STOP-Bang, explained

Who made it

STOP-Bang was developed by Dr. Frances Chung and colleagues at Toronto Western Hospital, University Health Network, and published in 2008 (Chung 2008). It was designed to find likely obstructive sleep apnea in patients before surgery, where undiagnosed sleep apnea raises the risk of complications (Chung 2008). The questionnaire is owned by University Health Network, which licenses its use (stopbang.ca).

What the letters mean

S for snoring, T for tiredness, O for observed breathing pauses, P for high blood pressure; then B for BMI over 35, A for age over 50, N for neck size over 40 cm, and G for male gender (Chung 2016). Each yes is one point, for a total of 0 to 8 (Chung 2016).

How accurate it is

In the first validation (177 surgical patients with sleep studies), the full score found 84% of people with any sleep apnea, 93% with moderate or worse, and 100% with severe sleep apnea (Chung 2008). The trade-off is many false alarms: a high score often turns out to be mild or no sleep apnea. A later study of 746 patients showed the chance of moderate to severe sleep apnea rising with the score, from 36% at 3 to 60% at 7 or 8 (Chung 2012).

Limits

• It was built and tested mainly in surgical patients, not the general public (Chung 2008).
• Two of the eight points (male sex, a neck over 40 cm) favor men, so women with sleep apnea can score lower.
• It cannot diagnose sleep apnea. Only a sleep study can (NHLBI).

Sleep apnea symptoms

In sleep apnea, breathing stops and restarts many times during sleep (NHLBI). Most of the signs happen while you are asleep, so a bed partner often notices them first. NHLBI lists these (NHLBI):

• At night: breathing that stops and starts, frequent loud snoring (more common in men), gasping for air, and waking up often to urinate.
• During the day: sleepiness and tiredness that make it harder to learn, focus and react, dry mouth, and lower sex drive.
• More common in women: fatigue, headache and insomnia.

That last group matters for STOP-Bang. Its snoring and tiredness questions catch the classic picture, but fatigue, headaches and insomnia are not scored, and two of the Bang points favor men. A woman with these symptoms and a low score still has a good reason to ask about a sleep study.

How sleep apnea is diagnosed

A questionnaire cannot diagnose sleep apnea. The American Academy of Sleep Medicine makes this a strong recommendation: clinical tools, questionnaires and prediction rules should not be used to diagnose it without a sleep test (AASM 2017). There are two kinds:

A sleep study counts how many times an hour breathing stops (apnea) or becomes shallow (hypopnea). This is the apnea-hypopnea index, or AHI. The STOP-Bang studies used the common severity lines: an AHI over 5 for any sleep apnea, over 15 for moderate to severe, and over 30 for severe (Chung 2008).

Why it is worth checking

NHLBI notes that untreated sleep apnea raises the risk of stroke, heart attack and other serious problems, and can affect concentration and memory (NHLBI). Daytime sleepiness also slows reactions (NHLBI), which matters for anyone who drives.

Screening people without symptoms

The US Preventive Services Task Force concluded in 2022 that there is not enough evidence to recommend screening adults who have no symptoms (USPSTF 2022). If you do have symptoms such as loud snoring, choking or gasping at night, or heavy daytime sleepiness, that is a reason to talk to a doctor (NHLBI).

Common questions

What STOP-Bang score is high risk?

The authors group 0 to 2 as low risk, 3 to 4 as intermediate and 5 to 8 as high risk. A score of 3 or 4 also counts as high if 2 or more STOP items are yes and you are male, have a BMI over 35 or a neck over 40 cm (Chung 2016).

Can I use STOP-Bang to rule out sleep apnea?

A low score makes moderate to severe sleep apnea less likely, but it does not rule it out, especially in women. If you have symptoms, a sleep test is the only way to know (AASM 2017).

Is a home sleep test as good as a lab study?

For adults without major other health problems whose symptoms point to moderate to severe sleep apnea, the AASM accepts either. If a home test is negative or unclear, it recommends a lab study (AASM 2017).

Back to the sleep apnea page.