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A Decision Rule for Diagnostic Testing in Obstructive Sleep Apnea

Department of Medicine, Division of Respiratory Medicine; Department of Community Health Sciences; and Department of Anesthesia, University of Calgary, Calgary, AB, Canada

Correspondence and requests for reprints should be addressed to Dr. Willis H. Tsai, Rockyview General Hospital, 7007 14th St SW Calgary, AB, Canada T2V 1P9. E-mail: tsai{at}ucalgary.ca

Obstructive sleep apnea (OSA) is traditionally diagnosed using overnight polysomnography. Decision rules may provide an alternative to polysomnography. A consecutive series of patients referred to a tertiary sleep center underwent prospective evaluation with the upper airway physical examination protocol, followed by determination of the respiratory disturbance index using a portable monitor. Seventy-five patients were evaluated with the upper airway physical examination protocol. Historic predictors included age, snoring, witnessed apneas, and hypertension. Physical examination–based predictors included body mass index, neck circumference, mandibular protrusion, thyro–rami distance, sterno–mental distance, sterno–mental displacement, thyro–mental displacement, cricomental space, pharyngeal grade, Sampsoon-Young classification, and over-bite. A decision rule was developed using three predictors: a cricomental space of 1.5 cm or less, a pharyngeal grade of more than II, and the presence of overbite. In patients with all three predictors (17%), the decision rule had a positive predictive value of 95% (95% confidence interval [CI], 75–100%) and a negative predictive value of 49% (95% CI, 35–63%). A cricomental space of more than 1.5 cm (27% of patients) excluded OSA (negative predictive value of 100%, 95% CI, 75–100%). Comparable performance was obtained in a validation sample of 50 patients referred for diagnostic testing. This decision rule provides a simple, reliable, and accurate method of identifying a subset patients with, and perhaps more importantly, without OSA.

Key Words: obstructive sleep apnea • decision rule • diagnostic testing • physical examination

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