Almost routinely, I see patients who repeatedly stop breathing at night but don’t have any significant apneas on sleep studies. Jennifer was told by her husband that she choked multiple times at night with frequent arousals. But her apnea hypopnea index (AHI) on her in-lab sleep study was 1.0, well below the 5.0 threshold needed for an obstructive sleep apnea diagnosis. She underwent every possible test, including an MRI to rule out a brain tumor, but everything came back normal.
Eventually, drug induced sleep endoscopy (DISE) revealed severe tongue base and soft palate obstruction. Essentially, people with upper airway resistance syndrome (UARS) obstruct often but wake up to light sleep too quickly, less than the 10 seconds that are needed to be scored as an apnea or hypopnea.
Here are 5 reasons why UARS is harder to treat than obstructive sleep apnea:
1. If your AHI is less than 5, you’re told by sleep doctors that you don’t have sleep apnea. Your severe fatigue and various other conditions are often blamed on hormonal (pre-menstrual, menopause), neurologic (multiple sclerosis), infectious (Lyme, mononucleosis), rheumatologic (chronic fatigue, fibromyalgia), food/environmental allergies, mold sensitivities, or nutritional/vitamin deficiencies. As a result, treatment for a sleep-breathing problems is not even considered.
2. If you’ve already been diagnosed with one of the above conditions in #1, then it’s very unlikely that you or your doctor will consider an alternative explanation, especially if you’ve already invested so much time, energy and resources.
3. If your doctor wants to treat you for UARS with continuous positive airway pressure (CPAP) or a dental appliance (that pulls your tongue forward), insurance won’t usually cover it, since your AHI is less than 5.
4. Most people with upper airway resistance syndrome also have various degrees of nasal congestion. Having a small mouth with dental crowding also leads to narrow nasal passageways, making it more likely that you’ll have a deviated nasal septum, enlarged or over-reactive turbinates, or flimsy nostrils. Having a stuffy nose will prevent you from being able to use CPAP or dental appliances.
5. UARS is a structural problem caused by smaller-than-normal jaw structures, leading to narrowed air-passageways that lead to severe breathing problems at night. All the truly effective solutions involve using gadgets, devices or surgery. With few exceptions that can lead to temporary relief, you can’t treat it with a pill.
The most common manifestations of UARS are severe chronic fatigue and exhaustion (not sleepiness), anxiety/depression, headaches, nasal congestion, TMJ problems, cold hands/feet, low blood pressure, diarrhea/constipation/bloating, frequent nighttime urination, and hypothyroidism. The typical exam findings include a high arched hard palate, narrow dental arches, crooked teeth, bite problems, head forward posture, and a relatively large tongue (due to a small mouth).
If you fit some or all of the features described above, you may have upper airway resistance syndrome. For a more detailed description of UARS, you can read an article by clicking here. Please note that you can have UARS and various other conditions. But not being able to breathe and sleep properly can significantly aggravate any other condition that you already have. In addition, you can have obstructive sleep apnea and UARS overlap to various degrees.
Unfortunately, many mainstream sleep physicians will be resistant to acknowledging that UARS exists. If you do your research, you should be able to find a sleep physician that will be willing to treat your UARS even if you don’t have sleep apnea. Other specialists such as otolaryngologists and dentists may be more receptive to UARS, but even then, they are in the minority. A good place to start looking is to listen to some of my past expert interviews, particularly the episodes with Doctors Guilleminault, Krakow, Gold, Lawler, Palmer, Silkman, Belfor and Singh.