For the over 25 million Americans living with asthma, difficulty breathing is an everyday experience. Their symptoms interfere with all aspects of their lives, from daytime activities like exercise and play to nighttime activities like sleep.
In fact, at night, a new form of asthma takes hold. So-called nocturnal asthma refers to the worsening of symptoms at night, and it affects over half of those living with asthma.
Below we review how asthma affects your sleep, with a special look at nocturnal asthma in particular, before sharing our top tips to sleep better with asthma.
What is asthma?
Asthma is a chronic lung condition characterized by inflamed and narrowed airways. It affects 1 in 13 people, making it one of the more common diseases in America and the most common among children. Primary symptoms include wheezing (where you make a whistling sound when you breathe), coughing, tightness in the chest, and shortness of breath.
How asthma works: Our airways are responsible for transporting air to and from our lungs. In people with asthma, however, these airways are inflamed and highly sensitive to certain triggers. When their airways encounter one of these triggers, they respond by tightening the muscles, worsening swelling and inflammation, and increasing mucus production. Each of these in turn further narrows the airways and restricts air flow – resulting in asthma attack.
The list of potential triggers for an asthma attack is a long one. They include:
Illness, such as cold, flu, and virus
Allergens, such as dust, mold, and animal dander
Smoke and other odors
Changes in weather or temperature
Drugs, such as anti-inflammatory medications and beta blockers
Scientists still do not know what causes asthma, or what accounts for its increase in diagnoses in recent years. Potential risk factors could be family history or predisposition to allergies, exposure to pollution, respiratory infections, or obesity. It’s also possible that exposure to a viral infection or certain allergens during early childhood, when the immune symptom is still developing, may increase a person’s risk as well.
The first signs of asthma typically appear during childhood, and some people may eventually grow out of it. There is no cure for asthma. However, with treatment, symptoms can be minimized to promote maximum quality of life.
Over 3,000 people die from asthma each year. Adult women, boys, and African-Americans are most at risk of dying from asthma.
Nocturnal asthma refers to the phenomenon of asthma symptoms worsening at night. When people with asthma experience coughing, wheezing, chest tightness, shortness of breath, and general difficulty breathing at night, it interferes with their sleep.
Over half (60%) of people with persistent asthma experience nocturnal asthma, and up to 75% experience coughing or wheezing at least one night a week. Some people are at increased risk for nocturnal asthma, especially if they:
Nocturnal asthma is a particularly troubling condition because not only does it negatively impact sleep, but it’s also associated with an increased risk of death.
Causes of nocturnal asthma
Everyone, whether asthmatic or not, experiences optimal airway function around 4pm in the afternoon. Our worst functioning is about 12 hours later at 4am, when most of us are asleep. During sleep, resistance develops in both our upper and lower airways. They narrow and simply function less well. For people without asthma, the effect isn’t pronounced enough to be a problem. They continue enjoying uninterrupted sleep.
It’s a different story for people with asthma. As the airways become more restricted, the more likely they are to experience the symptoms of nocturnal asthma. In fact, this may be why people with asthma first start to display symptoms during sleep.
Researchers are still looking into what causes nocturnal asthma. So far, they’ve noted several potential causes, any of which could combine to worsen symptoms:
Our brain produces less epinephrine during the night, a hormone which opens our airways, while producing more histamine, a hormone which closes them. As a result, we experience increases in both mucus and drainage (sinusitis) during the night, blocking our airways.
Nocturnal asthma could be a real-time reaction to indoor allergens from the bedroom, like dust mites in the mattress.
Alternately, it could be a delayed response to allergens encountered during the daytime. While an asthma attack usually ends within an hour, about half of people experience a late phase response, 3 to 8 hours after their initial exposure to the original asthma trigger. The effect is increased bronchial inflammation and airway obstruction.
Stress affects our ability to sleep, and is itself a trigger for asthma. If people are stressed at night before they go to bed, they may be more likely to experience a nocturnal asthma attack.
