Upper Airway Resistance Syndrome (UARS)

UARS is classified as a Sleep Breathing Disorder SBD that is associated with fragmentation of sleep due to the upper airway collapsing whilst breathing during sleep which results in decreased Restorative sleep. This lack of restorative sleep results in numerous Functional Somatic Syndromes FSS syndromes and anxiety disorders. There is a long list of FSS, but among the most prevalent are chronic fatigue syndrome, fibromyalgia syndrome, and irritable bowel syndrome IBS

There are four sleep stages identified by the American Academy of Sleep Medicine:

Stage 1: features alpha waves and is the period of light sleep, wakefulness when a person is first falling asleep.

Stage 2: features theta waves and transitions between wakefulness and deeper sleep.

Stage 3: deepest and most restorative sleep is associated with muscle relaxation and is the period when glucose levels are stabilised and when testosterone and human growth hormone are stimulated and the physical bodily is restored.

Stage REM: body becomes immobile and relaxed as muscles are turned off. This is when a person dreams and is associated with cellular regeneration, cognitive restoration, memory allocation, and memory retention.

For adult humans, restorative sleep should account for 50% of the total night's sleep, evenly divided between Stage 3 and Stage REM sleep (20-25% each). In someone suffering from UARS, this causes cessation of these two stages as these patients usually wake up just before stage 3 or Stage REM because of the muscle relaxation during this period. Their tongue, which is too big for their mouths, falls back and obstructs the airways. This occurs numerous times throughout the night resulting in these UARS patients never entering restorative sleep.

These patients usually don't know they are deprived of restorative sleep; rather, they're tired, fatigued, moody, or just don't feel healthy, rested, or well. This can have a major impact on our overall quality of life. We all need at least 7 to 8 hours a night of uninterrupted sleep to leave our bodies and minds rejuvenated for the next day. If sleep is cut short, the body doesn’t have time to complete all of the phases needed for muscle repair, memory consolidation and release of hormones regulating growth and appetite. We then wake up less prepared to concentrate, make decisions, or engage fully in our work and social activities.

Sleep helps us thrive by contributing to a healthy immune system, and can also balance our appetites by helping to regulate levels of the hormones ghrelin and leptin, which play a role in our feelings of hunger and fullness. So when we’re sleep deprived, we may feel the need to eat more, which can lead to weight gain.

The one-third of our lives that we spend sleeping, far from being “un productive,” plays a direct role in how full, energetic and successful the other two-thirds of our lives can be.

UARS will NOT be diagnosed if in a sleep study, the RERAS (respiratory effort related arousals) and RDI (respiratory disturbance index) are not measured. The overnight sleep study must measure RERAS and these are recorded manually. Automated computer analysis of polysomnogram PSGs does not measure RERAs and these automated PSGs are unable to diagnose the sleep disordered breathing of UARS. At Sleep Renewal, the overnight sleep study includes the measurement of RERAS and our neurophysiologist measures and analyses the PSG manually in order to diagnose this condition.

All UARS patients have some form of fatigue, almost all state that they are “light sleepers,” and almost invariably, they don’t like to sleep on their backs. Some people attribute their poor quality sleep to insomnia, stress or working too much. Due to repetitive arousals at night, especially during the deeper levels of sleep, one is unable to get the required deep, restorative sleep which is the period when Human growth hormone is stimulated. One needs restorative sleep to feel refreshed in the morning. 

UARS is associated with typical symptoms which include:

• Insomnia / waking up in the early hours of the morning and unable to fall asleep again - due to respiratory arousals 
• Fatigue during the day - fragmented sleep / never getting restorative / REM sleep 
• Difficulty concentrating- due to changes in levels of neurotransmitters
• Morning headaches or migraines - due to clenching / grinding teeth during night to own airway and dysregulated sleep 
• Unrefreshing sleep ( due to frequent awakenings during the night and fragmentation of sleep )

The reported prevalence rates of UARS are 31% in women less than 40 years. One interesting study looked at UARS and its association with a wide-ranging list of medical conditions and symptoms such:

