Sleep Breath (2010) 14:371–376

DOI 10.1007/s11325-010-0350-7

ORIGINAL ARTICLE

Simplifying STOP-BANG: use of a simple questionnaire

to screen for OSA in an Asian population
Thun How Ong & Siti Raudha & Stephanie Fook-Chong &
Nancy Lew & A. A. L. Hsu

Received: 30 December 2009 / Revised: 31 March 2010 / Accepted: 4 April 2010 / Published online: 26 April 2010
# Springer-Verlag 2010

Abstract severe OSA. Using cutoffs of 30 for BMI, 40 cm for neck

Objective We aim to assess the utility of a simple-to-use circumference, and 50 years for age simplifies the application
8-point questionnaire in screening for moderate–severe of the tool without affecting performance.
obstructive sleep apnea (OSA) and to assess the validity
of cutoffs used to score body mass index (BMI) in this Keywords Screening . Obstructive sleep apnea .
questionnaire. Asian population . Body mass index
Methods Patients undergoing diagnostic polysomnography
(PSG) were asked to fill in a questionnaire with a simple
dichotomized 8-point questionnaire, represented by the Background
mnemonic STOP-BANG. A score of 3 or more out of a
possible 8 was taken to indicate high risk for presence of Obstructive sleep apnea (OSA) is a condition where
OSA. These were then evaluated versus results from the intermittent obstruction of the airway during sleep causes
overnight, monitored PSG. sleep fragmentation and repeated desaturations [1]. Un-
Results Three hundred and forty-eight patients underwent treated sleep apnea in patients with severe apnea causes a
overnight diagnostic PSG, of whom 319 (91.2%) completed 46% excess mortality over 8 years, an increase attributed
the questionnaire. Seventy-four (22.7%) were classified as chiefly to increases in cardiovascular mortality [2]. OSA
being at low risk of OSA and 252 (77.3%) were classified has been associated with impaired RV function despite
as being high risk. The sensitivities of the STOP-BANG normal systemic pressures [3]. The prevalence of OSA was
screening tool for an AHI of >5, >15, and >30 were 86.1%, estimated from large population studies such as the Sleep
92.8%, and 95.6%, respectively, with negative predictive Heart Health study at up to 18% [4], although overt
values of 84.5% and 93.4% for moderate and severe OSA, prevalence is reported at 4% of men and 2% of women
respectively. Using cutoffs of 30 or 35 for scoring the BMI [1]. In certain populations, a much higher prevalence has
did not significantly change the performance of the been reported; for example, in patients with acute myocar-
screening tool. dial infarctions, some studies have reported up to 65%
Conclusion STOP-BANG is a clinically useful tool with high prevalence [5]. Part of this difference in prevalence is one
sensitivity that can be used to screen patients for moderate and of underdiagnosis: it is notoriously difficult to diagnose
OSA clinically. Much of the difficulty lies in problems of
T. H. Ong (*) : S. Raudha : N. Lew : A. A. L. Hsu accessibility: the gold standard for diagnosis of OSA
Sleep Disorders Unit, Singapore General Hospital,
remains the in-laboratory, monitored polysomnography [6]
Outram Road,
Singapore 169608, Singapore (PSG), yet this is a cumbersome and expensive test. In an
e-mail: [email protected] era of cost containment, it is simply not practical to send
everyone for a full PSG, and even if cost were not an issue,
S. Fook-Chong
long waiting times at the sleep laboratory are a frequent
Department of Clinical Research, Singapore General Hospital,
Outram Road, issue as well. Ideally, patients should be screened before
Singapore 169608, Singapore being referred for a PSG, but it has proven unexpectedly
372 Sleep Breath (2010) 14:371–376

