Obesity Surgery

, Volume 28, Issue 11, pp 3544–3552 | Cite as

The Evaluation of Screening Questionnaires for Obstructive Sleep Apnea to Identify High-Risk Obese Patients Undergoing Bariatric Surgery

  • Stephen A. GlazerEmail author
  • Ann L. Erickson
  • Ross D. Crosby
  • Jennifer Kieda
  • Agata Zawisza
  • Mervyn Deitel
Original Contributions



Obstructive sleep apnea (OSA) is extremely common among bariatric surgical candidates. Identifying those at risk for moderate to severe OSA is challenging. Testing all bariatric surgical candidates with a level 1 polysomnographic study is expensive and resource intensive. The aim of this study is to evaluate three standardized screening questionnaires that are utilized to identify high-risk patients for OSA undergoing bariatric surgery.


A retrospective review of data collected prospectively was undertaken on bariatric surgical patients who have not had a preexisting diagnosis of OSA. Each patient was subjected to the STOP BANG and Berlin Questionnaires as well as the Epworth Sleepiness Scale (ESS), after which a level 1 polysomnogram was undertaken. Nonparametric receiver operating characteristic analyses were used to evaluate the relationship between questionnaire scores and OSA as determined by a formal sleep lab study.


There were 266 patients subjected to a standard overnight polysomnogram and screening questionnaires. Area under the curve (AUC) values for analyses including the entire sample were significantly (p < .05) greater than chance (i.e., AUC = .50) for all questionnaire scores except the ESS for both severe OSA (AUC range = .584–.631) and moderate/severe OSA (AUC range = .589–.660), although the magnitude of the AUC values was quite modest. Sensitivity and specificity values from the current study are substantially lower than those previously reported in the literature.


Neither the STOP BANG nor Berlin questionnaires appear to be effective tools for detecting moderate- or high-risk patients for OSA undergoing bariatric surgery.


STOP BANG questionnaire Berlin questionnaire Epworth Sleepiness Scale Obstructive sleep apnea Bariatric surgery 



The authors acknowledge Dr. Michel Gagner for his significant guidance, contribution, and expertise in the preparation of this manuscript.

The authors also wish to acknowledge the contribution of Jhanvi Patel, R.N., Bariatric Surgical Program Clinic Director, Humber River Hospital, Toronto, Canada, for her assistance with the data collection.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no competing interests.

Ethical Approval

This study has been approved by the Research Ethics Board at Humber River Hospital.

Informed Consent

For this type of study, formal consent is not required.


