Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
JAMA. 2013 Aug 21;310(7):731-41. doi: 10.1001/jama.2013.276185.
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.
To systematically review the clinical examination accuracy in diagnosing obstructive sleep apnea.
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.
For inclusion, studies must have used full, attended nocturnal polysomnography for the reference standard (n = 42).
Community and referral-based prevalence of obstructive sleep apnea; accuracy of symptoms and signs for the diagnosis of obstructive sleep apnea.
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).
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.
阻塞性睡眠呼吸暂停是一种常见疾病，可导致白天嗜睡。在将患者转介进行明确诊断测试之前，应在临床检查中确定阻塞性睡眠呼吸暂停的可能性。
系统评价临床检查在诊断阻塞性睡眠呼吸暂停中的准确性。
从 1966 年至 2013 年 6 月，在 MEDLINE 和文章的参考文献中搜索了数据。审查标题和摘要（n=4449）的资格，并评估证据水平。
纳入研究必须使用完整的、有夜间多导睡眠图（PSG）的睡眠评估作为参考标准（n=42）。
社区筛查患者的阻塞性睡眠呼吸暂停患病率；症状和体征对阻塞性睡眠呼吸暂停诊断的准确性。
社区筛查患者的睡眠呼吸暂停患病率为 2%至 14%（样本量 360-1741），睡眠评估转介患者的患病率为 21%至 90%（样本量 42-2677）。患病率因评估中使用的呼吸暂停低通气指数（apnea-hypopnea index，AHI）阈值（≥5 次/小时，患病率 14%；≥15 次/小时，患病率 6%）和疾病定义是否需要除异常 AHI 之外的症状（≥5 次/小时并伴有症状，患病率 2%-4%）而异。在接受睡眠评估的患者中，患有睡眠呼吸暂停的患者体重更重（综合体重指数，31.4；95%CI，30.5-32.2），而没有睡眠呼吸暂停的患者体重更轻（综合 BMI，28.3；95%CI，27.6-29.0；P<0.001）。当通过 AHI≥10/h 诊断为阻塞性睡眠呼吸暂停时，最有助于识别患有阻塞性睡眠呼吸暂停的患者的观察结果是夜间窒息或喘息（综合似然比[LR]，3.3；95%CI，2.1-4.6）。打鼾在睡眠呼吸暂停患者中很常见，但对于确定诊断没有用处（综合 LR，1.1；95%CI，1.0-1.1）。轻度打鼾且 BMI 低于 26 的患者不太可能患有中度或重度阻塞性睡眠呼吸暂停（LR，0.07；95%CI，0.03-0.19，AHI 阈值≥15/h）。
夜间窒息或喘息是阻塞性睡眠呼吸暂停最可靠的指标，而打鼾特异性不高。对疑似阻塞性睡眠呼吸暂停的患者进行临床检查有助于选择进行更明确的检查。
