How is UARS Diagnosed?

Good afternoon: With the help of Chunky Frog and Pugsy, Latinist and many, many others, I have been a succesful NEWBIE! I finally got the hang of the CPAP machine and actually don't mind it at all. In fact, the worst part of the whole thing for me is the cleaning in the morning of the tubes, mask because I am so crunched for time for work at 5:30 am every morning.

Unfortunately, as I wrote before, I am still not having good sleep and wake up almost every hour with vivid dreams. Pugsy and I dicussed the possible of this insomnia being Cymbalta related that I need to take for my low-back pain. The doc I see now (I am changing in July) feels that the Cymbalta is not causing insomnia (awakenings in the middle of the night, frequent with more dreams), and feels even if it is insomnia, well this is just the "side effects" of Cymbalta. You take the good with the bad. I am wondering about UARS. I have mild apnea and could not be tested in a hospital sleep study lab, as I was unable to sleep at all (and I normally don't have trouble falling asleep). It's a shame I could not complete the hospital lab (I had a home study sleep test which diagnosed a lot of snoring, breathing issues, but of course, does not measure brain waves. Since my apnea is mild, could UARS be responsible for all the awakenings, as it seems I have the sleep apnea under control. Leak rates of 13, AHI's of 0.0, 0.4., 0.5, 0.8 and pressure of 13 with a 10-20 range. How would UARS be tested? And wouldn't the control of the sleep apnea (which I think I have mastered) help the UARS as well? Thank you very much.

Luthie2006 wrote:Good afternoon: With the help of Chunky Frog and Pugsy, Latinist and many, many others, I have been a succesful NEWBIE! I finally got the hang of the CPAP machine and actually don't mind it at all. In fact, the worst part of the whole thing for me is the cleaning in the morning of the tubes, mask because I am so crunched for time for work at 5:30 am every morning.

Unfortunately, as I wrote before, I am still not having good sleep and wake up almost every hour with vivid dreams. Pugsy and I dicussed the possible of this insomnia being Cymbalta related that I need to take for my low-back pain. The doc I see now (I am changing in July) feels that the Cymbalta is not causing insomnia (awakenings in the middle of the night, frequent with more dreams), and feels even if it is insomnia, well this is just the "side effects" of Cymbalta. You take the good with the bad. I am wondering about UARS. I have mild apnea and could not be tested in a hospital sleep study lab, as I was unable to sleep at all (and I normally don't have trouble falling asleep). It's a shame I could not complete the hospital lab (I had a home study sleep test which diagnosed a lot of snoring, breathing issues, but of course, does not measure brain waves. Since my apnea is mild, could UARS be responsible for all the awakenings, as it seems I have the sleep apnea under control. Leak rates of 13, AHI's of 0.0, 0.4., 0.5, 0.8 and pressure of 13 with a 10-20 range. How would UARS be tested? And wouldn't the control of the sleep apnea (which I think I have mastered) help the UARS as well? Thank you very much.

Luthie2006,

I am not sure how to put this delicately but doctors generally tend to minimize side effects. Obviously, you will have to make up your own mind about Cymbalta but I know if I was on the med and I was having horrific sleep, I would either ditch the med or switch to something else if I felt I needed to be on an antidepressant.

Yeah, UARS can cause awakenings but in my opinion, I would be looking at Cymbalta. Of course, I am not a doctor so keep that in mind.

49er

Thanks 49'r, so UARS can cause awakenings even though my sleep apnea numbers were excellent in the morning on the LCD? Unfortunately as I told Pugsy, I need the Cymbalta for the low-back pain (not anti-depressant issues) and allegedly supposedly that medication with the combination of Celebrex seems to be holding my back pain steady at a 0-2 back pain, and I don't have pain sleeping usually. I am going to see a new Primary at the end of July and see what his opinion is. Pugsy told me about a med that I will also mention to the doctor. But my pain level was at a solid chronic "10" every day, all day, every minute, sitting, laying, sleeping, walking. I have not had trauma, just horrendous degentative disc disease. So I think my Primary is thrilled (or owns stock in Eli Lilly) that I am on 2 meds that help my back. I am not sleeping well, and I know now this has nothing to do with the pressure of the CPAP machine. Well, I solved one problem (for now) at least, the CPAP machine does work, and according to my numbers that I will be bringing in to my sleep clinician soon, my sleep apnea with machine works well for me. I still have insomnia for some reason even though I am relaxed and rested, with frequent awakenings, but I least I am breathing well. Any idea how UARS is diagnosed?

Luthie2006 wrote:Good afternoon.How would UARS be tested? And wouldn't the control of the sleep apnea (which I think I have mastered) help the UARS as well? Thank you very much.

