The Reason For Asking My 3 Questions

[Steven Y Park, MD]

I asked everyone on this forum the following 3 questions:

1. do you prefer to sleep on your back, side or stomach?
2. did you or do you have cold hands or feet?
3. did or do either of your parents snore and do they have any medical problems?

Overwhelmingly, the answers were: mainly side and stomach only, the vast majority have cold hands or feet, and almost everyone has one or two parents that snore heavily with various degrees of heart disease. Many of you also complain of intense fatigue.

This sounds amazingly like what I see in patients with upper airway resistance syndrome. UARS is a mild variation or precursor to sleep apnea, but it's different in that it's typically seen in young thin women (and men) who don't snore, can't sleep on their backs, have cold hands or feet, have normal or low BP with lightheadedness or dizziness, chronic fatigue and unrefreshing sleep no matter how long one sleeps, various unexplained gastrointestinal problems, hypothyroidism, depression, and many others. Later on, as they gain weight many of these symptoms improve (especially the cold hand and dizziness), but begin to develop high blood pressure, diabetes, heart disease, heart attack or stroke.

Anatomically, they all have relatively narrowed jaws with very narrowed breathing passageways when on their backs. Due to gravity, the tongue (which takes up too much space within a smaller jaw cavity) falls, back partially, and then when in deep sleep, can obstruct completely due to muscle relaxation. If you stop breathing and wake up after 10 seconds, then that's called an apnea. If you stop breathing and wake up anywhere from 1-9 seconds, then you'll wake up to light sleep or be awake, but it won't get counted as an apnea. The minimum number of apneas you need every hour on average to receive a diagnosis of sleep apnea is 5. But if you stop breathing 25 times every hour and wake up after 2-9 seconds, then you're told you don't have any sleep apnea.

There is a significant group of people who stay in UARS, and with the chronic extra stress response due to the inefficient sleep with repeated arousals, their nervous systems and immune systems are heightened. Having a hypersensitive nervous system or immune system can have certain consequences. UARS patients have normal or heightened nervous systems, whereas OSA patients have diminished nervous systems.

Your anatomy is hereditary, so you got your smaller jaws from one or both of your parents. As people with UARS get older and gain more weight, they'll have the classic signs and symptoms of obstructive sleep apnea: severe snoring, breathing pauses, and medical complications such as heart disease, depression, heart attack or stroke.

I can't say if one definitely causes the other but I can say that there's a definitely link between MS and sleep-breathing problems. Some of you already have sleep apnea. I know it's impractical, but it would be interesting if everyone could get formal sleep studies to see how many people with MS have OSA or UARS. One is not exclusive of the other, so if you have a family history of snoring and heart disease, it's important to get checked for sleep apnea.

Snoring is a sign of major breathing problems at night, and is nothing to be laughed at. A heavy snorer should definitely be checked for sleep apnea, since untreated, it raises your heart attack and stroke rate by 3 and 5 times, respectively. Not to mention high blood pressure, obesity, depression, anxiety, heart disease, and Alzheimers (this one's controversial, but there's plenty of convincing evidence). Also, you don't have to snore to have significant sleep-breathing problems.

[Steven Y Park, MD]

It sounds like you're OK from a breathing standpoint, but in some people, they can have major breathing issues that don't show up on a formal sleep study. This is a very technical explanation, but most people with UARS will have more than the usual spontaneous arousals, some of which are related to slight breathing pauses, but most of which are not.

One possible explanation that I heard from Dr. Guilleminault, a Stanford pioneer in sleep medicine and the person that originally described UARS is as follows: As your airway starts to narrow due to muscle relaxation, there are pressure sensors in your throat that picks up the fact that you're about to stop breathing. It sends a signal to your deep brain areas and your brain sends a signal to the rest of the body (and the tongue) to wake up to a lighter stage of sleep to prevent the tongue from collapsing. All this happens automatically, without you ever being aware, and without any evidence of brain wave activity on the scalp EEG leads since these signals never reach the outer brain areas.

There are other ways to determine UARS and the consequences of inefficient deep sleep, such as inspiratory flow limitation (IFL - seen as flattening of your nasal airflow tracings) and an abnormal CAP analysis (mathematical analysis of your brain waves to detect deep sleep instability. This is all fascinating information that I'm sure you'll see more about in a few years.

[essdipity]

I did have an overnight study in a hospital, and saw all the graphs, etc., it produced. That's why I know it confirmed that I don't have breathing problems.

ess

[Steven Y Park, MD]

Thanks for your suggestion.

Has anyone here on this forum undergone a sleep study, and if so, what was the result?

I'm not clear—did you undergo a formal sleep study or just undergo pulmonary testing in the office?

One possible reason for why you may not be able to get deep, restorative sleep is because in certain individuals with the anatomy that I described earlier, every time you go into deep sleep, because of muscle relaxation, you'll stop breathing temporarily and wake up to light sleep. You'll never know if you wake up at all. If these pauses last for more than 10 seconds, then it's called an apnea. But people with upper airway resistance syndrome can stop breathing 10-20 or more times every hour and will have no apneas on a sleep study. These are the "light" sleepers, prone to waking up with every sound, movement or pain in the body. Also, there is no typical sleep apnea or UARS patient.

[essdipity]

Why not ask the members here whether they've had a sleep study? I had one last spring, and followed up with a sleep specialist who is a pulmonologist. I even had to go through a half hour of breathing tests in her office. As I was virtutally sure, my sleep problems are not from sleep apnea or anything related to breathing. I just don't get anywhere enough deep and restorative sleep.

Many of our members, diagnosed and otherwise, do have sleep problems, and quite a few have had sleep studies. You might be interested in their experiences.

ess

[opie74]

Thank you for all of your time!  I have learned alot!

[sllowe]

Thank you so much for this!

So, you think you can get up some funding for a study? You've already got the participants! Count me in!

Thank you again, Dr.

-Shell