Is asthma keeping you awake at night?
Facts | 14/12/2022
Asthma attacks commonly come on at night, but this could be a sign that the condition is not being managed properly. Find out why night-time symptoms occur and what to do about them.
Have you ever woken up due to shortness of breath, wheezing or coughing? This could be a sign that you suffer from nocturnal asthma symptoms, which reportedly affects up to 60% of asthmatics.
Dr Ulla Anttalainen, Docent in Pulmonary Diseases and Clinical Allergology at the University of Turku, Finland, confirms that there is a recognised link between asthma and sleep disturbance, with many patients reporting difficulty falling asleep, sleep disruption and early awakenings.
She adds that nocturnal symptoms are generally considered a sign of poor asthma control. “Well-controlled or mild asthmatic patients are less likely to experience sleep disturbance. Various risk factors for asthma may also be linked to poor sleep, such as rhinosinusitis, allergies, smoking, reflux, anxiety, and depression.”
Why do symptoms come on at night?
The precise reasons why symptoms worsen at night are complex, with evidence suggesting that airway hyper-responsiveness, which is typical in asthma, might be increased overnight. Advances in scientific understanding of circadian rhythms additionally suggest that asthmatic airway inflammation may be diurnal in nature, peaking early in the morning. “Variations in hormones and mediators may also play a minor role in worsening of airway constriction at night in asthma. There are circadian variations in plasma cortisol and histamine concentrations, with the lowest values for cortisol at midnight and highest value for histamine at 4 am in normal patients,” observes Dr Anttalainen.
Why am I coughing at night?
Whatever the underlying causes, poor sleep is an undeniable problem for many asthmatics. Recent studies have revealed that 40% of severe asthma patients complain of daytime sleepiness, and 31% have an elevated Epworth Sleepiness Score. Night-time asthma symptoms are also associated with diminished cognitive performance.
“In children, this area has been studied more extensively, and nocturnal asthma symptoms have been shown to negatively affect school attendance and performance,” observes Dr Anttalainen.
She adds that coughing is not always related to asthma, nor do all asthmatics suffer symptoms at night. “Night-time cough can be related to other diseases such as reflux, heart failure, other pulmonary diseases and respiratory infections. Although night cough is common among asthmatics – at least when their asthma is not stable – not all asthma patients have night-time symptoms.”
What triggers should be avoided?
An attack might be triggered by allergens such as dust mites, pet hair or mould, but Dr Anttalainen points out that if nocturnal asthma symptoms are caused by airway hyper-responsiveness, there may be no specific triggers at all.
“Potential triggers include allergen exposure, airway cooling, reflux or untreated sleep apnoea. Or the patient may simply have forgotten to take their evening asthma medication,” she notes.
Obstructive sleep apnoea is a problem that occurs when you sleep, causing repetitive pauses in breathing, poor sleep quality, and non-restorative sleep. Both sleep apnoea and asthma are common, leading to an inevitable overlap between the two conditions.
“But the prevalence of sleep apnoea is consistently higher in asthmatics than in the non-asthmatic population – about 50% of asthmatics are at risk for sleep apnoea. It is difficult to ascertain whether the high incidence of patients with both conditions is simply association, or whether there is a more complex, potentially two-way interaction occurring,” notes Dr Anttalainen.
The good news is that treatment of sleep apnoea with nasal continuous positive airway pressure (CPAP) also helps to combat nocturnal and daytime symptoms of asthma.
Sleep tips for asthmatics
1. Minimize exposure to allergens
Keep your bedroom free of dust and other organic allergens such as pet fur. Make sure the room is sufficiently ventilated and that humidity is optimal – try a humidifier if the air seems dry. High-efficiency filtration systems are effective at decreasing allergen exposure.
2. Prop yourself with pillows
Lying flat on your back makes it harder to breathe by putting pressure on your chest and lungs. It can also cause mucus to drip to the back of your throat and worsens reflux, which can irritate your airways. A half-sitting position can make it easier for people with asthma and sleep apnoea to breathe.
3. Get help for sleep apnoea
If you have asthma, you are also at risk for sleep apnoea. Continuous Positive Airway Pressure (CPAP) is used for treating sleep apnoea. It is delivered during sleep, and it can relieve the symptoms of both apnoea and nocturnal asthma. For those with sleep apnoea, it is also important to seek support for weight control if they are overweight, exercise regularly, avoid alcohol before bedtime, and quit smoking.
4. Stay active and destress
Try to stay active during the day to boost your immune system and increase your lung strength. Some people experience anxiety when an attack comes on at night. Breathing exercises and yoga before bed can be beneficial for stress relief.
Literature
Joanne Kavanagh, David J. Jackson, and Brian D. Kenta, ‘Sleep and Asthma’
Current Opinion in Pulmonary Medicine: November 2018 - Volume 24 - Issue 6
https://pubmed.ncbi.nlm.nih.gov/30199406/
Chantal Raherison, Abdel Abouelfath, Vincent Le Gros, André Taytard, Mathieu Molimard, ‘Underdiagnosis of nocturnal symptoms in asthma in general practice’, Journal of Asthma, 2006
https://pubmed.ncbi.nlm.nih.gov/16754521/
Ran Wang, Stefan Mihaicuta, Angelica Tiotiu, Alexandru Corlateanu, Iulia Cristina Ioan, Andras Bikov, ‘Asthma and obstructive sleep apnoea in adults and children – an up-to-date review’, Sleep Medicine Reviews 61, 2022 https://www.sciencedirect.com/science/article/abs/pii/S1087079221001490
Date of preparation: January 2023 / EASYH-2844
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