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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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