Reply,

Yes, from the several treatments of UARS the PAP therapy is the simplest. See my posts here:

viewtopic.php?f=1&t=98136&p=909902#p909902


Why should Cymbalta cause a back ache, and what kind of backache are you talking about? Is it a lumbar Spinal Stenosis for which I had surgery for a couple of months ago?

Thank you Avi123: No, the Cymbalta does not cause a backache. It prevents my back from giving me pain (supposedly) along with Celebrex and Cymbalta blocks the pain receptors in the brain from perceiving pain in the lower back. I have degerative disc disease, spondylosis, spondylothesis (Grade 1),
2 bulging discs, facet joint swelling. I went to a spine surgeon who mostly what he does is surgery, and he stated that he would not do surgery on me, as it is a progressive dengerative disease from aging. So Cymbalta blocks the pain perceived in the lower back, although I think that it causes awakenings. How did your spine surgery go? I hope you are doing well and not in too much pain.
Luthie2006 at lunch hour at work.

Good afternoon.How would UARS be tested? And wouldn't the control of the sleep apnea (which I think I have mastered) help the UARS as well? Thank you very much.

Let me try to answer "How UARS is diagnosed" part of the question, partially sharing my 4 years experience dealing with it. I think I have UARS, too - but I've never been formally diagnosed with it. All I had is a VERY mild sleep apnea diagnosis (AHI just barely over 5 threshold) and really bad sleepiness and brain fog symptoms.

There is a "golden standard" of using a pressure probe placed in the airway for UARS study (don't know exact details as I've never been through it). But for whatever reasons most doctors (including Stanford sleep which is in a turn a "golden standard" of sleep medicine in the US) don't use it.
So while a sleep study can accurately record arousals during the sleep, linking them to breathing is problematic, and (at least for me) they always ended up in the "spontaneous arousals" category. The problem is that there is no accepted threshold for those, so whether you have 10 or 100 per hour - there will be no diagnosis or treatment suggested.
as a result, I've been in CPAP for almost 3 years without any improvements - which eliminated apneas but not symptoms. Then on bilevel for another 6 months with the same results. Now on ASV for 3 months and finally seeing things getting better.
In my own experience, sustained sleep quality is the most reliable indicator of the treatment actually working. By "sustained" I mean being able to sleep for 6-8 hours without awakening during the night and troubles getting back to sleep, for more than a week or two after starting a new treatment.
Last part was tricky for me as virtually ANY improvement in the treatment leaded to a good night sleep for few nights, before things got worse again.
While on CPAP I managed to eliminate leaks - it gave me a week of good sleep; then back to those awakenings and morning headaches.
Switched to bilevel - a week of good sleep again, then night awakenings are back.
gradually Increased PS setting on bilevel - also refered as a "gap" (Dr Krakow suggested in one of his articles that UARS patient benefits from higher pressure support) - few good night sleep before reaching level of 7 which gave me massive central apneas.
Finally, unable to convince doctors to try ASV bought one off craigslist - that's where things started to get better. I've spent a month on older ASV device and had decent sleep during that month. Used that as an argument with the doctor to have an ASV study, got it done and got S9 ASV machine two month ago. my sleep became even better - a week without a single 2am awakening is a norm now. Brain functioning is not yet 100% back but it is improving, and I know it takes longer.
You asked whether CPAP/apnea treatment helps with UARS - the answer is it depends. For some it does and for other it does not. Some doctors believe ASV treats UARS better, but others (and insurance companies, too) do not.

Here is some reading that ultimately helped me to find a solution:
our-collective-cpap-wisdom/flow-limitat ... BiPAP.html
http://www.sleepreviewmag.com/2014/01/a ... a-and-sdb/

Good luck

Luthie2006 wrote:Thank you Avi123: No, the Cymbalta does not cause a backache. It prevents my back from giving me pain (supposedly) along with Celebrex and Cymbalta blocks the pain receptors in the brain from perceiving pain in the lower back. I have degerative disc disease, spondylosis, spondylothesis (Grade 1),
2 bulging discs, facet joint swelling. I went to a spine surgeon who mostly what he does is surgery, and he stated that he would not do surgery on me, as it is a progressive dengerative disease from aging. So Cymbalta blocks the pain perceived in the lower back, although I think that it causes awakenings. How did your spine surgery go? I hope you are doing well and not in too much pain.
Luthie2006 at lunch hour at work.

Lutie2006, I had lumbar discs problems since 1963. Two months ago I had Laminectomies surgery (without Fusion and no Hardware) on L2, L3, and L4. NO facets were cut. I still have some pain shooting into both legs, (not while a sleep). But every day it is less and less. Still using a cane so not to lose my balance and fall.

