FPIN's Clinical Inquiries
Clinical Indicators of Obstructive Sleep Apnea
Am Fam Physician. 2011 May 1;83(9).
Which clinical signs and symptoms are predictive of obstructive sleep apnea (OSA)?
Clinical indicators (e.g., sex, snoring severity, history of apnea, age, menopausal status, waist-to-hip ratio, body habitus) can predict OSA as diagnosed using overnight polysomnography or sleep study. (Strength of Recommendation: B, based on multiple cross-sectional studies.) There is insufficient evidence to specify which measure of body habitus (i.e., body mass index [BMI] or neck circumference) is more predictive of OSA.
Nine cross-sectional studies examined the predictive value of varying clinical characteristics in patients with OSA. Almost all study participants were from referral populations. Varying apnea-hypopnea index threshold values were used to define OSA.
Four studies found a statistically significant association between male sex and OSA,1-4 whereas one study found no association.5 Other studies have demonstrated that persons who snore have an increased risk of OSA,2,6 and that there is a statistically significant correlation between breathing pauses and OSA (odds ratio [OR] = 2.09 to 2.47).2,4
Several studies examined the relationship between age and OSA, with conflicting results.1,2,4,7-9 One study found a statistically significant association between older age (as measured in 10-year increments) and increased prevalence of OSA,2 and another showed a nine- to 11-fold increased prevalence of OSA in persons 20 to 65 years of age.8,9 However, other study results did not demonstrate a statistically significant relationship between age and OSA.1,4,7
There is also a link between a larger waist-to-hip ratio and OSA (OR = 1.07 to 3.41).1-3,5 Two studies determined that a BMI greater than 30 kg per m2 was not an independent variable for OSA,1,4 whereas two other studies showed that an increasing BMI (in increments of 5.3 or 5.6 kg per m2) was associated with an increased risk of OSA.2,3 A BMI greater than or equal to 31.1 kg per m2 in men and 32.3 kg per m2 in women was found to be predictive of OSA (OR = 7.8 and 12.8, respectively).8,9
Five studies examined the link between neck circumference and OSA, although each study used a different clinical indicator and results were conflicting.1-5 An incremental increase in neck circumference or percentage of predicted neck circumference (based on height) was found to be significantly associated with OSA (OR = 1.23 to 5.0).2,3,5 However, two studies found no statistically significant association between OSA and a predetermined neck circumference greater than 43 cm for men and greater than 47 cm for women.1,4
Recommendations from Others
According to the Institute for Clinical Systems Improvement, the following clinical indicators may suggest a significant risk of OSA: awakening with choking, hypertension, intense snoring, large neck circumference, male sex, postmenopause, obesity, apnea or choking as reported by sleep partner, atrial fibrillation, and daytime sleepiness.10
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1. Martinez-Rivera C, Abad J, Fiz JA, Rios J, Morera J. Usefulness of truncal obesity indices as predictive factors for obstructive sleep apnea syndrome. Obesity (Silver Spring). 2008;16(1):113-118.
2. Young T, Shahar E, Nieto FJ, et al. Predictors of sleep-disordered breathing in community-dwelling adults: the Sleep Heart Health Study. Arch Intern Med. 2002;162(8):893-900.
3. Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med. 1993;328(17):1230-1235
4. Ibrahim AS, Almohammed AA, Allangawi MH, et al. Predictors of obstructive sleep apnea in snorers [published correction appears in Ann Saudi Med. 2008;28(1):64]. Ann Saudi Med. 2007;27(6):421-426.
5. Sharma SK, Kurian S, Malik V, et al. A stepped approach for prediction of obstructive sleep apnea in overtly asymptomatic obese subjects: a hospital based study. Sleep Med. 2004;5(4):351-357.
6. Morris LG, Kleinberger A, Lee KC, Liberatore LA, Burschtin O. Rapid risk stratification for obstructive sleep apnea, based on snoring severity and body mass index. Otolaryngol Head Neck Surg. 2008;139(5):615-618.
7. Hessel NS, Laman M, van Ammers VC, van Duijn H, de Vries N. Diagnostic work-up of socially unacceptable snoring. I. History or sleep registration. Eur Arch Otorhinolayngol. 2002;259(3):154-157.
8. Bixler EO, Vgontzas AN, Lin HM, et al. Prevalence of sleep-disordered breathing in women: effects of gender. Am J Respir Crit Care Med. 2001;163(3 pt 1):608-613.
9. Bixler EO, Vgontzas AN, Ten Have T, Tyson K, Kales A. Effects of age on sleep apnea in men: I. Prevalence and severity. Am J Respir Crit Care Med. 1998;157(1):144-148.
10. Institute for Clinical Systems Improvement. Diagnosis and treatment of obstructive sleep apnea. 6th ed. Bloomington, Minn.: Institute for Clinical Systems Improvement; June 2008. http://www.icsi.org/sleep_apnea/sleep_apnea__diagnosis_and_treatment_of_obstructive_.html. Accessed August 2, 2010.
Clinical Inquiries provides answers to questions submitted by practicing family physicians to the Family Physicians Inquiries Network (FPIN). Members of the network select questions based on their relevance to family medicine. Answers are drawn from an approved set of evidence-based resources and undergo peer review. The strength of recommendations and the level of evidence for individual studies are rated using criteria developed by the Evidence-Based Medicine Working Group (http://www.cebm.net/?o=1025).
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