The B‐ APNEIC score as a reliable tool to guide clinical practice

Thiruvenkatarajan et al. are to be commended for their prospective validation of the B-APNEIC score for predicting severe obstructive sleep apnoea in an Australian population 1, showing its superior sensitivity and diagnostic accuracy compared with the STOP-BANG questionnaire. This rigorous work provides important evidence for developing more objective and simplified pre-operative screening tools. We would like to offer two reflections to inform further refinement and clinical translation of this score. The B-APNEIC score was developed exclusively in a population in the USA and has now been validated effectively in an Australian cohort. While the authors mention the need for validation in populations with different demographic characteristics, the racial/ethnic composition of the study participants was not reported. Given that obesity and craniofacial structure are established independent risk factors for obstructive sleep apnoea 2 and that the distribution of core B-APNEIC metrics may vary across ethnicities, future validation studies should document ethnicity. We therefore recommend future multicentre validation in geographically and socio-economically diverse populations to determine whether the score possesses genuine global applicability or requires population-specific adjustments. The authors focused on pre-operative screening for severe obstructive sleep apnoea, justified by its established association with postoperative cardiopulmonary complications. We believe this focus has potential limitations. While Chan et al. showed a higher incidence of postoperative cardiovascular events in patients living with severe obstructive sleep apnoea (30%) compared with moderate (22%) or mild (19%) 3, this should not be interpreted as implying mild-to-moderate obstructive sleep apnoea lacks clinical significance. Peri-operative respiratory risk is dynamic and highly influenced by factors such as anaesthetic drugs (particularly opioids), the mode of anaesthesia and the invasiveness of surgery 4, 5. Therefore, a patient with a pre-operative score indicating mild-to-moderate obstructive sleep apnoea may transition to a high-risk state due to surgical stress and postoperative analgesia. We suggest that some patients classified with the B-APNEIC score as having a ‘non-severe’ peri-operative risk might have had their risk underestimated. The score might therefore not be equally suitable for guiding postoperative monitoring in these groups. Future research should validate postoperative respiratory complication rates stratified by apnoea-hypopnoea index risk categories, aiming to optimise peri-operative management for all severities of obstructive sleep apnoea, rather than employing a severe vs. non-severe dichotomy. The B-APNEIC score shows promising potential as a more objective screening tool, and the study by Thiruvenkatarajan et al. is a crucial step in its clinical translation. We believe addressing the questions of ethnic generalisability and refined risk stratification will facilitate the future precise and widespread application of this score across diverse clinical settings.