difficult to accurately predict the presence or absence of night before the sleep study was performed. The patient’s
OSA based on clinical parameters [7]. One alternative height and weight were also measured and recorded at this
available is for partial or home sleep studies. Various partial time so that the BMI (weight in kilograms divided by
sleep study devices have been on the market, but under height in meters squared) could be calculated. The patient’s
current American academy of sleep medicine guidelines, neck circumference was also measured at the level of the
they are meant to be used in patients with high pretest cricoid cartilage in centimeters and recorded by the
probabilities only and in conjunction with a comprehensive technician on duty.
sleep evaluation; negative studies using these devices
should still be followed up with a full in-laboratory PSG STOP-BANG questionnaire
[8]. Another approach is for scoring systems to try and
improve clinical prediction of OSA. Patients were invited to complete a simple, four-question
Multiple scoring systems based on clinical character- self-administered questionnaire on the evening prior to their
istics [9–13] have been designed and tested and mostly sleep study. This consisted of four simple yes/no questions,
have been shown to have reasonably good sensitivity but with one point awarded for each yes answer. Simple
poor specificity; that is, they may have reasonable utility for demographic data were also collected and one point each
exclusion of OSA, which makes them suitable for use in a was added for the presence of four clinical characteristics,
primary care setting [14]. However, many of these rules which were dichotomized according to pre-specified cut-
involve complicated mathematical contortions and are not offs. The originally validated STOP-BANG questionnaire
designed to be remembered off the cuff, making them used the following cutoffs for scoring: BMI>35, age>
unattractive for general use by physicians outside the sleep 50 years, neck circumference >40 cm, gender=male. A
medicine field and limiting their widespread usage. score of 3 or more out of a total possible score of 8 is
The STOP-BANG questionnaire is a simple 8-point tool considered high risk for OSA (see Table 1).
for screening patients who might have OSA. It has
previously been validated for screening of preoperative Polysomnography
surgical patients, showing a sensitivity of 92.9% in the
validation cohort [15]. The good sensitivity, along with a The nocturnal polysomnograph consisted of continuous
snappy acronym and ease of use, makes this an attractive polysomnographic (Compumedics E Series, Australia)
candidate for a more generally usable tool for general recordings of a standard electroencephalographic montage
screening of patients for OSA. consisting of four electroencephalograms (C3–A2, C4–A1,
We sought to test its validity in a more high-prevalence O1–A2, O2–A1), right and left electro-occulogram, submen-
population such as in patients referred to our Sleep tal and bilateral tibial electromyogram, and electrocardiogram
Disorders Unit. We also wished to establish the veracity using surface electrodes. Respiration was monitored with
of the equation’s prediction rule as well as the cutoffs used oronasal thermocouples and with nasal pressure transducers.
in this prediction rule to score body mass index (BMI) and Thoracoabdominal movements were monitored using Piezo-
neck circumference in an Asian population, especially in electric strain gauges (Piezo, Compumedics). Continuous
light of previous data showing that Asians may have sleep pulse oximetry was also monitored. Sleep stage scoring was
apnea even at lower BMI [16]. performed in 30-s epochs by certified registered polysomno-
graphic technologists according to Rechtschaffen and Kales’
criteria [17]. The scoring technologists were blinded to the
Materials and methods patient’s STOP-BANG scores. Apnea was defined as
cessation of airflow for more than 10 s. Hypopneas were
This study was performed at the Sleep Disorders Unit of the scored as at least 30% decrease in airflow with 4% oxygen
Singapore General Hospital, the largest tertiary care desaturation or with 3% oxygen desaturation and arousal.
hospital in Singapore. All patients undergoing diagnostic The Apnea–Hypopnea Index (AHI) was defined as the total
overnight PSG between November 2008 and April 2009 number of apneas and hypopneas per hour of sleep time.
were prospectively included in this study. The study was
approved by the Institutional Review Board of the Statistics
Singapore General Hospital.
Association between presence/absence of moderate and
Demographics severe OSA and BMI and neck circumference was
determined using χ2 test. Sensitivities, specificities, positive
Patient characteristics such as age and gender were predictive values, and negative predictive values were
recorded on admission to the sleep disorders clinic on the calculated from 2×2 cross tabulation of OSA classification
Sleep Breath (2010) 14:371–376 373

Table 1 Questionnaire
characteristics Questionnaire No. (%) of patients answering yes

S: Do you snore loudly? 190 (58.3)

