Advertisement

Clinical Outcomes in OSA—SLEEP GOAL—a More Holistic Approach

  • Kenny P. PangEmail author
  • Scott B. Pang
  • Brian Rotenberg
Sleep Apnea (B Rotenberg, Section Editor)
  • 12 Downloads
Part of the following topical collections:
  1. Sleep Apnea
  2. Sleep Apnea

Abstract

Purpose of Review

Obstructive sleep apnea (OSA) is a systemic disease that is due to a narrow upper airway that collapses and obstructs during sleep, which results in frequent nocturnal hypoxemia, sympathetic overdrive, tachycardia, nocturnal hypertension, and oxidative metabolic stress. Symptoms include unrefreshed sleep, daytime tiredness, loss of memory, irritability, lack of concentration, poor work productivity, poor quality of life (QOL), mood swings, and even depression. This upper airway disorder can lead to systemic diseases such as hypertension, cardiovascular events, myocardial infarct, and fatal arrhythmias.

Recent Findings

The standard diagnostic test for OSA is commonly assumed to be the overnight polysomnography (PSG); however, it is widely known that there is discordance between the levels of AHI (apnea–hypopnea index) used to denote outcomes/success of therapy and real-world clinical outcomes such as QOL, patient perception of disease, cardiovascular measures, and/or survival.

Summary

Hence, the use of a single parameter AHI is inadequate and unrealistic; sleep specialists need more holistic and less biased parameters to assess treatment outcomes. Some of these parameters include snoring level, sleep satency, execution time, Epworth Sleepiness Scale, blood pressure, gross weight (BMI), oxygen duration below 90%, AHI, and QOL scores.

