STOP-BANG Sleep Apnea Risk Score

STOP-BANG is an 8-item binary (Yes/No) screening questionnaire for obstructive sleep apnea (OSA). It is widely used by anesthesiologists before surgery, primary care physicians during annual checkups, and sleep medicine clinicians during initial consultations. It was developed and validated at the Toronto Western Hospital in 2008 and is recommended by the American Society of Anesthesiologists for preoperative OSA screening.

A score of 5–8 places you in the High Risk category, associated with a 60–75% prevalence of moderate-to-severe OSA (AHI ≥ 15). You should discuss these results with your physician and ask for a referral for a home sleep apnea test (HSAT) or polysomnography. If you are due for surgery, inform your surgical team — a perioperative management protocol may be needed.

The combined pathway reclassifies some patients with a total score of 3–4 as High Risk. It applies when you score Yes on at least 2 of the 4 STOP criteria (Snoring, Tired, Observed, Pressure) AND have at least one of the following: male gender, BMI greater than 35, or neck circumference greater than 16 inches (40 cm). Research by Nagappa et al. (2015) showed this combination has a sensitivity of 87% and specificity of 60% for moderate-to-severe OSA, making it more useful than the total score alone for this middle-range group.

No. STOP-BANG is a screening tool — it cannot diagnose OSA. A definitive diagnosis requires either overnight polysomnography in a sleep laboratory or a validated home sleep apnea test (HSAT) interpreted by a licensed clinician. A high STOP-BANG score means you should seek further evaluation, not that OSA is confirmed. Conversely, a Low Risk score substantially reduces the probability of significant OSA, but it does not rule it out, especially in women with atypical symptoms.

At a cut-off of 3 or more, STOP-BANG has a sensitivity of approximately 93% for moderate-to-severe OSA (AHI ≥ 15) and 100% for severe OSA (AHI ≥ 30). Specificity at this threshold is moderate at around 47%. The high sensitivity means few true cases are missed, but the moderate specificity means many people without significant OSA will screen positive — this is acceptable for a surgical screening tool where missing a case carries greater consequences than an unnecessary sleep study.

OSA is a disorder in which the upper airway repeatedly collapses during sleep, causing breathing pauses (apneas) and partial obstructions (hypopneas) that fragment sleep and lower blood oxygen. First-line treatment is CPAP (continuous positive airway pressure), a mask worn during sleep that delivers pressurised air to keep the airway open. Alternative treatments include oral mandibular advancement devices for mild-moderate OSA, positional therapy for position-dependent OSA, and surgical options in selected cases.

STOP-BANG tends to be slightly less sensitive in women because the G (Gender: Male) criterion inherently disadvantages women. Women with OSA also more commonly present with insomnia, mood disturbance, and fatigue rather than loud snoring — symptoms that may not fully register in the S and T questions. Despite this, STOP-BANG remains a validated and clinically useful tool for women; a score of 3 or more still warrants further evaluation regardless of gender.

No. STOP-BANG was developed and validated in adult populations (age 18 and older). Paediatric OSA has a different aetiology (predominantly enlarged adenoids and tonsils), different presentation, and different severity criteria. The Paediatric Sleep Questionnaire (PSQ) is the validated screening tool for OSA in children aged 2–18 years.

BMI is calculated as 703 × weight (lb) ÷ height (in)², or weight (kg) ÷ height (m)². A BMI above 35 corresponds to Class II obesity. Excess adipose tissue around the neck and tongue base narrows the pharyngeal airway, and excess abdominal fat reduces functional residual capacity during sleep, both of which promote upper airway collapse. The 35 threshold was chosen in the STOP-BANG validation study as the level at which obesity independently adds predictive value for moderate-to-severe OSA.

Several STOP-BANG criteria are modifiable. Losing weight can reduce BMI below 35 and reduce neck circumference below 16 inches — directly removing two criteria and reducing OSA severity. Treating hypertension through lifestyle and medication may reduce the P criterion over time. Sleeping on your side (positional therapy) can reduce snoring severity and apnea frequency in mild-moderate positional OSA. However, gender and age are fixed, and daytime tiredness or observed apneas should prompt evaluation regardless of other factors.