T: Do you often feel tired, fatigued, or sleepy during daytime? 244 (74.8)
O: Has anyone observed you stop breathing during your sleep? 114 (35)
P: Do you have high blood pressure? 128 (39.4)
B: BMI>35? 46 (14)
A: Age>50? 141 (43)
N: Neck circumference >40 cm? 147 (45.8)
G: Gender male? 229 (70.5)
STOP-BANG score 3.8±1.66
No. of patients classified as high risk 241 (71)

from PSG and OSA risk classification by STOP-BANG and The clinical characteristics of patients used in the
their significance was assessed using Pearson’s χ2 test. All validation cohort are described in Table 3. Among our
statistical analysis was performed using SPSS statistical patients, approximately half had at least moderate sleep
software version 17 (SPSS Inc, Chicago, IL, USA) apnea and one third had severe sleep apnea. Use of the
STOP-BANG screening questionnaire would have identified
a large proportion (73.9%) of patients as high risk for OSA,
Results and this would have picked up 95.4% (all but 5) of the patients
with severe sleep apnea.
Three hundred and forty-eight patients completed diagnos-
tic overnight (both full night and split night) PSG between Cutoff for BMI and neck circumference
November 2008 and April 2009. The racial makeup of the
patients comprised 76.4% Chinese, 6.1% Malay, 14.1% There was a clear and statistically significant separation of
Indian, and 3.4% others (Caucasians and Eurasians). The BMI and neck circumference among patients with and
proportion of Chinese and non-Chinese patients approximated without OSA. The mean BMI among patients with AHI<15
that of the national (Singapore’s) population [18]. A total of and AHI≥15 was 25.6 and 30.25, respectively; median neck
319 (91.2%) patients completed the self-administered ques- circumference was 37.9 cm versus 41.5 cm for patients with
tionnaire. The proportion of patients scoring for each point of AHI<15 and ≥15, respectively (p<0.001).
the questionnaire is detailed in Table 1. There was no Using a cutoff of BMI>26 for a positive score increased
significant difference in age, gender, race, BMI, neck the number of patients who would have been identified as
circumference, or actual AHI among patients who did or high risk from 240 to 257, increasing the sensitivity of the
did not complete the questionnaire (Table 2). The vast STOP-BANG score for detecting moderate OSA from
majority of patients (333/348, or 95%) had a sleep study for 91.3% to 94.4%, while decreasing specificity from 40.4%
evaluation of OSA; of the remaining patients, 11 were to 32.7%. An extension of McNemar χ2 statistics showed
studies done for a research protocol, 3 were done as part of that both the sensitivities and specificities (overall perfor-
evaluation for narcolepsy, and 1 was done for evaluation of mance) of STOP-BANG at BMI cutoffs of 35 and 26 are
possible parasomnia. significantly different (p=0.0002) [19]. Using a cutoff of

Table 2 Demographics of
patients who did/did not answer Patients who answered Patients who did not P value
the questionnaire the questionnaire answer the questionnaire

n 314 34
Male, n (%) 220 (70.5) 23 (68.4) 0.85
Race: Chinese, n (%) 244 (77.7) 29 (85.7) 0.792
Age (years) 46.8±15.0 50.64±17.8 0.334
BMI 27.9±6 25.9±4.6 0.124
Neck circumference (cm) 39.75±4.1 40.13±4.6 0.731
AHI 26.2±26.9 31.9±31.5 0.339
374 Sleep Breath (2010) 14:371–376

