An update on the various practical applications of the STOP-Bang questionnaire in anesthesia, surgery, and perioperative medicine

Mahesh Nagappa, Jean Wong, Mandeep Singh, David T Wong, Frances Chung, Mahesh Nagappa, Jean Wong, Mandeep Singh, David T Wong, Frances Chung

Abstract

Purpose of review: The present review aims to provide an update on the various practical applications of the STOP-Bang questionnaire in anesthesia, surgery, and perioperative medicine.

Recent findings: The STOP-Bang questionnaire was originally validated as a screening tool to identify surgical patients who are at high-risk of obstructive sleep apnea (OSA). A recent meta-analysis confirmed that STOP-Bang is validated for use in the sleep clinic, surgical, and general population. Patients with a STOP-Bang score of 0--2 can be classified as low-risk for moderate-to-severe OSA. Those with a score of 5--8 can be classified as high-risk for moderate-to-severe OSA. In patients with a score of 3 or 4, a specific combination of a STOP score at least 2 + BMI more than 35 kg/m or STOP score at least 2 + male or STOP score at least 2 + neck circumference more than 40 cm indicates higher risk for moderate-to-severe OSA. Further, patients with a STOP-Bang score at least 3 can be classified as high risk for moderate-to-severe OSA if the serum HCO3 at least 28 mmol/l. STOP-Bang can be used as a novel tool for perioperative risk stratification because it easily identifies patients who are at increased risk of perioperative complications.

Summary: STOP-Bang at least 3 was recommended previously to identify the suspected or undiagnosed OSA. To reduce the false positive cases and to improve its specificity, a stepwise stratification is recommended to identify the patients at high risk of moderate-to-severe OSA. Because of its practical application, STOP-Bang is a useful screening tool for patients with suspected or undiagnosed OSA.

Figures

Box 1
Box 1
no caption available
FIGURE 1
FIGURE 1
Updated STOP-Bang questionnaire for screening OSA. In STOP-Bang, one point is scored for each positive answer. The total score ranges from 0 to 8. Patients can be classified for OSA risk based on their respective scores. Proprietary to University Health Network. Adapted with permission from [,,▪▪].
FIGURE 2
FIGURE 2
Probability of obstructive sleep apnea in surgical population. The relationship between STOP-Bang score and the probability of moderate-severe OSA (AHI ≥15) and severe OSA (AHI ≥30) in surgical patients. With a stepwise increase of the STOP-Bang score to 3, 4, 5, 6, and 7/8, the probability of moderate-to-severe (AHI ≥15) and severe OSA (AHI ≥30) increases proportionally. OSA, obstructive sleep apnea; SBQ, STOP-Bang questionnaire; Modified with permission from [▪▪].
FIGURE 3
FIGURE 3
Two-step strategy for using STOP-Bang questionnaire. The first step is to check the STOP-Bang score to divide the patients into one of the three category (low-risk, intermediate-risk, or high-risk for OSA). The second step is for patients with STOP-Bang score of 3 or 4 to identify those at high-risk of moderate-to-severe OSA. OSA, obstructive sleep apnea; SBQ, STOP-Bang questionnaire. Adapted with permission from [14].

References

    1. Ramachandran SK, Kheterpal S, Consens F, et al. Derivation and validation of a simple perioperative sleep apnea prediction score. Anesth Analg 2010; 110:1007–1015.
    1. Frey WC, Pilcher J. Obstructive sleep-related breathing disorders in patients evaluated for bariatric surgery. Obes Surg 2003; 13:676–683.
    1. Hallowell PT, Stellato Ta, Petrozzi MC, et al. Eliminating respiratory intensive care unit stay after gastric bypass surgery. Surgery 2007; 142:608–612.
    1. Finkel KJ, Searleman AC, Tymkew H, et al. Prevalence of undiagnosed obstructive sleep apnea among adult surgical patients in an academic medical center. Sleep Med 2009; 10:753–758.
    1. Singh M, Liao P, Kobah S, et al. Proportion of surgical patients with undiagnosed obstructive sleep apnoea. Br J Anaesth 2013; 110:629–636.
    1. Kaw R, Chung F, Pasupuleti V, et al. Meta-analysis of the association between obstructive sleep apnoea and postoperative outcome. Br J Anaesth 2012; 109:897–906.
    1. Hai F, Porhomayon J, Vermont L, et al. Postoperative complications in patients with obstructive sleep apnea: a meta-analysis. J Clin Anesth 2014; 26:591–600.
    1. Opperer M, Cozowicz C, Bugada D, et al. Does obstructive sleep apnea influence perioperative outcome? A qualitative systematic review for the society of anesthesia and sleep medicine task force on preoperative preparation of patients with sleep-disordered breathing. Anesth Analg 2016; 122:1321–1334.

