UARS: The Hidden Sleep Condition

You’ve gained some weight over the years and you’re just not sleeping well. Your husband says you’ve begun snoring. You know that your father has obstructive sleep apnea and is doing well with CPAP. You mention this to your doctor and she orders a sleep study. The sleep study comes back completely normal. Now what?

The Real Reason for Your Chronic Fatigue

Before you begin searching for other reasons for your chronic fatigue, don’t rule out a sleep-breathing problem too quickly, even if you don’t have obstructive sleep apnea. In fact, a sleep-breathing problem can cause if not aggravate conditions such as hypothyroidism, chronic fatigue syndrome, depression, insomnia, and even irritable bowel syndrome.

Sleep doctors have defined obstructive sleep apnea as having at least 5 apneas or hypopneas every hour on average. An apnea means you stop breathing completely for 10 seconds or longer. Hypopneas are similar 10 second or longer pauses but with restricted airflow. But what what happens if you stop breathing 25 times every hour but each episode lasts only a few seconds?

In the early 1990s, Dr. Christian Guilleminault of Stanford University looked at young, thin men and women who were tired all the time, no matter how long they slept. These people were found not to have obstructive sleep apnea after undergoing formal sleep studies. However when they placed thin pressure catheters in their chest and throat, they found the they had frequent episodes of partial obstruction which led to subtle, but significant limitation of nasal airflow, along with very negative vacuum pressures in the throat. Most of these minor episodes were not apneas or hypopneas, but still lead to an arousal—from deep to light sleep. What was happening was multiple partial obstructions and arousals that were not severe enough to be called apneas or hypopneas, but enough to wreak havoc on deep sleep quality.

It’s been shown that even very subtle levels of restricted breathing can lead to deep brain stimulation and arousals that prevents your ability to stay in deep sleep. These reflex signals to the brain can be so weak that it doesn’t even reach the outer layers of the brain where standard scalp electrodes can pick up these disturbances.

Blame It On Your Parents (And Your Jaws)

The fundamental problem in UARS is due to smaller upper airway anatomy, caused by having smaller jaws and dental crowding. The smaller the space behind the tongue, the more likely you’ll obstruct while breathing when on your back (due to gravity, the tongue can fall back), and when in deeper levels of sleep (when your muscles relax). This is why most people with UARS can’t, or prefer not to sleep on their backs. The problem is that you can still have breathing problems despite sleeping on your side or stomach, just not as bad as being on your back.

Lack of sleep and especially lack of deep sleep has been found to cause a whole host of physiologic changes. In general this happens due to chronic overstimulation of your sympathetic nervous system. This is the fight-or-flight half of your involuntary nervous system. Since your body thinks it’s under attack, it heightens your nervous system, making you en garde, edgy, hypersensitive or overreact to normal situations. This also leads to diversion of blood flow, energy and resources away from less essential body parts and organs, such as your digestive system, reproductive organs, skin, hands, feet, and other “end organs.”

Due to this “hypersensitivity,” the nose and sinuses can be overly sensitive, reacting to stimulants such as weather changes, chemicals, scents, and even allergies. Chronic stress that results from sleep deprivation also can heighten your immune system.

Is It Hormones or Your Breathing?

A number of other studies point out that UARS patients are more prone to have cold hands or feet, hypothyroidism, irritable bowel syndrome, depression, chronic fatigue, and various other “somatic” syndromes. I see this all the time in my practice. In fact, a recent study even showed that chronic long-term sleep deprivation caused significant lowering of the TSH and T4 levels, with women being much more susceptible to this effect compared with men.

With time, as people age, and especially as they gain weight, most people will progress into true obstructive sleep apnea. You’ll find that most younger, thinner people with UARS will have one or two parents with significant obstructive sleep apnea.

Now that you’re convinced that you may have this condition, what can you do about it? For the most part, it’s treated just like obstructive sleep apnea. You should start with all the conservative options first, such as weight loss (if you’re overweight), diet, exercise, improving your nasal breathing, and not eating late. If these options don’t work, then all the formal options for treating obstructive sleep apnea are possible including CPAP, oral appliances, and even surgery.

Unfortunately, if you don’t officially have a sleep apnea diagnosis based on a sleep study, then insurances generally won’t cover any of the treatments. The irony is that our health care system won’t treat or prevent diseases in the early stages, and would rather wait until it’s much more severe before covering for medical services.

If you think you may have upper airway resistance syndrome, you may be disappointed to find that the medical community in general will not be responsive to your queries. With a few exceptions, many sleep doctors are not convinced that UARS is even a legitimate condition, and would rather lump it into the spectrum of snoring to obstructive sleep apnea. Time after time, whenever I see patients who are told they don’t have obstructive sleep apnea and I treat the upper airway narrowing and inflammation, patients almost always feel better. Your best option is to continue to educate yourself and be persistent. Your first priority should be to be able to breathe better so that you can sleep better.

Please note: I reserve the right to delete comments that are offensive or off-topic.

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5 thoughts on “UARS: The Hidden Sleep Condition

  1. Hi Dr. Park,

    Do you think that orthodontic treatment with ALF might be an appropriate approach to addressing the reduced airway in this condition? Have you seen this approach taken with any success?

  2. What do you recommend for the inflamation? I already have a c-pap but have difficulty using it because my nose stops up during the night. Nasal spray helps but I know I shouldn’t use them long term. I have used some of the steroid sprays as well as allergy medication but they don’t always help. I have had chronic nasal drip most of my adult life. I am 65 years old.

  3. There are studies showing that those that are treated for Hypothyroid found a reduction in snoring, their overall AHI. There is a definitive link between thyroid function and sleep disordered breathing. I would go as far to say that with UARS, symptoms are usually found in women at the same age most develop Hypothyroidism.
    If your family is predisposed to thyroid conditions and if you’ve been diagnosed with sleep disordered breathing I would also check with your doctor to ensure you thyroid is functioning properly. There is still a debate on which comes first, Hypothyroid/Hyperthyroidism or sleep disordered breathing. I would argue that having your thyroid gland swollen and it being located near the upper airway would obviously exacerbate andy breathing issues you may already have. Say a deviated septum coupled with an enlarged thyroid may be a recipe for sleep disordered breathing like UARS/OSA.

    For me, (a 20ish year old of normal/below normal weight) I was diagnosed with UARS immediately after a very stressful life event which also triggered my Hyporthyroidism (I have Hashimoto’s Thyroiditis). I was already predisposed to thyroid related issues as it runs in my family. The symptoms of UARS and thyroid disease are both very similar (constipation, cold hands and feet, insomnia). I have had surgery for a deviated septum, used a CPAP and a dental appliance (both very expensive as these were not covered by insurance). Neither of these things actually helped me until I began treatment to fix my thyroid.
    Now which one came first UARS or Hypothyroid is a real question that still needs to be answered and may help in treating the cause of SDB and not the symptoms.

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  4. Dr Park, are there any sleep labs in California that can detect and score UARS as aggressive as Stanford?

  5. Mr. Quintero,

    Sorry, but my understanding is that Stanford’s scoring process is similar to all other sleep labs due to standardization requirements by the American Academy of Sleep Medicine.