The Night Monster - Nocturnal Asthma

Ever felt incredibly sleepy but suddenly become breathless as you nodded off? Had a sudden choking feeling in your lungs? Began to gasp for air and woke up sweating and terrified? It is not a dream, its actually happening. You’re having an asthma attack while sleeping.

If your sleep is disturbed by cough, breathlessness, chest tightness, then you are not alone. Studies have shown that nearly 30 to 70% of patients suffering with asthma are kept awake by these symptoms, at least once a month. It is not just a matter of disturbed sleep but is more sinister than that. It actually reflects a poorly controlled asthma and can prove to be fatal. Almost 50% of deaths because of asthma occur while sleeping. Even in a normal state, our lung functions follow a circadian rhythm, being at their best around 4 pm in the evening and their worst at around 4 am early morning. This normal variation is exaggerated in asthma patients.

Various factors are known to contribute to night-time airway inflammation and asthma in predisposed individuals. Sinusitis with post nasal drip in reclining position, gastroesophageal reflux leading to micro-aspirations, gravity placing extra pressure on the chest and lungs, very low room temperatures forcing an individual to breathe cold air, dust-mites in the mattress, pillows and bedsheets and moulds on the walls of the bedroom are the common triggers. Neurohormonal changes and increased cholinergic tone during sleep are the two important mechanisms responsible for causing the tissues of airways lungs to swell, resulting in narrowing and making it harder to breathe.

Other conditions which may mimic such night-time symptoms are Chronic Obstructive Pulmonary Disease (COPD), Obstructive Sleep Apnea (OSA) and Congestive Heart Failure (CHF). The goals of management include reduction of symptoms, improvement in lung functions and reducing the risk of an exacerbation.

Therapy of nocturnal asthma is generally based on the severity and frequency of symptoms. Indirect therapies include control of the triggering factors as mentioned above. Specific interventions include optimisation of the medication regimen. For patients with infrequent nocturnal asthma symptoms, a short-acting, inhaled bronchodilator is used for quick relief of symptoms. For patients who have nocturnal asthma symptoms one or more times a week, proper asthma medication in which A long acting bronchodilator combined with corticosteroid delivered through an asthma inhaler form the mainstay of therapy. Patients are usually advised to monitor their lung functions using peak flow meter, which is a simple inexpensive device but helps to confirm the diagnosis and allows for assessment of the response to therapy. It gives a fairly accurate status of the asthma and indicates the need for additional medication.

How to prevent night-time asthma symptoms?

1. Take the asthma medications regularly and follow an asthma action plan charted out by the pulmonologist

2. Proper timing of the medication dosing can help optimize its effect

3. Symptomatic gastroesophageal reflux and sleep apnea should be controlled, when present

4. The bedroom should be kept clean (dust free) and dry

5. Zippered, sealed covers to be used over pillows and mattresses

6. The room should not be chilled and the fan never at full speed at night

7. The pets should be kept out of the bedroom and never allowed on the bed

8. Avoid sleeping absolutely flat. Keep the head elevated by at least 30 degrees during sleep.