First AD

Second AD

You are performing an annual visit evaluation for a 54-year-old sales manager. He has a history of hypertension and hyperlipidemia, both managed. He has no major complaints. He reports restful sleep and no daytime sleepiness. On examination, his BMI is 37 and his blood pressure is 126/82 mm Hg. 

You should consider him to be at high risk for obstructive sleep apnea (OSA) if which of the following also is present:

E. No additional conditions necessary; his risk of OSA is already elevated

Answer: E. No additional conditions necessary; his risk of OSA is already elevated


According to the STOP-BANG scoring model

 developed by Dr Frances Chung to evaluate the risk of OSA in patients scheduled for surgery, the combination of any 3 or more of the following factors imparts a high risk of OSA:

noring
   Do you snore loudly (louder that talking or loud enough to be heard through closed doors)?


ired
   Do you often feel tired, fatigued, or sleepy during daytime?


bserved
   Has anyone observed you stop breathing during your sleep?
Blood 

ressure
   Do you have or are you being treated for high blood pressure?


eck Circumference
   Neck circumference greater than 40 cm (15.75 in)?


High risk of OSA: “Yes” answer to 3 or more items
Low risk of OSA: “Yes” answer to fewer than 3 items

. 2008;108:812-821.)

While snoring and smoking are associated with an increase in the risk of OSA, in the case of this patient, no additional factors are necessary to place him at high risk for OSA; his clinical characteristics already include 3 risk factors: male sex, BMI greater than 35, and a history of hypertension. Patients who are at high risk for OSA should be referred for polysomnography, or sleep testing, to establish the diagnosis and the severity of the condition. Left untreated, OSA can increase the risk of various impairments, such as daytime hypersomnolence, cognitive impairment leading to occupational decrements, and accidents. It can also increase the risk of various medical and psychiatric morbidities, such as hypertension, cardiac arrhythmias, MI, CVA, and depression, among others.

The STOP-BANG inventory has a high sensitivity for severe OSA, but has a fairly low specificity. Its sensitivity diminishes with decreasing OSA severity values. In addition, it has not been validated in all patient populations. Therefore, although questionnaires may be useful screening tools, they cannot substitute for a thorough clinical evaluation, which includes a systematic review of symptoms and comorbidities associated with OSA, followed by a pertinent physical examination. The 

 is a similar inventory that has received wider validation studies.

   • OSA is a common condition, which poses a heightened risk for occupational and social impairment, as well as medical and psychiatric comorbidities.

   • Developing a method for the systematic screening of OSA patients can help identify patients at risk.

To continue this case and take another quiz, 

1. Chung F, Yegneswaran B, Liao P, et al. STOP Questionnaire: a tool to screen patients for obstructive sleep apnea. 

2. Netzer NC, Stoohs RA, Netzer CM, et al. Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome.

Sleep Disorders

During his annual physical examination, a 54-year-old man has no major complaints, reports restful sleep, and is not tired during the day. Is he at risk for obstructive sleep apnea?

Obstructive Sleep Apnea: Just Who Is at Risk?