Keywords

OSA Sleep apnea Surgical outcomes AHI SLEEP GOAL 

Notes

Compliance With Ethical Standards

Conflict of Interest

The authors declare that they have no conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Moyer CA, Sonnad SS, Garetz SL, Helman JI, Chervin RD. Quality of life in obstructive sleep apnea: a systematic review of the literature. Sleep Med. 2001;2(6):477–91.CrossRefGoogle Scholar
  2. 2.
    Epstein LJ, Kristo D, Strollo PJ Jr, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009;5(3):263–76.Google Scholar
  3. 3.
    Wright J, Johns R, Watt I, Melville A, Sheldon T. Health effects of obstructive sleep apnoea and the effectiveness of continuous positive airways pressure: a systematic review of the research evidence. BMJ. 1997;314(7084):851–60.CrossRefGoogle Scholar
  4. 4.
    Thong JF, Pang KP. Clinical parameters in obstructive sleep apnea: are there any correlations? J Otolaryngol Head Neck Surg. 2008;37(6):894–900.Google Scholar
  5. 5.
    Piccirillo JF. Outcomes research and obstructive sleep apnea. Laryngoscope. 2009;110(S94):16–20.CrossRefGoogle Scholar
  6. 6.
    Tam S, Woodson BT, Rotenberg BW. Outcome measurements in obstructive sleep apnea: beyond the apnea-hypopnea index. Laryngoscope. 2013;124:337–43.  https://doi.org/10.1002/lary.24275.CrossRefGoogle Scholar
  7. 7.
    Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrance of SDB among middle-aged adults. N Engl J Med. 1993;328:1230–5.CrossRefGoogle Scholar
  8. 8.
    Young T, Evans L, Finn L, Palta M. Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle aged men and women. Sleep. 1997;20:705–6.CrossRefGoogle Scholar
  9. 9.
    Nieto JF, Young TB, Lind BK, Shahar E. Association of SDB, sleep apnea & hypertension in a large community based study. JAMA. 2000;283:1829–36.CrossRefGoogle Scholar
  10. 10.
    Peppard PE, Young T, Palta M, Skatrund J. Prospective study of the association between SDB & hypertension. N Engl J Med. 2000;342:1378–84.CrossRefGoogle Scholar
  11. 11.
    Somers VK, Dyken ME, Clary MP, Abbond FM. Sympathetic neural in OSA. J Clin Invest. 1995;96:1897–904.CrossRefGoogle Scholar
  12. 12.
    Shakar E, Whitney CW, Redline S, et al. SDB & Cardiovascular disease. Am J Respir Critical Care Med. 2001;163:19–25.CrossRefGoogle Scholar
  13. 13.
    Robinsky G, Miller M, Anlt K, et al. Spontaneous platelet activation & aggregation during OSA & its therapy with nasal CPAP. Chest. 1995;108:625–30.CrossRefGoogle Scholar
  14. 14.
    Ranqemark C, Hedner JA, Carlson JT, et al. Platelet function and fibrolytic activity in hypertensive & normotensive sleep apnea patients. Sleep. 1995;18:188–94.CrossRefGoogle Scholar
  15. 15.
    Dean RT, Wilcox I. Possible atherogenic effects of hypoxia during OSA. Sleep. 1996;16:S15–22.CrossRefGoogle Scholar
  16. 16.
    Schulz R, Mahmoudi S, Hattar K, et al. Enhanced release of superoxide from polymophonuclear neutrophils in OSA. Am J Respir Crit Care Med. 2000;162:566–70.CrossRefGoogle Scholar
  17. 17.
    Mooe T, Franklin KA, Holmstrom K, et al. Sleep disordered breathing & coronary artery disease: long term prognosis. Am J Resp Crit Care Med. 2001;164:1910–3.CrossRefGoogle Scholar
  18. 18.
    Peker Y, Hedner J, Kraiczi H, et al. Respiratory disturbance index: an independent predictor of mortality in coronary artery disease. Am J Resp Crit Care Med. 2000;162:81–6.CrossRefGoogle Scholar
  19. 19.
    Bradley TD. Right & left ventricular functional impairment and sleep apnea. Clin Chest Med. 1992;13:459–79.Google Scholar
  20. 20.
    Partinen M, Palomaki H. Snoring & cerebral infarction. Lancet. 1985;2:1325–6.CrossRefGoogle Scholar
  21. 21.
    Kos Kenvuo M, Partinen M. Sarnas et al. snoring as a risk factor for hypertension and angina pectoralis. Lancet. 1985;1:893–5.CrossRefGoogle Scholar
  22. 22.
    Hoffstein V. Snoring. Snoring Chest. 1996;109:201–22.CrossRefGoogle Scholar
  23. 23.
