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Breathe Better E-Newsletter>
What To Do When You're Tired All The Time
August 19, 2008
If you're tired all the time, no matter how long you sleep, and suffer from recurrent colds or unexplained infections that just won't go away and you continue to get sick despite being on multiple medications and antibiotics, you may be suffering from a common yet mostly ignored sleep breathing problem called upper airway resistance syndrome.
Although it's not commonly recognized by most physicians, this is fast becoming a major issue amongst many patients who suffer from chronic fatigue issues. However, there are ways to manage this condition successfully, if you know what it is and what you can do about it.
What is UARS?
Upper airway resistance syndrome (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.
Different From OSA
To understand how upper airway resistance syndrome is distinct from obstructive sleep apnea, once must first understand obstructive sleep apnea.
Obstructive sleep apnea is a well-known sleep related breathing disorder characterized by repetitive breathing cessations during sleep due to total collapse of the 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 cessation 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 one sleeps, gives us 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.
Unlike obstructive sleep apnea, where you have obstruction, apnea, then arousal, UARS people have mostly obstruction and arousals. As mentioned previously, all UARS patients have some form of fatigue. Almost all state that they are "light" sleepers, and almost invariably, they do not like to sleep on their backs. In some cases, they absolutely cannot sleep on their backs. Some people attribute their poor quality sleep to insomnia, or 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 that one needs 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 cause obstruction, including being too large, or being overweight, but once it occurs, the only thing you can do is to wake up.
Can’t Get Deep Sleep
In the deeper levels of sleep, and especially during REM sleep, the normal protective levels of muscle tone that keeps the airway open during inspiration diminishes. Thus if your airway is narrow to begin with and you take a deep breath in, a vacuum-like pressure is set up, and the back of your tongue can fall back completely. In many cases, whenever I examine this narrowed airway with the patient laying flat on his or her back, all I see is an 1-2 mm slit between the back of the tongue and the throat. When awake, you're fine, but once you start to fall asleep, the tongue falls back, and you wake up. This is why many people cannot fall asleep on their backs, and therefore have unconsciously trained themselves to roll over to their sides or stomach, where tongue collapse is less likely (but still can happen). This can happen 10, 20 or 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 (from deep to light sleep).
If this happens for a few night in a row, and you return to your normal sleep habits, then you're fine, but if it occurs months to years continuously, then certain events may occur: Due to the repetitive arousals, your body goes into a chronic state of low-level stress. Think about what would happen if some poked you with a finger every few minutes while you tried to sleep for 6 months straight. Think about how you would feel the next morning. Think about 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 even feel depressed.
Blame It On Stress
Physiologically, these multiple arousals also affect your autonomic nervous system (AMS). The AMS is the internal nervous system that regulates your internal body functions such as digestion, breathing, heart rate, blood pressure, etc. It is divided into two parts: the sympathetic and parasympathetic parts. When you are frightened or running away from a bull, your heart rate and blood pressure goes up, your vision and hearing are very sensitive, and all your blood flow and energy are mobilized to run or fight. These functions are activated by the sympathetic nervous system. After a good meal, your digestive organs kick in and begin to break down your food, and you feel sleepy. This is your parasympathetic nervous system working. Your autonomic nervous system is in a constant state of relative balance between the two, depending on what you are doing.
Imagine if you are stressed because you keep waking up at night for years. Your sympathetic nervous system starts to become overly activated, and stays activated, even when awake. A number of events can then occur:
Cold Hands: Your hands or feet can feel cold or numb in general, aggravated by cold temperatures or stress. Some people sleep with mittens or socks all year round. This condition is called Raynaud's phenomenon, and is very common. There are a number of different theories as to why so many people have this condition and why it happens, but there is no definitive cure. Since you're under stress, your body thinks that it is under attack, and shunts blood from your peripheries to the more central muscles and to the heart, so that you can run or fight more effectively. This actually may validate the saying, "cold hands, warm heart".
Chronic Gastrointestinal Problems: Similarly, since you don't need to digest food when you are fighting, blood gets shunted away from your entire gastrointestinal system to the heart and muscles, leading to chronic diarrhea, constipation, indigestion, acid reflux, or bloating. Remember the last time you were stressed? How well were you able to eat or digest food if you had just eaten? We already know that stress can aggravate acid production in the stomach.
Acid Reflux: In addition to chronic gastrointestinal problems, many people with UARS also have LPRD, or laryngopharyngeal (throat and voice box) reflux disease. It is somewhat different than GERD (gastro-esophageal reflux disease). In most cases you will not feel and heartburn or the classic symptoms associated with GERD. The common complaints include one or many of the following: chronic throat clearing, post-nasal drip, hoarseness, cough, throat or ear pain, lump in the throat, difficulty swallowing, tightness or pain with swallowing. Studies have shown that once acid reaches the throat, it can also go into the lungs (causing or aggravating asthma or bronchitis), and even into the nose and ears, causing or aggravating nasal congestion, sinus or ear infections. Pepsin, one of the stomach’s digestive enzymes, and even H. plyori, a bacteria that can cause stomach infections, have been found in the ears and nasal cavity in people with infections in this area. Any degree of swelling or irritation blocking the very narrow ear or sinus openings can cause pressure build-up or infections.
