Taking the Mystery Out of UARS: A Must Read

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.


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24 thoughts on “Taking the Mystery Out of UARS: A Must Read

  1. I think, based on my personal research, that UARS is a different problem than OSA.
    I have severe OSA (sleep study), which has been under control by CPAP with a full face mask for over 6 years. However when my nostrils are partially obstructed, the additional effort required for breathing facilitates UARS, even without OSA.
    When this happens, I stent my nostrils with a nasal dilator (developed by my company, sold under the trade name “eeezi-vent”), in addition to the CPAP.
    This has the effect of not only keeping the upper airway open, but keeping the upper airway resistance at a minimum. My research also ndicates that eeezi-vent tends to stay in place all night and reduces upper airway resistance significantly more than any other device on the market.
    Happy New Year
    Best Regards
    George Volgyesi, President,
    Voltek Enterprises Inc.

  2. It is unfortunate that people who suffer from UARS are underserved simply because:

    1. business-wise – there is no money in it. Manufacturers focus more on higher-margin products that are reimbursed by payors such as PAP devices and oral appliances.
    2. health system-wise – the algorithm of patients without “enough” AHI, they’re mostly set aside or as you have mentioned – given a different diagnosis.
    3. practice-wise – esophageal balloons are not obiquituous in sleep labs and they are probably performed mainly in research labs. It is not a common practice nor sleep techs have the comfort level in doing so. On the patient end, it is also quite uncomfortable. In short, we are lacking a better technology in addressing UARS.

    Most sleep labs are also ran by pulmonologists and some neurologists who also practice in hospitals and have busy clinics. This dilemma of course is a result of the ststus quo in our health system. What is missing is the time to truly allow physicians to get these UARS patients back in the sleep lab and to try various possible treatment options or even application of co-therapy such as a PSG with a pro-vent, short-range APAP titration, PSG with MRD, positional therapy, use of wedge, etc.

    In short, to truly try to help these underserved group of patients.


  3. Kkhem,

    I totally agree with you. What manufacturers don’t realize is that people with UARS are oftentimes willing to pay out of pocket for treatment options. But they are never given this option. Unfortunately, it’s difficult to predict which option will work. My algorhythm is to address conservative and lifestyle issues, first, then optimize nasal breathing. Then try oral appliances or CPAP. Some people even will consider surgery. If you have any significant dental occlusion issues, then jaw surgery is a very good option along with orthodontics.

    My feeling is that knowing what we know, esophageal monastery is not needed any more. A UARS diagnosis can be made based on the history, sleep study, and physical exam. With the advent of sleep endoscopy, we are now able to more specifically target areas of obstruction. I’m just finishing up editing the chapter on UARS for my upcoming book, The Sleep Apnea Solution: Dr. Park’s Complete Guide to Getting the Sleep You Need and the Life You Want.

  4. George,

    Addressing nostril collapse and anything else that can cause nasal congestion is the first step in properly treating OSA and UARS. I’ve had great success in treating nostril collapse using a number of different device options, but unfortunately, it works to various degrees in different people. Regardless, it’s important to be able to breathe well through your nose for CPAP or oral appliances to work effectively.

  5. I recently had a second sleep study and also brought along an x-ray of my extremely narrow airway and an ENT doctor’s report of the x-ray for the sleep physician to evaluate before the sleep study. For this second study, I had gone from moderate OSA on my first sleep to study to mild OSA on this second sleep study. The sleep doctor said it only took a pressure of five to keep my airway open and congratulated me for the “accomplishment” to mild OSA. I knew that pressure would never work for me, but smiled at her anyway as I left the office. I need almost three times the pressure (13.5), and that is with the bed elevated 8 inches. If I don’t manage my airway practically perfect with this pressure, I don’t feel well the next day. That sleep doctor had no idea what she was talking about and had no understanding of UARS, and I wasn’t about to waste my precious time explaining it to her. At a pressure of 5, on a flat bed, I would be dead in 2 days.

  6. I have always thought that Upper Airway Resistance Syndrome (UARS) tends to have a high ventilatory control system loop gain aspect. Part of it seems to be a reaction to the obstruction I suppose. The constant increase in esophageal pressure with each breath but with little affect on the actual amount of air moved seems to indicate an airway that is more and more obstructing as ventilatory drive is increased to compensate.

    But what would cause the airway to more and more obstructed?

    Perhaps there is a clue in this. I use stuffy nose symptoms as a key to make myself aware of over breathing. It is usually the fist thing that happens when I am over breathing. And consistently reducing my air use clears the nose. I have thus cleared my nose and made my airway much more happy by reducing air use hundreds and hundreds of times.

