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The Rational Clinical Examination |

Does This Patient Have Obstructive Sleep Apnea?  The Rational Clinical Examination Systematic Review

Kathryn A. Myers, MD, EdM, FRCPC1; Marko Mrkobrada, MD, FRCPC1; David L. Simel, MD2
[+] Author Affiliations
1Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
2Durham Veterans Medical Center and Duke University, Durham, North Carolina
JAMA. 2013;310(7):731-741. doi:10.1001/jama.2013.276185.
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Published online

Importance  Obstructive sleep apnea is a common disease, responsible for daytime sleepiness. Prior to referring patients for definitive testing, the likelihood of obstructive sleep apnea should be established in the clinical examination.

Objective  To systematically review the clinical examination accuracy in diagnosing obstructive sleep apnea.

Data Sources  MEDLINE and reference lists from articles were searched from 1966 to June 2013. Titles and abstracts (n = 4449) were reviewed for eligibility and appraised for evidence levels.

Study Selection  For inclusion, studies must have used full, attended nocturnal polysomnography for the reference standard (n = 42).

Main Outcomes and Measures  Community and referral-based prevalence of obstructive sleep apnea; accuracy of symptoms and signs for the diagnosis of obstructive sleep apnea.

Results  The prevalence of sleep apnea in community-screened patients is 2% to 14% (sample sizes 360-1741) and 21% to 90% (sample sizes 42-2677) for patients referred for sleep evaluation. The prevalence varies based on the apnea-hypopnea index (AHI) threshold used for the evaluation (≥5 events/h, prevalence 14%; ≥15/h, prevalence 6%) and whether the disease definition requires symptoms in addition to an abnormal AHI (≥5/h with symptoms, prevalence 2%-4%). Among patients referred for sleep evaluation, those with sleep apnea weighed more (summary body mass index, 31.4; 95% CI, 30.5-32.2) than those without sleep apnea (summary BMI, 28.3; 95% CI, 27.6-29.0; P < .001 for the comparison). The most useful observation for identifying patients with obstructive sleep apnea was nocturnal choking or gasping (summary likelihood ratio [LR], 3.3; 95% CI, 2.1-4.6) when the diagnosis was established by AHI ≥10/h). Snoring is common in sleep apnea patients but is not useful for establishing the diagnosis (summary LR, 1.1; 95% CI, 1.0-1.1). Patients with mild snoring and body mass index lower than 26 are unlikely to have moderate or severe obstructive sleep apnea (LR, 0.07; 95% CI, 0.03-0.19 at threshold of AHI ≥15/h).

Conclusions and Relevance  Nocturnal gasping or choking is the most reliable indicator of obstructive sleep apnea, whereas snoring is not very specific. The clinical examination of patients with suspected obstructive sleep apnea is useful for selecting patients for more definitive testing.

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Figure 1.
Craniofacial Anatomy and Surface Measurements
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Figure 2.
Oropharyngeal Anatomy
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Figure 3.
Mallampati Classification System

Mallampati classification is assessed with the tongue protruded and without phonation, or in a modified form with the tongue remaining on the floor of the mouth. Class 1 is characterized by visualization of the soft palate, uvula, palatine tonsils, and pillars. As Mallampati class increases, these structures become obscured until only the hard palate is visible (class 4).

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