Cooler air is more conducive to sleep, but it’s important to keep the bedroom cool rather than cold – as too-cold air can trigger asthma. Unfortunately, air conditioning tends to dry out the air, and dry air is another asthma trigger. For best results, individuals with asthma can use a humidifier to reintroduce moisture into their bedroom.
The supine position
When we lie down to sleep, we experience more gravity and, therefore, more pressure on our lungs and chest. The longer we stay in that position, the more drainage, post nasal drip, and mucus tend to accumulate in our airways. Meanwhile, our airway resistance naturally grows as the night goes on, due to histamine production and decreased lung functioning. Together, these effects make it tougher to breathe.
Between one-third to nearly 90% of people with asthma also have GERD, which tends to flare up at night.
When you’re lying down, stomach acid can come back up through your esophagus, triggering an asthma attack. If that stomach acid reaches your throat, it can enter your trachea, airways, and lungs, irritating already restricted airways while increasing mucus. If the medication you’re taking for asthma relaxes that valve between your esophagus and stomach (a common side effect of many asthma medications), the effect is even worse.
Nocturnal asthma in children
Nocturnal asthma is especially dangerous because 70% of deaths and 80% of respiratory arrests caused by asthma occur at night.
Children are at particular risk because they typically underreport their nocturnal symptoms, and so their parents are unaware of the full extent of their nocturnal asthma. As a result, they may not receive comprehensive treatment that they need, increasing their mortality risk and further impairing their daytime functioning.
One study observed the effects nocturnal asthma had on both the children with asthma and their parents. Up to 41% of the children participants with asthma also experienced nocturnal symptoms, negatively impacting their sleep quality, and reducing quality of life for both themselves and their parents.
Children with nocturnal asthma are more likely to display behavioral problems and perform worse academically. They’re also more likely to miss school altogether, just as their parents are more likely to miss work. Similar studies have documented a direct relationship: the more weeknights a child wakes up from nocturnal asthma, the worse the effects.
In addition to nocturnal symptoms, children with asthma also tend to disproportionately experience other sleep issues, such as:
Sleep-maintenance insomnia (waking up during the night)
Sleep apnea is a condition where the individual literally stops breathing during sleep. Obstructive sleep apnea (OSA) is much more common. It occurs due to a narrowing or blockage of the airways, as can happen with asthma, obesity, or enlarged tonsils.
Central sleep apnea (CSA) is less common. It occurs when the brainstem, which controls your breathing, doesn’t function properly during sleep. A recent study of 137 children found that those with asthma were much likelier than their peers without asthma to experience central sleep apnea during the night:
How asthma affects sleep
Whether they have nocturnal asthma or not, people with asthma are more likely to experience overall lower-quality sleep, difficulty falling asleep, waking up too early or frequently during the night, and excessive sleepiness during the day.
Over one-third of adults with asthma have insomnia. Adults with asthma and insomnia are also more likely to have depression or anxiety and report poorer quality of life than non-insomniac adults with asthma. Having insomnia also predicts poorer health outcomes related to asthma. These individuals are 2.4 times more likely to have worse asthma and 1.5 times more likely to have to visit a health care provider due to their asthma symptoms.
People with asthma are also 70% more likely to have sleep apnea. A large study of nearly 40,000 individuals found that individuals with asthma were over 2.5 times more likely to develop OSA, and their risk increased if they failed to adhere to their asthma treatment.
When people with asthma don’t get enough sleep, they end up sleep-deprived. Even a night of sleep deprivation affects you the following day, impairing your focus, making you moodier, and worsening your overall cognitive performance. In the long-term, chronic sleep deprivation is linked with increased risk of obesity, diabetes, cancer, and other serious health issues.
Sleep deprivation occurs whenever you don’t get sufficient sleep. That means sleeping less than the recommended 7 hours minimum for adults, or between 9 to 12 hours, depending on your child’s age. Even if you get enough sleep, you can experience the results of sleep deprivation if your sleep is interrupted during the night, such as happens with nocturnal asthma or sleep disorders like sleep apnea.
