Natalie
@nataliezzz.bsky.social
Sharing info on the connection between sleep-disordered breathing/upper airway resistance syndrome (UARS) & ME/CFS & related disorders. Mostly following art accounts here to have a chill feed; don’t be offended if I don’t follow you. On Xitter @nataliezzz3
Reposted by Natalie
Here is a follow-up study of 94 UARS patients 4.5 years after they were diagnosed with UARS. Insurance refused to provide CPAP for 90/94 patients. When will doctors help fix this disaster? (I don't blame any individual dr. btw, but individual drs. can help!) 58/n
sciencedirect.com/science/arti...
sciencedirect.com/science/arti...
September 8, 2025 at 11:32 PM
Here is a follow-up study of 94 UARS patients 4.5 years after they were diagnosed with UARS. Insurance refused to provide CPAP for 90/94 patients. When will doctors help fix this disaster? (I don't blame any individual dr. btw, but individual drs. can help!) 58/n
sciencedirect.com/science/arti...
sciencedirect.com/science/arti...
PSG findings suggested UARS. Upon treatment with CPAP, "his complaints resolved dramatically." The authors concluded: "This case seemed interesting in showing that UARS may clinically present as symptoms of chronic fatigue, anxiety and depression in young, non-obese people." 60/n
October 15, 2025 at 9:28 PM
PSG findings suggested UARS. Upon treatment with CPAP, "his complaints resolved dramatically." The authors concluded: "This case seemed interesting in showing that UARS may clinically present as symptoms of chronic fatigue, anxiety and depression in young, non-obese people." 60/n
Case report: 17-year old male with complaints of chronic fatigue, insomnia, social and academic problems was unsuccessfully treated for anxiety, depression and insomnia with hypnotics, sedatives and antidepressants. He was referred for PSG for insomnia eval; 59/n
www.researchgate.net/publication/...
www.researchgate.net/publication/...
October 15, 2025 at 9:28 PM
Case report: 17-year old male with complaints of chronic fatigue, insomnia, social and academic problems was unsuccessfully treated for anxiety, depression and insomnia with hypnotics, sedatives and antidepressants. He was referred for PSG for insomnia eval; 59/n
www.researchgate.net/publication/...
www.researchgate.net/publication/...
No one has ever been able to explain why ppl w/ a genetic disorder affecting collagen (who often had no previous issues other than occasional dislocating joints prior to an infection/other stressor) are more likely to develop ME/CFS, fibro, etc. Well, UARS/OSAS explains it!
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It could also explain why ppl w/ hypermobility/EDS are more likely to develop ME/CFS (more lax connective tissue = more collapsible upper airway). A meta-analysis found a 48.9% prevalence of OSA in EDS/Marfan syndrome pts (many more of them could have milder SDB). 10/n
jcsm.aasm.org/doi/10.5664/...
jcsm.aasm.org/doi/10.5664/...
September 23, 2025 at 12:02 AM
No one has ever been able to explain why ppl w/ a genetic disorder affecting collagen (who often had no previous issues other than occasional dislocating joints prior to an infection/other stressor) are more likely to develop ME/CFS, fibro, etc. Well, UARS/OSAS explains it!
bsky.app/profile/nata...
bsky.app/profile/nata...
I cited 2 case reports (from different authors & countries) of fibro cures from treating OSA, one with the objective finding of alpha-delta sleep (the only consistent objective finding associated with fibro) disappearing along with fibro symptoms with tx of OSA. Also, this ⬇️
bsky.app/profile/nata...
bsky.app/profile/nata...
And if you're not yet convinced that UARS/OSAS is causing fibro...why would fibro pts have more collapsible upper airways? Pcrit is a measure of how collapsible the upper airway is (not how much it's collapsing during sleep), so this negates that SDB in the fibro pts is 23/n
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bsky.app/profile/nata...
Pcrit (pharyngeal critical closing pressure) values for 14 of the fibromyalgia (FM) patients vs. normal controls (adults w/out habitual snoring or daytime sleepiness & AHI <5), UARS patients & OSA patients. Pcrit is considered the gold standard for measuring upper airway collapsibility. 19/n
September 22, 2025 at 11:56 PM
I cited 2 case reports (from different authors & countries) of fibro cures from treating OSA, one with the objective finding of alpha-delta sleep (the only consistent objective finding associated with fibro) disappearing along with fibro symptoms with tx of OSA. Also, this ⬇️
bsky.app/profile/nata...
bsky.app/profile/nata...