    Another clue is likely found in the fact that my “urge to breath” which seems to be driving this over breathing subsides after about thirty to sixty seconds of reduced breathing. I stop WANTING to breath forcefully and find myself very content to breath at ease gently. After reading about cerebreovascualar carbon dioxide reactivity (the tendency of the reduced carbon dioxide blood to constrict circulation in the brain in particular where more carbon dioxide tends to increase circulation therein) I have come to believe that my breathing control is severely affected during the “constricted” state and does not “reset” until circulation is restored. Things that I have done to increase circulation (e.g.: Niacin, moving from a Beta blocker to an Alpha blocker, active lifestyle, MHR interval training, EERS, foods that increase circulation) all do seem to help keep me from going into the high “urge to breath” state and keep my airway, not to mention the rest of my body (feet, legs, hands, tummy, the rest), much happier as I move through the night.

    So if you take someone who already has a limited airway and then add a bit of stuffiness brought about by the limited circulation and metabolism caused by hypocapnea what would result?

    I simply wonder if high ventilatory control system gain might well be part of what is going on with many who develop UARS.

  7. In my previous post I misspelled cerebrovascular and used the wrong tense of obstruct. I regret that.

    I wanted to add this because if I am right about ventilatory control system issues being part of UARS it would directly apply and is likely to be useful regardless.

    Simply I have stared to use chronotherapy. Blue blockers at night and bright light (w/blue – sunlight the best) in the morning. What amazed me is the affect of the blue blockers (mine are actually attached to the brim of a base ball cap with added “flip up” blockers when I use the computer which seems very bright). As soon as I put them on it is easier to control my breathing levels. In a brightly lit store at night in the middle of winter (and close to the time of year I was assaulted in the past) my breathing becomes hard to control. The blue blockers seem to immediately swamp this out.

    As well it is nice to much more feel the “sleep pressure” at bed time and there are very good indications of a positive effect in regards to much more stable breathing while using my CPAP at night. Much less ventilatory instability while using CPAP.

    So perhaps the lack of blue light helps set the body into “night time breathing mode” and makes sleep go better.

    Simply an observation which I hope will prove useful.

  8. Dr Park: I am very interested in your feedback and general provide experience with patients as it relates to Ms. smith’s 1/1/2015 8:43am post, especially where she describes needing a very high pressure setting (13) and bed raised 8″, vs her doctor recommending the CPAP setting of 5. I have all the symptoms of UARS, very mild OSA, but 5.1 on one study to justify a CPAP; my current pressure setting is 5 and I feel horrible the next day. (Note I have also tried and use an advanced mandibular device; even together, I can barely get out of bed and function daily). I feel somewhat better at this pressure if my AHIs are high; WHY is this?!? At a pressure of 4, I feel like I cannot move in the morning bec I am exhausted. I also too feel much better is sleeping upright, though I still m not at a “functional” level.
    I felt somewhat better when my pressure setting was higher (7-15), though 8 had lot of difficulty with burping, bloated painful stomach, hyperventilation at night; also, my doc (who is open mind and believes in UARS, as opposed to the two Sleep docs I saw previously who did not) is concerned that the higher pressures are causing me to develop central sleep apnea (based on my data output). My doc is recommending bi-pap and a sleep study titration, though she is concerned that my levels may look “too good” and my insurance company may not want to cover…

    Also, I realize every person is different in terms of physiology, anatomy, etc. However, is their a general rule of thumb for how to best treat a UARS patient in terms of settings etc? I have heard you state in various webinars that many of your patients do better with bi-pap, and also utilizing multiple approaches and devices.

    Thanks for your ongoing discussion of UARS!

  9. Hi, In follow up to my comment above, I first wish to apologize about the typos. I will try to proof more closely in the future!
    To clarify my questions:
    1) with UARS patients, why is I that one would feel more rested with a higher AHI? I have read this response from other UARS patients. I do have most symptoms of CFIDS and a fibromyalgia diagnosis (plus many other diagnoses). Based on one of your (Dr. Park’s) previous papers and posts, intracranial hypertension could be a co-condition worth considering, and is one I’m going to have a LP for a further assessment. Could that perhaps be a plausible reason to explain feeling more rested? My sleep physician is perplexed. Note that I also seem to be more rested when taking specific Triptan migraine medicine prior to sleep to stop a migraine; it is a strong vasodilator. I have noticed I often feel unbelievably better and refreshed in the morning when I take this at bedtime (using my CPAP of course).
    2) To clarify my other question, I specifically meant to ask what general CPAP or biPAP settings are “typically” recommended for UARS patients? Are hey different than the OSA patient? I realize each patient needs to be treated individually; however, I remember hearing in Dr. Gold’s guest webinar with you that he recommended a range (7-?.uncertain). Please note that I do not change my pressure settings, and only have them changed by my sleep physician, however, I have presented many things I have heard on your webinars to her and she has Ben very opening to trying different options to improve my health (which is poor).

