Today, I had good news and bad news for Anna, a 28 year old patient regarding her sleep study results. The good news was that she didn’t have obstructive sleep apnea. The bad news was that she stopped breathing 15 times every hour. More bad news: She woke from deep to light sleep 25 times every hour over the course of the entire 7 hours. Lastly, some good news: She has a treatable condition called upper airway resistance syndrome.
Most sleep physicians think of upper airway resistance syndrome (UARS) as a wastebasket diagnosis when you don’t officially have OSA, despite having many of the symptoms of OSA including severe fatigue, unrefreshing sleep, and brain impairment. Snoring is also sometimes lumped into UARS. But when questioned about what can be done, most will tell you the standard sleep hygiene list of bullet points: lose weight, don’t watch TV before bedtime, don’t eat late, and various other important things that everyone must do, even if you don’t have sleep apnea or UARS. Since most people with UARS are not overweight, it’s hard for some doctors to believe that you can have a sleep-breathing problem, especially if your official score on the sleep study is 0.
The problem is that you need at least 5 apneas or hypopneas per hour (AHI) to qualify for a sleep apnea diagnosis based on a sleep study. By definition, apneas are total breathing pauses for more than 10 seconds. Hypopnea are more than 30% obstructed breathing for more than 10 seconds. The total number of apneas and hypopnea per hour is how the AHI is calculated.
But if you stop breathing 25 times every hour, and each episode is anywhere from 1 to 9 seconds, then your AHI will be 0. This was the case for Anna, the woman I saw today. Not having a sleep apnea diagnosis means that you won’t be covered for sleep apnea treatment options by your insurance company—even if you stop breathing 25 times every hour.
Anna’s main complaints were blamed on anemia by her doctors. However, anemia alone can’t explain her daily headaches, anxiety, lightheadedness and dizziness, lower blood pressure, and intense fatigue, no matter how long she sleeps.
Interestingly, she told me that her symptoms got much worse 3 weeks ago when she began to sleep on her back, when she used to sleep on her tummy. When asked what prompted her to make the change, she commented that her dermatologist recommended staying off her tummy since it can cause facial wrinkles. Not too surprisingly, having her switch back to her tummy improved her symptoms back to baseline again.
Most people with UARS have very narrowed jaws and upper airways, rather than being overweight. Due to severe dental crowding, gravity, and muscle relaxation in deep levels of sleep, the tongue, soft palate, or even the epiglottis will fall back and cause you to wake up suddenly, long before the 10 second apnea threshold. In a nutshell, once you obstruct, sleep apnea patients take too long to wake up, whereas UARS patients wake up too quickly. Because the pauses are so short, you won’t have any significant levels of oxygen deprivation.
The problem with so many frequent obstructions and arousals is that your sleep is severely fragmented. You may get the normal amount of deep sleep, but if it’s fragmented, it’s like not getting any deep sleep at all. Not getting deep sleep will cause you to have problems with memory, executive function, and no energy to do anything at all.
One interesting consequence of UARS is how your heart responds to repeated obstructions. Every time you obstruct, tremendous vacuum forces are created in your chest cavity. This causes your heart muscle to becomes stretched, and your body thinks that there’s too much fluid. The heart then makes a hormone called atrial natriuretic peptide (ANP), which goes to your kidneys to make you produce more urine than usual. This is one of many factors that can cause people with sleep-related breathing disorders to go to the bathroom at night. Usually, you’ll wake up a the same time intervals, about 90 to 120 minutes apart, which happens to be one sleep cycle. Every time you go into deeper levels of sleep, due to muscle relaxation in your throat, you’ll have a more severe obstruction and arousal, and you’ll think you have to go to the bathroom. But oftentimes, it’s not a lot of urine.
Other interesting properties of ANP include low blood pressure, weight loss, digestive problems, low magnesium levels, anemia, and neuro-excitability. Essentially, your entire nervous system is overactive, especially to emotions, weather changes, smoke, chemical, and odors. It’s estimated that about 5 to 10% of people with UARS progress to OSA every year, especially if you gain weight. I often see overweight, snoring women in their 50 and 60s who have high blood pressure, with classic OSA, but when in their 20s, were stick thin and with low blood pressure. Even the cold hands and feet that they had when younger tends to go away after menopause.
Now that you’re more familiar with UARS, you may be asking what you can do about it. In general, you have to treat it just like for obstructive sleep apnea. The challenge is that since insurance won’t pay for treatment, you’ll have to pay for a CPAP machine or dental appliance. I’ve covered OSA treatment options in great detail in other articles, teleseminars and my book, starting with conservative options to standard devices and gadgets, dental appliances, and lastly, surgical options. However, for nasal congestion, it’s generally covered, since that’s a different diagnosis.
Most people with undiagnosed UARS can’t be helped by traditional medical options. Oftentimes, you may be diagnosed with anemia, hypothyroidism, anxiety, depression, headaches, irritable bowel syndrome, nutritional or vitamin deficiencies, allergies, for even food sensitivities. I have had every one of these conditions resolve partially or completely when UARS is addressed fully. Some do well with only lifestyle adjustments like not eating late and using Breathe Right Strips. Others do well with CPAP or a mandibular advancement device. Some need aggressive surgery to feel relief. Unfortunately, not too many people ever end up going up the ladder for UARS treatment, since it takes time, resources and having access to the right health care practitioners that are even aware that this exists.
By now, you’re probably more knowledgeable about UARS than most physicians in this country. Hopefully, you can use this information to search out the root cause of many of your symptoms, which is an extremely narrowed airway preventing you from getting deep sleep.
If you have some, or even all of the symptoms of UARS, which options have worked for you? How did your doctor respond to your concerns? Please enter your responses in the text area below.
I interviewed two of the foremost sleep physicians on UARS in my past teleseminars: Drs. Barry Krakow and Avram Gold. Click here to go to iTunes podcast page. Search for Episodes 27 and 31. After listening, please subscribe and rate my podcast. The more feedback you give me and topics that you want to hear about, the more programs I can develop to address your particular needs.