Upper airway resistance syndrome (UARS)

UARS is relatively new description of a condition that’s related to obstructive sleep apnea which has enormous ramifications on one's health.

The lack of education about UARS in the medical community has allowed these patients to go undiagnosed and untreated. At Skin, Body & Health Renewal we see this sleep breathing disorder over and over again and we are excited to share this vital information with you.

Frequently Asked Questions

  • 1What is UARS?
  • 2Who is at risk?
  • 3Who first described UARS?
  • 4How is UARS different from OSA?
  • 5What is the evolutionary history of a compromised Airways?
  • 6What happens during these repetitive arousals?
  • 7Why do these arousals happen?
  • 8What do repetitive arousals eventual do to one's Health?
  • 9What physiological changes occur due to repetitive arousals?
  • 10What symptoms/syndromes could UARS lead to? Do you have any of the following?
  • 11What is the course of UARS?
  • 12So how does one diagnose UARS?
  • 13How does one treat UARS?
  • 14Why are patients with UARS misdiagnosed?
  • 15What can one do about it?

UARS is associated with typical symptoms which include excessive daytime sleepiness, fatigue, difficulty concentrating, morning headaches, and unrefreshing sleep. The reported prevalence rates of UARS is 31% in women less than 40 years. One interesting study looked at UARS and its possible association with a wide-ranging list of medical conditions like chronic fatigue syndrome, fibromyalgia, hypothyroidism, irritable bowel syndrome and more. Obviously, not all patients with the above conditions have UARS but based on this paradigm, but a significant number of people with these conditions actually have UARS instead.

Individuals with abnormal airway anatomy including those with a decreased space behind the tongue, narrow nasal passages or a small neck circumference. Patients are typically not obese, with a mean BMI often <25. They are also usually less than 38 years. Snoring is not a requisite symptom with 10% to 15% or more of patients having never or only intermittently snored.

This syndrome was first described by researchers at Stanford University in 1993 in a group of young women and men who complained of chronic fatigue and excessive daytime sleepiness. They all underwent a conventional sleep study and all were found not to meet the official criteria for obstructive sleep apnea OSA. (RERAS were not measured) However, by treating them as if they had obstructive sleep apnea, most of their symptoms improved significantly.

Unlike sleep apnea where you have obstruction, apnea, then arousal, UARS patients typically have mostly obstructions and then arousals. UARS patients do not have Apneas. As mentioned previously, all UARS patients have some form of fatigue, almost all state that they are “light sleepers,” and almost invariably cannot sleep on their backs. Most people attribute their poor quality sleep to insomnia, stress or working too much.

Evolutionary biologists have explained that the upper airway is the" Achilles Heel” of the human race. Unfortunately, being able to talk and communicate has come at a price.

Our voice box takes up vital airway space and our flattened faces (compared to primates) further compromise the upper airway. Our modern day diet with processed food eaten with a knife and fork has allowed our jaws to become smaller resulting in crowding of our teeth. However our tongues have remained the same sizeand when one lies flat on one's back during sleep, the airways is narrowed to a 1-2mm slit because of the collapse of an over large tongue in a narrowed down airway. This results in repetitive arousals during sleep. 

During REM sleep, most of the muscles of the body (except the diaphragm) relax and the normal protective layers of muscle tone that keeps your airway open during inspiration diminishes. In addition, the tongue relaxes and falls back against the airways, limiting airflow. This causes repetitive arousals during sleep and decreases restorative sleep. One is unable to get the required deep sleep that one needs to feel refreshed in the morning.

In most cases, the anatomic reason for this collapse is the tongue. When you take a deep breath in, a vacuum-like pressure is set up and the back of your tongue can fall back completely. There are many reasons for the tongue to cause obstruction including being too large or being overweight. But once it occurs, the only thing you can do is to wake up.

When awake, you’re fine, but once you start to fall asleep, the tongue falls back and you wake up again, either fully or subconsciously. This is why so many people can’t fall asleep on their backs and therefore, have unconsciously trained themselves to roll over to their side or their stomach where the tongue collapse is less likely. This can happen 10 to 30 times every hour preventing you from sustaining deep sleep. You may realize that you are waking up sometimes, but the vast majority of arousals are subconscious. If this happens for a few nights in a row and you return to your normal sleep habits, you’re fine. But if it occurs continuously for months or years, then certain events can happen. 

Due to repetitive arousals, your body goes into almost a chronic state of low-grade stress. Think of what would happen if somebody poked you with their finger every few minutes while you tried to sleep for 6 months straight. How would you would feel the next morning? How you would feel after months or years of inefficient sleep. You would feel tired, groggy with no motivation to do anything, have focus or concentration problems, or, you could feel depressed and anxious.

UARS has the potential for significant impact on the daytime functioning and quality of life in untreated patients and there is growing evidence to suggest that symptoms are progressive without treatment. Physiologically, these multiple arousals cause your ANS (autonomic nervous system) to be in a constant state stress because you keep waking up at night for years on end causing:

Chronic stimulation of adrenals: These multiple arousals cause your sympathetic nervous system to become overly activated and stay active even when you are asleep! The very period when you should be relaxed and resting! Your hands or feet can become cold or numb, in general, activated by cold temperatures or stress.

Daytime symptoms

  • Excessive daytime sleepiness
  • Fatigue/ Chronic fatigue syndrome
  • Morning headaches
  • Myalgia’s/ Body pain / Fibromyalgia
  • Difficulty concentrating/ short term memory loss

GIT effects/IBS:

  • Chronic diarrhea, constipation, indigestion, acid reflux or bloating. Similarly, since you don’t need to digest food when you’re fighting, blood gets shunted away from your entire gastrointestinal system to the heart muscles, leading to these symptoms.
  • We already know that stress can aggravate acid production in the stomach.

