nach oben

Erschienen in:

05.06.2023 | original article

Revisiting the Epworth sleepiness scale

Is excessive daytime sleepiness still a valid screening tool for obstructive sleep apnea in a population at risk?

verfasst von: Hrvoje Puretić, MD, Assist. Prof. Marijana Bosnar Puretić, MD, PhD, Assoc. Prof. Gordana Pavliša, MD, PhD, Prof. Marko Jakopović, MD, PhD

Erschienen in: Wiener klinische Wochenschrift | Ausgabe 13-14/2024

Einloggen, um Zugang zu erhalten

Summary

Objective

Obstructive sleep apnea (OSA) is a common medical problem with numerous comorbidities and high costs. Since the introduction of the Epworth sleepiness scale (ESS), excessive daytime sleepiness (EDS) has been considered the most common and prominent symptom of OSA. Aim of this study was to re-evaluate the ESS for detection of OSA in a population at risk compared to the gold standard overnight polysomnography (PSG).

Methods

A total of 266 patients (mean age 57.9 ± 11.6 years; 189 men and 77 women), referred to our sleep laboratory for probable OSA, were given ESS followed by an overnight PSG. The ESS values were compared to PSG apnea hypopnea index (AHI) with sensitivity (SE), specificity (SP), positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy (DA) calculated for ESS. The positive cut-off value for ESS was ≥ 10 and for AHI ≥ 5.

Results

Only 92 (34.6%) subjects had a positive ESS. An OSA was diagnosed by PSG in 213 (80.1%) subjects: 46 having mild, 37 moderate and 130 severe apnea. Most subjects with positive ESS (88.0%) were found to have OSA but most subjects with a negative ESS (75.9%) were also positive for OSA (42% with AHI ≥ 30). The area under the receiver operating characteristic (ROC) curve for ESS was 0.60 (95% confidence interval, CI 0.54–0.66; p = 0.020) with SE 38.0%, SP 79.3%, PPV 88.0%, NPV 24.1% and DA 46.2%.

Conclusion

It was found that excessive daytime sleepiness, measured by ESS, is not a valuable screening tool for OSA, especially when the test is negative. Other screening tests that involve additional parameters, beside daytime sleepiness alone, should be considered.

Vorheriger Artikel Statements of Austrian hospices and palliative care units after the implementation of the law on assisted suicide

Nächster Artikel High-density lipoprotein (HDL) has an impact on myeloma outcome: Lower HDL associates with worse progression-free survival

American Academy of Sleep Medicine. International classification of sleep disorders. 2nd ed. Diagnostic and coding manual. Westchester, IL: American Academy of Sleep Medicine; 2005.

Schreier DR, Banks C, Mathis J. Driving simulators in the clinical assessment of fitness to drive in sleepy individuals: a systematic review. Sleep Med Rev. 2018;38:86–100. https://doi.org/10.1016/j.smrv.2017.04.004.CrossRefPubMed

Sangal RB, Thomas L, Mitler MM. Disorders of excessive sleepiness. Treatment improves ability to stay awake but does not reduce sleepiness. Chest. 1992;102(3):699–703. https://doi.org/10.1378/chest.102.3.699.CrossRefPubMed

Stepanski E, Zorick F, Roehrs T, Young D, Roth T. Daytime alertness in patients with chronic insomnia compared with asymptomatic control subjects. Sleep. 1988;11(1):54–60. https://doi.org/10.1093/sleep/11.1.54.CrossRefPubMed

Léger D, Stepnowsky C. The economic and societal burden of excessive daytime sleepiness in patients with obstructive sleep apnea. Sleep Med Rev. 2020;51:101275. https://doi.org/10.1016/j.smrv.2020.101275.CrossRefPubMed

Markowitz AJ, Rabow MW. Palliative management of fatigue at the close of life: “it feels like my body is just worn out”. JAMA. 2007;298(2):217. https://doi.org/10.1001/jama.298.2.217.CrossRefPubMed

Young TB. Epidemiology of daytime sleepiness: definitions, symptomatology, and prevalence. J Clin Psychiatry. 2004;65(16):12–6.PubMed

Chervin RD. Sleepiness, fatigue, tiredness, and lack of energy in obstructive sleep apnea. Chest. 2000;118(2):372–9. https://doi.org/10.1378/chest.118.2.372.CrossRefPubMed

Patel SR, White DP, Malhotra A, Stanchina ML, Ayas NT. Continuous positive airway pressure therapy for treating sleepiness in a diverse population with obstructive sleep apnea: results of a meta-analysis. Arch Intern Med. 2003;163(5):565–71. https://doi.org/10.1001/archinte.163.5.565.CrossRefPubMed

10.