The following was my MRI before surgery:

I should have done this surgery 20 years ago (while in my 60s) and then also should replaced both of my knee joints.

Patient Name: Avi....
Unit No: M000191378

EXAM# TYPE/EXAM RESULT
001263927 MRI/MRI LUMBAR SPINE WO

LUMBAR SPINE MRI WITHOUT CONTRAST

CLINICAL INFORMATION: 724.02 SPINAL STENOSIS,LUMBAR REGION. Low back
pain with bilateral lower extremity radiculopathy, right worse than
left. Bilateral lower extremity paresthesias.

PROCEDURE: Routine lumbar spine MRI without contrast.

COMPARISON: None

FINDINGS:

L4-L5 grade 1 anterolisthesis due to severe facet arthropathy.
The lumbar vertebral body heights are maintained.
The conus medullaris is positioned at the L1 level.

There are Modic type I acute degenerative endplate signal changes at
L1-L2, L2-L3, and L4-L5.
Numbering of the lumbar segments is predicated upon the presence of
five lumbar type vertebrae.

T12-L1: Disc desiccation. No disc herniation. No stenoses.

L1-L2: Disc desiccation. Endplate remodeling. Moderate
circumferential disc bulge. Severe spinal canal stenosis with
compression of the cauda equina (image 8, series 2; image 21, series
7).

L2-L3: Disc desiccation. Large circumferential disc bulge. Moderate
facet arthropathy. Severe spinal canal stenosis with compression of
the cauda equina (image 17, series 7; image 8, series 2). Moderate
bilateral neuroforaminal narrowing.

L3-L4: Disc desiccation. Moderate disc height loss. Mild diffuse
posterior disc herniation. Posterior endplate spurring. Severe
bilateral facet arthropathy. Severe spinal canal stenosis. Severe
bilateral neuroforaminal narrowing (image 3 and 11, series 2).

L4-L5: Disc desiccation with moderate disc height loss. Rate 1
anterolisthesis due to severe bilateral facet arthropathy. Severe
spinal canal stenosis. Severe bilateral neuroforaminal narrowings
with compression of the foraminal left L4 nerve root (image 3, series
2).

L5-S1: Disc desiccation with mild disc height loss. Moderate diffuse
PAGE 1 Signed Report (CONTINUED)


Phys: Bagley,Carlos A {my Spinal Neurosurgeon, Google his name}
Exam Date: 02/06/2014 Status: REG CLI

Patient Name: Avi
Unit No: M000191378

EXAM# TYPE/EXAM RESULT
001263927 MRI/MRI LUMBAR SPINE WO

posterior disc herniation. Moderate bilateral neuroforaminal
narrowing.


IMPRESSION:

1. Severe spinal canal stenosis at L1-L2, L2-L3, L3-L4 and L4-L5
(worst at L1-L2 and L2-L3) due to multiple disc herniations and facet
osteoarthropathy.

2. Severe bilateral neuroforaminal stenoses at L3-L4 and L4-L5


** REPORT SIGNED IN OTHER VENDOR SYSTEM 02/06/2014 **
Reported By: Tedric D. Boyse MD {read my MRI}

To Avil123: So sorry to hear and read about your lumbar issues. I am getting there as well, but hopefully not as bad. I am glad you are healing up and taking care of yourself.

I never heard of ASV. I am a Newbie. I have an S9 autopap machine and to make matters more difficult, like I said, I had a very limited hospital lab sleep study that I could not sleep at. At the home sleep study, I slept well but of course no EEG on that.

I want to learn more about UARS and will read your article. You health well, and take care of yourself. And perhaps you can enlighten me on an ASV?
Adapt Servo Ventilation? Is this a machine?

Luthie2006, I think that you can find most of the questions that you had about the formal diagnosis of UARS in this paper by Guilleminault, the father of UARS.

http://www.medscape.com/viewarticle/494651

If you don't want to read through the multiple screens at this address, the short summary is:
1. There is a difference in the physiology between UARS and OSA. He says that OSA patients tend to be overweight and predominantly male while UARS patients have slender builds and are often female.
2. While the measures of OSA severity and quality of treatment are the AHI value and O2 desaturation, most UARS patients tend to have untreated AHI values <10 and O2desat values >92%.
3. The complications from untreated UARS are different from those of OSA.
4. Studies of throat tissues from OSA and UARS patients have shown nerve damage in the OSA cases but not in the UARS. He postulates elsewhere that this means that as the throat collapses, a UARS patient's nervous system is able to detect the collapse and rouse the individual. This results in frequent Respiratory Arousals (RERAs) that can only be properly detected by EEG (since it needs to be determined that the patient has awakened (at least partially).
5. Proper diagnosis of UARS requires the use of either an esophageal catheter to measure pressure (Pes) or the use of a sensitive nasal cannula that measures pressure changes. Most hospitals and clinics that conduct sleep studies are not set up to do the Pes measurements and only a few are currently using the nasal cannulas.

