The Relationship Between Sleep and Asthma
Section snippets
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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Cited by (10)
Sleep duration patterns from adolescence to young adulthood and the risk of asthma
2020, Annals of EpidemiologyCitation Excerpt :However, it is unclear whether the association is bidirectional; that is, if sleep quantity may play a role in the pathogenesis of asthma. The few longitudinal studies that examined the association between sleep and asthma mostly focused on sleep quality or insomnia, with some finding such associations [13–16]. We found one study that examined the impact of sleep duration in childhood on the risk of asthma in adolescence.
Impact of sleep opportunity on asthma outcomes in adolescents
2020, Sleep MedicineCitation Excerpt :Thus, the purpose of the current study was to use an experimental manipulation of sleep opportunity to examine the causal impact of sleep opportunity on lung function and functional outcomes in adolescents with asthma. The nocturnal worsening of asthma has been well established and attributed to multiple factors, including circadian rhythms and sleep posture [11–16]. Early studies with adults with asthma found that acute total sleep deprivation (ie, 1–2 nights with no sleep) decreased peak expiratory flow rate (PEFR) [17,18].
Understanding the Relationship Between Asthma and Sleep in the Pediatric Population
2016, Journal of Pediatric Health CareCitation Excerpt :Factors that may contribute to nocturnal symptoms or increase bronchoconstriction at night include nocturnal variations in circadian rhythm, exposure to environmental allergens and cold air, co-morbid medical conditions such as gastroesophageal reflux disease, obstructive sleep apnea, obesity, or sleep positions that result in decreased lung volume (Atanasov & Calhoun, 2007; Greenberg & Cohen, 2011). Poor sleep quality, daytime sleepiness, and decreased quality of life can affect immune function, learning, and emotional well-being (Atanasov & Calhoun, 2007; Gerber, 2014). Before 1990, few studies regarding the effects of nocturnal asthma symptoms were performed with children (Diette et al., 2000).
Missed sleep and asthma morbidity in urban children
2012, Annals of Allergy, Asthma and ImmunologyCitation Excerpt :In a sample of urban children with asthma, night wakings from asthma occurred in 40% of the sample during a 1-month period.12 Several factors contribute to nocturnal worsening of asthma, including circadian variations of lung functioning, supine posture, air temperature, allergens in the bedroom, hormonal variations, and diurnal variations of lung inflammation (for a review see Atanasov13). In addition, children with asthma report more fatigue and less daytime alertness.14
Association between immune system and sleep parameters among adults with bronchial asthma
2021, Electronic Journal of General MedicineSleep Medicine Pearls
2014, Sleep Medicine Pearls