Eight hours of sleep, but you're still exhausted. You wake up feeling like garbage despite plenty of time in bed. Your partner insists you don't snore, yet something's clearly wrong with your sleep.

This could be Upper Airway Resistance Syndrome, or UARS. It's not quite sleep apnea, but it's not normal sleep either. Many providers overlook it, which is why you may not have heard of it, even if you've had it for years.

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What is UARS?

Upper Airway Resistance Syndrome occurs when your upper airway becomes partially blocked during sleep, increasing resistance to airflow.

Unlike traditional sleep apnea, where breathing completely stops or significantly obstructed, UARS involves subtle narrowing that makes your breathing work harder without fully cutting off airflow. This increased resistance forces your respiratory muscles to work overtime during sleep.

Your brain detects the struggle and briefly wakes you just enough to restore normal breathing. These are called respiratory effort-related arousals (RERAs). You usually won't remember these micro-awakenings, but they fragment your sleep and prevent you from getting the deep, restorative rest you need.

The key difference from sleep apnea is that oxygen levels typically remain normal in UARS.

Standard home sleep tests typically cannot detect UARS because they primarily look for drops in oxygen or complete breathing blockage or stops, rather than the subtle increases in breathing effort associated with UARS.

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What symptoms usually signal UARS?

The symptoms of UARS can be surprisingly varied and often mimic other conditions. This often leads to misdiagnosis or remaining overlooked. Symptoms can include:

• Persistent and overwhelming daytime fatigue that affects your ability to perform daily tasks. Despite getting adequate sleep, you wake up tired and remain exhausted throughout the day.
• Sleep that doesn't refresh leaves you feeling like you never truly rested, even after what should be a full night's sleep. You might feel like you were awake all night or experienced light, unsatisfying sleep.
• Difficulty falling asleep or frequent awakenings during the night are common. Your sleep feels fragmented, and you may struggle to fall back asleep after waking.
• Morning headaches often occur due to the increased effort required to breathe during sleep, which can result in muscle tension and increased stress.
• Cognitive problems, including difficulty concentrating, memory issues, and brain fog, are common complaints. The lack of restorative sleep affects your brain's ability to function well.
• Physical symptoms may include muscle aches, frequent urination at night, and feelings of coldness or circulation problems.
• Mental health comorbidities such as depression, anxiety, and irritability often develop from chronic sleep deprivation.

Constant fatigue can significantly impact both your physical and mental health, reducing your ability to function in daily life.

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Who is more likely to be affected by UARS?

UARS tends to affect a different demographic than typical sleep apnea. It's more common in younger adults, often in their 20s, 30s, and 40s. Women are often affected, especially during times of hormonal changes like menstruation, pregnancy, or menopause.

People with UARS are often of normal weight or thin, which is why the condition gets overlooked when healthcare providers mainly look for sleep apnea in overweight patients.

Certain physical characteristics increase the risk of UARS, including a narrow upper airway, a high palate, a receding chin, or enlarged tonsils. Nasal congestion from allergies or structural problems can also contribute to airway resistance.

Stress and anxiety can worsen UARS symptoms, creating a cycle where poor sleep increases stress, which in turn worsens sleep quality.

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How to get the right diagnosis?

Diagnosing UARS requires specialized sleep testing that measures breathing effort, not just airflow and oxygen levels. An in-lab sleep study (polysomnography) with esophageal pressure monitoring is the gold standard for diagnosing UARS.

The esophageal pressure monitor uses a thin catheter placed through the nose to measure the effort your respiratory muscles exert during sleep. This can detect the increased work of breathing that characterizes UARS, even when oxygen levels remain normal.

Many sleep centers don't routinely use esophageal pressure monitoring, so you may need to request testing at a facility experienced in diagnosing UARS.

Sleep specialists familiar with UARS will also examine your sleep architecture (amount of time spent in different sleep stages). UARS often causes fragmented sleep, characterized by frequent, brief arousals that prevent deep, restorative sleep.

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How is UARS treated?

Treatment for UARS focuses on reducing upper airway resistance and improving sleep quality. The approach depends on what is causing the increased resistance in your case.

• Continuous Positive Airway Pressure (CPAP) can be effective for UARS by providing enough pressure to keep the airway open. People with UARS often require lower pressures than those used for sleep apnea, and some may benefit from bilevel pressure (BiPAP), which varies between inhaling and exhaling.
• Oral appliances that reposition the jaw or tongue can help open the airway and reduce resistance to breathing. These are often well-tolerated and can be effective for people with jaw positioning issues.
• Nasal treatments address congestion or structural problems that contribute to airway resistance. This might include allergy management, nasal sprays, or surgery to improve nasal breathing.
• Positional therapy can help if your UARS is worse when sleeping on your back. Special devices or techniques can help you maintain a side sleeping position.
• Surgical options may be considered in rare cases for structural problems that contribute to airway resistance. These could include procedures to address nasal obstruction, enlarged tonsils, or jaw issues.

Every patient requires a personalized approach tailored to their unique circumstances. A sleep specialist will be able to guide you through your options.

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Does lifestyle play a role?

Lifestyle modifications can improve UARS symptoms, often in combination with other therapies.

• Sleep hygiene becomes important when your sleep is already fragmented. Maintaining consistent sleep and wake times, creating an optimal sleep environment, and avoiding stimulants before bed can help maximize the quality of your sleep.
• Weight management may be beneficial for some individuals with UARS, although many with the condition are already at a normal weight.
• Stress management is crucial because stress and anxiety can worsen sleep quality and increase airway resistance. Relaxation techniques, therapy, or stress reduction strategies can help.
• Allergy management can help reduce nasal congestion, which contributes to airway resistance. This might involve identifying triggers, using medications, or making environmental changes.
• Sleep position matters for many people with UARS. Sleeping on your side rather than your back often reduces airway resistance.

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Why are diagnosis and treatment so important for UARS?

Unlike some sleep disorders that primarily affect older adults, UARS often impacts people during their most productive years.

Untreated UARS can significantly impact your quality of life and long-term health. Chronic sleep fragmentation affects cognitive function, mood, immune system function, and cardiovascular health. Constant fatigue can impact your work performance, relationships, and overall well-being. Many people with undiagnosed UARS struggle with depression or anxiety that may improve with proper sleep treatment.

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If you're experiencing persistent un-refreshing sleep and/or fatigue despite adequate sleep, our sleep specialists at Neura have experience with UARS diagnosis and treatment. Book a visit to discuss your symptoms and explore whether UARS might be affecting your sleep and quality of life.

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