Table 3 Patient characteristics patient. We believe that the STOP-BANG scoring system
Age (years) 47±15.2 fulfills these criteria. Among our patients, a high proportion
Male gender, n (%) 229 (70.5) (>90%) were able to complete the questionnaire without
BMI 27.8 (5.9)
any help.
BMI>26, n (%) 178 (55.6)
Other questionnaires such as the Berlin questionnaire,
BMI>30, n (%) 94 (28.8)
the Wisconsin questionnaire, and the Sleep Apnea of Sleep
Disorders have been available for some time but have not
BMI>35, n (%) 46 (14)
managed to gain traction for general use. A recent systemic
Epworth sleepiness scale 9.4±5.2
review by Abrishami et al [20]. examined the use of these
Neck circumference (cm) 39.8 (4.1)
questionnaires and found a pooled sensitivity of 77% and
AHI 26.2±26.9
specificity of 53% in patients without history of sleep
REM AHI 27.5±26.8
disorders. The STOP-BANG questionnaire compares fa-
AHI>5, n (%) 244 (74.8)
vorably to other commonly used screening questionnaire in
AHI>15, n (%) 166 (50.9)
terms of results, with the added advantage of remarkable
AHI>30, n (%) 113 (34.7)
ease of use.
Total sleep time 356.4±94
American Academy of Sleep Medicine practice guide-
% Supine sleep 62.5±60.5
lines indicate CPAP treatment for OSA of at least moderate
Sleep efficiency 78±16.4
(AHI>15) severity [21]; treatment of mild OSA with an
% Light sleep (N1, N2) 62.4±17.4
AHI from 5 to 15 has proven more controversial, with some
% Slow-wave sleep (N3) 21.4±12.9
studies indicating minimal or at best modest benefit in
% REM sleep 16.6±8.0 terms of improving blood pressure control and poor
Nadir SpO2 82±13 compliance [22]. Hence, the indication for treating patients
with mild OSA hinges mainly on whether they are
symptomatic, especially viz., excessive daytime sleepiness.
BMI>30 as compared to the original BMI cutoff of 35, the As seen from Table 4, the STOP-BANG screening tool has
number of patients identified as high risk increased from lower sensitivity for picking up mild OSA (sensitivity,
240 to 244 but with minimal change in sensitivity or 86%; NPV, 52%). However, we believe that based on the
specificity, as seen in Table 5 (overall performance: p value inconclusive evidence of treatment benefit and even of
not significant). Different cutoffs for neck circumference increased cardiovascular risk with mild OSA, these patients
did not significantly change the sensitivity or predictive should be investigated only if they have symptoms
accuracy of the STOP-BANG questionnaire. significant enough to cause disruption in patient’s func-
tioning, or if they show complications that are associated
with OSA (e.g., young or difficult-to-control hypertension).
Discussion We note also that this tool has very high sensitivity in
picking up patients with severe OSA; it is these patients
Our results confirm the clinical utility of the STOP-BANG precisely that there is greater imperative to identify OSA;
screening tool even in a high-prevalence population of recent data from the sleep heart health study indicate that it
patients undergoing overnight PSG at a sleep disorders unit. is in patients who have severe untreated OSA that have
For widespread use, a screening tool for OSA has to increased mortality [2].
have high sensitivity and negative predictive value, such The STOP-BANG questionnaire has previously been
that practitioners would be able quickly to make a validated for screening of preoperative surgical patients. We
reasonable decision that a particular patient is unlikely to believe that this simple and easy-to-remember formula is an
have sleep apnea and does not need a referral to a sleep ideal tool for even more general use, especially in
physician or that he does and should be referred. In other populations that have recently been identified as having
words, it is more important for this tool to pick up most of relatively high prevalence such as patients with the
the patients with OSA severe enough to warrant treatment, metabolic syndrome, or where a diagnosis of OSA is likely
so that they can be referred on for further treatment (high to have a more significant impact, such as patients who are
sensitivity), and that with a patient who has been identified already known to have ischemic heart disease or heart
as having low risk with this tool, the practitioner can be failure. It has been reported that patients with cardiac
reasonably sure that he or she is unlikely to have significant failure may not display the classic symptoms of daytime
OSA (high negative predictive value). The screening tool sleepiness, and hence, the cardiologist may not necessarily
should also be easy to remember and to score, so that one be alerted to the need to investigate further [23]. By
does not need a computer or calculator to risk stratify a educating practitioners in other fields to routinely screen for
Sleep Breath (2010) 14:371–376 375

Table 4 Predictive parameters

for STOP-BANG AHI≥5 AHI≥15 AHI≥30

Sensitivity (%) 84.7 (80.2–89.3) 91.1 (85.6–95.1) 95.4 (89.5–98.5)

