SNORES Classification: Multicenter Prospective Validation for Obstructive Sleep Apnea

OBJECTIVES: To validate a clinically feasible, multidimensional classification system-SNORES (Severity of apnea-hypopnea index, Nasal airflow limitation, Oxygen desaturation burden, Respiratory effort, Awake Endoscopic anatomy, and Sleep position dependency)-for obstructive sleep apnea (OSA), and to evaluate its ability to predict therapy escalation, CPAP adherence, and surgical intervention beyond the apnea-hypopnea index (AHI) alone. METHODS: In this prospective multicenter cohort study, 1560 adults with newly diagnosed OSA confirmed by in-laboratory polysomnography were enrolled. Each SNORES domain was scored from 0 to 3 using predefined objective criteria derived from routine diagnostic testing. Primary outcomes were therapy escalation, CPAP adherence, and surgical intervention. Predictive performance was compared with AHI alone. RESULTS: Higher SNORES scores were independently associated with therapy escalation (hazard ratio [HR] 3.10, 95% CI 2.62-3.67; p < 0.001) and surgical intervention (HR 2.71, 95% CI 2.21-3.33; p < 0.001). The SNORES framework demonstrated superior discrimination for therapy escalation (area under the curve [AUC] 0.82, 95% CI 0.78-0.86) compared with AHI alone (AUC 0.52, 95% CI 0.46-0.57; ΔAUC +0.30, p < 0.001). Removal of individual domains-particularly oxygen desaturation or respiratory effort-meaningfully attenuated predictive performance (ΔAUC -0.09 to -0.11). CONCLUSION: SNORES is a feasible, reproducible, multidimensional framework that captures clinically relevant heterogeneity in OSA and guides individualized therapy more effectively than traditional AHI-only models.