    Dement WC, Siedel W, Carskadon MA. Daytime alertness, insomnia & benzodiazepines. Sleep. 1982;5:S28–45.CrossRefGoogle Scholar
  24. 24.
    Cohen-Zion M, Stepnowsky C, Marler, Shochat T, Kripke DF, Ancoli-Isreal S. Changes in cognitive function associated with SDB in older people. J Am Geriatric Society. 2001;49:1622–7.CrossRefGoogle Scholar
  25. 25.
    Findley LJ, Barth JT, Powers DC, Wilhoit SC, Boyd DG, Suratt PM. Cognitive impairment in patients with OSA & associated hypoxemia. Chest. 1986;90:686–90.CrossRefGoogle Scholar
  26. 26.
    Redline S, Strauss ME, Adims N, et al. Neurophysiological function in mild SDB. Sleep. 1997;20:160–7.CrossRefGoogle Scholar
  27. 27.
    Bonnett MH. Performances & sleepiness as a function of the frequency & placement of sleep disruption. Psychophysiology. 1986;23:263–71.CrossRefGoogle Scholar
  28. 28.
    Colt HG, Haas H. Rich GB. Hypoxemia vs sleep fragmentation as a cause of excessive daytime sleepiness in OSA. Chest 1991;100:1542–1548.Google Scholar
  29. 29.
    Chediak AD, Acevedo-Crespo JC, Seiden DJ, Kim HH, Kiel MH. Nightly variability in the indices of sleep-disordered breathing in men being evaluated for impotence with consecutive night polysomnograms. Sleep. 1996;19:589–92.CrossRefGoogle Scholar
  30. 30.
    Le Bon O, Hoffmann G, Tecco J, Staner L, Noseda A, Pelc I, et al. Mild to moderate sleep respiratory events: one negative night may not be enough. Chest. 2000;118:353–9.CrossRefGoogle Scholar
  31. 31.
    Dean RJ, Chaudhary BA. Negative polysomnogram in patients with obstructive sleep apnea syndrome. Chest. 1992;101:105–8.CrossRefGoogle Scholar
  32. 32.
    Carlile J, Carlile N. Repeat study of 149 patients suspected of having sleep apnea but with an AHI < 5 [abstract] Sleep. 2008;31.Google Scholar
  33. 33.
    Levendowski D, Zack N. Rao SM. Sleep Breath: Assessment of the test-retest reliability of laboratory polysomnography; 2008.Google Scholar
  34. 34.
    Stepnowsky CJ Jr1, Orr WC, Davidson TM. Nightly variability of sleep-disordered breathing measured over 3 nights. Otolaryngol Head Neck Surg 2004;131(6):837–843.Google Scholar
  35. 35.
    Levendowski D, Steward D, Woodson BT, Olmstead R, Popovic D, Westbrook P. The impact of obstructive sleep apnea variability measured in-lab versus in-home on sample size calculations. Int Arch Med. 2009 Jan 2;2(1):2.CrossRefGoogle Scholar
  36. 36.
    Westbrook P, Levendowski D, Cvetinovic M, Zavora T, Velimirovic V, Henninger D, et al. Description and validation of the apnea risk evaluation system: a novel method to diagnose sleep apnea-hypopnea in the home. Chest. 2005;128:2166–75.CrossRefGoogle Scholar
  37. 37.
    Ayappa I, Norman RG, Seelall V, Rapoport DM. Validation of a self-applied unattended monitor for sleep disordered breathing. J Clin Sleep Med. 2008;4:26–37.Google Scholar
  38. 38.
    Zafar S, Ayappa I, Norman R. Choice of oximeter affects apnea-hyponea index sleep staging reliability. Sleep. 2004;27:1171–9.CrossRefGoogle Scholar
  39. 39.
    Dauglas NJ. Sleep Apnoea. In: Fausi AS, Kasper DL, Longo LD, Braunwald E, Hauser SL, Jameson JL, et al., editors. Harrisons principles of internal medicine. New York: Mc Graw –Hill; 2008. pp. 1665–7.Google Scholar
  40. 40.
    Marrone O, Bonsignore MR. Pulmonary haemodynamics in obstructive sleep apnoea. Sleep Med Rev. 2002;6(3):175–93.CrossRefGoogle Scholar
  41. 41.
    Guilleminault C, Connolly S, Winkle R. Cyclical variation of the heart rate in sleep apnoea syndrome. Mechanisms, and usefulness of 24 h electrocardiography as a screening technique. Lancet. 1984;1(8369):126–31.CrossRefGoogle Scholar
  42. 42.
    Rossi VA, Stradling JR, Kohler M. Effects of obstructive sleep apnoea on heart rhythm. Eur Respir J. 2013;41(6):1439–51.CrossRefGoogle Scholar
  43. 43.
    Gami AS, Olson EJ, Shen WK, Wright RS, Ballman KV, Hodge DO, 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.CrossRefGoogle Scholar
  44. 44.