• Mood disorders such as anxiety, depression, ADHD or bipolar disorder - due to changes in levels of neurotransmitters and un-restorative sleep.
• Irritability - due to changes in levels of neurotransmitters and lack of restorative sleep
• Insomnia- due to airflow blockages causing repetitive arousals which wake you up
• Sleep walking -due to arousal during REM sleep
• Cognitive impairment including short term memory loss -due to damage of hippocampus/memory processing
• Chronic fatigue syndrome or daytime fatigue- due to lack of restorative sleep
• Fibromyalgia or chronic pain - due to changes in levels of neurotransmitters
• Increased sensitivity to pain - due to changes in levels of neurotransmitters
• Morning headaches / migraines due dysregulation of sleep processes impacting headache vulnerability or threshold
• Restless leg syndrome - due to sympathetic autonomic activation
• Irritable bowel syndrome IBS - due to parasympathetic autonomic activation
• TMJ - tempero mandibular joint syndrome - one grinds at night to open the airway to prevent asphyxiation
• Sick house syndrome / multiple chemical sensitivity syndrome - due to changes in levels of neurotransmitters
• Dizziness or light headedness - due to parasympathetic autonomic activation
• Increased Heartburn and reflux - due to reflux of gastric contents up the osophagus when there is a blockage of airflow.
• Chronic sinusitis- due to reflux of gastric contents up the osophagus and into the sinuses when there is a blockage of airflow.
• Constantly clearing the throat / post nasal drip - due to chronic reflux
• Persistent cough - due to chronic reflux
• Low Body Mass Index (BMI)- due to low grade cortisol stimulation
• Urinary frequency - due to parasympathetic autonomic activation
• Increased mobility of gastrointestinal tract -due to parasympathetic autonomic activation
• Hypothyroidism and more

We think it's safe to say to say that a significant number of people with these conditions actually have UARS instead. People with these somatic syndromes all have in common some form of chronic fatigue, as well as an inability to sleep well. If you fix the sleep disorder UARS, all the chronic symptoms go away.

• These two conditions cause a range of daytime mental symptoms primarily due to the lack of restorative sleep. Symptoms of brain damage include shortened attention span, moodiness, and especially reduced short-term recall or memory as people with sleep disruption have trouble converting short-term memories into long term ones.
• Consolidating memories, or storing experiences so that they can be accessed later, is a vital link in the memory-creating process that occurs during sleep. When slumber is impacted by these sleep disorders, people have trouble incorporating and categorizing their experiences, which leads to impaired memory formation and forgetfulness.
• Poor sleep quality and progressive brain damage induced by OSA and UARS could also be responsible for emotional problems and decreased cognitive functioning.

Patients with UARS have usually consulted numerous doctors who are not able to diagnose the condition as they are unaware of this newly documented condition. These doctors usually prescribe anti-depressants and sleeping tablets for the anxiety, depression and insomnia . Sleeping tablets make the condition worse as it collapses the already compromised airway even further. All the above prescription medications do not improve the UARS and this condition with all its deleterious effects festers on.

Instead, any patient with insomnia and any of the symptoms mentioned above should be sent for an overnight Sleep Study. Once diagnosed, UARS is better treated with a MAD mandibular advancement device which opens the airway and up improves all of the symptoms these patients suffer from.

Individuals with abnormal airway anatomy including those with the following:

• A decreased space behind the tongue/ high riding tongue
• narrow nasal passages/ flimsy nostrils
• small neck circumference
• patients with an overbite / recessed lower mandible/ retrognathia
• UARS patients are typically very thin
• Suffer from Bruxism and tension headaches or migraine
• Have adrenal burnout , chronic fatigue and IBS
• Snoring is not a requisite symptom with 10% to 15% or more of patients having never or only intermittently snored

The natural course of UARS is highly variable with some patients remaining unchanged for years or decades, where others slowly progress into sleep apnea. Some older, overweight women in their 50’s or 60’s with sleep apnea relate to us that when they were in their 20’s, they were very thin and had cold hands, low blood pressure, chronic diarrhoea, and dizziness. With weight gain and ageing, these conditions disappear and at exchanged for high blood pressure, snoring and severe fatigue/ sleepiness - synonymous with Sleep Apnea.

Evolutionary biologists have explained that the upper airway is the" Achilles Heel” of the human race. 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 size. 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 restorative sleep.

Due to repetitive arousals, your body goes into almost a chronic state of low-grade stress. 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.