    Thanks for this ongoing discussion!

  10. Mr. Merley,

    Thanks for your insightful comments. I’m still mulling over the issues that you mentioned regarding ventilatory control, CO2 levels and nasal breathing. This may explain how Buteyko breathing may help certain patients. Sooner or later, I will write something about the connections.

    Your comment about using blue light blockers is interesting. I’ve blogged in the past about using blue light software filters for laptops and computers to prevent insomnia. What you’re saying is that blue light stimulates your breathing. There must be a physiologic mechanism. I just don’t know of a study that shows the connection.

  11. Ms. Bensen,

    Thanks for sharing. Using CPAP can be challenging for people with UARS. There is no right setting for UARS. Some people do well, but most don’t, and even feel worse. Please listen to my interview with Dr. Barry Krakow on using an ASV machine for UARS.

  12. Thank you so much for this article!

    I just posted the link to a sleep technologist forum I occasionally visit as it has become clear to me that the people running sleep studies do not take this problem very seriously and equate it to snoring, which is inaccurate and does not help the patient to better understand why they are having trouble with daytime sleepiness and nighttime breathing. While sleep techs cannot diagnose, they can still call out sleep breathing issues which aren’t obviously related to OSA, and they can also spend the first part of their night with the patient educating them in a general way about the different kinds of SDB and share the many potential treatments besides CPAP.

    This is part of the larger problem in healthcare… and perhaps one reason why patients don’t trust doctors like they used to: nobody is telling them their options or explaining the necessity of certain diagnostic procedures.

    I am a sleep health professional and do understand how UARS can often be treated as a minor problem when in fact it can be very serious for some people.

    I am also (or WAS also) a UARS sufferer. My AHI was <3 was my RDI (measuring arousals due to respiratory distress) was high… as I recall, in the 50s.

    I treated mine using a mandibular advancement device (Scott's Upper Airway Device) almost 5 years ago. I paid out of pocket for my device at the time and it has been well worth it.

    In addition, the slight increase in my airway has allowed my sinuses to drain appropriately during allergy season. I have narrow airways (sinus, pharynx, even my ear canals are tiny). Add to this the insult of inflammation and congestion from allergies and it's no wonder I couldn't breathe at night.

    The ongoing problems I had with postnasal drip have basically vanished since then, and so have all the medications I used to need. Now I just spray Flonase as needed (or even saline spray) and I'm good to go. That is no small thing. Because of my diagnosis and treatment I was able to eliminate two different health problems simultaneously. No more snoring or daytime sleepiness + no more chronic laryngitis, bronchitis or sinusitis, which have been hallmarks of my health status for almost 50 years now.

    Taking my UARS seriously has added great quality to my daily life and I hope more patients' doctors take notice and are more proactive about treating it however they are best able to.

    Tamara Sellman RPSGT CCSH

  13. I finally got a CPAP machine to treat my UARS and in only the month I have been using it, it has changed my life! I really had to fight to get the sleep lab to prescribe the CPAP, though. The sleep report came back saying that I didn’t have OSA, but I kept insisting I had UARS and they finally relented and prescribed the CPAP.
    I was wondering Dr. Park, do you have any opinion on the pressure setting for treating UARS? I have the ResMed Airsense 10 Autoset and the CPAP machine’s nightly sleep report says it automatically increases to around a pressure of 8. I haven’t been able to find any literature concerning whether a higher or lower pressure is more effective for UARS.
    Thanks for all of your research into UARS!

