHI) cutoff ＞5], Berlin and STOP questionnaire sensitivity and specificity were significantly different among the age groups. Among the moderate-to-severe OSA sub-group (AHI cutoff ＞15), the specificity of Berlin, STOP, and STOP-Bang questionnaire was significantly different among age groups.Conclusion: The Berlin and STOP questionnaires differed with patient age in OSA screening. The ESS questionnaire, by contrast, did not show any age-related differences of sensitivity and specificity in OSA screening or moderate-to-severe OSA screening.

Prediction of obstructive sleep apnea: comparative performance of three screening instruments on the apnea-hypopnea index and the oxygen desaturation index

Purpose

To evaluate the performance of the NoSAS (neck, obesity, snoring, age, sex) score, the STOP-Bang (snoring, tiredness, observed apneas, blood pressure, body mass index, age, neck circumference, gender) questionnaire, and the Epworth sleepiness score (ESS) as a screening tool for obstructive sleep apnea (OSA) severity based on the apnea-hypopnea index (AHI) and the oxygen desaturation index (ODI).

Methods

Data from 235 patients who were monitored by ambulant polysomnography (PSG) were retrospectively analyzed. OSA severity was classified based on the AHI; similar classification categories were made based on the ODI. Discrimination was assessed by the area under the curve (AUC), while predictive parameters were calculated by four-grid contingency tables.

Results

The NoSAS score and the STOP-Bang questionnaire were both equally adequate screening tools for the AHI and the ODI with AUC ranging from 0.695 to 0.767 and 0.684 to 0.767, respectively. Both questionnaires perform better when used as a continuous variable. The ESS did not show adequate discrimination for screening for OSA (AUC ranging from 0.450 to 0.525). Male gender, age, and BMI proved to be the strongest individual predictors in this cohort.

Conclusion

This is the first study to evaluate the predictive performance of three different screening instruments with respect to both the AHI and the ODI. This is important, due to increasing evidence that the ODI may have a higher reproducibility in the clinical setting. The NoSAS score and the STOP-Bang questionnaire proved to be equally adequate to predict OSA severity based on both the AHI and the ODI.

Electronic supplementary material

The online version of this article (10.1007/s11325-020-02219-6) contains supplementary material, which is available to authorized users.

The STOP-Bang Test Is Useful for Predicting the Severity of Obstructive Sleep Apnea

Introduction:

The STOP-Bang test was used to detect patients at high risk of obstructive sleep apnea (OSA). We evaluated the usefulness of the STOP-Bang test for predicting the severity of OSA in Japanese patients.

Methods:

We retrospectively evaluated the patients who performed full polysomnography at the Mihara Medical Association Hospital. We evaluated the correlation between the STOP-Bang score and the apnea hypopnea index (AHI) using Spearman's rank correlation analysis. We then used multivariate analyses to examine the independent risk factor for severe OSA (AHI ≥ 30/hr).

Results:

One hundred seven patients were diagnosed as no (n = 5), mild (n = 17), moderate (n = 30), and severe (n = 55) OSA. The median age was 67 years old (range: 35-84), and 73 of the 107 patients were males. The correlation coefficient between the STOP-Bang score and AHI was 0.701 (P < 0.001). A STOP-Bang score ≥ 5 had sensitivity of 80.0% and specificity of 76.9% for detecting severe OSA. A STOP-Bang score ≥ 5 and BMI ≥ 30 kg/m² were the independent risk factor for severe OSA.

Conclusions:

The STOP-Bang score correlates with AHI and is useful for predicting OSA severity. Polysomnography should be performed actively for the patients with high STOP-Bang scores.

Diagnostic accuracy of the Berlin questionnaire and therapeutic effect of nasal continuous positive airway pressure in OSAHS patients with glucose metabolic dysfunction

PURPOSE

Obstructive sleep apnea-hypopnea syndrome (OSAHS) is associated with alterations in glucose metabolism. The Berlin questionnaire (BQ) is effective in identifying subjects with high risk of OSAHS. However, its validity in patients with glucose metabolic dysfunction remains unclear. Our study aims to examine the diagnostic efficacy of the BQ in detecting OSAHS in patients with glucose metabolic dysfunction and to explore the effect of nasal CPAP on glucose metabolism.

