Look into UARS. Most sleep labs aren't assessing for UARS though. So they don't score the RERAs (respiratory effort related arousals). Such labs/docs say 'you don't have apnea, so you don't have a problem' which is more about 'insurance doesn't pay me to diagnose and treat this problem you have, therefore, your problem isn't my problem'. So, it ends up just being the patients problem...or they get sent to a psychiatrist for the somatic symptoms resulting from the sleep breathing issues the sleep doc isn't acknowledging.

Usually, the sleep docs/ents that diagnose and treat UARS either went to a school that is famous for sleep med (like Stanford) or had the problem themself and had to figure out how to treat it and now offer the same care to patients in need.

UARS patients will desat, but not necessarily by much, so SP02 isn't the best measure. If your study shows a high number of arousals that the sleep doc said weren't related to respiratory events, then UARS is quite possible. Figuring out if Airway plays a role in TMD/Sleep is more about measuring how active the autonomic nervous system is compensating to maintain airway patency. If the ANS is compensating, then addressing the anatomical/environmental insults impairing the airway can resolve the symptoms (i.e. sleep bruxism or a forward head posture).

You're seeing the inherent problem with the AHI already, but I'll spell it out more clearly. If someone has an apnea/hyponeas lasting 9 seconds 1000 times a night, they have an AHI of 0. If someone has an apnea/hyponea lasting 10 seconds 5 times a night, they have an AHI of 5, which is a serious medical condition which would benefit from treatment. From a physiologic standpoint, it would be absurd to suggest the first person has a lesser problem than the second, yet that is what many sleep laboratories are doing. The AHI is a...'good enough' metric that many phsycians focused on patient well-being use as only one part of assessing sleep breathing. For doctors like Steven Park, "Treat the patient, not the numbers"; the AHI is a suggestion whose primary utility is improving how well medical insurance can be utilized during patient care.

I had an AHI of 4.7, but 76 arousals through the night. My Sleep Study did not score RERAs, and doc said 'something else other than breathing is at fault'. A year later, an ENT says 'you definetly have UARS based upon symptoms and indications in the sleep study'. Which, by that time came as no surprise to me, but it took two years of educating myself on airway, sleep, and craniofacial anatomy to learn as much.

@LastQuestiom:  Thanks for the reply.  My study was done at Stanford and did include testing for UARS (my general doc did not order UARS monitoring, but I had read up on it and asked for it).

The official conclusion of multiple docs at Stanford was... no Apnea, no UARS.

My report does not show the number of RERAs but does show a RERA index of 1.1, and a RDI of 2.8.

I had 0 apnea events, and 9 hypopnea events.  

I did have 284 PLM events, but all were w/o arousal.

On the whole the Stanford sleep docs were pretty useless.  Definitely seemed a case of treating numbers instead of the patient, and stupidly or lazily focusing on arbitrary and binary thresholds and notions of normal/abnormal.

When you say you had 76 arousals, do you mean apnea + hypopnea events?

Re: the ANS compensating, not clear how this would be measured.  Also I'd think oxygen levels during sleep would be a good indicator of airway problems.

It doesn't get much better than Stanford for sleep studies. Of course, the study quality would differ based upon the treating doctor. So, maybe there's more to your sleep, but I don't have much to offer in terms of 'better' options for sleep studies.

I had 76 arousals during the night of my study which the sleep doctor said were not related to respiratory events. Essentially, I just 'woke up' for reasons unknown. He suggested it was due to 'jaw pain' related to bruxism. In studying further I've gathered my bruxism/jaw pain are related to my airway issues, and it is during sleep that these are at their worst. In addition, there's a history of pediatric OSA diagnosed a decade earlier, treated with tonsiladenoidectomy/septoplasty, and the literature shows high rates of relapse with that approach. My patient history supports an assertion of relapse occuring. My anatomy supports the assertion of airway compromise being responsible for the continued health issues. My Sleep doc, however, limited his diagnosis to the sleep study. An ENT I saw, though, acknowledged the problem and recommended maxillary expansion.