  1. 1.
    Shahi B, Praglowski B, Deitel M. Sleep-related disorders in the obese. Obes Surg. 1992;2:159–68.Google Scholar
  2. 2.
    Hallowell PT, Stellato TA, Schuster M, et al. Potentially life-threatening sleep apnea is unrecognized without aggressive evaluation. Am J Surg. 2007;193(3):364–7. discussion 367.CrossRefPubMedGoogle Scholar
  3. 3.
    Marshall NS, Wong KK, Liu PY, et al. Sleep apnea as an independent risk factor for all-cause mortality: the Busselton Health Study. Sleep. 2008;31(8):1079–85.Google Scholar
  4. 4.
    Terán-Santos J, Jiménez-Gómez A, Cordero-Guevara J. The association between sleep apnea and the risk of traffic accidents. Cooperative Group Burgos-Santander. N Engl J Med. 1999;340(11):847–51.CrossRefPubMedGoogle Scholar
  5. 5.
    Somers VK, Dyken ME, Clary MP, et al. Sympathetic neural mechanisms in obstructive sleep apnea. J Clin Invest. 1995;96(4):1897–904.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Parra O, Arboix A, Bechich S, et al. Time course of sleep-related breathing disorders in first-ever stroke or transient ischemic attack. Am J Respir Crit Care Med. 2000;161(2 Pt 1):375–80.CrossRefPubMedGoogle Scholar
  7. 7.
    Mehra R, Benjamin EJ, Shahar E, et al. Association of nocturnal arrhythmias with sleep-disordered breathing: the Sleep Heart Health Study. Am J Respir Crit Care Med. 2006;173(8):910–6.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Tasali E, Mokhlesi B, Van Cauter E. Obstructive sleep apnea and type 2 diabetes: interacting epidemics. Chest. 2008;133(2):496–506. Review.CrossRefPubMedGoogle Scholar
  9. 9.
    Macey PM, Kumar R, Woo MA, et al. Brain structural changes in obstructive sleep apnea. Sleep. 2008;31(7):967–77.Google Scholar
  10. 10.
    Young T, Palta M, Dempsey J, et al. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med. 1993;328(17):1230–5.CrossRefPubMedGoogle Scholar
  11. 11.
    Gasa M, Salord N, Fortuna AM, et al. Obstructive sleep apnoea and metabolic impairment in severe obesity. Eur Respir J. 2011;38(5):1089–97. Scholar
  12. 12.
    Anvari M. The Ontario bariatric network group. Ontario bariatric network data, produced and distributed by the Centre for Surgical Invention and Innovation, supported by the Ministry of Health and Long Term Care. Ontario; 2018.Google Scholar
  13. 13.
    Peromaa-Haavisto P, Tuomilehto H, Kössi J, et al. Prevalence of obstructive sleep apnoea among patients admitted for bariatric surgery. A prospective multicentre trial. Obes Surg. 2016;26:1384–90.CrossRefGoogle Scholar
  14. 14.
    Quintas-neves M, Preto J, Drummond M. Assessment of bariatric surgery efficacy on obstructive sleep apnea (OSA). Rev Port Pneumol (2006). 2016;22(6):331–6.Google Scholar
  15. 15.
    Fritscher LG, Canani S, Mottin CC, et al. Bariatric surgery in the treatment of obstructive sleep apnea in morbidly obese patients. Respiration. 2007;74(6):647–52.CrossRefPubMedGoogle Scholar
  16. 16.
    Lee YH, Johan A, Wong KK, et al. Prevalence and risk factors for obstructive sleep apnea in a multiethnic population of patients presenting for bariatric surgery in Singapore. Sleep Med. 2009;10(2):226–32. Scholar
  17. 17.
    Longitudinal Assessment of Bariatric Surgery (LABS) Consortium, Flum DR, Belle SH, et al. Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med. 2009;361(5):445–54.
  18. 18.
    Gupta RM, Parvizi J, Hanssen AD, et al. Postoperative complications in patients with obstructive sleep apnea syndrome undergoing hip or knee replacement: a case-control study. Mayo Clin Proc. 2001;76(9):897–905.CrossRefPubMedGoogle Scholar
  19. 19.
    Polysomnography Task Force, American Sleep Disorders Association Standards of Practice Committee. Practice parameters for the indications for polysomnography and related procedures. Sleep. 1997;20(6):406–22.CrossRefGoogle Scholar
  20. 20.
    Gentil B, de Larminat JM, Boucherez C, et al. Difficult intubation and obstructive sleep apnoea syndrome. Br J Anaesth. 1994;72(3):368.Google Scholar
  21. 21.
    Nagappa M, Liao P, Wong J, et al. Validation of the STOP-Bang Questionnaire as a screening tool for obstructive sleep apnea among different populations: a systematic review and meta-analysis. PLoS One. 2015;10(12):e0143697.
  22. 22.
    Sharkey KM, Orff HJ, Tosi C, et al. Subjective sleepiness and daytime functioning in bariatric patients with obstructive sleep apnea. Sleep Breath. 2013;17(1):267–74. Scholar
  23. 23.
    Chung F, Abdullah HR, Liao P. STOP-Bang questionnaire: a practical approach to screen for obstructive sleep apnea. Chest. 2016;149(3):631–8. Scholar
  24. 24.
    Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008;108(5):812–21. Scholar
  25. 25.
    Chung F, Subramanyam R, Liao P, et al. High STOP-Bang score indicates a high probability of obstructive sleep apnea. Br J Anaesth. 2012;108(5):768–75. Scholar
  26. 26.
    Enciso R, Clark GT. Comparing the Berlin and the ARES questionnaire to identify patients with obstructive sleep apnea in a dental setting. Sleep Breath. 2011;15(1):83–9. Scholar
  27. 27.
    Chung F, Ward B, Ho J, et al. Preoperative identification of sleep apnea risk in elective surgical patients, using the Berlin questionnaire. J Clin Anesth. 2007;19(2):130–4.Google Scholar
  28. 28.
    Chung F, Yegneswaran B, Liao P, et al. Validation of the Berlin questionnaire and American Society of Anesthesiologists checklist as screening tools for obstructive sleep apnea in surgical patients. Anesthesiology. 2008;108(5):822–30. Scholar
  29. 29.
    Johns MW. Reliability and factor analysis of the Epworth Sleepiness Scale. Sleep. 1992;15(4):376–81.CrossRefPubMedGoogle Scholar
  30. 30.
    Sareli AE, Cantor CR, Williams NN, et al. Obstructive sleep apnea in patients undergoing bariatric surgery--a tertiary center experience. Obes Surg. 2011;21(3):316–27. Scholar
  31. 31.
    Deitel M, Field SK, Mehta A, et al. Obstructive sleep apnea in the obese. In: Deitel M, Gagner M, Dixon JB, Himpens J, editors. Handbook of obesity surgery. Toronto: FD Communications; 2010. p. 251–4.Google Scholar
  32. 32.
    Chung F, Yang Y, Liao P. Predictive performance of the STOP-Bang score for identifying obstructive sleep apnea in obese patients. Obes Surg. 2013;23:2050–7.CrossRefPubMedGoogle Scholar
  33. 33.
    Chiu H-Y, Chen P-Y, Chuang L-P, et al. Diagnostic accuracy of the berlin questionnaire, STOP-BANG, STOP, and Epworth sleepiness scale in detecting obstructive sleep apnea: a bivariate meta-analysis. Sleep Med Rev. 2017;36:57–70.Google Scholar
  34. 34.
    Chung F, Chau E, Yang Y, et al. Serum bicarbonate level improves specificity of STOP-Bang screening for obstructive sleep apnea. Chest. 2013;143(5):1284–93. Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Internal Medicine, Medical Director Bariatric ProgramHumber River HospitalTorontoCanada
  2. 2.TorontoCanada
  3. 3.Neuropsychiatric Research InstituteFargoUSA
  4. 4.Department of Biomedical StatisticsNeuropsychiatric Research InstituteFargoUSA
  5. 5.Humber River HospitalTorontoCanada
  6. 6.Obesity SurgeryTorontoCanada

Personalised recommendations