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Upper Airway Resistance Syndrome
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zonk Offline

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Post: #1
Upper Airway Resistance Syndrome
[copied from old forum]


Upper Airway Resistance Syndrome
http://www.chestnet.org/accp/pccsu/upper...e?page=0,3

Professional Practice Gap
Over the past few years, numerous articles have been published that have increased our understanding of the features of upper airway resistance syndrome (UARS). UARS has been previously described as a distinct clinical syndrome, although there is ongoing controversy and some consider it to be part of a spectrum of sleep-disordered breathing that includes primary snoring, obstructive hypopnea syndrome (OHS), and obstructive sleep apnea syndrome (OSAS). However, patients with UARS present with different polysomnographic abnormalities and do not meet generally accepted criteria for either apneas or hypopneas. The lack of education about UARS in the medical community has allowed these patients to go undiagnosed and untreated. Increased research into UARS will help us to identify the optimal treatment for these patients, as well as to educate clinicians about this relatively under-recognized population.

Introduction
UARS is characterized by abnormal respiratory effort, nasal airflow limitation, absence of obstructive sleep apnea, minimal pulse oximetry fluctuation with oxygen saturation nadirs >92%, and frequent nocturnal arousals or reflex brainstem activation. It was first recognized in children in 1982, although the term UARS was not used until the first adult cases were reported in 1993. The incidence and prevalence of UARS has been systematically investigated in a recent São Paulo epidemiologic study (discussed below in "Epidemiologic Studies of UARS"). Prior to the São Paulo study, some have reported prevalence rates of 8% to 20% in the literature.5,6 We now know that this syndrome has recognizable clinical and polysomnographic characteristics that differ from those observed in patients with OHS/OSAS. UARS occurs in all age groups without any clear sex preferences, although some studies suggest that women may be at increased risk. UARS has the potential for significant impact on the daytime functioning and quality of life in untreated patients and there is growing evidence to suggest that symptoms are progressive without treatment.

Treatment
The optimal treatment for patients with UARS is not currently known. Continuous positive airway pressure (CPAP) has been quite useful in the treatment of sleep-disordered breathing and there are some notable positive results in CPAP treatment of UARS. In a study of 15 heavy snorers with clinical evidence of UARS, treatment with nasal CPAP was associated with decreases in observed nocturnal arousals on polysomnography and decreases in mean sleep latency times on multiple sleep latency testing (MSLT) after several nights of treatment.3,36 A follow-up study of 15 subjects (in the original description of UARS) with daytime sleepiness and fatigue and who had undergone a therapeutic trial of positive pressure therapy reported similar findings. After treatment with approximately a month of nasal CPAP, significant improvements were seen in mean sleep latency times on MSLT (5.3 minutes vs 13.5 minutes), Pes nadir pressure (-33.1 cm H2O vs -5.3 cm H2O), amount of slow-wave sleep (1.2% vs 9.7%), and EEG arousals (31.3 vs 7.9 events/hour of sleep). Along with an improvement in sleep latency times on MSLT, there were subjective reports of improved daytime symptoms. Lastly, in a study of 130 postmenopausal women with chronic insomnia and evidence of UARS (n=62) or normal breathing (n=68), treatment with either nasal turbinectomy or nasal CPAP was associated with improvements in subjective reports of sleep quality as measured with a visual analog scale as well as mean sleep latency times on polysomnography. Despite the growing body of evidence supporting the use of positive pressure therapy for UARS patients, it remains difficult to obtain therapy. In a follow-up study of more than 90 patients conducted 4 to 5 years after the initial diagnosis of UARS was made, none of the subjects were receiving CPAP treatment; the main rationale given was that their insurance provider declined to provide the necessary equipment. Formal follow-up clinical evaluations of these patients noted significant worsening in their sleep-related complaints, with increased reports of fatigue, insomnia, and depressive mood. More disturbingly, prescriptions for hypnotics, stimulants, and antidepressants increased more than fivefold.

Other interventions, such as surgery or oral appliances, have also been used with some success in the treatment of patients with UARS. Procedures such as uvulopalatopharyngoplasty, laser-assisted uvuloplasty (LAUP), septoplasty with turbinate reduction, genioglossus advancement, and radiofrequency ablation of the palate have all been described in the literature.37-40 A study of LAUP in nine patients with UARS who underwent uvulopalatopharyngoplasty (n=2), multilevel pharyngeal surgery (n=1), or LAUP (n=6) reported improvements in subjective daytime sleepiness as measured with Epworth Sleepiness Scale scores. In the two patients for whom postoperative polysomnographic data was available, significant improvements in Pes nadir pressures were seen. But patients had several interventions and it is difficult to assess which one was successful. A study of 14 patients with UARS who underwent radiofrequency ablation of the palate also reported improvement in subjective sleepiness, with concurrent improvements in Pes nadir levels and reports of snoring. However, prior reviews of the available literature have noted that many of the studies evaluated small numbers of patients, consisted of uncontrolled case reports or series without clear characterization of the subjects enrolled, and had no consistent end points for an adequate evaluation of efficacy. Further investigation is required to determine the specific role for surgical intervention in these patients. Other authors have also reported successful treatment of UARS with use of oral appliances, although these studies suffer from the same limitations as the surgical literature. In children, orthodontic approaches, such as maxillary distraction or use of expanders, have also shown promising results.