    2. This article is the most recent comprehensive update on the periopertaive complications associated with patients with OSA by Society of Anesthesia and Sleep Medicine Task Force. It identified 63 publications with association between patients with obstructive sleep apnea and perioperative complications.

    1. Mokhlesi B, Hovda MD, Vekhter B, et al. Sleep-disordered breathing and postoperative outcomes after elective surgery: analysis of the nationwide inpatient sample. Chest 2013; 144:903–914.
    1. Memtsoudis SG, Stundner O, Rasul R, et al. The impact of sleep apnea on postoperative utilization of resources and adverse outcomes. Anesth Analg 2014; 118:407–418.
    1. Chung F, Memtsoudis SG, Ramachandran SK, et al. Society of Anesthesia and Sleep Medicine Guidelines on preoperative screening and assessment of adult patients with obstructive sleep apnea. Anesth Analg 2016; 123:452–473.

    2. This article is the most recent guideline for Preoperative Screening and Assessment of patients with OSA based on recent evidence and expert opinion by the Society of Anesthesia and Sleep Medicine task force. It provides a compressive review of literature and recommendations on screening and optimal preparation of surgical patients with diagnosed and suspected OSA.

    1. Gross JB, Apfelbaum JL, Caplan RA, et al. Practice guidelines for the perioperative management of patients with obstructive sleep apnea. An updated report by the American Society of Anesthesiologists Task Force on perioperative management of patients with obstructive sleep apnea. Anesthesiology 2014; 120:268–286.

    2. This article is the perioperative management of patients with OSA by American Society of Anesthesiologists Task Force

    1. Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology 2008; 108:812–821.
    1. Chung F, Abdullah HR, Liao P. STOP-Bang Questionnaire: a practical approach to screen for obstructive sleep apnea. Chest 2016; 149:631–638.
    1. Nagappa M, Liao P, Wong J, et al. Validation of the STOP-Bang questionnaire as a screening tool for obstructive sleep apnea among different populations: a systematic review and meta-analysis. PLoS One 2015; 10.e0143697. doi:10.1371/journal.pone.0143697.

    2. This article confirmed the validation of the STOP-Bang questionnaire in sleep clinic, surgical and general population. This is a meta-analysis of 17 articles that validated STOP-Bang in various population

    1. Chudeau N, Raveau T, Carlier L, et al. The STOP-Bang questionnaire and the risk of perioperative respiratory complications in urgent surgery patients: a prospective, observational study. Anaesthesia, Crit Care Pain Med 2016; 35:347–353.
    1. Gokay P, Tastan S, Orhan ME. Is there a difference between the STOP-Bang and the Berlin Obstructive Sleep Apnoea Syndrome questionnaires for determining respiratory complications during the perioperative period? J Clin Nurs 2016; 25:1238–1252.
    1. Xara D, Mendonca J, Pereira H, et al. Adverse respiratory events after general anesthesia in patients at high risk of obstructive sleep apnea syndrome. Brazilian J Anesthesiol 2015; 65:359–366.
    1. Seet E, Chua M, Liaw CM. High STOP-Bang questionnaire scores predict intraoperative and early postoperative adverse events. Singapore Med J 2015; 56:212–216.
    1. Acar HV, Uysal HY, CeyhanKaya A, et al. Does the STOP-Bang, an obstructive sleep apnea screening tool, predict difficult intubation? Eur Rev Med Pharmacol Sci 2014; 18:1869–1874.
    1. Corso RM, Petrini F, Buccioli M, et al. Clinical utility of preoperative screening with STOP-bang questionnaire in elective surgery. Minerva Anestesiol 2014; 80:877–884.
    1. Proczko MA, Stepaniak PS, de Quelerij M, et al. STOP-Bang and the effect on patient outcome and length of hospital stay when patients are not using continuous positive airway pressure. J Anesth 2014; 28:891–897.
    1. Pereira H, Xará D, Mendonça J, et al. Patients with a high risk for obstructive sleep apnea syndrome: postoperative respiratory complications. Rev Port Pneumol 2013; 19:144–151.
    1. Lockhart EM, Willingham MD, Abdallah AB, et al. Obstructive sleep apnea screening and postoperative mortality in a large surgical cohort. Sleep Med 2013; 14:407–415.
    1. Vasu TS, Doghramji K, Cavallazzi R, et al. Obstructive sleep apnea syndrome and postoperative complications: clinical use of the STOP-Bang questionnaire. Arch Otolaryngol Head Neck Surg 2010; 136:1020–1024.
    1. Coté GA, Hovis CE, Hovis RM, et al. A screening instrument for sleep apnea predicts airway maneuvers in patients undergoing advanced endoscopic procedures. Clin Gastroenterol Hepatol 2010; 8:660–665.
    1. Chia P, Seet E, Macachor JD, et al. The association of preoperative STOP-Bang scores with postoperative critical care admission. Anaesthesia 2013; 68:950–952.
    1. Chung F, Yegneswaran B, Liao P, et al. Validation of the Berlin questionnaire and American Society of Anesthesiologists checklist as screening tools for obstructive sleep apnea in surgical patients. Anesthesiology 2008; 108:822–830.
    1. Sleep-related breathing disorders in adults: Recommendations for syndrome definition and measurement techniques in clinical research. The Report of an American Academy of Sleep Medicine Task Force. Sleep 1999; 22:667–689.
    1. Berry RB, Budhiraja R, Gottlieb DJ, et al. Rules for scoring respiratory events in sleep: Update of the 2007 AASM manual for the scoring of sleep and associated events. J Clin Sleep Med 2012; 8:597–619.
    1. Chung F, Subramanyam R, Liao P, et al. High STOP-Bang score indicates a high probability of obstructive sleep apnoea. Br J Anaesth 2012; 108:768–775.
    1. Guralnick AS, Pant M, Minhaj M, et al. CPAP adherence in patients with newly diagnosed obstructive sleep apnea prior to elective surgery. J Clin Sleep Med 2012; 8:501–556.
    1. Chung F, Chau E, Yang Y, et al. Serum bicarbonate level improves specificity of STOP-Bang screening for obstructive sleep apnea. Chest 2013; 143:1284–1293.
    1. Kaw R, Hernandez AV, Walker E, et al. Determinants of hypercapnia in obese patients with obstructive sleep apnea: a systematic review and meta-analysis of cohort studies. Chest 2009; 136:787–796.
    1. Chung F, Yang Y, Brown R, Liao P. Alternative scoring models of STOP-bang questionnaire improve specificity to detect undiagnosed obstructive sleep apnea. J Clin Sleep Med 2014; 10:951–958.