Dempsey JA, Veasey SC, Morgan BJ, O’Donnell CP. Pathophysiology of sleep apnea. Physiol Rev. 2010;90(1):47–112. https://doi.org/10.1152/physrev.00043.2008. Erratum in: Physiol Rev.2010;90(2):797–8.CrossRefPubMedPubMedCentral

11.

Chervin RD. Use of clinical tools and tests in sleep medicine. In: Kryger MH, Roth T, Dement WC, editors. Principles and practice of sleep medicine. St Louis: Elsevier Saunders; 2011. p. 666.CrossRef

12.

Littner MR, Kushida C, Wise M, et al. Standards of practice committee of the American academy of sleep medicine. Practice parameters for clinical use of the multiple sleep latency test and the maintenance of wakefulness test. Sleep. 2005;28(1):113–21. https://doi.org/10.1093/sleep/28.1.113.CrossRefPubMed

13.

Kushida CA, Littner MR, Morgenthaler T, et al. Practice parameters for the indications for polysomnography and related procedures: an update for 2005. Sleep. 2005;28(4):499–521. https://doi.org/10.1093/sleep/28.4.499.CrossRefPubMed

14.

Iber C, Ancoli-Israel S, Chesson AL Jr., Quan SF. The AASM manual for the scoring of sleep and associated events: rules, terminology, and technical specification. Westchester, IL: American Academy of Sleep Medicine; 2007.

15.

Berry RB, Budhiraja R, Gottlieb DJ, American Academy of Sleep Medicine, et al. Rules for scoring respiratory events in sleep: update of the 2007 AASM manual for the scoring of sleep and associated events. Deliberations of the sleep apnea definitions task force of the American academy of sleep medicine. J Clin Sleep Med. 2012;8(5):597–619. https://doi.org/10.5664/jcsm.2172.CrossRefPubMedPubMedCentral

16.

Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991;14(6):540–5. https://doi.org/10.1093/sleep/14.6.540.CrossRefPubMed

17.

Johns MW. Daytime sleepiness, snoring, and obstructive sleep apnea. The Epworth sleepiness scale. Chest. 1993;103(1):30–6. https://doi.org/10.1378/chest.103.1.30.CrossRefPubMed

18.

Johns M. Rethinking the assessment of sleepiness. Sleep Med Rev. 1998;2(1):3–15. https://doi.org/10.1016/s1087-0792(98)90050-8.CrossRefPubMed

19.

Smolley LA, Ivey C, Farkas M, Faucette E, Murphy S. Epworth sleepiness scale is useful for monitoring daytime sleepiness. J Sleep Res. 1993;22:389.

20.

Manni R, Politini L, Ratti MT, Tartara A. Sleepiness in obstructive sleep apnea syndrome and simple snoring evaluated by the Epworth sleepiness scale. J Sleep Res. 1999;8(4):319–20. https://doi.org/10.1046/j.1365-2869.1999.00166.x.CrossRefPubMed

21.

Kendzerska TB, Smith PM, Brignardello-Petersen R, Leung RS, Tomlinson GA. Evaluation of the measurement properties of the Epworth sleepiness scale: a systematic review. Sleep Med Rev. 2014;18(4):321–31. https://doi.org/10.1016/j.smrv.2013.08.002.CrossRefPubMed

22.

Kapur VK, Baldwin CM, Resnick HE, Gottlieb DJ, Nieto FJ. Sleepiness in patients with moderate to severe sleep-disordered breathing. Sleep. 2005;28(4):472–7. https://doi.org/10.1093/sleep/28.4.472.CrossRefPubMed

23.

El-Sayed IH. Comparison of four sleep questionnaires for screening obstructive sleep apnea. Egypt J Chest Dis Tuberc. 2012;61(4):433–41.CrossRef

24.

Silva GE, Vana KD, Goodwin JL, Sherrill DL, Quan SF. Identification of patients with sleep disordered breathing: comparing the four-variable screening tool, STOP, STOP-bang, and Epworth sleepiness scales. J Clin Sleep Med. 2011;7(5):467–72. https://doi.org/10.5664/JCSM.1308.CrossRefPubMedPubMedCentral

25.