Conclusion
Although UARS has a symptomatology close to the one seen in patients with OSAS, there are distinct clinical differences between the two syndromes. In clinical studies, it is seen more in younger, slim subjects and in premenopausal women; it is more commonly associated with an increase in vagal tone during sleep than with sympathetic hyperactivity (as seen in association with apnea and hypopnea and oxygen desaturation).21 Can individuals with UARS become patients with OSAS? Guilleminault and colleagues suggested that weight increase (with development of a chest-bellow problem related to abdominal obesity) and the association of the supine position and sleep (leading to a restrictive impairment and secondary oxygen saturation drop and sympathetic hyperactivity) will lead to passage from one presentation to another with different complications; but more data are needed from additional systematic, longitudinal studies. UARS is underdiagnosed owing to unfamiliarity with the syndrome and the lack of polysomnographic criteria for either hypopneas or apneas that are associated with other types of sleep-disordered breathing. The advent of use of an esophageal catheter for esophageal pressure measurement (Pes) has allowed clinicians to more clearly identify patients with UARS. Although Pes measurement is the most sensitive method available to detect the abnormal respiratory events in UARS, it has not been used widely for several reasons, including lack of clinician experience and patient reports of discomfort. Usage of the nasal cannula pressure transducer allows recognition of flow limitation. But guidelines on how to tabulate the amount of flow limitation during total sleep time are lacking. Patients with UARS have significant impairment in their daytime functioning, with reports of sleepiness, fatigue, and sleep disruption. A follow-up study of these patients has shown that they often go untreated and experience progressive worsening of their symptoms. Among those patients who have been treated, typically with CPAP therapy, many have experienced symptomatic improvement. The current fund of knowledge regarding UARS has been growing, and we are beginning to understand the underlying pathophysiology.
02-23-2012 12:42 AM
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jamica5555 Offline

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Post: #2
RE: Upper Airway Resistance Syndrome
So to diagnose UARS you have to have something more extensive done some type of tube in the throat, or is there another way?
02-21-2013 01:43 AM
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archangle Offline
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Post: #3
RE: Upper Airway Resistance Syndrome
My understanding is that a definitive diagnosis requires a small tube to be inserted into your airway during a sleep test.

I believe that an experienced person can make a pretty good guess from a PSG test or even data from a good CPAP by studying the shape of the airflow waveforms and other data.

Unfortunately, the insurance companies tend to deny coverage for UARS treatment with CPAP.

Get the free SleepyHead software here.
Useful links.
Click here for information on the main alternative to CPAP.
If it's midnight and a DME tells you it's dark outside, go and check it yourself.
02-21-2013 07:24 PM
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woozie38 Offline

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Post: #4
RE: Upper Airway Resistance Syndrome
(02-23-2012 12:42 AM)zonk Wrote:  [copied from old forum]
Upper Airway Resistance Syndrome
Professional Practice Gap
Over the past few years, numerous articles have been published that have increased our understanding of the features of upper airway resistance syndrome (UARS). UARS has been previously described as a distinct clinical syndrome, although there is ongoing controversy and some consider it to be part of a spectrum of sleep-disordered breathing that includes primary snoring, obstructive hypopnea syndrome (OHS), and obstructive sleep apnea syndrome (OSAS).

G'day zonk, I read with great interest your post on UARS. I'm beginning to think this may explain why. after nearly 15 years of PAP therapy, I still feel much the same as I did when I started. My question is, what can be done to help me. I am 76 and really would like to lose this foggy fatigue and have some energy to complete my life.
My AHI is not high but as a percentage of events in the pie chart hypopnoea is by far the most dominant feature. I have an appointment with a sleep specialist next month, but am not hopeful as many of these docs are less informed than some of the posters on this forum. This SH report is typical of all my nights. Any help or advice from anyone - much appreciated.

[Image: signature.png]Keep on breathin'
10-07-2014 06:41 PM
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zonk Offline

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Post: #5
RE: Upper Airway Resistance Syndrome
Hi woozie38
vsheline is your man, Vaughn knows a great deal about this subject and very helpful

UARS: A Critical Link to Optimizing PAP Therapy Results by Barry Krakow MD
http://www.apneaboard.com/forums/Thread-...-and-BiPAP

If were me, try avoid sleeping on my back and turn off senseawake

I might also do a trial with S9 AutoSet or AirSense 10 AutoSet 4Her
Both machines differentiate between central apnea and obstructive apnea and AirSesne 10 AutoSet 4Her report RERAs in all 3 modes (CPAP, AutoSet, AutoSet 4Her)

Edit: S9 AutoSet is more aggressive treating hypopnea than s8 AutoSet because of the enhanced algorthim
S8 AutoSet did not treat apnea above 10, my S8 used to score quite a lots of hypopnea
(This post was last modified: 10-07-2014 07:48 PM by zonk.)
10-07-2014 07:37 PM
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PsychoMike Offline

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Post: #6
RE: Upper Airway Resistance Syndrome
(02-21-2013 07:24 PM)archangle Wrote:  My understanding is that a definitive diagnosis requires a small tube to be inserted into your airway during a sleep test.

I believe that an experienced person can make a pretty good guess from a PSG test or even data from a good CPAP by studying the shape of the airflow waveforms and other data.

Unfortunately, the insurance companies tend to deny coverage for UARS treatment with CPAP.

100% definitive, yes, a tube is required. But a home sleep study with oximetery and flow monitoring (as was done in my case) usually gives sufficient info for a sleep doc to make that differentiation. A high RDI / AHI ratio is a common marker.

Insurance....well, that depends on the company. Mine had no issue covering my CPAP with the sleep study's results of RDI = 50+, AHI = 6 and diagnosis of UARS. It could be that they still need to see an AHI>5, or it could simply be the insurance company accepts UARS as a legitimate health issue.
(This post was last modified: 10-08-2014 11:52 AM by PsychoMike.)
10-08-2014 11:51 AM
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