    2. This article showed that a combination of a STOP score at least 2 + BMI > 35 kg/m2 or STOP score at least 2 + male or STOP score at least 2 + neck circumference > 40 cm can further classify patients as high-risk of moderate-to-severe obstructive sleep apnea.

    1. Chung F, Yang Y, Liao P. Predictive performance of the STOP-Bang score for identifying obstructive sleep apnea in obese patients. Obes Surg 2013; 23:2050–2057.
    1. Agrawal S, Gupta R, Lahan V, et al. Prevalence of obstructive sleep apnea in surgical patients presenting to a tertiary care teaching hospital in India: A preliminary study. Saudi J Anaesth 2013; 7:155–159.
    1. D’Apuzzo MR, Browne JA. Obstructive sleep apnea as a risk factor for postoperative complications after revision joint arthroplasty. J Arthroplasty 2012; 27:95–98.
    1. Wong JK, Maxwell BG, Kushida CA, et al. Obstructive sleep apnea is an independent predictor of postoperative atrial fibrillation in cardiac surgery. J Cardiothorac Vasc Anesth 2015; 29:1140–1147.
    1. Foldvary-Schaefer N, Kaw R, Collop N, et al. Prevalence of undetected sleep apnea in patients undergoing cardiovascular surgery and impact on postoperative outcomes. J Clin Sleep Med 2015; 11:1083–1089.
    1. Toshniwal G, McKelvey GM, Wang H. STOP-Bang and prediction of difficult airway in obese patients. J Clin Anesth 2014; 26:360–367.
    1. Kim GH, Lee JJ, Choi SJ, et al. Clinical predictors of apnoea-hypopnoea during propofol sedation in patients undergoing spinal anaesthesia. Anaesthesia 2012; 67:755–759.
    1. Lam KK, Kunder S, Wong J, et al. Obstructive sleep apnea, pain, and opioids: Is the riddle solved? Curr Opin Anaesthesiol 2016; 29:134–140. doi:10.1097/ACO.0000000000000265.
    1. Nagappa M, Mokhlesi B, Wong J, et al. The effects of continuous positive airway pressure on postoperative outcomes in obstructive sleep apnea patients undergoing surgery: a systematic review and meta-analysis. Anesth Analg 2015; 120:1013–1023.

    2. This the first meta-analysis comparing the effect of CPAP on Postoperative outcomes comparing OSA and non-OSA patients.

    1. Chung F, Nagappa M, Singh M, Mokhlesi B. CPAP in the perioperative setting: evidence of support. Chest 2016; 149:586–597.

    2. This article provides the comprehensive review about the CPAP in the perioperative period.

    1. Kunisaki KM, Brown KE, Fabbrini AE, et al. STOP-Bang questionnaire performance in a veterans affairs unattended sleep study program. Ann Am Thorac Soc 2014; 11:192–197.
    1. Nicholl DD, Ahmed SB, Loewen AH, et al. Diagnostic value of screening instruments for identifying obstructive sleep apnea in kidney failure. J Clin Sleep Med 2013; 9:31–38.

Source: PubMed

Sponsoren und Mitarbeiter

Krankheiten

Drogeninterventionen

3
Abonnieren