Asthma and Sleep

Asthma, known medically as reactive airway disease, is a chronic lung condition that affects about 20 million Americans, according to the National Heart, Lung, and Blood Institute (NHLBI) at the National Institutes of Health. Symptoms of asthma occur when the airway becomes inflamed and constricts to make breathing difficult. What causes asthma or why incidences of asthma are on the rise is not known, but some have suggested that it could be the result of environmental factors such as an increase in exposure to pollution or indoor allergens. Its increase may also be related to the increase in obesity that is simultaneously occurring. Many researchers are looking for a genetic factor for asthma based on the fact that a person has a higher risk of developing asthma if a member of his or her family has it. Whatever causes asthma, it is a serious and sometimes fatal condition that must be carefully managed.

People with asthma often suffer from nighttime coughing, wheezing and breathlessness that disturb their sleep. It is not clear whether there is a circadian rhythm factor (a circadian rhythm is a rhythm of biological functions occurring in a 24-hour periodic cycle) responsible for these nighttime disturbances or whether sleep in some way contributes to them, but studies designed to uncover the exact influence of sleep or circadian rhythms on asthma have been largely inconclusive. Even so, many researchers believe that asthmatic symptoms are at least partly due to circadian rhythms and use the term "nocturnal asthma" to describe the phenomenon of asthma symptoms worsening at night. Not all asthma sufferers experience nocturnal asthma. Those who do should discuss their symptoms with their doctor in order to develop a treatment plan that addresses the nighttime condition. People with asthma should also be aware that nocturnal asthma is associated with more severe disease and increased mortality.

There are several underlying mechanisms that may shed light on how and why nighttime seems to exacerbate asthma symptoms. First, airway resistance increases throughout the night, whether or not a person sleeps, although the increase is much greater if the person sleeps. Second, evidence suggests that airway function is best just before the onset of sleep and decreases as sleep progresses. That is, the more a person with asthma sleeps, the greater the impairment of his or her lungs. This phenomenon is true for all people, although the effect tends to be greater for people with asthma. These airway changes do not typically disturb sleep in healthy subjects. However, people with asthma frequently show the first symptoms of their disease during sleep, according to research.

Although asthma affects people of all ages, it often starts in childhood and is more common in children than adults, according to the NHLBI. It is extremely important for children with asthma to get adequate sleep. An April 2005 Harris poll conducted for the Asthma and Allergy Foundation of America found that 48% of child asthma sufferers experienced disturbed sleep as a result of asthma. Also, the NHLBI reports that asthma is one of the leading causes of children missing school.

In a study published in Archives of Diseases in Children, sleep disturbance was studied in children with nocturnal asthma. Researchers found that children whose sleep was disturbed by nocturnal asthma also exhibited signs of psychological problems and impaired performance in school. However, they also found that if treatment were given to improve the nocturnal symptoms and thus reduce sleep disturbance, improvement in mental function followed. This and other studies provide evidence that the effects of asthma on sleep and the possible psychological consequences are important aspects of overall care.

Even though the cause of asthma is not known, it is important for a person with asthma to know the factors that may trigger an asthmatic attack. The following are some common triggers:

• Colds
• Flu and viruses
• Dust and/or dust mites
• Allergens, including mold
• Animal dander
• Smoke
• Strong odors
• Exercise
• Reflux disease
• Weather
• Medication*
• Food
• Emotions
• Laughter

*Medications that may trigger asthma include anti-inflammatory drugs (aspirin and other over-the-counter pain relievers) and beta blockers (for high blood pressure, migraine headaches, etc.).

Symptoms

Symptoms of asthma occur when the airway becomes inflamed and constricts to make breathing difficult. People with asthma often suffer from nighttime coughing, wheezing and breathlessness that disturb their sleep.

Treatment

There is no cure for asthma but it can be controlled. The goal of any asthma treatment plan is to minimize flare-ups and maintain normal or near- normal breathing and to participate in a full range of activities such as exercise and childhood play. In addition to modifications to lifestyle and self-directed disease management, most people with asthma use a combination of quick-fix and long-term medicinal remedies. It is important to note that sleep disturbance or insomnia is sometimes a side effect of asthma medication. Be sure to discuss any sleep problems that you or your child might be experiencing with your doctor.

The most effective long-term therapies for asthma are those that reduce swelling in the airway. The following medications are indicated for long term use by asthmatics to reduce airway swelling :

• Inhaled steroids (e.g. Flovent, Pulmicort)
• Inhaled cromolyn sodium (e.g. Intal)
• Inhaled nedocromil sodium (e.g. Tilade)
• Leukotriene modifier (e.g. Accolate, Singulair, Zyflo)
• Long-lasting Beta2-Agonist (e.g. Foradil, Serevent)

Inhaled quick relief medications relieve asthma symptoms right away quickly and last for a few hours. They include :

• Inhaled short-acting Beta2-Agonists (e.g. Albuterol, Alupent, Maxair, Xopenex)
• Anticholinergic (e.g. Atrovent, Combivent)
• Steroid (e.g. Deltasone, Medrol, Orapred, Prelone, Pediapred)

Coping

Most people with asthma are able to live a normal life and to participate in a full range of activities. In order to do this, however, asthma patients must take their medications as prescribed, be able to recognize and avoid things that may trigger an attack, and act quickly when asthma symptoms appear to be getting worse. Here are some tips for living with asthma:

• Take medication at the prescribed time -- this is very important in managing asthma symptoms. Patients should work with their doctors to develop and maintain a medication regime that works best for them.
• Use a peak flow meter* -- asthma patients should monitor their symptoms at all times. A peak flow monitor meter detects changes in lung function and warns patients of an impending asthma attack before they experience symptoms.
• Avoid asthma triggers -- no two asthma patients are exactly the same and something that triggers an attack in one person may not in another. Asthma patients should learn what triggers an attack for them and take steps to avoid exposure to those things.

*Peak flow meters are available online and at most major pharmacies.

For people with asthma, especially children, it is very important to get adequate sleep. One common trigger of nighttime symptoms is dust mites. In order to reduce exposure to dust mites, make sure that the bedroom is clean and free of dust. Nocturnal asthma symptoms may result from decreased respiratory function during sleep. Taking anti-inflammatory medications may help this condition.

Also, there is some evidence that people with asthma are at greater risk of developing sleep apnea, a condition in which breathing is briefly and repeatedly interrupted during sleep. A visit to a sleep center is required to determine whether a person with asthma also suffers from sleep apnea. People with asthma may request a referral to a sleep center from their primary care physicians.

Poll Data

According to the National Sleep Foundation's 2004 Sleep in America poll, about 10% of parents or caregivers say their children have trouble breathing (including heavy or loud breathing) while sleeping at least a few times per week.

Reviewed by Barbara Phillips, M.D., M.S.P.H.

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