My SDB - "functional somatic syndromes" mega-thread is now 58 comments long now lol. You may find the discussion I've added about mental health in SDB patients interesting too. Lots of exciting research waiting to happen in this arena!
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Here is a study that found that UARS pts had "more neurotic & sensitive personalities" as well as greater depression, anxiety & obsessive-compulsiveness than OSAS pts. UARS was AHI <10 so included some mild OSAS pts; of course I don't think UARS & OSAS are 54/n
pmc.ncbi.nlm.nih.gov/articles/PMC...
pmc.ncbi.nlm.nih.gov/articles/PMC...
September 22, 2025 at 9:49 PM
My SDB - "functional somatic syndromes" mega-thread is now 58 comments long now lol. You may find the discussion I've added about mental health in SDB patients interesting too. Lots of exciting research waiting to happen in this arena!
bsky.app/profile/nata...
bsky.app/profile/nata...
Hi Dr. Zoffness, I've now made a detailed 🧵 here on the SDB - fibromyalgia connection. SDB (well, the brain's stress response to it) can indeed cause fibro! In addition to case reports & smaller studies, there's even meta-analysis level data supporting this! (see the full 🧵)
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🧵 with more info on the sleep-disordered breathing (SDB) - fibromyalgia (FM/FMS) connection, including 2 case reports of dramatic resolution of fibro symptoms from treating OSA (1 CPAP, 1 mandibular advancement device). 1/n
pubmed.ncbi.nlm.nih.gov/17589851/
pmc.ncbi.nlm.nih.gov/articles/PMC...
pubmed.ncbi.nlm.nih.gov/17589851/
pmc.ncbi.nlm.nih.gov/articles/PMC...
September 22, 2025 at 9:45 PM
Hi Dr. Zoffness, I've now made a detailed 🧵 here on the SDB - fibromyalgia connection. SDB (well, the brain's stress response to it) can indeed cause fibro! In addition to case reports & smaller studies, there's even meta-analysis level data supporting this! (see the full 🧵)
bsky.app/profile/nata...
bsky.app/profile/nata...
PRO: Upper Airway Resistance Syndrome Represents a Distinct Entity from Obstructive Sleep Apnea Syndrome (Tobias & Won 2016)
aadsm.org/journal/pro_...
CON: Upper Airway Resistance Syndrome Does Not Exist as a Distinct Disease (Selim 2016)
aadsm.org/journal/pro_...
9/n
aadsm.org/journal/pro_...
CON: Upper Airway Resistance Syndrome Does Not Exist as a Distinct Disease (Selim 2016)
aadsm.org/journal/pro_...
9/n
Pro/Con Debate - PRO Issue 3.1
aadsm.org
September 22, 2025 at 8:25 PM
PRO: Upper Airway Resistance Syndrome Represents a Distinct Entity from Obstructive Sleep Apnea Syndrome (Tobias & Won 2016)
aadsm.org/journal/pro_...
CON: Upper Airway Resistance Syndrome Does Not Exist as a Distinct Disease (Selim 2016)
aadsm.org/journal/pro_...
9/n
aadsm.org/journal/pro_...
CON: Upper Airway Resistance Syndrome Does Not Exist as a Distinct Disease (Selim 2016)
aadsm.org/journal/pro_...
9/n
Upper Airway Resistance Syndrome Is a Distinct Syndrome (Guilleminault & Chowdhuri 2000)
www.atsjournals.org/doi/full/10....
Upper Airway Resistance Syndrome Is Not a Distinct Syndrome (Douglas 2000)
www.atsjournals.org/doi/10.1164/...
8/n
www.atsjournals.org/doi/full/10....
Upper Airway Resistance Syndrome Is Not a Distinct Syndrome (Douglas 2000)
www.atsjournals.org/doi/10.1164/...