So, among many functions, the ANS works to make sure you have a patent airway to breath through. There are sensors throughtout the nose, palate, and throat that detect fluctuations in pressure and adapt and it's the ANS that runs the show telling the muscles what to do. In particular, cranial nerve one plays a major role in detecting changes in barometric pressure. In additoin, the turbinites will detect flow limitation and by reflex respiratory effort will increase. The airway is such a dynamic system feeding into other systems that sleep studies have shortcomings and figuring out if someone has a problem requires taking into account anatomy and clinical finding (symptoms, pt history, understanding systems biology). The more unstable the airway, the more active the ANS is in managing the airway patency. Some behaviors the ANS quite often uses (which differ between individuals) are bruxing, clenching teeth, posturing the jaw protrusively or laterally, thrusting the tongue forward, posturing the head and neck forward, posturing the head/body laterally, and many others. For many reasons, this can result in the breathing difficulty acting as a chronic stressor, and this sensitizes the HPA-Axis and leads to these actions being 'learned as necessary to survival' and they become 'habits'. The sensitization is why so many people with airway issues get pushed into psychiatric care.

As to measuring the ANS activity, that is tricky. It's nascent science that no one really has figured out. It's a situation in which some doctors are trying to figure it out, and think it's the best tool they have for certain patients, but it's a long way from being adopted into the standard of care. I think currently the best is using a high-resolution pulse oximeter which is very sensitive to gather multiple nights of data, or using heart-rate variability as an indication of how balanced the ANS is. Even then, if someone is symptomatic and has anatomy which is deficient, then sometimes all there is to do is undergo treatment to address the anatomy and hope for the best.

Now as long as my post is, I just wanted to make it clear, I've been studying my sleep issues primarily as an airway issue with other concerns (such as mental health) being peripheral events occuring as a result of poorly functioning airway adversely impacting sleep. There are other sleep related disorders that are neurological. Brain trauma, infections (lyme as an example), exposure to toxic agents, psychotropic medications, even genetic disorders, are all known to have adverse impacts on sleep. I've even heard of Vitamin D being too low having adverse impact on the neural networks involved in regulating sleep staging... Sleep is complicated. I've 'heard of' those things, but never looked at them deeply. So, if you're having sleep issues and the study from Stanford suggests it's not due to the airway, it may be worth considering other causes with serious contemplation. Yet, if your anatomy is suggestive of airway compromise (as your presence on this forum suggests)...idk. If you live in California, and Stanford wasn't a one-off trip, there's a dentist in LA I respect a lot. Dr. Mark A. Cruz. I think if you want to follow pursuing 'is this airway' to it's max, see him next. He really understands how the face develops and it influences airway and health. And he's staying on top of the latest non-surgical and surgical treatment options to fix airway problems related to facial development. He's a very intelligent man I wish I had the resources to see myself.

Re: Stanford, the sleep study itself was fine, but the docs added little or nothing of value.  They showed little or no interest in getting to the bottom of whatever SDB or other sleep issues might be present.  Example response below.  Western docs in my experience are largely mindless drug-dispensing drones.  The Stanford docs were much the same.  None mentioned appliances or forwardontics.  

"Based off the data, which included a PES, there does not seem to be any degree of Sleep apnea or UARS (upper airway resistance syndrome) for that matter. Although you have a narrow airway, it does not manifest with symptoms of sleep apnea. The data did show that you had a delayed sleep onset and it took you a while to fall asleep. If this is a continued issue than i would recommend CBTi which is a nonpharmacologic intervention to help you with insomnia."

I'm just trying to get what I can out of the data collected and go beyond AHI.

Re: bruxism and sleep, Mew says tongue not on roof of the mouth and thus not able to counteract biting muscles is primary cause.

I'd think if your arousals were airway-related, some part of the sleep study monitoring would have picked something up. 

My anatomy is definitely suggestive of compromised airway and 3D cone beam scan showed narrowing, and i have history of bruxism, waking up gasping for breath, waking with hands clasped behind neck (involuntary), waking with tachycardia, wake exhausted, crippling CFS... the list goes on.  I actually was dx'd with Lyme but interventions along those lines mostly went nowhere.

