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Revisiting the Epworth sleepiness scale

Is excessive daytime sleepiness still a valid screening tool for obstructive sleep apnea in a population at risk?

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Summary

Objective

Obstructive sleep apnea (OSA) is a common medical problem with numerous comorbidities and high costs. Since the introduction of the Epworth sleepiness scale (ESS), excessive daytime sleepiness (EDS) has been considered the most common and prominent symptom of OSA. Aim of this study was to re-evaluate the ESS for detection of OSA in a population at risk compared to the gold standard overnight polysomnography (PSG).

Methods

A total of 266 patients (mean age 57.9 ± 11.6 years; 189 men and 77 women), referred to our sleep laboratory for probable OSA, were given ESS followed by an overnight PSG. The ESS values were compared to PSG apnea hypopnea index (AHI) with sensitivity (SE), specificity (SP), positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy (DA) calculated for ESS. The positive cut-off value for ESS was ≥ 10 and for AHI ≥ 5.

Results

Only 92 (34.6%) subjects had a positive ESS. An OSA was diagnosed by PSG in 213 (80.1%) subjects: 46 having mild, 37 moderate and 130 severe apnea. Most subjects with positive ESS (88.0%) were found to have OSA but most subjects with a negative ESS (75.9%) were also positive for OSA (42% with AHI ≥ 30). The area under the receiver operating characteristic (ROC) curve for ESS was 0.60 (95% confidence interval, CI 0.54–0.66; p = 0.020) with SE 38.0%, SP 79.3%, PPV 88.0%, NPV 24.1% and DA 46.2%.

Conclusion

It was found that excessive daytime sleepiness, measured by ESS, is not a valuable screening tool for OSA, especially when the test is negative. Other screening tests that involve additional parameters, beside daytime sleepiness alone, should be considered.

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Authors and Affiliations

  1. University Department of Pulmonology, University Hospital Centre Zagreb, Zagreb, Croatia

    Hrvoje Puretić MD,  Gordana Pavliša MD, PhD &  Marko Jakopović MD, PhD

  2. Laboratory for sleep-related breathing disorders, University Department of Pulmonology, University Hospital Centre Zagreb, Jordanovac 104, Zagreb, 10000, Croatia

    Hrvoje Puretić MD

  3. University Department of Neurology , Sestre milosrdnice University Hospital Centre, Zagreb, Croatia

    Bosnar Puretić Marijana MD, PhD

  4. Faculty of Education and Rehabilitation Sciences , University of Zagreb, Zagreb, Croatia

    Bosnar Puretić Marijana MD, PhD

  5. School of Medicine, University of Zagreb, Zagreb, Croatia

    Gordana Pavliša MD, PhD &  Marko Jakopović MD, PhD

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H. Puretić, M. Bosnar Puretić, G. Pavliša and M. Jakopović declare that they have no competing interests.

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Puretić, H., Bosnar Puretić, M., Pavliša, G. et al. Revisiting the Epworth sleepiness scale. Wien Klin Wochenschr (2023). https://doi.org/10.1007/s00508-023-02213-4

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