STOP-Bang sleep apnea screening

What this assessment is

STOP-Bang is an eight-factor screen for risk of obstructive sleep apnea, or OSA.

Its name combines four symptom questions, called STOP, with four background factors, called Bang. Each factor receives a yes-or-no result.

Frances Chung and colleagues developed the measure for surgical patients and published the original validation study in 2008.

STOP-Bang estimates risk. It does not diagnose sleep apnea or measure its severity.

Who it was designed for

STOP-Bang was first validated in adults attending preoperative clinics. It has since been studied in sleep clinics, surgical groups, and general populations.

Performance changes with the setting.

A high score is common in groups where OSA risk factors are common. A low score can be more useful for ruling out moderate or severe OSA in some surgical populations than in every community setting.

This page covers the current eight-factor adult scoring method. Modified versions and population-specific rules need separate evidence.

How it is administered

STOP-Bang records eight factors:

• snoring
• tiredness or daytime sleepiness
• observed breathing pauses
• high blood pressure
• body mass index
• age
• neck circumference
• sex recorded as male in the original scoring rule

Each factor is scored yes or no. Some can be self-reported. Height, weight, neck circumference, and blood pressure are stronger when measured accurately.

Use all eight factors. Do not replace a missing factor with no.

What it measures

STOP-Bang combines OSA symptoms with demographic and physical risk factors. It is designed to identify people who may need closer assessment or diagnostic testing.

The Berlin Questionnaire also estimates OSA risk, but it uses three scored categories. The ESS measures daytime sleepiness and does not include the other OSA risk factors.

No one questionnaire covers the full clinical assessment.

The sex factor is part of the original algorithm. It can reduce the score for women and does not capture every person's biological or clinical risk. Interpret it with symptoms, menopause status, body measurements, health history, and the population being assessed.

How scoring works

Give one point for each positive factor. Add the eight points for a total from 0 to 8.

The current official scoring guide uses these basic groups:

• 0 to 2: low risk
• 3 to 4: intermediate risk
• 5 to 8: high risk

There is also an additional high-risk rule. A person with at least two positive STOP symptom factors is high risk if they also have any one of these: male sex, body mass index above 35, or neck circumference above 40 centimetres.

Apply that rule as written. A total of 3 or 4 can therefore move from intermediate to high risk.

How to interpret a STOP-Bang score

A higher result means that more OSA risk factors are present. It does not mean that breathing events are more severe in a fixed one-point step.

Low risk does not mean no risk. High risk does not confirm OSA.

Use the result with the person's symptoms, medical history, airway examination, sleep opportunity, medicines, and the reason for screening. The threshold for further testing can differ between a preoperative clinic and general primary care.

NICE guidance recommends considering STOP-Bang alongside a preliminary assessment when OSA is suspected.

If you are struggling to stay awake while driving, stop driving and seek medical advice. Do not wait for a higher score.

What the score cannot tell you

STOP-Bang cannot diagnose OSA, count breathing events, measure oxygen loss, or distinguish obstructive from central sleep apnea.

It also cannot explain tiredness or snoring. Those symptoms can have several causes.

The score can be high because of age, body measurements, sex, or blood pressure even when symptoms are limited. It can be lower in someone whose risk is not well represented by the original factors.

Do not use it as a stand-alone decision to start or rule out treatment.

Evidence and limitations

The original study found high sensitivity for moderate and severe OSA in a surgical population. Later research supported the screen in several settings but also showed its central tradeoff: it identifies many at-risk people and can produce many false positives.

A practical scoring study added the combined high-risk rule for people with totals of 3 or 4. That rule improves risk separation without turning the questionnaire into a diagnostic test.

The American Academy of Sleep Medicine guideline states that questionnaires should not diagnose OSA without polysomnography or an appropriate home sleep apnea test.

Use the exact scoring version and record all eight factors.