Upper Airway Resistance Syndrome (UARS) - A Common Cause of CFS & Fibromyalgia

Sleep disordered breathing (SDB) is a common trigger for CFS and Fibromyalgia (CFS/FMS). Sleep Apnea is fairly well known. We are now learning about a different form of SDB called Upper Airway Resistance Syndrome (UARS). UARS almost exactly mimics CFS/FMS, is very addressable, and can be picked up on special testing. If you snore at night, you may have UARS or sleep apnea. Tape yourself one night to see if you snore. (Don't count on your husband to tell you. Most of us have a better sense of survival than that!)

Sleep Disordered Breathing (SDB)

Although one would think that we should take our ability to breathe while sleeping for granted, problems can occur anywhere from air entering our nose to the pipes that carry air into our lungs. During sleep we are designed to breathe through our nose. However, there are several reasons as to why some people find it difficult to breathe through the nose during sleep. These include the size of our nostrils, obstruction of the air passageways, and nasal congestion caused by yeast overgrowth secondary to excess sugar and antibiotic use (see Chapter 7 in FFTF on Candida). In addition, if the tissues are prone to collapsing anywhere along the path your air is carried, this can also prevent you from getting the air you need while you're sleeping. If oxygen is unable to be delivered around the body and in particular to the brain during sleep, sleep quality is affected and can cause not just excessive sleepiness during the day, but also many of the symptoms seen in chronic fatigue syndrome and fibromyalgia.

If the breathing problem occurs in your upper airways (e.g. your nose) it is called 'nasal resistance.' Nasal resistance can contribute to sleep disordered breathing by causing upper airway resistance syndrome (UARS), snoring and obstructive sleep apnea (OSA). Upper airway resistance syndrome and obstructive sleep apnea are part of the spectrum of sleep disordered breathing. When it is mild, it manifests as UARS, and most standard sleep studies will not detect it unless they are specifically looking for it. When the blockage of air is more severe, as often occurs lower down in the airway, it manifests as sleep apnea. Paradoxically, the symptoms of UARS may be more severe than those of apnea and are more likely to mimic CFS and fibromyalgia. Just as it is common to find that people with CFS/FMS have sleep disordered breathing, the reverse is also true. In a study of those with sleep disordered breathing, half of the women and 6 percent of the men were also found to have fibromyalgia.²¹

Although both UARS and sleep apnea are caused by blocked airflow while sleeping, there are many critical differences in the problems they cause:²²

• Chronic insomnia with frequent awakenings and the inability to fall back asleep tends to be more common in patients with UARS than those with sleep apnea.²³
• Patients with sleep apnea tend to fall asleep easily during the day (such as when driving), however, patients with UARS are more likely to complain of fatigue than sleepiness.
• Patients with sleep apnea tend to be overweight; however, those with UARS can be any weight.
• About 50 percent of with UARS are women, while only 8 percent of those with sleep apnea are female.
• Upper airway resistance syndrome is often accompanied by a spastic colon and low blood pressure with lightheadedness on standing^24,25 while sleep apnea is usually associated with high blood pressure.²⁶
• People with UARS usually have cold hands and feet and other symptoms of hypothyroidism and a brainwave pattern called alpha intrusion into Delta sleep, which often occurs in CFS and fibromyalgia.

Upper airway resistance syndrome (UARS)

UARS is often misdiagnosed as chronic fatigue syndrome, fibromyalgia, or even ADD/hyperactivity²⁷ and may be a key contributor to CFS and fibromyalgia. The sleep disorder was first recognized in children in 1982,²⁸ but the term UARS was not used until adult cases were reported in 1993.²⁹ With use of newer techniques, it has become easier to identify subtle changes in breathing patterns during sleep, and recently, UARS has been linked to not just CFS and fibromyalgia but also to attention deficit disorder and chronic insomnia.

Unfortunately, there is no good way to diagnose UARS without going to a sleep lab that specializes in looking for it. Unlike sleep apnea, which actually prevents air from getting into your body and causes the oxygen levels in your blood to drop, UARS does not cause this or necessarily even a decrease in airflow. It is simply the increased work of breathing, which tends to repeatedly disrupt sleep during the night. If you are going to have a sleep study, check with the lab before doing so to be sure that they will be checking for UARS and know how to do it right. Although in the past the "gold standard" for doing this testing required putting a small tube down into the esophagus, newer technologies that look for pressure changes in your nose or even alterations in breathing or pulse wave signals is already making this testing more user-friendly.

