Upper Airway Resistance Syndrome (UARS)

A less well-known, yet common sleep disorder, is Upper Airway Resistance Syndrome (UARS) and is often the case when people have a sleep study with the results stating too low an AHI (apnoea-hypopnoea index) score to be classed as a diagnosis for Sleep Apnoea. (The minimum criteria for the diagnosis of Sleep Apnoea is an AHI 5). It should be noted that very often UARS does eventually progress into Sleep Apnoea for various reasons, such as ageing and loss of muscle tone in the upper airway, weight gain, the need for sedating medications or regular alcohol use etc.

If you haven't had a sleep study to rule out Sleep Apnoea this is advisable first as many people assume they have UARS when it's actually Obstructive Sleep Apnoea (OSA) they are suffering from. Whilst most people with OSA do snore, it is possible to be diagnosed with OSA without snoring. For accuracy, the sleep study should not only use a finger pulse oximeter, as often people with UARS or even OSA do not have regular oxygen desaturations, despite having breathing events. In fact, the August 2021 NICE Guidelines for OSA state "consider respiratory polygraphy or polysomnography if oximetry results are negative but the person has significant symptoms." A sleep study using nasal cannulas is needed and if you are having difficulty getting a sleep clinic referral we do have a sleep study service for diagnosing Obstructive Sleep Apnoea.

Sadly, UARS is often not always recognised and people can suffer with just as severe daytime symptoms as someone untreated for Sleep Apnoea! Many people who are sure they have Sleep Apnoea, undergo a sleep study and then get informed they don't have it and are consequently discharged from the sleep clinic and the suffering continues..... There are some sleep clinics though who do treat suspected UARS when patients are symptomatic, affecting their quality of life.

Dr Christian Guilleminault was a French physician, pioneer and researcher in the field of sleep medicine who first discovered UARS in children in 1982, but it was not recognised in adults until 1993 - yet it is still not widely diagnosed or even suspected today, and sufferers of UARS are often left to struggle with no treatment offered. 

Signs and Symptoms

UARS symptoms are very similar to those for Sleep Apnoea and it is just as common in men, women and children. Very often people are of average size or very slim with narrow small jaws. 

UARS does often appear to be common with Ehler's Danlos Syndrome, POTS (Postural Orthostatic Tachycardia Syndrome) and Hypotension (Low Blood Pressure).

Put simply, UARS appears to be Sleep Apnoea without the diagnosis, as UARS sufferers don't actually stop breathing for the minimum of 10 seconds which is classed as an apnoea (no breathing), but they struggle to breathe during sleep and suffer from sleep arousals and unrefreshed sleep.

Common Signs & Symptoms:-

• Snoring - usually milder than for OSA (obstructive sleep apnoea)
• Noisy Breathing or Moaning/Groaning (Catathrenia)
• Insomnia
• Disturbed Sleep
• Restless Sleep
• Night Sweats
• Cold Hands and Feet
• Daytime Fatigue (possibly diagnosed with Chronic Fatigue Syndrome)
• Migraines and/or Headaches
• Depression and/or Anxiety

Other Signs & Symptoms

• Low Blood Pressure
• Lack of concentration, poor work or school performance
• Memory problems
• Morning headaches
• Dry mouth and/or sore throat on waking
• Decreased sex drive
• Body pain (sometimes diagnosed with Fibromyalgia)
• Bruxism (tooth grinding)
• ADHD symptoms and this is a common misdiagnosis particularly in children
• Many other symptoms can be present due to sleep deprivation.