8/n
Upper Airway Resistance Syndrome Is a Distinct Syndrome | American Journal of Respiratory and Critical Care Medicine
www.atsjournals.org
September 22, 2025 at 8:25 PM
Upper Airway Resistance Syndrome Is a Distinct Syndrome (Guilleminault & Chowdhuri 2000)
www.atsjournals.org/doi/full/10....
Upper Airway Resistance Syndrome Is Not a Distinct Syndrome (Douglas 2000)
www.atsjournals.org/doi/10.1164/...
8/n
www.atsjournals.org/doi/full/10....
Upper Airway Resistance Syndrome Is Not a Distinct Syndrome (Douglas 2000)
www.atsjournals.org/doi/10.1164/...
8/n
While the diagnosis of UARS has been absorbed under OSA in the International Classification of Sleep Disorders – Third Edition (ICSD-3), it has been debated from the beginning (continuing to today) whether or not UARS & OSAS are distinct disorders (links to follow). 7/n
September 22, 2025 at 8:25 PM
While the diagnosis of UARS has been absorbed under OSA in the International Classification of Sleep Disorders – Third Edition (ICSD-3), it has been debated from the beginning (continuing to today) whether or not UARS & OSAS are distinct disorders (links to follow). 7/n
They chose a cutoff of ≥ 10 arousals/hour based on a small previous study 🔽, tho later data has shown that healthy ppl w/out OSA (RERAs weren't scored/taken into account in this study) or PLMD can have arousal indexes well over 10 (esp. with advancing age). 6/n
pmc.ncbi.nlm.nih.gov/articles/PMC...
pmc.ncbi.nlm.nih.gov/articles/PMC...
September 22, 2025 at 8:25 PM
They chose a cutoff of ≥ 10 arousals/hour based on a small previous study 🔽, tho later data has shown that healthy ppl w/out OSA (RERAs weren't scored/taken into account in this study) or PLMD can have arousal indexes well over 10 (esp. with advancing age). 6/n
pmc.ncbi.nlm.nih.gov/articles/PMC...
pmc.ncbi.nlm.nih.gov/articles/PMC...
UARS was first formally described in '93 by Dr. Christian Guilleminault et al. They ID'd a group of hypersomnolent pts w/ mild SDB who didn't meet OSA criteria whose hypersomnolence was alleviated by CPAP (snoring wasn't actually required; 2/15 didn't snore). 5/n
journal.chestnet.org/article/S001...
journal.chestnet.org/article/S001...
September 22, 2025 at 8:25 PM
UARS was first formally described in '93 by Dr. Christian Guilleminault et al. They ID'd a group of hypersomnolent pts w/ mild SDB who didn't meet OSA criteria whose hypersomnolence was alleviated by CPAP (snoring wasn't actually required; 2/15 didn't snore). 5/n
journal.chestnet.org/article/S001...
journal.chestnet.org/article/S001...
Here are OSA severity levels (unless otherwise specified, I will be using these cutoffs when referring to mild/moderate/severe OSA). However, I forgot to specify for the study below that UARS was considered AHI <10 (mild/mod OSA: AHI 10-39; mod/severe OSA: AHI ≥ 40). 4/n
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September 22, 2025 at 8:25 PM
Here are OSA severity levels (unless otherwise specified, I will be using these cutoffs when referring to mild/moderate/severe OSA). However, I forgot to specify for the study below that UARS was considered AHI <10 (mild/mod OSA: AHI 10-39; mod/severe OSA: AHI ≥ 40). 4/n
bsky.app/profile/nata...
bsky.app/profile/nata...