Thx for the pointer to the LA guy.  That's a long way from me, but not out of the question.  I'm consulting with local people for now.  

Well, I'm surprised the Standford docs takes that approach to some degree, but not entirely. Being a doctor means medical libility and having practical realities that limit what they can do clinically. It's in part teh medical system that's broken. Not excusing their behavior, simply pointing out, that what's occuring isn't simply inepttitude or laziness, and understanding this has helped me better learn to navigate healthcare and make use of what I can; model the problem to find the best solution.

I mentioned the senseitization of the HPA-Axis. There are a lot of ways at attenuate the HPA-Axis and improve sysmptoms. I found yoga helpful. I found calming herbs helpful. Anything that helps vagal tone and promotes parasympathetic activity helped. CBT is known to help as well. So the Stanford docs recommendation isn't groundless. It certainly doesn't deal with the cause of your symptoms (which seem genuine and in need of being addressed) but it can help you manage better. For me, I experience muscle pain related to my airway issues, and physical therapy with dry needling helps me manage it. The pain comes back fast without it. A long-term solution will need to include fixing my anatomy, but short-term I function better going to PT once to twice a week. I've found ways to improve fatigue, but none that make me 'better' just slightly less impaired...

So, it sounds like you and I have similar situations in terms of anatomy compromising airway and being frustrated with physicians going only so far. Even if Dr. Cruz isn't close by, I'd recommend you contact his office and ask if he knows of anyone close to you. Another resource might be Dr. Jeff Rouse in Texas. He also teaches dentists on airway through Spear.

@ LastQuestion:  Yes agree the system constrains docs.  Still docs who work in that system both profit from it and perpetuate it.

I've done a lot in the area of HPA and stress response... meditation, many many herbs, magnesium, acupuncture, million other interventions. 

The Stanford doc mentioned CBT for sleep onset problem, but this problem was an anomaly caused by the study itself... pressure to fall asleep in order to get data, discomfort from cables and leads attached to head, ambient light messing with melatonin, and almost certainly insanely high levels of EMFs in close proximity.  

In some ways the process was scientifically dubious and borderline brain dead... putting people in a lab setting and then assuming the result reflects real-world.  

Thanks re: Rouse.  Will have a look at his website.

@darkindigo:  I dont know my MCA.  How did you get this?  The dentist who ordered and interpreted my cone beam scan did not quantify my airway, she just said it was narrow.

I dont have the capacity to organize starting a FB group but am interested in participating in airway discussion.

Thx re: the Utah guy.  From his site I cant tell what services he offers.

Posted by: Buggy

@ LastQuestion:  Yes agree the system constrains docs.  Still docs who work in that system both profit from it and perpetuate it.

I've done a lot in the area of HPA and stress response... meditation, many many herbs, magnesium, acupuncture, million other interventions. 

The Stanford doc mentioned CBT for sleep onset problem, but this problem was an anomaly caused by the study itself... pressure to fall asleep in order to get data, discomfort from cables and leads attached to head, ambient light messing with melatonin, and almost certainly insanely high levels of EMFs in close proximity.  

In some ways the process was scientifically dubious and borderline brain dead... putting people in a lab setting and then assuming the result reflects real-world.  

Thanks re: Rouse.  Will have a look at his website.

Dr. Rouse's website hasn't really been kept up to date. Too busy with other tasks I imagine. I'd suggest calling his office or spear education and asking if there are any dentist who have taken Dr. Rouses courses which are near to you.

Seems like you and I are on a similar journeys. It's really been disappointing with how doctors are so preoccupied with reimbursement that focusing on the patients problems  and trying to address them get's viewed as a luxury they don't have time for. Most seem focused foremost on easy reimbursement with and covering their ass for medical liability; if the patient get's well during the pursuit of those goals, then that's great, if not, #notmyproblem.