In these patients, they are more stressed when they are sleeping than when they are awake!! Physiologically, these multiple arousals during the night cause you to be in a constant state stress because you keep waking up at night for years on end. 

This causes chronic stimulation of adrenals and eventual adrenal burnout: These multiple arousals cause your sympathetic nervous system to become overly activated (Restless leg syndrome) and stay active even when you are asleep, the very period when you should be relaxed and resting!

Bruxism/ Grinding is the new red flag for Sleep Apnea and UARS. Thanks to powerful new research, it's now accepted that grinding is an instinctual response that helps us to survive whilst breathing during the night. During the night, the brain cycles through lighter and deeper stages of sleep. As the brain approaches deep sleep, all the muscles in the body have to fully let go and relax. This easily causes trouble for the airway — and the tongue, when fully relaxed, expands to almost twice its size to block/ obstruct the airway.

You’re not sleeping well if you grind your teeth. Tensing up the muscles to grind is an instinctual response to bounce the body out of deep sleep which opens the airway. All the health benefits of sleep you read about come from deep sleep.

Note: A mouth guard makes things worse. A mouth guard is put in place to protect the teeth from grinding, but since it can reposition the jaw, it can actually make the obstruction of the airway worse. If you grind your teeth, it should be considered that you likely have a small airway and a large tongue and the reason you’re grinding is to open your collapsed airway while you’re sleeping. Treating the airway with a MAD - Mandibular Advancement Device or CPAP usually cures teeth grinding and improves UARS symptoms by keeping the airway open during the night

Population studies are generally consistent in several findings:

• The prevalence of sleep disorders is greater among individuals with headache than individuals without headache;
• Sleep disorders are more prevalent among individuals with chronic headache than episodic headache;
• There is evidence from one longitudinal study that sleep complaints may be a negative prognostic indicator at least for tension-type headache.
• The majority of studies have addressed sleep-disordered breathing, but a wide range of sleep disorders are implicated. This is generally consistent with clinical literature suggesting sleep disorders are prevalent among headache sufferers seeking treatment, especially insomnia.
• These various sleep disorders linked to headache are diverse in nature but common to all is the, and possibly progression of the headache disorder over time if the sleep disordered in not treated.

There is clinical evidence in the case of obstructive sleep apnea and insomnia that treatment of the sleep disorder may improve headache. Therefore, it is recommended that screening and management for the more severe and prevalent sleep disorders be considered in headache practice. It is also proposed that basic sleep regulation strategies that manage snoring and optimise the duration, quality, and regularity of sleep been encouraged in headache sufferers.

If the above symptoms apply to you, the first step is to visit one of our Health Renewal doctors. Based on an extensive series of questionnaires, we can determine whether or not you need an overnight home sleep study to measure the AHI (Apnea Hypopneas Index) AND the RERAS. This will give the RDI (Respiratory Distress Index). Measuring the RERAS and RDI is the gold standard for diagnosing UARS.

Overnight home Sleep Studies are available at certain Sleep Renewal branches. If your report is positive for UARS we will refer you back to your referring Sleep Renewal doctor for a complete evaluation. Certain blood tests will be done to assess your levels of inflammation and cortisol levels. When the doctors look in the mouth, the back of the throat is very narrow and there is a tongue that sits very high up, covering up the uvula, the little thing that hangs down in the middle of your throat. Usually the side of the tongue is serrated and a line can be felt on the cheek mucosa, all indicating that the tongue is too big for the mouth.

When the UARS patient lies down during sleep, the tongue falls back even more, leaving a 1-2mm slit. When you are awake, you can breathe through this slit. But as you fall asleep, the muscles relax as you get deeper into sleep or REM sleep (when you’re dreaming) and that’s when you start to obstruct. Then, once you obstruct, you stop breathing and you get aroused, going to light sleep and the cycle happens over and over again, bypassing restorative sleep with all its consequences 

In general, the options are:

• Nasal breathing optimization by treating allergies properly with medications or avoidance measures or even allergy shots.
• Dental appliances such as the MAD, a dental device that pulls the lower jaw forward and pulls the tongue forward resulting in a vast improvement in the caliber of the airway.
• CPAP to continually blow air into the airways, stenting the airway to keep it from closing
• A last resort would be surgery which will treat a deviated septum, enlarged tonsils etc.
• Avoiding regular use of muscle relaxants/ sleeping pills/ sedatives and other substances that may suppress respiration.
• Minimise sleep altering substances such as caffeine, nicotine and alcohol.

