title: Reconsidering first-line treatment for obstructive sleep apnea: a systematic review of the literature.
abstract: BACKGROUND
  Continuous positive airway pressure (CPAP) is typically recommended as first line therapy for obstructive sleep apnea, but the adherence rate of CPAP is problematic. This study's objective was to systematically review the literature relating to CPAP as first line therapy for OSA and compare it to surgical literature on the same topic.
  
  
  METHODS
  A systematic review was conducted according to PRISMA guidelines, examining Medline-Ovid, Embase, and Pubmed databases. The primary search objective was to identify all papers reporting the results of (1) randomized clinical trials (RCT) of CPAP for the treatment of adults with OSA; and (2) both randomized and non-randomized clinical trials and case series on the surgical treatment of OSA in adults. A PhD-level biostatistician first screened papers, and then those that met study criteria were retrieved and analyzed using standardized forms for each author. The primary outcomes were adherence rates of CPAP.
  
  
  RESULTS
  A total of 82 controlled clinical trials for CPAP and 69 controlled and non-controlled surgery trials were identified for analysis. Variation in CPAP use within reported RCT trials were identified, and the majority of patients in the studies would eventually be considered non-adherent to CPAP.
  
  
  CONCLUSIONS
  When considering the numerous patient-related factors that come into play when CPAP is prescribed, the concept of CPAP as gold-standard therapy for OSA should be reconsidered. In many cases surgery can provide a better overall outcome. This study's results suggest that certain patients with OSA may be managed more effectively with surgery than CPAP, without confounding issues of treatment adherence.
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Western University, London, Ontario, Canada. brian.rotenberg@sjhc.london.on.ca.|St. Joseph's Hospital, Room B2-501, 268 Grosvenor Street, London, ON, N6A 4V2, Canada. brian.rotenberg@sjhc.london.on.ca.
authors.forename: Brian W
authors.initials: BW
authors.lastname: Rotenberg
authors.affiliation: Head & Neck Department, ASL of Romagna, ENT and Oral Surgery Unit, Morgagni-Pierantoni Hospital (Forlì), Ospedale degli Infermi (Faenza), Forlì, Italy.
authors.forename: Claudio
authors.initials: C
authors.lastname: Vicini
authors.affiliation: Asia Sleep Centre, Paragon, Singapore.
authors.forename: Edward B
authors.initials: EB
authors.lastname: Pang
authors.affiliation: Asia Sleep Centre, Paragon, Singapore.
authors.forename: Kenny P
authors.initials: KP
authors.lastname: Pang
mesh_terms: D045422:Continuous Positive Airway Pressure / Q000379:methods*; D006801:Humans; D010349:Patient Compliance; D020181:Sleep Apnea, Obstructive / Q000628:therapy*
keywords: CPAP; Obstructive sleep apnea; Uvulopalatoplasty