Mehmet Nurullah ORMAN, Özgür BATUM, Burcu OKTAY ARSLAN, Zeynep Zeren UÇAR

Validation of the NoSAS score for screening sleep-disordered breathing: A sleep clinicbased study in Turkey

Background/aim: The NoSAS score is a new tool for the identification of high-risk patients for sleep-disordered breathing (SDB). The aim of this study was to validate the NoSAS score in a sleep clinical population in Turkey and compare its performance with the Epworth Sleepiness Scale (ESS), STOP-Bang, and Berlin questionnaires for high-risk SDB. Materials and methods: This was a retrospective study. Patients who had a full-night PSG examination between 01.03.2017 and 01.01.2018 at the sleep center of our hospital were included in the study. Demographic characteristics, anthropometrics measurements, ESS, STOP-Bang, and Berlin scores were collected from the existing data of the patients. The NoSAS score was subsequently calculated based on available data. Predictive parameters for each screening questionnaires were calculated to compare the discriminative power of those for high-risk SDB.Results: A total of 450 patients were included in the study. The sensitivity, specificity, PPV, and NPV of the NoSAS score were 81%, 51.2%, 88.2%, and 37.5% for an AHI (apnea–hypopnea index) ≥ 5 event/h and 84.5%, 38.2%, 66%, and 63.4% for an AHI ≥ 15 event/h, respectively. AUC percentages for the NoSAS score, STOP-Bang questionnaire, Berlin questionnaire, and ESS were 0.740, 0.737, 0.626, and 0.571 for an AHI ≥ 5 events/h and 0.715, 0.704, 0.574, and 0.621 for an AHI ≥ 30 events/h. The NoSAS score had a false negative rate of 2.9% for severe SDB.Conclusion: The NoSAS score had a good degree of differentiation for SDB and can be used as an easily applicable, subjective, and effective screening tool in a sleep clinical population in Turkey. Not only in moderate to severe SDB but also in mild SDB, the NoSAS score performed better than the other 3 screening tools.Key words: NoSAS score, sleep-disordered breathing, STOP-Bang, Berlin questionnaire