    Wolf J, Hering D, Narkiewicz K. Non-dipping pattern of hypertension and obstructive sleep apnea syndrome. Hypertens Res. 2010;33(9):867–71.CrossRefGoogle Scholar
  45. 45.
    Logan AG, Perlikowski SM, Mente A, Tisler A, Tkacova R, Niroumand M, et al. High prevalence of unrecognized sleep apnoea in drug-resistant hypertension. J Hypertens. 2001;19(12):2271–7.CrossRefGoogle Scholar
  46. 46.
    Baguet J-P, Lévy P, Barone-Rochette G, Tamisier R, Pierre H, Peeters M, et al. Masked hypertension in obstructive sleep apnea syndrome. J Hypertens. 2008;26(5):885–92.CrossRefGoogle Scholar
  47. 47.
    Marin JM, Carrizo SJ, Vicente E, Agusti AGN. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet. 2005;365(9464):1046–53.CrossRefGoogle Scholar
  48. 48.
    Calhoun DA, Jones D, Textor S, Goff DC, Murphy TP, Toto RD, et al. Resistant hypertension: diagnosis, evaluation, and treatment: a scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Circulation. 2008;117:e510–26.CrossRefGoogle Scholar
  49. 49.
    Muiesan ML, Salvetti M, Rizzoni D, Paini A, Agabiti-Rosei C, Aggiusti C, et al. Resistant hypertension and target organ damage. Hypertens Res. 2013;36:485–91.CrossRefGoogle Scholar
  50. 50.
    Pedrosa RP, Drager LF, Gonzaga CC, Sousa MG, de Paula LK, Amaro AC, et al. Obstructive sleep apnea: the most common secondary cause of hypertension associated with resistant hypertension. Hypertension. 2011;58:811–7.CrossRefGoogle Scholar
  51. 51.
    Drager LF, Genta PR, Pedrosa RP, Nerbass FB, Gonzaga CC, Krieger EM, et al. Characteristics and predictors of obstructive sleep apnea in patients with systemic hypertension. Am J Cardiol. 2010;105:1135–9.CrossRefGoogle Scholar
  52. 52.
    Calhoun DA, Harding SM. Sleep and hypertension. Chest. 2010;138:434–43.CrossRefGoogle Scholar
  53. 53.
    Parati G, Lombardi C, Hedner J, Bonsignore MR, Grote L, Tkacova R, et al. Position paper on the management of patients with obstructive sleep apnea and hypertension: joint recommendations by the European Society of Hypertension, by the European Respiratory Society and by the members of European COST (COoperation in Scientific and Technological research) ACTION B26 on obstructive sleep apnea. J Hypertens. 2012;30:633–46.CrossRefGoogle Scholar
  54. 54.
    Somers VK, White DP, Amin R, et al. Sleep apnea and cardiovascular disease: an American Heart Association/American College Of Cardiology Foundation Scientific Statement from the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council On Cardiovascular Nursing. In collaboration with the National Heart, Lung, and Blood Institute National Center on Sleep Disorders Research (National Institutes of Health). Circulation. 2008;118:1080–111.CrossRefGoogle Scholar
  55. 55.
    Milleron O, Pillière R, Foucher A, et al. Benefits of obstructive sleep apnoea treatment in coronary artery disease: a long-term follow-up study. Eur Heart J. 2004;25:728–34.CrossRefGoogle Scholar
  56. 56.
    Marin JM, Carrizo SJ, Vicente E, et al. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet. 2005;365:1046–53.CrossRefGoogle Scholar
  57. 57.
    Weaver TE, Mancini C, Maislin G, Cater J, Staley B, Landis JR, et al. Continuous positive airway pressure treatment of sleepy patients with milder obstructive sleep apnea: results of the CPAP Apnea Trial North American Program (CATNAP) randomized clinical trial. Am J Respir Crit Care Med. 2012;186:677–83.CrossRefGoogle Scholar
  58. 58.
    Craig SE, Kohler M, Nicoll D, Bratton DJ, Nunn A, Davies R, et al. Continuous positive airway pressure improves sleepiness but not calculated vascular risk in patients with minimally symptomatic obstructive sleep apnoea: the MOSAIC randomised controlled trial. Thorax. 2012;67:1090–6.CrossRefGoogle Scholar
  59. 59.
    Bratton DJ, Stradling JR, Barbé F, Kohler M. Effect of CPAP on blood pressure in patients with minimally symptomatic obstructive sleep apnoea: a meta-analysis using individual patient data from four randomised controlled trials. Thorax. 2014;69:1128–35.CrossRefGoogle Scholar