LPRD, or laryngopharyngeal (throat and voice box) reflux

The common complaints of LPRD include one or many of the following:

  • chronic throat clearing, chronic lump in throat
  • postnasal drip
  • hoarseness
  • cough, throat or ear pain,
  • Difficulty swallowing, tightness or pain with swallowing.

Nasal congestion, sinus or ear infections:

  • Studies have shown that UARS can cause acid reflux to the throat but can also reflux into the lungs, causing or aggravating asthma or bronchitis.
  • Acid can also reflux into the nose and ears causing more aggravating nasal congestion, sinus or ear infections.

Low blood pressure:

  • UARS patients are frequently are dizzy or lightheaded, aggravated by standing up too soon.
  • This is called orthostatic intolerance.
  • They also have cold hands and feet.

Classic migraine and tension headaches:

Are also frequent in UARS along with TMJ (temporo-mandibular joint) problems, due to grinding and clenching of the teeth / Bruxism and TMJ which can also give you ear pain, headaches along the side of your head and can also wear down your teeth.

Depression, anxiety or attention deficit problems are associated with UARS

Patients resistant to treatment with anti-depressants may be suffering from UARS

Sleep disturbances:

  • Frequent nocturnal awakenings / arousals resulting in deep sleep deprivation with
  • Difficulties initiating sleep Insomnia
  • Difficulties staying sleep Insomnia
  • Bruxism during sleep
  • Restless leg syndrome
  • Unrefreshing sleep

Crazy or vivid dreams:

  • People with UARS also state that they have crazy or vivid dreams or sometimes no dreams at all.
  • This is because when you wake up while you’re dreaming in REM sleep; you’ve remembered your dreams vividly.
  • By definition, all dreams are wild and vivid. Only because you tend to wake up more frequently when you are dreaming, do you remember your dreams more vividly.

No dreams at all:

Some people wake up as they begin to enter the dreaming stage, so they never dream at all.

Chronic cortisol stimulation

In addition, if you don’t sleep deeply, it’s been shown that your body produces increased levels of cortisol with resultant inflammation and disease such as:

Insulin resistance, leading to diabetes:

Cortisol lowers your immune system’s ability to fight infections and aggravate insulinresistance, leading to diabetes.

Difficulty losing weight:

And as we all know, cortisol is what makes you gain weight and eat more.

Family history is also very important

This is one way to gauge what the patient might look like in 20-40 years. And in many cases, patients with UARS or sleep apnea have one or more parents that snore severely with one or many of the cardiovascular consequences such as obesity, diabetes, high blood pressure or heart disease. If one parent is noted to have had a heart attack or stroke in their 40’s or 50’s, we take the patient’s condition more seriously.   

Left untreated for many years, patients can gain more weight which can result in the onset of Obstructive sleep apnea OSA which has severe health consequences such as high blood pressure, Type 2 diabetes and severe fatigue.

A diagnosis of UARS requires patient symptoms, evidence of upper airway narrowing or craniofacial abnormalities, and appropriate sleep study findings. The first step is to consult with one of our Health Renewal doctors who is aware of and understands the condition.

Diagnosis is based on an extensive series of questionnaires, physical examination, past family history, blood pressure and upper airways evaluation. Once evaluated, resulting effects of chronic cortisol stimulation such as inflammation will be managed. If you have allergies which are aggravating the condition by causing nasal stuffiness, these will be treated.

Sleep Study:

  • Your HR doctor will evaluate you to decide whether you need to be referred for an overnight Sleep Study.  Health Renewal is proud and excited to launch our home-based testing for sleep breathing disorders. We have streamlined the process in order to make the experience as painless as possible for the patient, while at the same time collecting all the necessary data to make an accurate diagnosis. All of this is done in the comfort of your own home while you sleep in your own bed. This Sleep Study will confirm whether you do indeed have OSA and/or UARS, allowing you to treat potentially harmful sleep disorders.

ENT:

  • You may also be referred to an ENT who understands and is aware of this sleep breathing disorder.
  • He will look for craniotomy facial abnormalities which could result in increased nasal airflow resistance such as collapsible nasal valves, enlarged nasal turbinate’s, a deviated septum or a combination of these.
  • He will also check for obstruction of airways in various sleep positions 
  • Nasal breathing optimization means if you have any degree of nasal congestion or obstruction, this needs to be dealt with. So, for most people, allergies are a very common reason that can be treated properly with medications or avoidance measures or even allergy shots.
  • Dental Appliance: if diagnosed, a dental Appliancee is useful in people with snoring, sleep apnea and UARS patients as it opens up the airway.
  • CPAP, or Continuous Positive Airway Pressure, is the gold standard treatment for OSA Obstructive Sleep apnea and is not the first choice for UARS.
  • Surgery is always a last resort. If you have tried and failed these conservative options, then there are surgical options as well.

Patients with UARS have significant impairment in their daytime functioning, with reports of sleepiness, fatigue, and sleep disruption. A follow-up study of these patients has shown that they often go untreated and experience progressive worsening of their symptoms. Among those patients who have been treated, many have experienced symptomatic improvement. UARS can potentially explain many symptoms. Typically, these patients see multiple doctors for various complaints without ever finding complete relief. In the end, some even lose faith in Western or allopathic medicine and look elsewhere in alternative or complimentary forms of treatment.

UARS is a treatable condition. The first step is a thorough evaluation by someone who knows what to look for. If you have any of the symptoms above together with some form of chronic fatigue, as well as an inability to sleep well, you may have this condition.

Please see one of our Heath Renewal doctors to get a complete medical evaluation before considering this diagnosis. Patients who are successfully treated for UARS usually report a “life-changing experience”.

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