Pecotic R, Dodig IP, Valic M, Ivkovic N, Dogas Z. The evaluation of the Croatian version of the Epworth sleepiness scale and STOP questionnaire as screening tools for obstructive sleep apnea syndrome. Sleep Breath. 2012;16(3):793–802. https://doi.org/10.1007/s11325-011-0578-x.CrossRefPubMed

26.

Mazzotti DR, Keenan BT, Thorarinsdottir EH, Gislason T, Pack AI, Sleep Apnea Global Interdisciplinary Consortium. Is the Epworth sleepiness scale sufficient to identify the excessively sleepy subtype of OSA? Chest. 2022;161(2):557–61. https://doi.org/10.1016/j.chest.2021.10.027.CrossRefPubMed

27.

Basille D, Baud ME, Andrejak C, Basille-Fantinato A, Jounieaux V. Correlation between the Epworth sleepiness scale and the maintenance of wakefulness test in obstructive sleep apnea patients treated with positive airway pressure. Respir Med Res. 2020;78:100787. https://doi.org/10.1016/j.resmer.2020.100787.CrossRefPubMed

28.

Young T, Finn L, Peppard PE, et al. Sleep disordered breathing and mortality: eighteen-year follow-up of the Wisconsin sleep cohort. Sleep. 2008;31(8):1071–8.PubMedPubMedCentral

29.

Gami AS, Olson EJ, Shen WK, et al. Obstructive sleep apnea and the risk of sudden cardiac death: a longitudinal study of 10,701 adults. J Am Coll Cardiol. 2013;62(7):610–6. https://doi.org/10.1016/j.jacc.2013.04.080.CrossRefPubMed

30.

Marshall NS, Wong KK, Liu PY, Cullen SR, Knuiman MW, Grunstein RR. Sleep apnea as an independent risk factor for all-cause mortality: the Busselton health study. Sleep. 2008;31(8):1079–85.PubMedPubMedCentral

31.

Marin JM, Agusti A, Villar I, et al. Association between treated and untreated obstructive sleep apnea and risk of hypertension. JAMA. 2012;307(20):2169–76. https://doi.org/10.1001/jama.2012.3418.CrossRefPubMedPubMedCentral

32.

Shahar E, Whitney CW, Redline S, et al. Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the sleep heart health study. Am J Respir Crit Care Med. 2001; https://doi.org/10.1164/ajrccm.163.1.2001008.CrossRefPubMed

33.

Barbé PJ, Muñoz A, Findley L, Antó JM, Agustí AG. Automobile accidents in patients with sleep apnea syndrome. An epidemiological and mechanistic study. Am J Respir Crit Care Med. 1998;158(1):18–22. https://doi.org/10.1164/ajrccm.158.1.9709135.CrossRefPubMed

34.

Finkel KJ, Searleman AC, Tymkew H, et al. Prevalence of undiagnosed obstructive sleep apnea among adult surgical patients in an academic medical center. Sleep Med. 2009;10(7):753–8. https://doi.org/10.1016/j.sleep.2008.08.007.CrossRefPubMed

35.

Kapur V, Strohl KP, Redline S, Iber C, O’Connor G, Nieto J. Underdiagnosis of sleep apnea syndrome in U.S. communities. Sleep Breath. 2002;6(2):49–54. https://doi.org/10.1007/s11325-002-0049-5.CrossRefPubMed

36.

Peppard PE, Young T, Barnet JH, Palta M, Hagen EW, Hla KM. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol. 2013;177(9):1006–14. https://doi.org/10.1093/aje/kws342.CrossRefPubMedPubMedCentral

37.

Kribbs N, Getsy J, Dinges D. Investigation and management of daytime sleepiness in sleep apnea. In: Saunders N, Sullivan C, editors. Sleeping and Breathing. New York: Marcel Dekker; 1993. p. 575.

38.

Netzer NC, Stoohs RA, Netzer CM, Clark K, Strohl KP. Using the Berlin questionnaire to identify patients at risk for the sleep apnea syndrome. Ann Intern Med. 1999;131(7):485–91. https://doi.org/10.7326/0003-4819-131-7-199910050-00002.CrossRefPubMed

39.

Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008;108(5):812–21. https://doi.org/10.1097/ALN.0b013e31816d83e4.CrossRefPubMed

40.

Chung F, Subramanyam R, Liao P, Sasaki E, Shapiro C, Sun Y. High STOP-Bang score indicates a high probability of obstructive sleep apnoea. Br J Anaesth. 2012;108(5):768–75. https://doi.org/10.1093/bja/aes022.CrossRefPubMedPubMedCentral

41.