  14. I just read your article. I have been diagnosed with Fibromalygia and Anxeity
    and DFS. I started this a year ago with muscle aches and twitching and continual
    weight gain have been put on Anxeity medications , see an acupuncturist .
    I finally saw an article on the Dental Appliance . I had every symptom of UARS
    in the article. My Kaiser coverage would not allow me to get the appliance without
    the sleep study. Upon seeing a Pulmonist she tested my Iron which turned out that
    I was severly anemic. Instead of normal 50 count I had 4. I have since had an Iron infusion and take supplements. Still not better this was over 2 months ago. This postponed the Sleep test as I thought maybe Iron defiency was the cause of all problems . (no such luck). I am having the sleep test next week and fear that I will be suffering for months even if diagonosed due to Kaiser and the lack of being able to get anything done quickly. I am willing to purchase the dental device if it would make me feel better. I am exhausted all of the time. Can you tell me how expensive out of pocket that would be? I appreciate you article and really would love for my Doctors to have been familiar with this.
    thank you for the validation.
    Donna Flatner

  15. Griffin,

    Glad to hear you’re doing better! Historically CPAP pressures for UARS have been very low, around 5 to 6. However, your automatic PAP machine will automatically calibrate your pressure, so there’s no need to worry about the pressure setting. Sometimes people prefer a constant setting versus variable pressures, so it’s all by manual trial and error. Good luck.

  16. Ms. Flatner,

    Thanks for sharing your story. formal mandibular advancement devices range from around $1000 to 4000 depending on the model and dentist’s fees.

    Good luck, and please keep us updated.

  17. Could Inspiratory Muscle Training (IMT)[1] be a potential treatment for Upper Airway Resistance Syndrome (UARS)?

    [1] Vranish JR, Bailey EF. Inspiratory muscle training improves sleep and mitigates cardiovascular dysfunction in obstructive sleep apnea. SLEEP 2016;39(6):1179–1185.

  18. This article is absolutely right on as it relates to UARS. I don’t test out positive for RLS but respond positively to Ropinirole. I’d love a five minute conversation with the author. Email me.

  19. My doctor, who spoke highly of you, Dr. Michael Abidin, wanted to try the balloon nasal surgery as s first step as I have nasal issues and scar tissue from a previous surgery. Unfortunately, my insurance company thought it was medically unnecessary. I had a cpap, but didn’t tolerate it well. I didn’t qualify for a study Dr. Abidin wawwas doing. So, I am still suffering! It is awful! I have headaches and am tired all the time. I’m nearly at my wits end. Calling Dr. Abidin tomorrow..,

  20. Dear Dr Park

    do you have any thoughts on UAR and atrial fibrillation? I was recently diagnosed with AF and had a sleep test which came out normal/very mild apnea. Would be interested if there are any studies on this.
    Thanks for your time.

  21. Mr. Collinge,

    I can’t say without examining you, but in general, UARS causes frequent obstructions and arousals, leading to a severe and chronic sympathetic state of physiologic stress. The heart rate will spike up significantly with each choking episode.

  22. Will you make one easy list of practices – Breathe Right Strips to palatal expansion – to help us out here who continue to experience EDS/executive functioning difficulties even after CPAP numbers are in the normal range. I’ll ask my doctor what he does but do sleep studies test for a whole range of possible causes or just sleep breathing? You have a tiny segment of people like me that constantly search that find you and understand what you are saying. In the end you will wake up other sleep specialists, primary care physicians and the pubic at large. Thank you for what you do.


  23. Dr. As requested I will comment.
    5 years ago I started having weird jaw positions in the morning.( jaw was forward and outside my normal occlusion. Started seeing a dentist who stated I was I tooth grinder but odd grinding pattern on just my front teeth. My teeth became sore and I began being more anxious during the day and more deppressed. Tried orthodontics but teeth and grinding continued. It was blamed on stress. In the past 5 years I now am fatigued during the day always . Still have sore teeth and unexplained teeth pain, , headaches, low motivation, high blood preasure, and sinus issues. I did a sleep study that stated I did not have sleep apnea. I do have a small jaw but not thin face, a deviated septum, a
    Conchobellosa in my right sinus cavity, can’t sleep in my back worth a darn, am a light sleeper, wake up often, sometimes have night sweats at night for no known reason, and as mentioned above grind my teeth. As
    Conservative doctors have found no issues, alternative medicine doctors diagnosed me with hypothyroidism and adrenal fatigue but treatment does Nothing for Me.
    I am a 45 year old male, 210lbs ( slightly overweight), and have a 17 inch neck size (not thin).
    I just read about UARS last week. No dr., including ENT, dentist, or orthodontist ever brought it up.
    My ENT said he has heard of
    It but didn’t really go much further with evaluating it. He has agreed
    I could Benoit from fixing my deviated septum though.
    I also notice my back muscles
    Around my lungs are always tight and I don’t breath easy in the day the past few months. From what you wrote
    In all your work regarding UARS I can only logician ly conclude this may be what I suffer from , unfortunately I have yet to find a Dr. To evaluate it with me.