Low Blood Pressure: A study showed that about 23% of people with UARS have low blood pressure, sometimes dangerously low. In addition, These people are frequently lightheaded or dizzy, aggravated by standing up too soon. This is called orthostatic hypotension. Even if the blood pressure is normal, you may still be more prone to episodes of dizziness (orthostatic intolerance). The recurrent periods of stress may confuse your AMS, so it doesn't respond to the changes in blood flow and head position appropriately or quickly enough.
Sinus Infections: Chronic or recurrent sinus pressure or pain which can be debilitating. Frequently, patients are seen multiple times for recurrent sinus infections, given antibiotics which helps only temporarily. In many cases migraines can masquerade as a sinus headache, without the classic symptoms. Your nose is also regulated by the two opposing parts of the AMS. Studies have shown that there is an imbalance of the parasympathetic and sympathetic nervous systems in the nose with obstructive sleep apnea. Thus many people with either OSA or UARS have chronically runny or stuffy noses with post-nasal drip, and are prone to sinus headaches and infections. This process, in addition to the acid exposure described earlier, is a very good reason for chronic nasal or sinus abnormalities.
Migraine Headaches & TMJ: Classic migraine and headaches are frequent in UARS along with TMJ problems due to grinding or clenching the teeth. Sometimes these sinus headaches and pressure respond to decongestants, and sometimes to anti-migraine medications. One does not have to have the typical “migraine” headache to have one: a recent study revealed that most cases of self-diagnosed sinus headaches are really migraines. Regardless of what comes first (chicken or the egg), one probably aggravates the other, leading to a vicious cycle. TMJ can also give you ear pain, headaches along the side of your head, and it can wear down your teeth.
Depression, Anxiety or ADHD: For obvious reasons, long-term sleep deprivation (especially deep sleep deprivation with multiple arousals), can lead to any of these conditions.
Weight Gain and Immunity: Stress increases your cortisol levels, which promotes weight gain, insulin resistance, and lowers your immune system’s ability to fight infections.
Do You Have UARS?
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. 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.
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 sequelae, 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.
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 abate 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.
On a personal note, my wife has many features of UARS (cold hands, low blood pressure), but after each of her two pregnancies, her UARS symptoms were greatly exaggerated. After our first son, she had severe “post-partum depression” for almost one year. Only after she lost her entire pregnancy weight did she feel back to normal. After our second son was born, for four months, she was severely lightheaded and dizzy, to the point of being not able to function properly. She saw a number of doctors, and even had to go the emergency room because doctors thought she may be having a stroke. The only objective finding was that her low blood pressure, which was low to begin with, was even lower. Only after she lost her entire pregnancy weight did this condition subside. Sure enough, when I looked at her airway lying down, she had the typical very narrowed airway behind the tongue. Furthermore, her father has known moderate OSA, with diabetes.
You give a good explanation for UARS, but what can you do about it? In general, UARS is treated like OSA. In general, the options are: nasal breathing optimization, dental appliances, CPAP, or surgery (See Treating UARS).
A Success Story
An interesting case example will illustrate my point: A young woman in her 30’s came to see me with recurrent throat infections, and was found to be severely tired, have depression (on antidepressants), have cold hand and feet, have low blood pressure with lightheadedness and dizziness, recurrent sinus infections and migraines and chronic diarrhea. She was severely distraught, as her overall health had deteriorated to the point where she could not function at her job properly. A sleep study (fortunately) revealed mild OSA, at 14 events every hour. She tried CPAP, but couldn’t tolerate the mask. She refused a dental device. Finally, after a long discussion, we decided to perform sleep apnea surgery on her palate and tongue. (My approach to sleep apnea surgery at that time was that only people with moderate to severe numbers were candidates, but this case only confirms that numbers alone do not qualify candidates for surgery).
We did a conservative procedure on her palate called a uvulo-palatal flap, as well as a tongue base suture suspension and hyoid suspension (see OSA section for more detail). Six months later on a follow-up sleep study, her AHI dropped to 0.2. More surprisingly, however, was that she notes that her cold hands and feet were gone, her diarrhea was essentially gone, her sinus headaches and migraines were much better, and even her blood pressure had normalized on her last physical, and she was not as lightheaded and dizzy anymore. She was completely off her antidepressant medication, and reported a “life-changing” experience.
This woman had classic UARS, but because she met the criteria for OSA, was able to undergo definitive treatment. My guess is that untreated many years later, she would have gained more weight, and many of her UARS symptoms would disappear, as the classic OSA signs and symptoms begin to appear.
Exciting Possibilities
One interesting study looked at UARS and its possible association with the "somatic" syndromes. This includes a wide-ranging list of medical conditions including chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, and so on. Not all patients with the above conditions have UARS, but based on this paradigm, I think it's safe to say that a small but 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. Obviously, vigorous scientific study is needed in this area.
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. UARS is a treatable condition. The first step is a thorough examination in the office.
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