Clinical Question

Which clinical signs and symptoms are predictive of obstructive sleep apnea (OSA)?

Evidence-Based Answer

Clinical indicators (e.g., sex, snoring severity, history of apnea, age, menopausal status, waist-to-hip ratio, body habitus) can predict OSA as diagnosed using overnight polysomnography or sleep study. (Strength of Recommendation: B, based on multiple cross-sectional studies.) There is insufficient evidence to specify which measure of body habitus (i.e., body mass index [BMI] or neck circumference) is more predictive of OSA.

Evidence Summary

Nine cross-sectional studies examined the predictive value of varying clinical characteristics in patients with OSA. Almost all study participants were from referral populations. Varying apnea-hypopnea index threshold values were used to define OSA.

Four studies found a statistically significant association between male sex and OSA,^1–4 whereas one study found no association.5 Other studies have demonstrated that persons who snore have an increased risk of OSA,^2,6 and that there is a statistically significant correlation between breathing pauses and OSA (odds ratio [OR] = 2.09to 2.47).^2,4

Several studies examined the relationship between age and OSA, with conflicting results.^1,2,4,7–9 One study found a statistically significant association between older age (as measured in 10-year increments) and increased prevalence of OSA,2 and another showed a nine- to 11-fold increased prevalence of OSA in persons 20 to 65 yearsof age.8,9 However, other study results did not demonstrate a statistically significant relationship between age and OSA.^1,4,7

There is also a link between a larger waist-to-hip ratio and OSA (OR = 1.07 to 3.41).^1–3,5 Two studies determined that a BMI greater than 30 kg per m² was not an independent variable for OSA,1,⁴ whereas two other studies showed that an increasing BMI (in increments of 5.3 or 5.6 kg per m²) was associated with an increased risk of OSA.^2,3 A BMI greater than or equal to 31.1 kg per m² in men and 32.3 kg per m² in women was found to be predictive of OSA (OR = 7.8 and 12.8, respectively).8,⁹

Five studies examined the link between neck circumference and OSA, although each study used a different clinical indicator and results were conflicting.^1–5 An incremental increase in neck circumference or percentage of predicted neck circumference (based on height) was found to be significantly associated with OSA (OR = 1.23 to 5.0).^2,3,5 However, two studies found no statistically significant association between OSA and a predetermined neck circumference greater than 43 cm for men and greater than 47 cm for women.^1,4

Recommendations from Others

According to the Institute for Clinical Systems Improvement, the following clinical indicators may suggest a significant risk of OSA: awakening with choking, hypertension, intense snoring, large neck circumference, male sex, postmenopause, obesity, apnea or choking as reported by sleep partner, atrial fibrillation, and daytime sleepiness.¹⁰