older man with jaw pain
How to Get Tested
March 3, 2019
man sleeping with cpap
Sleep Apnea: Are You Male?
March 3, 2019
Show all
snoring and sleep problems

It’s on T-shirts with an illustration of a hurdle jump –“Risk… if you screw up, it’s your own damn vault”. Whether or not you follow the “get out of your comfort zone, take a risk”, idea or, “don’t be foolish and take a risk”, you are faced with all types of risk management in life daily. While it is true that sometimes you may need to take a risk to move forward, you also want to avoid “screwing up,” by taking unnecessary risks. So, take a leap of faith, and find out if you are at risk for OSA.

Sleeping and Counting Sheep

Sleeping is certainly a necessity, and for many or most people, a welcome pleasure. For many still, it’s a problem, tossing and turning, counting sheep, a feeling that it is just never enough.

Almost all of us feel exhausted once in a while, and like we are sleepwalking through the day. But those of you who almost always answer “tired” to the question of “how do you feel?” may be at risk for obstructive sleep apnea. Let’s try to find the cause of that exhaustion, and leave “the Walking Dead” to movies and TV screens!

OSA–Not Silent, but Can be Deadly

Obstructive sleep apnea, (OSA) is more common today than you might imagine. And it really is something to be concerned about because studies show that OSA is associated with high risk for traffic accidents and heart disease, and those are just two, of the many health risks associated with OSA. Many people may be walking around (probably sleepwalking around) with OSA and not even know it because it is not diagnosed often enough. The estimates are that 80% of men and 93% of women with moderate to severe sleep apnea go undiagnosed.

A for Apnea

The most common apnea is obstructive sleep apnea or OSA. It occurs when soft tissue in the back of the throat collapses and blocks up the airway, causing you to stop breathing during sleep–repeated times.

sleeping and snoring problems

When you fall asleep, the muscles that stiffen the airway behind the tongue and soft palate naturally relax, and in a normal airway, this is not a problem. But, if your airway is small, for example from excess weight, it can close shut. Breathing tries to continue with a closed airway, and gets harder to do. Blood oxygen levels drop and carbon dioxide levels increase, and all that increased effort to breathe causes you to wake up for a moment in order to make those muscle reopen in the airway to breathe.

Often that difficult breathing makes a vibration noise known as snoring. And, there can also be choking or gasping sounds as you snore. The moments that you wake are so very short that you go back to sleep right away and usually don’t even know that is happening. But it can happen frequently over and over during night, so your sleep is fragmented, your sleep is not what you need to restore your body functions, and daytime fatigue results.

These events of stop breathing are called obstructive hypopneas or apneas, and the full name of the problem is called obstructive sleep apnea-hypopnea syndrome.


The Apnea–Hypopnea Index or Apnea–Hypopnea Index (AHI), is an index used to indicate the severity of sleep apnea. It is represented by the number of apnea and hypopnea events per hour of sleep. The apneas (pauses in breathing) must last for at least 10 seconds and be associated with a decrease in blood oxygenation. Combining AHI and the amount of blood oxygen decrease gives an overall sleep apnea severity score that evaluates both the number of sleep disruptions and the degree of oxygen desaturation (low oxygen level in the blood).

The AHI is calculated by dividing the number of apnea events by the number of hours of sleep. The AHI values according to the American Academy of Sleep Medicine are:

Normal: 0-4

Mild sleep apnea: 5-14

Moderate sleep apnea: 15-29

Severe sleep apnea: 30 or more

According to the published manual by the American Academy of Sleep medicine, apnea is defined as equal to or greater than a 90% drop in air flow lasting equal to or greater than 10 seconds.

Hypopnea is defined as equal to or greater than 50% reduction in air flow lasting equal to or greater than 10 seconds. Apneas are obstructive if they are accompanied by respiratory effort.

AHI greater than 5 is considered having OSA

Identifying OSA

There is a growing awareness of obstructive sleep apnea which has created long waiting lists in many sleep laboratories. In order to deal with that, screening questionnaires have been developed to help people with disrupted sleep, and their doctors, to determine if OSA is their problem.


The easiest, most concise and the first developed questionnaire to determine OSA was the S.T.O.P. questionnaire. It was designed in yes/no format, of 4 questions related to snoring, tiredness during the day, stopped breathing during sleep and hypertension. The questions are designed for easy reading level and available online everywhere. It’s a self-report that takes about 1 minute to complete.

The acronym S.T.O.P represents:

  1. S- “Do you snore loudly or louder than talking or loud enough to be heard through closed doors? yes no
  2. T- “Do you often feel tired, fatigued or sleepy during daytime? yes, no
  3. 3.O.- “Has anyone observed you stop breathing during your sleep?” yes no
  4. 4.P- Do you have or are you being treated for high blood pressure?” yes no

This questionnaire was successfully tested under strict experiment/study regulations and the results published widely on the reliability of the test. Subjects who were involved in the study both took the quiz and were evaluated overnight in a polysomnographic study to validate how well it predicts the apnea-hypopnea index that was obtained from the polysomnography.

The results of the study showed a very high sensitivity of the S.T.O.P. questionnaire to predict OSA.

From the study of the S.T.O.P. questionnaire they also found that those at high risk of having OSA had significant more hypertension and reflux disease, larger BMI larger neck circumference, and higher AHI. There was a higher percentage of male patients with an AHI greater than 5.


The S.T.O.P.study then was enlarged to include 4 additional parameters/questions to add another scoring scale into it that incorporated BMI, age, neck circumference and gender. This was because the researchers discovered a high sensitivity of the subjects to those area. They termed this test the S.T.O.P.-B.A.N.G. according to the acronym presented. This is now a questionnaire of 8 yes or no questions.

When the researchers incorporated BMI, age, neck circumference, gender to the STOP score the sensitivity greatly increased.

The stop bang questionnaire is eight easily answered questions that start with the acronym STOP-Bang. A score of equal to or greater than 3 shows high sensitivity for detecting OSA.

The acronym stands for Snoring, Tiredness, Observed apnea, blood Pressure, Body mass index, Age, Neck circumference and Gender. These questions can help spot a person who has not been assessed in a formal sleep study.

In the stop bang model this rating has been determined for OSA:

If you answer Yes to 0-2 questions, -Low risk,

yes to 3-4 questions intermediate risk,

yes to 5-8 questions high risk.

The stop bang questionnaire has a predictive value of about 85% for identifying OSA.

The results from a study at Mount Sinai hospital in Toronto confirmed that a stop bang score equal to or greater than 3 is highly predictive to detect sleep apnea.

The Risks of OSA

OSA is a real health risk because evidence has revealed it leads to a greater risk of high blood pressure, heart attack, stroke, heart failure, diabetes, headaches, depression, cancer and even sudden death.

What you want to do is decrease these risks.

To start with, check with your partner or family about night time snoring. You may wish to start a daily sleep diary with information like when you fell asleep, how long you slept, when and why you woke up, and any daytime symptoms. You may wish to try using a recording device during the night or various available apps for information on what goes on during your sleep time.

Or, you may wish to speak to your physician about a sleep study.

Or, you can check out a simple sleep questionnaire like the S.T.O.P.-B.A.N.G. that we just discussed.

Tips and Takeaways

  • If you have poor or disrupted sleep, you may be at high risk of OSA
  • OSA has many health risks, some very severe
  • The S.T.O.P questionnaire is a very accurate predictor of your risk of OSA
  • STOP-BANG added more parameters such as BMI and neck circumference, which added even more accuracy
  • STOP-BANG is now the most widely accepted screening tool for OSA

Comments are closed.