When Can We Expect to See a Cascade Preference for RERAs and UARS? Part I

Just the other day, two converging experiences led me to wonder whether or not we are getting closer to a cascade preference regarding RERAs and UARS. Glenn Reynolds of Instapundit.com fame recently wrote about the concept of the cascade preference as it might relate to the current U.S. election year dramas, but the easiest way to understand the idea, which he also explains in his op-ed, is to consider how so many people behind the Iron Curtain prior to 1989 could have maintained their support of the tyrannical policies of the Soviet Union. 

In point of fact, the vast majority of Soviet citizens or their satellite neighbors arguably did not support these policies, but because the clamps on freedom of speech and freedom of the press were so tight, the populace did not easily recognize what other people were thinking about their cruel masters. At some point when some truths were exposed, people started to realize that many more of their countrymen were viscerally (but not previously expressively) opposed to the regime. As more and more people recognized it was safe to oppose the communist dictators, then the “cascade preference” ensued, and all sorts of folks from all classes of the social strata started expressing strong opinions on the need for a new government. If a government effectively and brutally suppresses opinion and oppresses other behaviors among the citizenry, it takes much longer for people to recognize their group misery (as opposed to their individual misery), which maintains the despotic power structure indefinitely.

We face a similar dilemma in sleep medicine at much lower level of intensity of course, but which nevertheless mirrors these concepts as they relate to the suppression of knowledge about RERAs and UARS. What got me reflecting on this problem was a conversation with another sleep doctor, living out of my region but caring for a mutual patient. I was stunned to learn that not only does their sleep lab forego measurement with the nasal cannula pressure transducer (NCPT), but also they never attempt to measure RERAs or UARS. Their staff was fully aware that their sole use of thermistor technology would limit the types of breathing information collected, yet apparently there was no urgency to meet the standards of the American Academy of Sleep Medicine. Even if the goal were to measure hypopneas more accurately, let alone RERAs, it would make a great deal of sense to use NCPT. Remarkably, this standard has been around for nearly a decade, and a sleep lab cannot be accredited without using NCPT.

The conversation arose, because I knew the patient who was to be tested in the state outside of New Mexico, and I was persuaded he suffered from a clinical picture unequivocally consistent with UARS. He had facial features of UARS, was a long sleeper, never awakened refreshed and was always tired or sleepy during the day. In fact, the patient had already undergone one diagnostic study two years earlier, which was read out as inconclusive, yet when I reviewed the results with the sleep physician at the time, it was again clear that UARS was present due to the obvious findings of sleep fragmentation. However, again due to inadequate technology in the original sleep lab, no diagnosis was made. Since the new and most recent sleep lab also did not use NCPT, I was able to help the patient seek care elsewhere.

So, the question at hand is why do so many physicians in the field of sleep medicine still limit their capacity to score RERAs, and why do they imagine it is reasonable to preclude the possible diagnosis of UARS in their patient population? I do not have a comprehensive answer to the question, but I can offer some explanations for barriers that influence the judgments and decision-making of healthcare professionals in general and sleep specialists in particular.

First and foremost we would like to see more physicians putting on their research hats, because they have access to an enormous numbers of patients they encounter on a daily basis. It is easy to imagine these encounters fill doctors’ brain with all sorts of interesting facts, ideas, theories, opinions and occasionally an epiphany. In fact, some of the best ideas in clinical medicine come from just these sorts of experiences, wherein a doctor finds something new and notices a clinical effect. That particular doctor may never research the interesting observation, but eventually this information is disseminated and either becomes adopted by others or becomes researched and proven and then adopted by others. 

Consider the discovery of UARS, where researchers at Stanford, led by the brilliant Dr. Christian Guilleminault were puzzled by a group of children who seemed like they should be suffering from sleep-disordered breathing, but there polysomnograms (PSGs) in the late 1970s and early 1980s were negative. These kids suffered daytime sleepiness. Somewhere along the way, Dr. Guilleminault and colleagues wondered if they should be looking at respiration in a different way than on standard PSGs. In doing so, they came up with esophageal manometry, which showed that movement of the chest cavity was exerting extra effort (often called “work of breathing), and they noticed that this work of breathing coincided with signs of sleep fragmentation on the sleep EEG of these patients. Once these children underwent tonsillectomies or tried PAP, the sleep doctors and researchers noticed the work of breathing and sleep fragmentation dissipated. The exclamation point on this research was the improvement or elimination of the sleepiness in these patients! 

Now, while the above sounds like a research scenario, I trust you can see how the clinical angle probably was the motivating influence that led to the chain of events that evolved into a research project. The doctors were puzzled by the clinical experience of children who were suffering daytime impairment from sleepiness, and they were hoping to find out what caused the problem. 

If you take a step further back in time, I am 100% certain there are records showing doctors in the late 19th and early 20th centuries having already made a similar discovery; that is, they encountered children who snored and presented with atypical facial features like a narrow face or a narrow roof of the mouth. They would have noticed enlarged tonsils and recommended removal. Sometime thereafter their patients showed more energy and appeared more alert. Yet, these observations were not necessarily published in research journals, but physicians would have spread the word to their colleagues.

In ideal circumstances the physician-scientist should be the norm in our society. Sadly, we are moving in the opposite direction. Physician creativity, curiosity, and innovation are all stifled in virtually every area of medical practice by a series of “non-medical” institutions. Only a much smaller proportion of doctors continue to operate in this investigative fashion, and with the expansion toward socialized medicine, hospital conglomeration and other sorts of mergers in medical-related fields, the physician-scientist population is likely to shrink further. As we discuss some of these other medical-related institutions, I believe you will see how these factors assert constraining influences on the way physicians practice, and perhaps more importantly how these influences stifle physicians’ reasoning powers in their daily efforts to provide quality of care, thus limiting the onset of a “preference cascade.”

In every step of our discussion on the current lack of a preference cascade, you will see why so many doctors, for example, in primary practice have never heard of UARS, but more germane to our interests, why so many sleep specialist know so little about RERAs and UARS.

Barry Krakow MD


Dr Krakow’s 27 years of sleep research have focused on the complex relationship between physiological and psychological sleep disorders. Dr Krakow currently operates private sleep medical center, Maimonides Sleep Arts & Sciences, Ltd., and serves as Classic SleepCare’s paid Medical Director.

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