ity in a neutral position. Initially, they called their observations the modified Mallampati grade9 but later adopted the term Friedman tongue position36 because it is, in fact, the position of the tongue in relation to the palate that is assessed. Friedman et al9 believed that this modification provides a natural and physiological tongue position similar to the one achieved during sleep.
The FTP score is assessed with the patient in a sitting position (the supine position increases the Mallampati score, as Tham et al37 observed) by opening the mouth in a natural, nonforced manner, with the tongue inside without swallowing or inspiring. We repeated the maneuver 5 times and took the most frequent result. A correct performance of the examination is time consuming but is necessary to avoid significant errors in determining the FTP score. In our cohort, those with FTP scores of 2 and 3 accounted for 74.1% of the whole population, but the severity of OSAS in the 2 groups was quite different. These results emphasize the importance of correct performance of the maneuver.
Our study has several limitations. First of all, the sleep studies are performed on an ambulatory basis and might underestimate the severity of sleep disorders. Nonetheless, these procedures are accepted in the literature, and our experience shows their reliability in clinical practice.38,39 The second point applies to the target population. Our study was performed in a white population; because some studies have reported higher prevalence and severity levels in Asian and African American populations,22,40 there is no guarantee that our results apply to these populations. Furthermore, because the sleep studies were not full polysomnographic studies, the AHI may have been underestimated. Finally, the oropharyngeal examination was performed by a specialist and may not be so accurate when implemented in primary care. The reproducibility of the examination has to be widely implemented.
Despite increasing awareness of the condition and improvements in diagnostic procedures, most patients with OSAS in the community remain undiagnosed and untreated. In the primary care sector there is considerable potential for improved diagnosis. In high-risk groups, such as patients with acute and chronic cardiovascular or cerebrovascular disease or those with diabetes mellitus, easy and inexpensive tests are necessary to help primary care physicians to detect patients at risk of OSAS. The complexity and cost of diagnosis is high, and many patients who are candidates for sleep studies may not receive adequate care owing to geographical or economic limitations. Moreover, the morbidity associated with the disease is dramatically reduced when patients are treated.22 All these characteristics reinforce the importance of our results. We advocate the use of a protocolized oropharyngeal examination at primary care level to diagnose and categorize the severity of the disease and thus to optimize the decision to send a patient to a sleep unit for further evaluation.
Correspondence: Christian Domingo, MD, PhD, Servei de Pneumologia, Corporació Parc Taulí, Parc Taulí s/n, 08208 Sabadell, Barcelona, Spain (email@example.com).
Submitted for Publication: May 20, 2011; final revision received July 19; accepted August 14, 2011.
Author Contributions: All authors had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Barceló and Domingo. Acquisition of data: Barceló and Bugés. Analysis and interpretation of data: Barceló, Mirapeix, Cobos, and Domingo. Drafting of the manuscript: Barceló. Critical revision of the manuscript for important intellectual content: Mirapeix, Bugés, Cobos, and Domingo. Statistical analysis: Mirapeix, Cobos, and Domingo. Administrative, technical, and material support: Barceló and Bugés. Study supervision: Mirapeix and Domingo.
Financial Disclosure: Dr Mirapeix has organized courses and received lecture fees from Schering-Plough and Merck Sharp & Dohme. Dr Domingo has 