Causes

Similar to the causes for obstructive sleep apnoea, but the following tend to be more common in UARS:-

• Small Jaw (often with a dental overbite)
• Narrow Nasal Passages
• Narrow Hard Palate
• Nasal Obstructions, such as deviated septum, enlarged turbinates, polyps, congestion, allergies etc
• Large Tonsils and/or Adenoids
• Large or Floppy Tongue

Diagnosing UARS

It is difficult to get a true diagnosis of UARS here in the UK as there are few hospitals that offer the gold standard diagnosis, which is Oesophageal Manometry (Pes) normally carried out by Gastroenterology departments.  However, it can be suspected by experienced scoring on a polysomnography sleep study, preferably with RIP bands to record chest movement in order to check for how much effort is being made to try to breathe, as UARS sufferers tend to work very hard to breathe during sleep to prevent oxygen desaturations.  A sleep consultant will study the wave forms and other relevant data. A Drug-induced Sleep Endoscopy (DISE) can also be helpful like it can be for OSA.

An ENT examination can be very useful to to look for causes of UARS. Here in the UK, we have a leading NHS hospital at the UCLH (University College London Hospitals) Snoring & Sleep Disorders Clinic that specialise in sleep disordered breathing, including UARS. In fact one of the consultants, Vik Veer, from the UCLH explains UARS in the following video:-

Some sleep clinics these days are willing to treat people for UARS at their discretion, but here in the UK the National Institute for Health and Care Excellence (NICE) does not offer guidance for the treatment of UARS.  In fact it was only in 2008 that they recommended CPAP for Obstructive Sleep Apnoea, so we have to hope things will improve for UARS sufferers soon.

Treating UARS

• CPAP very often successfully treats people with UARS, which is a prescription item and can be approved by a sleep professional. You can read one of these success patient stories from Carolanne Murphy - one of our own trustees
   
• ORAL MANDIBULAR DEVICES are very often successful for UARS. However, it is not recommended to purchase off-the-shelf 'mouth guards' for long-term use due to a risk of jaw pain and TMJ (temporo-mandibular joint dysfunction) but to have a dentist trained in sleep make a device. However, an off-the-shelf one used temporarily can certainly give an indication of whether a dentist-made oral appliance will help.
  (Do also note that the cheaper off-the-shelf devices that state 'NHS Approved' is usually a 'play on words for marketing' and referring to the fact that NHS clinicians often recommend oral devices, but not the specific one being sold).
   
• ENT CONSULTANT REFERRAL for a professional examination to see if surgery is applicable.
   
• eXciteOSA is a new daytime therapy for snoring, UARS and Obstructive Sleep Apnoea and if the tongue is one of the causes of the UARS, then strengthening this with NMES during the day with the eXciteOSA could well improve or reverse the UARS.  Click to read more about this.
   
• SELF-HELP with the following tips and solutions:-
  
  Nasal Strips, Nasal Cones and Dilators can help by opening up the nasal passages. We do have latex-free Nasal Strips on our website.
  
  Throat Sprays or Oral Strips if snoring itself is troublesome, and we do have Oral Strips for sale at the charity.
  
  Avoiding Alcohol within 3-4 hours of bedtime and any unnecessary sedating medications (prescribed medications will need discussing with your GP before stopping or reducing).
  
  Side Sleeping, as UARS (just like Sleep Apnoea) is normally worse in the supine position. Sleeping on the front can help the UARS, but it can lead to back and neck problems, so it's not usually advised.
  
  Sleeping Elevated by raising the head of the bed 4-6 inches.
  
  Clearing Nasal Passages of Congestion with the use of saline or prescribed nasal sprays. However, always read the label of over-the-counter sprays as many should only be used for a short time or can make things worse - especially when trying to come off them, which is known as the rebound effect.
  
  Losing Weight if applicable, although many people with UARS are not overweight.
   

We totally empathise with those of you who are struggling with the symptoms of UARS, and would encourage you to research local services in your area. A sleep study to rule out Sleep Apnoea is advisable, and as previously mentioned, very often when people suspect they have UARS without having had a sleep study, it can actually be Sleep Apnoea they are suffering from. Your GP can refer you to your local sleep clinic or if you are having difficulty getting a referral you can book our private sleep study service at the charity.

We would also recommend Dr Park's book 'Sleep Interrupted' where there is a wealth of information on UARS as well as Sleep Apnoea.