Patients with UARS do not always snore, or have the changes in airflow during the night, as well as drops in their oxygen levels.

• Excessive daytime sleepiness or fatigue
• Snoring
• Chronic insomnia
• Frequent arousals out of sleep
• Nocturia
• Bruxism
• TMJ pain
• Morning headaches
• Night sweats
• Sleepwalking, talking or sleep paralysis
• Anxiety about sleeping
• Depression
• Poor memory and concentration
• Morning nasal congestion
• Acid reflux/heartburn

When you go to sleep, the whole body starts to relax, including the jaw, tongue and throat. The jaw and tongue slide back and the throat become less rigid. This makes the diameter of the top of the throat narrower, making it difficult to pull air into the lungs. This creates a vibration of the soft tissue in the airway, referred to as snoring.

The body compensates for the narrowing airway by increasing the chest expansion that makes a stronger vacuum force to pull more air into the lungs. When a patient has OSA, the soft tissue collapses at the top of the throat due to this vacuum, thus closing the airway. Patients with UARS, this does not happen, as the airway stays open. But the narrowing of the airway does make it difficult to breathe during the night. Sometimes the jaw gets pushed forward, and clenches it in place to help keep the tongue forward and widen the diameter at the top of the airway. This pushing may cause the teeth grinding and the clenching can lead to sore muscles and headaches.

The narrow airway, makes it difficult to breathe, and causes the nervous system, to interpret it as abnormal, and sends signals to the brain that cause brief disruptions in sleep. This interrupts the normal sleep cycle, reducing the brains efficiency to restore itself, and may lead to daytime sleepiness and fatigue, with impaired concentration and memory.

The vacuum pressure in the chest increases the need for the heart to contract, and can lead to a decreased amount of blood ejected from the heart. This can cause mild swelling in the right side of the heart which influences the heart to release factors into the bloodstream which signal the kidneys to waste fluid to reduce the volume that enters the heart. This leads to frequent trips to the bathroom as there is an increased production of urine.

The vacuum pressure can also lead to heartburn at night. REM sleep is more prone to airway restriction, as well as predictable times of awakenings during the night. This can lead to an increased heart rate and night sweating too.

The patient is given treatment options such as:

• CPAP therapy,
• Oral appliance therapy or
• Surgical interventions.

These options each work differently to improve the airway resistance and help normalize breathing, which will help to get continuous restorative sleep. A sleep evaluation will be best to get a better night’s sleep.

A young woman in her 30s, who consulted with our Health Renewal doctors because of recurrent throat infections. She was also found to be extremely tired and had depression treated with anti-depressants. She also had severe cold hands and feet, low blood pressure with frequent lightheadedness and dizziness, recurrent sinus infections, migraines and chronic diarrhoea. She was severely distraught because her overall health had deteriorated to the point where she couldn’t function normally at her job. A sleep study showed that she had mild sleep apnea and UARS which as treated with a MAD brace. Six months later on a follow-up sleep study; her apnea/hypopnea index had dropped to 2, which is basically cured. But, more surprisingly, she noted that her cold hands and feet were gone, her diarrhoea was much better and even her sinus headaches and migraines were better. On her last doctor’s exam, she noted also that her blood pressure had normalised and she wasn’t lightheaded or dizzy anymore. She was completely off her anti-depressants and reported a “life-changing experience.” This woman had classic UARS. If this condition is left untreated for many years, she would have gained more weight eventually especially 9f she was prescribed anti-depressants. Many of her UARS symptoms would have disappeared as the onset of sleep apnea signs and symptoms began to appear.

As you can see, 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 a trained doctor who knows what to look for.

At Health Renewal we have launched Sleep Renewal which includes at home Sleep Studies for our patients. If the above symptoms appear to apply to you or someone you know and if you want more information about UARS, as well as a more complete picture of why we have so much of these problems and what we can do about it, then consult one of our Health Renewal doctors who will guide you through the process.