  60. 60.
    Pedrosa RP, Drager LF, de Paula LK, et al. Effects of OSA treatment on BP in patients with resistant hypertension: a randomized trial. Chest. 2013;144:1487–94.CrossRefGoogle Scholar
  61. 61.
    Lozano L, Tovar JL, Sampol G, Romero O, Jurado MJ, Segarra A, et al. Continuous positive airway pressure treatment in sleep apnea patients with resistant hypertension: a randomized, controlled trial. J Hypertens. 2010;28:2161–8.CrossRefGoogle Scholar
  62. 62.
    Martínez-García MA, Capote F, Campos-Rodríguez F, Lloberes P, Díaz de Atauri MJ, Somoza M, et al. Effect of CPAP on blood pressure in patients with obstructive sleep apnea and resistant hypertension: the HIPARCO randomized clinical trial. JAMA. 2013;310:2407–15.CrossRefGoogle Scholar
  63. 63.
    Schein AS, Kerkhoff AC, Coronel CC, et al. Continuous positive airway pressure reduces blood pressure in patients with obstructive sleep apnea; a systematic review and meta-analysis with 1000 patients. J Hypertens. 2014;32:1762–73.CrossRefGoogle Scholar
  64. 64.
    Montesi SB, Edwards BA, Malhotra A, Bakker JP. The effect of continuous positive airway pressure treatment on blood pressure: a systematic review and meta-analysis of randomized controlled trials. J Clin Sleep Med. 2012;8:587–96.Google Scholar
  65. 65.
    Fava C, Dorigoni S, Dalle Vedove F, Danese E, Montagnana M, Guidi GC, et al. Effect of CPAP on blood pressure in patients with OSA/hypopnea a systematic review and meta-analysis. Chest. 2014;145:762–71.CrossRefGoogle Scholar
  66. 66.
    Pang KP, Woodson BT. The Pang-Woodson protocol. Chapter 4. Advanced surgical techniques in snoring and OSA. Chief editor: Pang KP, co-editors: Rotenberg BR, Woodson BT. 1st edition. Plural Publishing.Google Scholar
  67. 67.
    Thong JF, Pang KP. Clinical parameters in obstructive sleep apnea: are there any correlations? OHNS. 2008 Dec;37(6):894–900.Google Scholar
  68. 68.
    Pang KP, Terris DJ, Podolsky R. Severity of obstructive sleep apnea: correlation with clinical examination and patient perception. Otolaryngol Head Neck Surg. 2006;135(4):555–60.CrossRefGoogle Scholar
  69. 69.
    Friedman M, Ibrahim H, Bass L. Clinical staging for sleep-disordered breathing. Otolaryngol Head Neck Surg. 2002;127(1):13–21.CrossRefGoogle Scholar
  70. 70.
    Nashi N, Kang S, Barkdull GC, Lucas J, Davidson TM. Lingual fat at autopsy. Laryngoscope. 2007;117(8):1467–73.CrossRefGoogle Scholar
  71. 71.
    Ahn SH, Kim J, Min HJ, Chung HJ, Hong JM, Lee JG, et al. Tongue volume influences lowest oxygen saturation but not apnea-hypopnea index in obstructive sleep apnea. PLoS One. 2015;17, 10(8).Google Scholar
  72. 72.
    Kim AM, Keenan BT, Jackson N, Chan EL, Staley B, Poptani H, et al. Tongue fat and its relationship to obstructive sleep apnea. Sleep. 2014;37(10):1639–48.CrossRefGoogle Scholar
  73. 73.
    Shelton KE, Woodson H, Gay S, Suratt PM. Pharyngeal fat in obstructive sleep apnea. Am Rev Respir Dis. 1993;148:462–6.CrossRefGoogle Scholar
  74. 74.
    Johns MW. A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale. Sleep. 1991;14(6):540–5.CrossRefGoogle Scholar
  75. 75.
    Baldwin CM, Griffith KA, Nieto FJ, O'Connor GT, Walsleben JA, Redline S. The association of sleep-disordered breathing and sleep symptoms with quality of life in the Sleep Heart Health Study. Sleep. 2001;24:96–105.CrossRefGoogle Scholar
  76. 76.
    D'Ambrosio C, Bowman T, Mohsenin V. Quality of life in patients with obstructive sleep apnea: effect of nasal continuous positive airway pressure—a prospective study. Chest. 1999;115:123–9.CrossRefGoogle Scholar
  77. 77.
    Jenkinson C, Stradling J, Petersen S. Comparison of three measures of quality of life outcome in the evaluation of continuous positive airways pressure therapy for sleep apnoea. J Sleep Res. 1997;6:199–204.CrossRefGoogle Scholar
