Stanford University

Tired of Being Tired? – Dr. Steven Y. Park

Are you tired all the time, no matter how long you sleep? Do you suffer from unexplained, recurrent or prolonged infections or colds that just won’t go away? Do you continue to get sick despite being on multiple medications and antibiotics? Have you undergone various tests, with no definitive answers? If so, you could have upper airway resistance syndrome (UARS).

UARS was first described by researchers at Stanford University in 1993. They described a group of young women and men who complained of chronic fatigue and excessive daytime somnolence. They all underwent a formal sleep study, and all were found not to meet the official criteria for obstructive sleep apnea. However, by treating them as if they had obstructive sleep apnea, most improved significantly.

This is probably the most common condition that I see in my ear, nose and throat practice. Despite most of my patients coming in to see me for routine, ear, sinus and throat problems, in the vast majority of cases, UARS can cause if not aggravate many of the above medical conditions. In contrast to medical specialists, I as an ENT physician and surgeon have an advantage: I can see the upper airway with a thin fiberoptic camera.

Different From OSA

To understand UARS, you must first understand obstructive sleep apnea. Obstructive sleep apnea is a well-known sleep related breathing problem where you literally stop breathing at night during sleep due to total collapse of your throat tissues in the throat. This can occur anywhere from a few times every hour to over 100 times every hour. By definition, an “apnea” is defined a total stoppage of breathing for 10 seconds or more. “Hypopnea” is restricted breathing with greater than 30% chest wall movement decrease and blood oxygen drop more than 4%, for 10 seconds or more. The total combination of apneas and hypopneas for the entire night, divided by the total number of hours you sleeps, gives you the apnea hypopnea index, or AHI. This is the most commonly used measure to diagnose obstructive sleep apnea. Untreated, OSA can lead to  hypertension,diabetes, obesity, depression, lack of sexual desire, heart disease, heart attack or stroke.

If you have UARS, you have many more than 5-10 obstructions and arousals every hour, but because the period of obstruction lasts less than 10 seconds, these episodes don’t get counted towards the final score the AHI.

Due to repeated arousals at night, especially during the deeper levels of sleep, you may be unable to get the required deep restorative sleep that you’ll need to feel refreshed in the morning. In most cases, the anatomic reason for this collapse is the tongue. There are many reasons for the tongue to obstruct, including a large tongue or being overweight, but once it occurs, the only thing you can do is to wake up.

Features of UARS

People with UARS don’t fit the typical OSA picture: Usually they are thin, with normal or low blood pressure. They can also have cold hands or feet, sinus problem, migraines, TMJ, depression, anxiety, various gastrointestinal problems. In addition to the above, almost invariably, people with UARS prefer not to sleep on their backs. Many people state that if they try, they choke as they fall asleep, or just keep waking up. Over the years, they have trained themselves to sleep on their side or stomach.  Even then, they still obstruct and wake up to a certain degree. Many people also state that they have crazy or vivid dreams, or sometimes no dreams at all. This is because when you wake up while you are dreaming in the REM stage, you will remember your dreams vividly. By definition, all dreams are wild and vivid. Only because you tend to wake up more frequently while you are dreaming do you remember your dreams more vividly. Some people wake up as they begin to enter the dreaming stage, so they never dream at all.

Some others blame their frequent arousals to having to go to the bathroom. One thing to note is that inefficient sleep with increased stress hormones promotes urine production. Another interesting study recently showed that in a large group of people who wake up frequently to go to the bathroom, using very sensitive instruments, they showed that people wake up because they stop breathing, and not because they had a full bladder.

Family history is also very important. This is one way I gauge what the patient may look like in 20-40 years. In many cases, patients with either UARS or OSA have one or both parents that snore severely, with one or many cardiovascular complications, such as obesity, diabetes, hypertension, or heart disease. If one parent is noted to have had a heart attack or stroke in their 40’s or 50’s, then I take the patient’s condition more seriously.

Do You Have UARS?

The natural course of UARS is highly variable, with some patients remaining unchanged for years or decades, or others slowly progressing into OSA. Some older overweight women in their 50’s or 60’s with OSA tell me that they were very thin in their 20’s, and had cold hands, low blood pressure, chronic diarrhea, dizziness, etc., and now do not have any of these conditions, except that now she has normal or high blood pressure, snoring and severe fatigue (classic OSA).

What seems to aggravate UARS symptoms most, however, is a relative change in their lives. Relative weight gain, even 5-10 pounds, can aggravate the symptoms, which gets better once the weight has stabilized, as the body adjusts and accommodates to the new weight. A bad cold or infection can also aggravate these symptoms, since it causes swelling, which narrows the upper airway. UARS people, who are already living on the “edge”, tend to have more prolonged or severe colds, as airway swelling causes more narrowing and anatomic collapse, which aggravates throat acid reflux, causing more swelling, perpetuating the vicious cycle. At a certain point, the body cannot adjust, and the vicious cycle is self-perpetuating. Poor sleep aggravates weight gain (for reasons described here), and weight gain narrows the throat even more, causing more obstruction and arousals. Stress is also a big factor-emotional, psychological, or physical. Whether the stress is internal or external, the body behaves the same way.

As you can see, UARS can potentially explain many symptoms. Typically, patients see multiple doctors for various complaints, without ever finding complete relief. In the end, some even lose faith in Western (allopathic) medicine and look elsewhere in alternative or complementary forms of treatment.

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