Guidelines for scoring apneas & hypopneas as obstructive vs. central. Diagnosis of central sleep apnea (CSA): central AHI ≥5 with >50% of all events being central. CSA is much less common than OSA (& typically a complication of conditions like heart failure/stroke or use of certain meds/drugs). 3/n
September 22, 2025 at 8:25 PM
Guidelines for scoring apneas & hypopneas as obstructive vs. central. Diagnosis of central sleep apnea (CSA): central AHI ≥5 with >50% of all events being central. CSA is much less common than OSA (& typically a complication of conditions like heart failure/stroke or use of certain meds/drugs). 3/n
Apnea-hypopnea index (AHI) = mean # of apneas & hypopneas per hour of sleep. Respiratory disturbance index (RDI) = AHI + RERA index (mean # of RERAs per hour). Here are AASM scoring guidelines for apneas, hypopneas & RERAs (scoring RERAs is optional and most sleep clinics don't). 2/n
September 22, 2025 at 8:25 PM
Apnea-hypopnea index (AHI) = mean # of apneas & hypopneas per hour of sleep. Respiratory disturbance index (RDI) = AHI + RERA index (mean # of RERAs per hour). Here are AASM scoring guidelines for apneas, hypopneas & RERAs (scoring RERAs is optional and most sleep clinics don't). 2/n
And if you're wondering why we don't have tons of fibro pts being fully cured by CPAP if UARS/OSAS is causing fibro, see 🔽 In Dr. Gold's clinical experience w/ hundreds of fibro pts, ~35-50% improvement on CPAP is typical (& consistent w/ the results of his fibro study) 25/n
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bsky.app/profile/nata...
🧵 w/ thoughts on why ME/CFS/fibro/etc. patients typically only feel ~35-50% better on PAP. Yes, there's the "stress of sham CPAP" (i.e. the mask on your face, etc.) but if it were just that it seems like we should feel ~90% better (the Gulf War illness pts on sham CPAP only got slightly worse). 1/n
Dr. Gold usually sees ~35-50% improvement in his ME/CFS & fibro pts on CPAP but no cures & he does not view it as a cure 🔽 He has published some case reports of complete remission from chronic insomnia, fatigue & depression from MMA surgery. 22/n
jmedicalcasereports.biomedcentral.com/articles/10....
jmedicalcasereports.biomedcentral.com/articles/10....
September 19, 2025 at 6:13 PM
And if you're wondering why we don't have tons of fibro pts being fully cured by CPAP if UARS/OSAS is causing fibro, see 🔽 In Dr. Gold's clinical experience w/ hundreds of fibro pts, ~35-50% improvement on CPAP is typical (& consistent w/ the results of his fibro study) 25/n
bsky.app/profile/nata...
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solely a downstream effect of some brain pathology causing 🔼 airway collapse during sleep e.g. Btw, you can see some controls have Pcrit values w/in the range of the fibro & UARS pts; these are people at risk of developing these disorders if/when they become sensitized to insp. flow limitation. 24/n
September 19, 2025 at 6:13 PM
solely a downstream effect of some brain pathology causing 🔼 airway collapse during sleep e.g. Btw, you can see some controls have Pcrit values w/in the range of the fibro & UARS pts; these are people at risk of developing these disorders if/when they become sensitized to insp. flow limitation. 24/n
And if you're not yet convinced that UARS/OSAS is causing fibro...why would fibro pts have more collapsible upper airways? Pcrit is a measure of how collapsible the upper airway is (not how much it's collapsing during sleep), so this negates that SDB in the fibro pts is 23/n
bsky.app/profile/nata...
bsky.app/profile/nata...
Pcrit (pharyngeal critical closing pressure) values for 14 of the fibromyalgia (FM) patients vs. normal controls (adults w/out habitual snoring or daytime sleepiness & AHI <5), UARS patients & OSA patients. Pcrit is considered the gold standard for measuring upper airway collapsibility. 19/n
September 19, 2025 at 6:13 PM
And if you're not yet convinced that UARS/OSAS is causing fibro...why would fibro pts have more collapsible upper airways? Pcrit is a measure of how collapsible the upper airway is (not how much it's collapsing during sleep), so this negates that SDB in the fibro pts is 23/n
bsky.app/profile/nata...
bsky.app/profile/nata...
The CPAP group (group 1) experienced greater improvement in symptoms compared to the control group (group 2) based on a 6-min walking test as well as Symptom Severity Scale (SS) & Short Form Health Survey (SF-36) Physical Component Summary (PCS) scores. 22/n
September 19, 2025 at 6:13 PM
The CPAP group (group 1) experienced greater improvement in symptoms compared to the control group (group 2) based on a 6-min walking test as well as Symptom Severity Scale (SS) & Short Form Health Survey (SF-36) Physical Component Summary (PCS) scores. 22/n
100 of the OSA patients with fibro were treated with CPAP and compared to a control group of 50 fibro patients treated with conventional therapy. It was noted that the control group was not adequately matched for sex/BMI. 21/n
September 19, 2025 at 6:13 PM
100 of the OSA patients with fibro were treated with CPAP and compared to a control group of 50 fibro patients treated with conventional therapy. It was noted that the control group was not adequately matched for sex/BMI. 21/n
In this study (a letter to the editor) of 900 consecutive OSA pts at a sleep clinic, 135 (15%) met ACR criteria for FM. Interestingly, 100 (74%) were men, perhaps bc men were more likely to be referred for suspected OSA (it was unstated what % of the 900 were men) 20/n
www.ejinme.com/article/S095...
www.ejinme.com/article/S095...
