Predictive Performance of the STOP-BANG Questionnaire for Difficult Airway Management in Iraqi Adults Undergoing Elective Surgery: A Single-Center Prospective Observational Cohort Study.

BACKGROUND: Failure to anticipate airway difficulty may increase the risk of major perioperative complications during anesthesia. The STOP-BANG questionnaire is a simple screening tool for obstructive sleep apnea (OSA) that may also help identify patients at risk of difficult airway management. Evidence from Iraqi surgical populations remains limited. OBJECTIVE: This study aimed to evaluate the predictive performance of the STOP-BANG questionnaire for difficult airway management in Iraqi adult patients undergoing elective surgery under general anesthesia. METHODS: This single-center prospective observational cohort study included 500 adults aged 18 to 70 years undergoing elective surgery under general anesthesia at Nasiriyah Teaching Hospital, Dhi Qar Governorate, Iraq. The STOP-BANG questionnaire was completed preoperatively. The primary composite outcome was any airway difficulty, defined as difficult mask ventilation and/or difficult intubation. Receiver operating characteristic analysis was used to assess discrimination. Risk ratios were calculated for the primary cohort comparison, and multivariable logistic regression was used to estimate adjusted odds ratios. RESULTS: Difficult intubation and difficult mask ventilation occurred in 213 (42.6%) and 80 (16.0%) patients, respectively. The primary composite outcome of any airway difficulty occurred in 218 (43.6%) patients. A STOP-BANG score of ≥5 identified 175 (35.0%) high-risk patients. The risk of any airway difficulty was 146/175 (83.4%) among patients with STOP-BANG ≥5 and 72/325 (22.2%) among patients with STOP-BANG <5, corresponding to an unadjusted risk ratio of 3.77 (95% CI, 3.04-4.66). For the primary composite outcome, STOP-BANG ≥5 demonstrated a sensitivity of 146/218 (66.97%), specificity of 253/282 (89.72%), positive predictive value of 146/175 (83.43%), and negative predictive value of 253/325 (77.85%), with an area under the receiver operating characteristic curve of 0.783. The continuous STOP-BANG score showed greater discriminative ability, with an area under the curve of 0.870. In multivariable analysis, STOP-BANG ≥5 remained independently associated with airway difficulty and difficult intubation. CONCLUSIONS: The STOP-BANG questionnaire showed clinically useful discrimination for difficult airway management among Iraqi adults undergoing elective surgery under general anesthesia. These findings support considering STOP-BANG as a practical adjunctive preoperative risk-stratification tool that complements, but does not replace, comprehensive airway assessment and clinical judgment. Further multicenter external validation is needed before broad implementation.