I showed up to my sleep study with blue blocking glasses, and the tech fitting me with wires thought it strange, and even made note of it being difficult to fit the wires b/c of the glasses. I find it rather remarkable how the Sleep labs design and operation seemed so ignorant of circadian biology. It would be the simplest thing in the world to have red lights for nighttime instead of blasting people with almost 5000 lux florescent lighting at 930pm. I guess they know the writing is on the wall for sleep labs going bye bye, so no sense in investing in a rennovation that reflects current knowledge. Also, so many blue and green LEDS inside the room I had to get the tech to turn off what he could and then occlude the rest with electrical tape. I really wonder what these sleep docs are really testing for with so many confounding variables; it's some strange fiction to propose one can accurately measure sleep and breathing with so many noxious inputs disrupting the biology.

@darkindigo

I haven't had my MCA measured by a dentist, but I did get them to send me home with the CBCT and a viewer. Doing it myself, the viewer says I have a 400mm2 (50CC) airway. Volume doesn't reflect collapsibility though, and my maxilla is really underdeveloped. Most of my issues are insufficient tongue space and flow limitation in the nose.

On top of this, I have a forward head posture, so...what's my airway like without a forward head posture? idk. CBCT won't show that. And so long as my airway issues persist my ANS isn't going to let proper head posture even happen. I've tried, I usually end up just making my TMD pain worse trying to get my body to do a proper chin tuck. And when I do find a way to manage to get the muscles to behave and reposition my neck/jaw, I'll have the first part of my sleep interrupted with signs of apnea (sudden waking to nightsweats, a pounding heart, and need to urinate despite very little in my bladder). Every morning my muscles have gotten super tight posturing the head and neck forward again, so I'm back to start again. I figure, the only to really fix the TMD pain is to address the airway issues that continue to provoke a forward head posture, bruxing, and jaw posturing. But, you wouldn't see that from a sleep study or HRPO. Even the anatomy doesn't make it clear. But once you plug in patient history and symptoms it's 'oh, of course'. Well, at least to someone who's studied the topic enough.

Pediatric airways are very different from adult airways. The neurology in particular. As is a child's need for sleep and the impact it has on their health (they're growing, the brain is developing; brain function is different from adults as well as having more needs to be met by deep sleep). That is why there are separate guidelines for diagnosing pediatric OSA, and it is necessary to see a pediatric sleep physician instead of a normal sleep doc. So, I'm not sure UARS applies to the pedatric population. I hear some pediatric sleep physicians voice opinions that certain symptoms (such as snoring, bed wetting, ADHD dx, or nighttime bruxing) indicate a need to treat regardless of PSG findings.

I honestly think one is better off focusing on symptoms and anatomy and after understanding those using some form of technology to get a more objective definition of the severity and type of problems present in order to guide treatment planning and act as a metric to be used to measure efficacy. i.e., big sp02 desats or small drops, RERAs, where is the flow limitation occurring?, bruxism correlates to respiratory effort?, number and frequency of arousals, altered sleep achitecture, etc. Figure out how much of this is central and how much anatomical and how well is the ANS managing the airway. Most doctors I've seen or listened to aren't really looking at anatomy and understanding how it relates to symptoms. So they get this 'study' and rely on it for an answer. Which leaves some people without a diagnosis.

Even those for whom the tools allow a diagnosis sometimes they are left with treatment that doesn't meet their needs because of the shortcomings of PSG/HRPO when anatomy/symptoms are ignored (i.e. their AHI is below 5 but they continue to have medical complications suggesting sleep/breathing is insufficiently managed). I think a common example of this is how sleep labs/docs/dentists continue to use the epworth sleep score even though we know UARS patients and others with airway issues worsening sleep will not score on it and the Fatigue Severity Scale is a better indicator. But, because insurance recognizes the epworth the sleep docs use it as part of diagnostics to get paid, so the epworth becomes the standard not because it's superior but because it gets the doctor paid. Dentists use it because they either do not know better or feel like when they communicate with doctors they need to use tools doctors are familiar with, regardless of whether or not the tool is going to be an accurate means by which to quantify a patients risk.