September 19, 2025 at 6:13 PM
In this study (a letter to the editor) of 900 consecutive OSA pts at a sleep clinic, 135 (15%) met ACR criteria for FM. Interestingly, 100 (74%) were men, perhaps bc men were more likely to be referred for suspected OSA (it was unstated what % of the 900 were men) 20/n
www.ejinme.com/article/S095...
www.ejinme.com/article/S095...
Here is a follow-up study of 94 UARS patients 4.5 years after they were diagnosed with UARS. Insurance refused to provide CPAP for 90/94 patients. When will doctors help fix this disaster? (I don't blame any individual dr. btw, but individual drs. can help!) 58/n
sciencedirect.com/science/arti...
sciencedirect.com/science/arti...
September 8, 2025 at 11:32 PM
Here is a follow-up study of 94 UARS patients 4.5 years after they were diagnosed with UARS. Insurance refused to provide CPAP for 90/94 patients. When will doctors help fix this disaster? (I don't blame any individual dr. btw, but individual drs. can help!) 58/n
sciencedirect.com/science/arti...
sciencedirect.com/science/arti...
people who are both highly sensitized to IFL (who likely often have innately sensitive nervous systems) & have mild SDB (high % IFL with little/no time spent in apnea), you get people with the most severe presentations of UARS (likely includes many ME/CFS patients). 57/n
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Two factors likely determine UARS severity: 1) % IFL 2) how sensitized one is to IFL. So is there a % IFL threshold below which one is not at risk for UARS? This study attempted to provide an answer, but we don't actually know. Here's Dr. Gold's take on it 🔽 20/n
pmc.ncbi.nlm.nih.gov/articles/PMC...
pmc.ncbi.nlm.nih.gov/articles/PMC...
September 8, 2025 at 11:32 PM
people who are both highly sensitized to IFL (who likely often have innately sensitive nervous systems) & have mild SDB (high % IFL with little/no time spent in apnea), you get people with the most severe presentations of UARS (likely includes many ME/CFS patients). 57/n
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I think there's a bidirectional relationship; ppl w/ more naturally sensitive/neurotic dispositions (a more sensitive limbic system?) are more likely to develop a (worse) UARS stress response, then the chronic stress of UARS = 🔼 sensitivity/neuroticism/anxiety/depression. I think when you take 56/n
September 8, 2025 at 11:32 PM
I think there's a bidirectional relationship; ppl w/ more naturally sensitive/neurotic dispositions (a more sensitive limbic system?) are more likely to develop a (worse) UARS stress response, then the chronic stress of UARS = 🔼 sensitivity/neuroticism/anxiety/depression. I think when you take 56/n
separate disorders and you'd likely see some of these symptoms/traits varying inversely with the AHI just like you do with "functional somatic syndrome" sx as previously shown 🔽 UARS was AHI <10 in the below study too (mild/mod OSA: AHI 10-39; mod/severe OSA: AHI ≥40). 55/n
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The predominance of mild SDB in ppl w/ chronic complex illnesses & the inverse relationship that has been identified between AHI & "functional somatic syndrome" sx in SDB patients could be explained by the fact that as frequency of apneas 🔼 exposure to IFL 🔽 13/n
www.researchgate.net/publication/...
www.researchgate.net/publication/...
September 8, 2025 at 11:32 PM
separate disorders and you'd likely see some of these symptoms/traits varying inversely with the AHI just like you do with "functional somatic syndrome" sx as previously shown 🔽 UARS was AHI <10 in the below study too (mild/mod OSA: AHI 10-39; mod/severe OSA: AHI ≥40). 55/n
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