PDF

___

1. Peppard PE, Young T, Barnet JH, Palta M, Hagen EW et al. Increased prevalence of sleep-disordered breathing in adults. American Journal of Epidemiology 2013; 177: 1006-1014. doi: 10.1093/aje/kws342
2. Young T, Evans L, Finn L, Palta M. Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women. Sleep 1997; 20 (9): 705-706. doi:10.1093/ sleep/20.9.705
3. Heinzer R, Vat S, Marques-Vidal P, Marti-Soler H, Andries D et al. Prevalence of sleep-disordered breathing in the general population: the HypnoLaus study. Lancet Respiratory Medicine 2015; 3(4):310-318. doi:10.1016/S2213-2600(15)00043-0
4. Flemons WW, Douglas NJ, Kuna ST, Rodenstein DO, Wheatley J. Access to diagnosis and treatment of patients with suspected sleep apnea. American Journal of Respiratory and Critical Care Medicine 2004; 169 (6):668-672. doi:10.1164/rccm.200308- 1124PP
5. Amra B, Rahmati B, Soltaninejad F, Feizi A. Screening questionnaires for obstructive sleep apnea: an updated systematic review. Oman Medical Journal 2018; 33 (3): 184- 192. doi: 10.5001/omj.2018.36
6. Chiu HY, Chen PY, Chuang LP, Chen NH, Tu YK 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 Medicine Reviews 2017; 36:57-70. doi:10.1016/j.smrv.2016.10.004
7. Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep 1991; 14 (6): 540-545. doi:10.1093/sleep/14.6.540
8. Marti-Soler H, Hirotsu C, Marques-Vidal P, Vollenweider P, Waeber G et al. The NoSAS score for screening of sleepdisordered breathing: a derivation and validation study. Lancet Respiratory Medicine 2016. doi:10.1016/S2213- 2600(16)30075-3
9. Netzer NC, Stoohs RA, Netzer CM, Clark K, Strohl KP. Using the Berlin questionnaire to identify patients at risk for the sleep apnea syndrome. Annals of Internal Medicine 1999; 131 (7): 485-491. doi:10.7326/0003-4819-131-7-199910050-00002
10. Chung F, Yegneswaran B, Liao P, Chung SA, Vairavanathan S et al. STOP questionnaire: A tool to screen patients for obstructive sleep apnea. Anesthesiology 2008; 108 (5): 812-21. doi:10.1097/ALN.0b013e31816d83e4
11. Izci B, Ardic S, Firat H, Sahin A, Altinors M et al. Reliability and validity studies of the Turkish version of the Epworth Sleepiness scale. Sleep and Breathing 2008; 12 (2): 161-168. doi:10.1007/s11325-007-0145-7
12. Yüceege M, Fırat H, Sever Ö, Demir A, Ardıç S. The effect of adding gender item to Berlin questionnaire in determining obstructive sleep apnea in sleep clinics. Annals of Thoracic Medicine 2015; 10 (1): 25-28. doi:10.4103/1817-1737.146856
13. Acar HV, Kaya A, Yucel F,Erdem M, Günal Eruyar S et al. Validation of the STOP-bang questionnaire: an obstructive sleep apnoea screening tool in Turkish population. Turkish Journal of Anaesthesiology and Reanimation 2013; 41 (4): 115- 120. doi:10.5152/TJAR.2013.46
14. Berry R, Brooks R, Gamaldo C, Harding S, Lloyd R et al. The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications, Version 2.3. Darien, Illinois, USA: American Academy of Sleep Medicine; 2016.
15. Randerath W, Bassetti CL, Bonsignore MR, Farre R, FeriniStrambi L et al. Challenges and perspectives in obstructive sleep apnoea: report by an ad hoc working group of the sleep disordered breathing group of the European Respiratory Society and the European Sleep Research Society. European Respiratory Journal 2018; 52 (3): 1702616. doi:10.1183/13993003.02616- 2017
16. Hong C, Chen R, Qing S,Kuang A, Yang H et al. Validation of the NoSAS Score for the screening of sleep-disordered breathing: a hospital-based retrospective study in China. Journal of Clinical Sleep Medicine 2018; 14 (2): 191-197. doi:10.5664/jcsm.6930
17. Tan A, Hong Y, Tan L, Van Dam R, Ceung Y et al. Validation of NoSAS score for screening of sleep-disordered breathing in a multiethnic Asian population. Sleep and Breathing 2017; 21 (4): 1033-1038.doi:10.1007/s11325-016-1455-4
18. Nahapetian R, Silva GE, Vana KD, Parthasarathy S, Quan SF. Weighted STOP-Bang and screening for sleep-disordered breathing. Sleep and Breathing 2016; 20 (2): 597-603. doi:10.1007/s11325-015-1255-2
19. Silva GE, Vana KD, Goodwin JL, Sherrill DL, Quan S. Identification of patients with sleep disordered breathing: comparing the four-variable screening tool, STOP, STOPBang, and Epworth sleepiness scales. Journal of Clinical Sleep Medicine 2011; 7 (5): 467-472.doi:10.5664/JCSM.1308
20. Peng M, Chen R, Cheng J, Li J, Liu W et al. Application value of the NoSAS score for screening sleep-disordered breathing. Journal of Thoracic Disease 2018; 10 (8): 4774-4782. doi:10.21037/jtd.2018.07.46
21. Peppard PE, Young T, Palta M, Skatrud J. Prospective study of the association between sleep-disordered breathing and hypertension. New England Journal of Medicine 2000; 342 (19): 1378-1384.doi:10.1056/NEJM200005113421901
22. Shahar E, Whitney CW, Redline S, Lee ET,Newman AB et al. Sleep-disordered breathing and cardiovascular disease: crosssectional results of the sleep heart health study. American Journal of Respiratory and Critical Care Medicine 2001; 163 (1): 19-25. doi:10.1164/ajrccm.163.1.2001008
23. Baldwin CM, Griffith KA, Nieto FJ, O’Connor GT, Walsleben JA et al. The association of sleep-disordered breathing and sleep symptoms with quality of life in the Sleep Heart Health Study. Sleep 2001; 24 (1): 96-105.doi:10.1093/sleep/24.1.96
24. Brown LK. Mild obstructive sleep apnea syndrome should be treated. Journal of Clinical Sleep Medicine 2007; 3 (3): 259- 262.doi:10.5664/jcsm.26793
25. Mau J, Pflugeisen BM, Crick BA, Amoroso PJ, Harmon KT et al. The discriminative power of STOP-Bang as a screening tool for suspected obstructive sleep apnea in clinically referred patients: considering gender differences. Sleep and Breathing 2018; 23 (1): 65-75. doi:10.1007/s11325-018-1658-y
26. Ardıç S, Demir A, Ucar ZZ, Firat H, Itil O et al. Prevalence and associated factors of sleep-disordered breathing in the Turkish adult population. Sleep and Biological Rhythms 2012; 11 (1): 29-39.doi:10.1111/sbr.12000