  78. 78.
    Buysse DJ, Reynolds CF 3rd, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28(2):193–213.CrossRefGoogle Scholar
  79. 79.
    Jing J, Huang T, Cui W, Shen H. Effect on quality of life of continuous positive airway pressure in patients with obstructive sleep apnea syndrome: a meta-analysis. Lung. 2008;186:131–44.CrossRefGoogle Scholar
  80. 80.
    • Weaver TE, Mancini C, Maislin G, et al. Continuous positive airway pressure treatment of sleepy patients with milder obstructive sleep apnea: results of the CPAP Apnea Trial North American Program (CATNAP) randomized clinical trial. Am J Respir Crit Care Med. 2012;186:677–83 This article illustrates the results of CPAP on sleepiness.CrossRefGoogle Scholar
  81. 81.
    Kuna ST, Gurubhagavatula I, Maislin G, Hin S, Hartwig KC, McCloskey S, et al. Noninferiority of functional outcome in ambulatory management of obstructive sleep apnea. Am J Respir Crit Care Med. 2011;183:1238–44.CrossRefGoogle Scholar
  82. 82.
    • Phillips CL, Cistulli PA, Grunstein RR. Health outcomes of continuous positive airway pressure versus oral appliance treatment for obstructive sleep apnea: a randomized controlled trial. Am J Respir Crit Care Med. 2013;187:8 Elegant study showing the comparisons . CrossRefGoogle Scholar
  83. 83.
    Woodson BT, Steward DL, Weaver EM, Javaheri S. A randomized trial of temperature-controlled radiofrequency, continuous positive airway pressure, and placebo for obstructive sleep apnea syndrome. Otolaryngol Head Neck Surg. 2003;128:848–61.CrossRefGoogle Scholar
  84. 84.
    Ware J, Kosinski M, Keller S. SF-36 physical and mental health summary scales: a user's manual. Health Assessment Lab. 1994.Google Scholar
  85. 85.
    Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992;30:473–83.CrossRefGoogle Scholar
  86. 86.
    Hunt SM, McKenna SP, McEwen J, Backett EM, Williams J, Papp E. A quantitative approach to perceived health status: a validation study. J Epidemiol Community Health. 1980;34:281–6.CrossRefGoogle Scholar
  87. 87.
    EuroQol Group. EuroQol—a new facility for the measurement of health-related quality of life. Health Policy. 1990;16:199–208.CrossRefGoogle Scholar
  88. 88.
    Rabin R, de Charro F. EQ-5D: a measure of health status from the EuroQol group. Ann Med. 2001;33:337–43.CrossRefGoogle Scholar
  89. 89.
    Weaver TE, Laizner AM, Evans LK, et al. An instrument to measure functional status outcomes for disorders of excessive sleepiness. Sleep. 1997;20:835–43.CrossRefGoogle Scholar
  90. 90.
    Flemons WW, Reimer MA. Measurement properties of the Calgary sleep apnea quality of life index. Am J Respir Crit Care Med. 2002;165:159–64.CrossRefGoogle Scholar
  91. 91.
    Sher AE, Schechtman KB, Piccirillo JF. The efficacy of surgical modifications of the upper airway in adults with obstructive sleep apnea syndrome. Sleep. 1996;19(2):156–77.CrossRefGoogle Scholar
  92. 92.
    • Hobson JC, Robinson S, Antic NA, et al. What is “success” following surgery for obstructive sleep apnea? The effect of different polysomnographic scoring systems. Laryngoscope. 2012;122(8):1878–81 This article illustrates the unreliability of the PSG as the sole success outcome . CrossRefGoogle Scholar
  93. 93.
    •• Pang KP, Rotenberg BW. Redefining successful therapy in obstructive sleep apnea: a call to arms. Laryngoscope. 2014;124(5):1051–2 Emphasizes the need for more and multiple success outcomes.CrossRefGoogle Scholar
  94. 94.
    Pang KP, Baptista PM, Olszewska E, et al. SLEEP GOAL—Multi-center Success Criteria Outcome Study on 302 OSA patients. ACTA ORL Submitted. 2018.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Kenny P. Pang
    • 1
    Email author
  • Scott B. Pang
    • 1
  • Brian Rotenberg
    • 2
  1. 1.OtolaryngologyAsia Sleep CentreSingaporeSingapore
  2. 2.Otolaryngology Head and Neck SurgeryWestern Universit0079LondonCanada

Personalised recommendations