To be honest, I haven't focused much on the minutiae and technical aspects of orthodontia. I'm familiar, but not studied - like I haven't sat down and learned to do ceph tracings or bothered to read Enlow's seminal work, but, I know about them and have some knowledge. I mostly have come at facial development from the standpoint of it's physiologic impact on health. When people talk about arch development and occlusion, I know a lot of the time their world starts and ends at teeth, with some concern for jaw orthopaedics but to me, teeth/jaws are...like a hologram. When someone talks about arch development my mind immediately views it as a flowchart branching out into the airway, trigeminal, brain stem, cervical, vagal, gut/GI organs, and bouncing back and forth between multiple systems with multiple influences on the brain. The brain use's straight teeth and other facial features like a heuristic for proper development. It's easy to get caught up in that. It's like...a statue of a face. Most people see the face. I see rock that's been contoured and shaped by hundreds of hours of human effort in order to refract light in such a way that the neurology of the human brain perceives a similarity to human faces, and that neurology is so dominant that for most people one stops seeing the rock and only see's the face.  Yet, it's an illusion. There is no face. A 'face' is really just a representation of organisms development; the feedback between genes and environment. Statue has no genes. Has no organic function. Yet, the brain of so many gets convinced 'face' - it's nature's holography; we see form where there is really only organized matter; we see function where there is simply interaction. So, I think the core of the issue isn't what does one believe, or what does one know, but how does one go about modeling the world around oneself.

Lot of interesting ideas and musings.  Will have to re-read.  I agree that anatomy and clinical symptoms should be main thing, and lab testing should be secondary.  But mainstream medicine is fixated on reductionist constructs like AHI, RDI, Epworth.  And everyone worships technology.  And the system exists to make money, not create health.

Not surprised about the blue blocking glasses thing.  Most people working in the system seem to be low awareness creatures who know little about health, but a lot about technology and disease.

My sleep study was reviewed by one of the pioneers in SDB - Christian Guilleminault - but he had very little useful input, mostly remarking on technical details, and gave zero recommendations.  He noted that I mouth breathed the entire night but did not bother to elaborate on this.

Re: MCA, i only received a CD with an .exe file, and no way to view it.  Will ask my dentist's office if they can open it and check MCA or other measurements.

Guilleminault also made an appearance at my pre-study consult.  He handled me kind of like a lab specimen, and also said things that implied the study would likely find problems and there might not be much they could do for me.  I left feeling despondent.  Then the study did not find issues that fit into standard boxes, so seemingly they lost interest.  The resident doc who was at both consults did send me a link to some tongue exercises but that was the extent of their involvement with my case.  But yea they have heavy patient volume so it's pretty much assembly line care.

Found out i have an MCA of 300mm.  At least according to one orthodontist.  But my nasal airway has problems.

Posted by: darkindigo

Oh yes... they may not be looking much at nasal.  That is a great MCA! Mine is just under 150 mm sq.  Oh yes... and the weirdest thing... so RPE is supposed to be awesome for airway... in kids and stuff.  I’m calling bull on this.  Braces all the way... unless you have a lot to go!  For mixed dention... RPE is super tricky.  Not recommended.  

So you think if pharyngeal airway is relatively spacious, palate expanders are not needed or are overkill?  I have quite narrow palate, so would think an appliance could possibly help expand airway further and correct dental crowding and messed up occlusion.  But maybe mewing is better option.  

The ortho asked if i wanted to correct dental occlusion and crowding, I said yes, and he recommended MSE appliance.

Posted by: darkindigo

Can you share the exercises he gave? I would be intetested.  :-)

You mean the ortho?  He didnt recommend any exercises yet, but did suggest I read Oxygen Advantage (am reading it already, coincidentally).

He also rec'd this book:

https://www.amazon.com/Achieve-Your-Victory-Solutions-Sleep/dp/1599329034#customerReviews

Yes most practitioners latch on to a limited number of interventions.

Re: braces vs RPE, not sure what you mean, as these have completely different objectives.  Braces i see as final step once skeletal issues are addressed.