Specificity (%) 52.6 (40.9–64.0) 40.4 (32.7–48.1) 35.0 (28.4–41.5)
PPV (%) 84.4 (79.8–89.0) 60.8 (54.5–67) 43.5 (37.1–49.8)
NPV (%) 53.2 (41.5–64.7) 81.8 (71.4–89.7) 93.5 (85.5–97.9)
Area under ROC curve 0.775 (0.716–0.835) 0.775 (0.725–0.826) 0.772 (0.719–0.825)

patients with OSA, we would be able to pick up definition of obesity [27] and taking a cutoff of BMI>30
substantially more of these patients. would be a practical compromise, which as well as makes
The other issue we considered here was whether the the numbers much easier to remember (BMI, 30; neck
cutoffs for BMI and neck circumference used by the circumference, 40 cm; age, 50 years; i.e., 30.40.50) without
original validation study would be applicable in other affecting the performance of the tool. Using different
populations, especially in Asians who are known to have cutoffs for neck circumference did not improve the
more severe OSA at lower BMI. Previous studies have performance of the STOP-BANG tool.
suggested that a BMI of 26 be used to indicate obesity in The strength of our study is that we were able to test the
Asians [24]. STOP-BANG questionnaire in a reasonably sized popula-
Our initial hypothesis was that lowering the BMI cutoff tion; however, one weakness of this study is of course that
would improve the sensitivity of STOP-BANG, and there it was undertaken in a high-prevalence setting (50% of our
was indeed a statistical improvement in the sensitivity of patients had AHI ≥ 15) where its sensitivity may be
the test using the BMI cutoff of 26 from 91.3% to 94.4%, expected to have been high, the corollary is of course that
although this also led to a significant drop in the specificity there is relatively low specificity (applying the STOP-
of the test from 40.4% to 32.7%. Using a cutoff of 30 for BANG tool, only 78/319 patients or 29% are categorized as
scoring the BMI, however, achieved very similar results in low risk); hence, a large number of patients will still have to
terms of sensitivity/specificity of the test as compared to the undergo more formal testing. However, looking at Chung’s
original cutoff of BMI>35, as can be seen from Table 5. original validation study [15], among the cohort of surgical
It is debatable whether the change in test parameters patients who actually underwent PSG testing, the preva-
would make changing the BMI cutoff to 26 a clinically lence of at least moderate OSA with an AHI≥15 was
relevant improvement to the STOP-BANG tool, as the remarkably similar, 39.5%. In this cohort, a very large
increase in sensitivity sacrifices the specificity of the tool. sample (2467) of surgical patients completed the question-
The results, however, serve as a useful reminder that naire and were invited to do an overnight PSG, of which
especially in Asians, OSA and other morbidity may be only 416 (17%) actually did come for the PSG. The
associated with a lower BMI [25]. This has been attributed sensitivity of STOP-BANG in this cohort in detecting
to differences in soft tissue and craniofacial morphology patients with an AHI of ≥15 and ≥30 here was 74.3% and
(longer soft palate, inferior placement of base of tongue, 79.5%, respectively. This suggests that the performance of
and increased craniocervical extension) [26]. In our cohort, this tool is likely to be reasonable even in a much more
the proportion of patients who were identified by a change general pool of patients, making it suitable for screening
in cutoff of BMI from 35 to 30 doubled from 14% to 28% purposes.
and increased further to 55% when BMI>26 was used. We In our patient population, the vast majority of patients
would suggest that using the World Health Organization had PSG to exclude sleep disordered breathing; only 15

Table 5 Predictive
characteristics of STOP-BANG STOP-BANG using different cutoffs for BMI
using different BMI cutoffs
BMI≥35 BMI≥30 BMI≥26

High-risk patients, n (%) 240 (75.7) 244 (77.0) 257 (81.1)

Low-risk patients, n (%) 77 (24.3) 73 (23.0) 60 (18.9)
Sensitivity for identifying AHI>15 91.3 (85.6–95.0) 93.8 (88.6–96.8) 94.4 (89.6–97.4)
Specificity for identifying AHI>15 40.4 (32.7–48.1) 40.4 (32.7–48.1) 32.7 (25.2–40.1)
PPV (AHI>15) 60.8 (54.5–67.0) 62.0 (56.0–68.1) 59.4 (53.4–65.5)
NPV (AHI>15) 81.8 (71.4–89.7) 86.3 (76.3–93.2) 84.7 (73.0–92.8)
376 Sleep Breath (2010) 14:371–376

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