Finally, you should be aware of the fact that many insurance companies will not cover any form of treatment for UARS. There are too many members of the medical community that see UARS as mini-OSA rather than a separate condition that requires further study and treatment to prevent future or current complications.

I hope that answers your question about how UARS is diagnosed, at least by the views of the doctor who coined the term.

Thank you RustSmith and Avil123.
I have the CPAP mask and machine to work now but still waking up all the time at night "just looking at my pillow."
I will ask my doctor about UARS? The Medscape did not open, but I appreciate the explanation. I think I have UARS and not insomnia from Cymbalta.
Thank you for enlightening me.

I want to learn more about UARS and will read your article. You health well, and take care of yourself. And perhaps you can enlighten me on an ASV?
Adapt Servo Ventilation? Is this a machine?

Yes, ASV is an adaptive servo ventilation machine. It is designed to treat central apneas by constantly monitoring breathing patterns and volume and dynamically adjusting pressure to compensate lack of respiratory efforts. There is no medical consensus that it is a preferred way to treat UARS - my doctor at Stanford told me that although it's possible that I have UARS, he does not believe ASV would help me. However other doctors do practice prescribing them for UARS, although getting it covered by the insurance is not trivial (for example they need to show complex/central apneas to justify)

Luthie2006 wrote:To Avil123: So sorry to hear and read about your lumbar issues. I am getting there as well, but hopefully not as bad. I am glad you are healing up and taking care of yourself.

I never heard of ASV. I am a Newbie. I have an S9 autopap machine and to make matters more difficult, like I said, I had a very limited hospital lab sleep study that I could not sleep at. At the home sleep study, I slept well but of course no EEG on that.

I want to learn more about UARS and will read your article. You health well, and take care of yourself. And perhaps you can enlighten me on an ASV?
Adapt Servo Ventilation? Is this a machine?

Reply,

Luthie2006 {is it not Lutsie and you probably speak Hungarian as my parents did}, in my opinion if you don't have Central Sleep Apnea syndrome than you don't need ASV. About the UARs(Upper Airway Resistance Syndrome), Dr Baryy Krakow ("Kraiko") recommends a BiPAP {BiLEVEL} machine which would allow you to use higher pressure on inhalation than for exhalation.

About that Cymbalta which you mentioned. My Internist Doc #1 c a year ago came up with an idea that I could replace three of my daily meds by taking Cymbalta. I could stop taking: Paroxetine HCL 10 mg (generic Paxil) plus Alprazolam 0.5 mg (generic Xanax) plus Gabapentin 300 mg capsule {all once daily} and instead take Cymbalta. He even gave my samples and a card for a one year free supply. BUT, my internist Doc #2 who also happened to be a Geriatric Doc told me NOT to take Cymbalta and explained why. So I have not done it. NO CYMBALTA FOR ME. In the meantime I stopped taking the Paxil. My wife is proud of me doing that. Paxil is a first class Rx hooker.

About my lower back spinal surgery (open Laminectomy), I sleep well with my CPAP. I took only 5 mg of Zolpidem before going to sleep. I slept for 7 hours with one only wakeup to go pee. But after waking up at 7 a.m. ALL my legs, hip's, and lower back, muscles, were sort of uncomfortable {semipainful}. Walking around inside my house took all the pain away.

p.s. you posted that Medscape did not open. You can't enter that article on UARS in CHEST without paying subscription for it. I entered it before it became closed and posted the content in my above post. I repeat here the treatment suggested for UARS:

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.3 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.19 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.1 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.37 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.40 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.39 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.41 In children, orthodontic approaches, such as maxillary distraction or use of expanders, have also shown promising results.42

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 colleagues1 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.1 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.43 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.

Thank you very much AVil123. I appreciate the information. I will speak to my sleep doctor hopefully next week and find out if he thinks that I have UARS. I fit all the symptoms, except I am not slim, I am a woman, I am post-menopausal, have a very large tongue and a very small jaw according to my ENT and dentist. NO SURGERY for me to have my tongued ablated or anything else. Thank you for the information. Knowledge is power and at least I know that I have bi-level in the back of my head too to bring up. I know that they said my AHI was so low (another symptom of UARS) that I would never need a bi-level machine. I will speak to them next week. Thank you kindly.
Luthie2006 It is a nick name for where I work, although I am of your faith as well.