METHODS

Patients with glucose metabolic dysregulation were first asked to complete the BQ and then recruited for polysomnogram (PSG). The diagnostic accuracy of the BQ and the relationships between groups with normal glucose tolerance (NGT), elevated fasting blood glucose (IFG), impaired glucose tolerance (IGT), and diabetes mellitus (DM) were analyzed. Subjects with both OSAHS and glucose dysregulation received CPAP treatment and underwent an oral glucose tolerance test. Changes in apnea-hypopnea indices (AHI) and glycemic parameters were calculated to determine the efficacy of CPAP.

RESULTS

Glycosylated hemoglobin and insulin levels were statistically different between the high-risk and low-risk groups according to the BQ. For diagnosis of subjects with OSAHS who also had glucose metabolic dysfunction, the sensitivity and specificity of the BQ using AHI cut-off values at 5 events per hour were 73% and 67%. CPAP therapy effectively reduced the blood glucose, HOMA-IR, and insulin levels.

CONCLUSIONS

The BQ can be considered to be an effective and economical screening tool for patieints with OSAHS who also have glucose metabolic dysfunction. Treatment with CPAP may improve glycemic parameters.

Comparison of screening methods for obstructive sleep apnea in the context of dental clinics: A systematic review

OBJECTIVE

To review the available bibliographic data to identify the best screening methods to detect potential obstructive sleep apnea (OSA) patients during dental clinical practice.

METHODS

Relevant studies published up to April 2020 were sourced from PubMed, Embase, MEDLINE, Cochrane, and LILACS databases.

RESULTS

Thirty studies were selected. For adults, the screening methods available to the dentist included questionnaires, scales, indexes, pulse oximetry, and anatomical factors. A combination of questionnaires is potentially the most reliable method to detect OSA risk. For children, only information on questionnaires and anatomical factors was found; two questionnaires accurately identified potential OSA risk cases. Anatomical factors also displayed a significant relation with OSA for both populations.

CONCLUSION

Dentists have a fundamental role in early detection of potential OSA cases since they can use the methods identified in this review to perform an initial screening of the population.

ABBREVIATIONS

OSA: Obstructive sleep apnea; PSG: Polysomnography; HST: Home sleep study; BMI: Body mass index; PPV: Positive predictive value; NPV: Negative predictive value; AHI: Apnea hypopnea index; RDI: Respiratory disturbance index; ODI: Oxygen desaturation index; PSQ: Pediatric Sleep Questionnaire; SRBD: Sleep-related breathing disorder; CSHQ: Children's Sleep Habits Questionnaire; ESS: Epworth Sleepiness Scale; PSQI: Pittsburgh Sleep Quality Index.

Night-time frequency of urination as a manifestation of sleep-disordered breathing: the Nagahama study

AIMS

Sleep-disordered breathing (SDB) is a well-known risk factor for cardiovascular outcomes. Studies of patients with SDB have identified frequent night-time urination as a manifestation related to SDB. We aimed to clarify whether night-time frequency of urination is independently associated with SDB in a general population. We also investigated whether night-time frequency of urination can help presumptive diagnose SDB.

METHODS

Study participants consisted of 7151 community residents. Oxygen saturation during sleep was measured for four nights using a pulse oximeter. SDB was defined as ≥15 events per hour in which oxygen desaturation exceeded or equal to 3% during an actigraphy-determined sleep period. Night-time frequency of urination was recorded for one week using a sleep diary.

RESULTS

Significant positive correlations were evident between night-time frequency of urination and SDB (none, 5.8%; once/night, 14.1%; twice/night, 20.1%; thrice/night, 28.7%; >thrice/night, 44.1%, P < 0.001). This association was independent of possible covariates, including sleep duration (adjusted odds ratio: once/night = 1.50, twice/night = 2.15, thrice/night = 3.07, >thrice/night = 3.73, P < 0.001). Other factors significantly associated with SDB were age, sex, obesity, observation of sleep apnea, and short sleep duration. The area under the curve of the risk score for SDB consisting of these conventional six items (0.834) significantly improved (0.842, P = 0.001) when night-time frequency of urination was considered as a risk score item.

CONCLUSION

Night-time frequency of urination was associated with SDB. Our findings suggest that the urination frequency should be considered a manifestation of SDB even in a general population.