The Relationship Between Sleep and Asthma

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Sleep-related asthma, also known as nocturnal asthma, is characterized by a decrease in forced expiratory volume in 1 second of at least 15% between bedtime and wake-up time in patients diagnosed with asthma. In some patients, these decrements in lung function can reach 50%. Nocturnal asthma seems to have significant clinical impact, and the most recent United States guidelines for asthma management emphasize that nocturnal symptoms indicate the need for more aggressive controller therapy. Several factors have been proposed to cause or worsen nocturnal bronchoconstriction, including horizontal posture in bed, airway cooling, exposure to allergens, gastroesophageal reflux, obesity, and obstructive sleep apnea. Several mechanisms of nocturnal bronchial spasm have also been proposed, including circadian fluctuations in hormone levels, circadian variations in autonomic nervous system activity, airway inflammation, and genetic predisposition.

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Asthma

Approximately 300 million people worldwide currently have asthma, and its prevalence increases by 50% every decade. In North America, 10% of the population has asthma. Worldwide, approximately 180,000 deaths annually are attributable to asthma, although overall mortality rates have decreased since the 1980s. In different Western countries, the financial burden on patients who have asthma ranges from $300 to $1300 per patient per year [1]. Sleep-related asthma, also known as nocturnal asthma, is

Epidemiology of sleep-related asthma

The 1988 study on the prevalence of nocturnal asthma symptoms by Turner-Warwick [3] included 7729 outpatients who had asthma. It showed that approximately 40% of patients experienced asthma symptoms every night, 64% reported awakening with symptoms at least three times a week, and 74% awoke with asthma symptoms at least once a week. In a study of 3129 patients who had nocturnal asthma, Dethlefsen and Repgas [4] concluded that approximately 94% of dyspneic episodes occurred between 10:00 pm and

Consequences of sleep-related asthma

Nocturnal asthma is believed to indicate uncontrolled asthma, but it also has important effects on quality-of-life (QOL) and psychometric indexes [6]. In a study of more than 400 children who had asthma and their parents, Diette and colleagues [7] at Johns Hopkins University showed that 40% of children had experienced nighttime awakening within the previous 4 weeks. Moreover, children who experienced nocturnal awakenings also had an increased number of days of school missed, increased symptom

Circadian alterations in lung function and airway responsiveness

Healthy humans and those who have asthma have two peaks of maximal sleepiness during the 24-hour period: 4:00 am and 4:00 pm, which vary in circadian fashion. Lung function has also been shown to fluctuate over the 24-hour period in both healthy individuals and those who have asthma, with peak lung function occurring at 4:00 pm and minimal lung function at 4:00 am. Both the peak and trough of lung function coincide with the sleepiest times of the 24-hour period. These fluctuations are

Factors causing or worsening bronchoconstriction during sleep

Several factors have been proposed to cause or worsen nocturnal bronchoconstriction, including horizontal posture in bed, airway cooling, exposure to allergens, gastroesophageal reflux, obesity, and obstructive sleep apnea (OSA).

Regarding horizontal posture, a study by Whyte and Douglas [17] strongly suggested that the supine posture is not an important cause of overnight bronchoconstriction. Clark and Hetzel [13] showed that patients who have asthma who lie in bed throughout the 24-hour period

Mechanisms of nocturnal bronchoconstriction

Several mechanisms of nocturnal bronchial spasm have also been proposed, including circadian fluctuations in hormone levels, circadian variations in autonomic nervous systems' activity, airway inflammation, and genetic predisposition.

Symptoms and signs

The essential features of sleep-related asthma are dyspnea, wheezing, coughing, air hunger, or chest tightness during sleep. These symptoms usually improve when bronchodilating medications are administered [54]. Sleep disruption and daytime sleepiness are the major presenting symptoms in individuals who have nocturnal asthma. They complain of dyspnea and wheezing that disrupt their sleep and cause daytime sleepiness and fatigue. Sleep disruption and daytime sleepiness have been verified with

Diagnosis

The diagnosis of sleep-related asthma requires the presence of asthma-related symptoms, including shortness of breath, wheezing, and cough occurring during the main sleep period (usually, but not invariably, at night) and is associated with a more than 15% decrement in overnight peak airflow rate.

Treatment of sleep-related asthma

According to current United States guidelines [10], nocturnal symptoms of asthma occurring more often than once weekly may indicate inadequate control of asthma. Because most patients who have nocturnal asthma have symptoms at least this frequently, most patients who have nocturnal asthma have persistent asthma of moderate or severe levels of severity, as determined by the guidelines. Furthermore, the preferred treatment for persistent asthma of these levels of severity is inhaled

Controversies in sleep-related asthma

A key and recurring question in the field of nocturnal asthma is whether patients who have nocturnal asthma simply have asthma that is more severe (with nocturnal symptoms being one indicator of severity) or have a qualitatively different disorder. Data exist on both sides of this question, and therefore a definitive answer is not currently available. The results of several studies have supported the concept that nocturnal asthma is simply asthma that is quantitatively more severe and is

Summary

Further research is needed to (1) elucidate the mechanisms of the coupling of central master clock signals to the regulation of inflammation and airway physiology; (2) distinguish the mechanisms that cause nighttime asthma from those that are a consequence of increased airway obstruction at night; (3) establish the most appropriate treatment strategy for nocturnal asthma symptoms, including effective treatment for GERD; and (4) match asthma populations with and without nocturnal worsening for

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