Johns M, Hocking B. Daytime sleepiness and sleep habits of Australian workers. Sleep. 1997;20(10):844–9. https://doi.org/10.1093/sleep/20.10.844.CrossRefPubMed

42.

Hara C, Lopes Rocha F, Lima-Costa MF. Prevalence of excessive daytime sleepiness and associated factors in a Brazilian community: the Bambuí study. Sleep Med. 2004;5(1):31–6. https://doi.org/10.1016/j.sleep.2003.09.009.CrossRefPubMed

43.

Johns MW. Sleep propensity varies with behaviour and the situation in which it is measured: the concept of somnificity. J Sleep Res. 2002;11(1):61–7. https://doi.org/10.1046/j.1365-2869.2002.00274.x.CrossRefPubMed

44.

Johns MW. Sleepiness in different situations measured by the Epworth sleepiness scale. Sleep. 1994;17(8):703–10. https://doi.org/10.1093/sleep/17.8.703.CrossRefPubMed

45.

Baldwin CM, Kapur VK, Holberg CJ, Rosen C, Nieto FJ, Sleep Heart Health Study Group. Associations between gender and measures of daytime somnolence in the sleep heart health study. Sleep. 2004;27(2):305–11. https://doi.org/10.1093/sleep/27.2.305.CrossRefPubMed

46.

Theorell-Haglöw J, Åkerstedt T, Schwarz J, Lindberg E. Predictors for development of excessive daytime sleepiness in women: a population-based 10-year follow-up. Sleep. 2015;38(12):1995–2003. https://doi.org/10.5665/sleep.5258.CrossRefPubMedPubMedCentral

47.

Lok R, Zeitzer JM. Physiological correlates of the Epworth sleepiness scale reveal different dimensions of daytime sleepiness. Sleep Adv. 2021;2(1):zpab8. https://doi.org/10.1093/sleepadvances/zpab008.CrossRefPubMedPubMedCentral

48.

Mazzotti DR, Keenan BT, Lim DC, Gottlieb DJ, Kim J, Pack AI. Symptom subtypes of obstructive sleep apnea predict incidence of cardiovascular outcomes. Am J Respir Crit Care Med. 2019;200(4):493–506. https://doi.org/10.1164/rccm.201808-1509OC.CrossRefPubMedPubMedCentral

49.

Société de Pneumologie de Langue Française, Société Française d’Anesthésie Réanimation, Société Française de Cardiologie, Société Française de Médecine du Travail, Société Française d’ORL, Société de Physiologie, Société Française de Recherche et de Médecine du Sommeil. Recommandations pour la pratique clinique syndrome d’apnées hypopnées obstructives du sommeil de l’adulte. Rev Mal Respir. 2010;27(7):806–33. https://doi.org/10.1016/j.rmr.2010.05.011.CrossRef

50.

Abrishami A, Khajehdehi A, Chung F. A systematic review of screening questionnaires for obstructive sleep apnea. Can J Anaesth. 2010;57(5):423–38. https://doi.org/10.1007/s12630-010-9280-x.CrossRefPubMed

Titel: Revisiting the Epworth sleepiness scale
Is excessive daytime sleepiness still a valid screening tool for obstructive sleep apnea in a population at risk?
verfasst von: Hrvoje Puretić, MD
Assist. Prof. Marijana Bosnar Puretić, MD, PhD
Assoc. Prof. Gordana Pavliša, MD, PhD
Prof. Marko Jakopović, MD, PhD
Publikationsdatum: 05.06.2023
Verlag: Springer Vienna
Erschienen in: Wiener klinische Wochenschrift / Ausgabe 13-14/2024
Print ISSN: 0043-5325
Elektronische ISSN: 1613-7671
DOI: https://doi.org/10.1007/s00508-023-02213-4

Springer Medizin Österreich

Summary

Objective

Methods

Results

Conclusion

Bitte loggen Sie sich ein, um Zugang zu diesem Inhalt zu erhalten

Weitere Artikel der Ausgabe 13-14/2024

Prospective use of molecular minimal residual disease for risk stratification in children and adolescents with acute lymphoblastic leukemia

High-density lipoprotein (HDL) has an impact on myeloma outcome: Lower HDL associates with worse progression-free survival

MUW researcher of the month

“A star is born”—A unique case of an intranasal foreign body

Eeny, meeny, miny, moe—Summer time and out are you? The working population in the EU would likely benefit from elimination of daylight saving time

Boots in summer vs sandals in winter? The dilemma that makes cancelling daylight saving time tricky