For a night of sleep to be considered “good,” it needs to meet the recommended amount for your age, and be uninterrupted. Throughout the night, we cycle through different stages of sleep several times, from light sleep to deep sleep to REM, before starting over again.
As we sleep, the time we spend in the REM stage increases, so the bulk of our total REM sleep gets concentrated in the latter half of the night. During REM, our brain processes and sorts through cognitive and emotional learnings from the day, committing them to memory. If we don’t sleep continuously at night, we don’t get sufficient REM. And without sufficient REM, we experience negative impacts to our cognitive performance and emotional well being.
A 1998 study of children with nocturnal asthma proved these effects. The children with nocturnal asthma tended to have more behavioral issues and poorer academic performance, when compared with their peers without nocturnal asthma. Fortunately, if they underwent treatment for their nocturnal symptoms, they got better sleep, and both their academic performance and behavior improved.
How to sleep better with asthma
The following behavioral tips and lifestyle changes can help reduce symptoms and make it easier to breathe – and sleep – better at night.
1. Follow your asthma treatment plan.
Take and use your asthma medication as prescribed to manage symptoms. Keep medications and inhalers close by so they’re easily accessible in case of a nocturnal asthma attack.
Patients with nighttime asthma are often prescribed inhaled steroids, which, with daily use, help manage inflammation and other symptoms. Bronchodilator inhalers may be used during an episode of nocturnal asthma.
If difficulty breathing is waking you or your child once or more per week, talk to a doctor. They can help you develop a treatment plan if it is indeed nocturnal asthma, or point you in the right direction if it’s another issue, like sleep apnea.
Prepare for your appointment by keeping an asthma diary. This can help you track symptoms so you’re more aware of your particular triggers, and either avoid them or take preventative medication when you know you’ll be encountering them. Similarly, monitor your lung function during the day using a peak flow meter. Along with your diary, this may reveal patterns that help your doctor put together a treatment plan for your nocturnal asthma.
Parents can use wheeze detection devices to monitor their children’s nighttime symptoms and aid in diagnosis of nocturnal asthma.
2. Address your stress.
Stress worsens asthma, and makes life less enjoyable. It’s also linked with insomnia. By managing your stress, you’ll not only sleep easier at night, but you’ll be less likely to experience an asthma attack.
During the day, take up a regular yoga or meditation practice.
At night, follow a bedtime routine. The key is to repeat the same set of calming activities in the same order each night, training your mind to prepare for sleep and easing your body into a state of relaxation. Take a warm bath, enjoy a cup of bedtime tea, and practice deep breathing or muscle relaxation exercises.
Include turning off your electronics in your bedtime routine, too. These devices tend to house annoying work emails or intense television dramas, either of which increase our stress levels. Plus, the blue light emanating from these devices is perceived especially strongly by our brains, which interpret it as sunlight, and then respond by trying to keep us awake.
If you have anxiety or depression that’s making your insomnia worse, talk to a therapist.
3. Eat well and exercise.
Obesity is a contributor to nocturnal asthma, as well as related GERD and sleep apnea. A healthy diet and regular exercise plan can both prevent and address obesity. Ensure you exercise in the morning or early afternoon if possible, so you’re energized during the day instead of at night.
Many of the foods that are good for you are also good for sleep, like yogurt, nuts, and leafy greens. Avoid overly sugary or fatty foods, especially at night – these are bad for your waistline and your sleep.
Avoid smoking, caffeine, and alcohol, too. These are all disruptors to sleep, and smoking is especially bad for people with asthma. Alcohol is a sedative, so while it helps you fall asleep, that same sleepiness gets applied to your airways, worsening snoring, sleep apnea, and nocturnal asthma.
4. Manage co-morbid GERD and sleep apnea.
Just like treating your asthma helps improve your sleep, so does treating any underlying conditions.
