Nocturnal Asthma

doi:10.1378/chest.123.3_suppl.399S

Chest

Volume 123, Issue 3, Supplement, March 2003, Pages 399S-405S

https://doi.org/10.1378/chest.123.3_suppl.399S Get rights and content

Lung function in a healthy individual varies in a circadian rhythm, with peak lung function occurring near 4:00 pm (1600 hours) and minimal lung function occurring near 4:00 am (0400 hours). An episode of nocturnal asthma is characterized by an exaggeration in this normal variation in lung function from daytime to nighttime, with diurnal changes in pulmonary function generally of > 15%. The occurrence of nocturnal asthma is associated with increased morbidity and inadequate asthma control, and has an important negative impact on quality of life (QOL). Newer data have shed light on physiologic and immunologic mechanisms that underlie the nocturnal development of airway obstruction. It remains controversial whether nocturnal asthma is a distinct entity or is a manifestation of more severe asthma. The current data do not resolve these two alternatives, as well-controlled studies have reached opposite conclusions. However, the clinical associations of gastroesophageal reflux disease and obesity appear to be strong. The treatment of asthma with effective controller agents can reduce nighttime symptoms, improve psychometric outcomes, and improve QOL.

Section snippets

Clinical Associations

Gastroesophageal reflux disease (GERD) is commonly associated with nocturnal asthma symptoms. A recent cross-sectional study provides new information on these interactions. More than 2,600 subjects were evaluated, including > 450 who had an existing diagnosis of asthma. GERD symptoms were consistently defined, and they occurred in 4.6% of the sample population. Subjects with GERD were significantly more likely to have nighttime wheezing and breathlessness, and to report nocturnal cough and

More Severe Asthma or a Separate Entity?

A key, and recurring, question in the field of nocturnal asthma is whether patients with 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, so 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 therefore more

Physiologic Insights

Desjardin and colleagues¹² evaluated the effect of sleep on pulmonary capillary blood volume (measured by CO diffusion) in healthy control subjects, subjects with nocturnal asthma, and subjects with asthma and no nocturnal worsening. No significant differences in awake physiology were seen between the two groups of asthmatic subjects. Only in subjects with nocturnal asthma were changes in capillary blood volume seen (ie, a 15% increase). The mechanism of this effect was not established, but the

Treatment of Nocturnal Asthma

According to current US guidelines,¹ nocturnal symptoms of asthma occurring more often than once weekly may indicate inadequate control of asthma. Because most patients with nocturnal asthma have symptoms at least this frequently, it follows that most patients with 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 corticosteroids.

Summary

Nighttime awakening is a common symptom in asthma patients, which are associated with asthma morbidity, increased asthma severity, and uncontrolled or undercontrolled disease. Nocturnal asthma remains an area of controversy on a number of fronts (Table 2). Considerable evidence has suggested that nighttime symptoms of asthma are associated with increased asthma severity, but several well-controlled studies have argued that nocturnal asthma may be a distinct entity. Whether or not nocturnal

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