If you are unable to go to a sleep clinic, there is a simple 'nose test' to see if you are suffering from nasal resistance. Looking in a mirror, press the side of one nostril to close it. With your mouth closed, breathe in through your other nostril. If the nostril tends to collapse, try holding it open with the flat side of a toothpick. Test both nostrils. If breathing is easier with your nostril held open, using nasal dilators or strips when sleeping (see below) may help.

Addressing UARS

Although a mild decrease in airflow while sleeping may not seem like a big problem, it has been shown to disrupt sleep enough to cause and/or perpetuate CFS/FMS. Therefore, keeping your airways open can be critical.³⁰

Over the years a simple nasal dilator called Nozovent (available online) has proved to be one of the most popular and easy to use devices to enhance nasal breathing. This device is not just for snorers but can be used by anybody who suffers from nasal resistance. Another easy option is "Breathe Right" nose strips. These are available at most pharmacies and many supermarkets. Also, a prescription nasal spray called the "Sinusitis Nose Spray" that combines itraconazole (Sporanox), xylitol, mupirocin (Bactroban), and dexamethasone is available by mail order from the ITC Pharmacy (see resources - appendix F in FFTF). It is often very effective at addressing the nasal congestion and sinusitis that can trigger UARS. Just as your physician to call in the prescription for 1 bottle of the "Sinusitis Nose Spray" to ITC Pharmacy. Use 1-2 sprays in each nostril for 2 x day. When the bottle is done, it can be used as needed, so most patients keep an extra bottle on hand as a spare. My sinusitis and nasal congestion patients LOVE IT, and it may help the UARS to go away.

I would try each of these for one month and even try all three together, if necessary, and see how you feel. If they do not help, you may wish to consider CPAP or an oral appliance.

Continuous Positive Airway Pressure (CPAP) is often one of the first recommendations a doctor will make for this condition. The CPAP delivers air into your airway through a specially designed nasal mask that prevents your nasal passages from collapsing. Oral appliances to move the jaw forward can also help, and in some severe cases, surgery on the soft palate or even to widen narrowed jaw bones may be necessary. Because the obstruction is mild, sometimes a newer, gentler machine that uses nose prongs instead of a mask can be used. Eliminating or even addressing the UARS can markedly improve your function!

Footnotes for UARS references:

21. D Germanowicz, MS Lumertz, D Martinez, and AF Margarites: Sleep disordered breathing concomitant with fibromyalgia syndrome. J Bras Pneumol, July 1, 2006; 32(4): 333-8.

22. Guilleminault C, Bassiri A: Clinical features and evaluation of obstructive sleep apnea-hypopnea syndrome and the upper airway resistance syndrome. In Principles and Practice of Sleep Medicine. Edn 4. Edited by Kriger MH, Roth T, Dement WC. Philadelphia: WB Saunders; 2004.

23. Guilleminault C, Palombini L, Poyares D, et al: Chronic insomnia, post menopausal women, and SDB, part 2: comparison of non drug treatment trials in normal breathing and UARS post menopausal women complaining of insomnia. J Psychosom Res 2002, 53:617-623.

24. Guilleminault C, Faul JL, Stoohs R: Sleep-disordered breathing and hypotension. Am J Respir Crit Care Med 2001, 164:1242-1247.

25. Guilleminault C, Khramtsov A, Stoohs RA, et al: Abnormal blood pressure in prepubertal children with sleep-disordered breathing. Pediatr Res 2004, 55:76-84.

26. Peppard PE, Young T, Palta M, et al: Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med 2000, 342:1378-1384.

27. Gold AR, Dipalo F, Gold MS, et al: The symptoms and signs of upper airway resistance syndrome: a link to the functional somatic syndromes. Chest 2003, 123:87-95.

28. Guilleminault C, Winkle R, Korobkin R, et al: Children and nocturnal snoring: evaluation of the effects of sleep related respiratory resistive load and daytime functioning. Eur J Pediatr 1982, 139:165-171.

29. Guilleminault C, Winkle R, Korobkin R, et al: Children and nocturnal snoring: evaluation of the effects of sleep related respiratory resistive load and daytime functioning. Eur J Pediatr 1982, 139:165-171.

30. Guilleminault C, Bassiri A: Clinical features and evaluation of obstructive sleep apnea-hypopnea syndrome and the upper airway resistance syndrome. In Principles and Practice of Sleep Medicine. Edn 4. Edited by Kriger MH, Roth T, Dement WC. Philadelphia: WB Saunders; 2004. Clinical presentation of OSAS and UARS with examples of craniofacial presentations and clinical scales to define patients.

Used with permission from the book "From Fatigued to Fantastic!" (Penguin/Avery Oct 2007) by Jacob Teitelbaum, MD.