People who take medication for their GERD tend to experience fewer nocturnal asthma symptoms and asthma attacks. If possible, get an adjustable bed frame so you can sleep with your head slightly elevated above your esophagus. This can help keep your airways open and prevent GERD.
For OSA, CPAP therapy is the most effective form of treatment for OSA. You will need a diagnosis of sleep apnea in order to receive a CPAP prescription. While you sleep, you wear a over you face that’s connected to one of these machines, allowing the machine to regulate your breathing and keep your airways open.
CPAP has shown to be helpful in reducing asthma symptoms for those with OSA and comorbid sleep apnea. However, you should not use CPAP if you only have asthma, without sleep apnea. It will just disrupt your sleep.
5. Remove allergens (including pets) from the bedroom.
Dust mites, pet dander, and more indoor allergens all conspire to make nocturnal asthma symptoms even worse.
If you’re allergic to your pets, don’t let them sleep with you. Even if you are not allergic to your pet, your pet rolls around in the outside world and brings irritating allergen back in with them, so it’s best to keep them out of the bedroom.
Protect against other allergens by regularly dustin shelves, furniture, and other decor. Also get a HEPA filter for your bedroom. It will help clear your indoor air of any additional allergens or dust.
6. Keep your bedding allergen-free.
To protect against dust mites, it’s essential that you keep your bedding as clean and as hypoallergenic as possible.
Use a mattress encasement. An encasement is a cover for your mattress that completely seals your mattress within an airtight zipper. This keeps out dust mites and bed bugs, and extends the life of your mattress. This is different than a mattress cover, which merely protects it from stains and regular wear and tear. Use a pillow cover, too.
Wash and clean your sheets at least weekly. Use the hot cycle on both the washer and dryer. Wash your pillows, too, and replace your mattress once it’s no longer supportive. If you start waking up with aches and pains, it’s no longer supporting you, and it’s probably accumulated dust mites in the process.
You might even consider investing in an all-latex mattress. These beds are expensive, but due to their organic construction, they are naturally 100% hypoallergenic and antimicrobial.
7. Keep your bedroom cool and dark.
Changes in temperature can also trigger asthma, so keep your bedroom consistently cool. Not only will this prevent triggering your asthma, but it also helps you sleep.
Thermoregulation is an important part of sleep – our body needs to stay a bit cooler for restful sleep. Set the thermostat to somewhere in the mid-60 degrees Fahrenheit, keep all your windows closed, and ensure there are no cracks allowing for outside air and allergens to enter.
To prevent the air from becoming too dry, keep moisture levels consistent with a humidifier. Plus, high humidity is a death zone for dust mites, so you’ll be protected against yet another potential trigger.
Also keep your bedroom dark. The darker it is, the easier for your mind to stay asleep. Remove electronics from the bedroom, face alarm clocks away from you, and use blackout curtains or an eye mask if needed.
If you have allergy-induced asthma, be sure to check our mattress and bedding guide for people with allergies. It includes helpful tips on reducing allergens from your bedroom and reviews of the best hypoallergenic bedding. For even more tips on eliminating allergens from the bedroom, check out this blog post.
Nocturnal asthma makes sleep especially challenging for children who may already be dealing with bedtime anxiety. Parents can get tips for improving their child’s sleep in our Parent’s Guide to Healthy Sleep.
The National Heart, Lung, and Blood Institute shares an in-depth overview on asthma, causes and risk factors, and how parents can go about getting their children screened for asthma. In addition, the site provides links to read the latest NIH-funded research or sign up for clinical trials.
The Asthma and Allergy Foundation of America is the largest nonprofit dedicated to asthma. Their website provides links to find local support groups, sign up for fundraising events, and browse helpful information about asthma, treatment options, and scientific research.
Many people blog about living with asthma or caring for a child with asthma. Healthline has rounded up the most popular on their 2018 list.