I can't Breathe at Night!
High Yield Review - Nocturnal Asthma
Case: A 40 y/o female with past medical history of
asthma, she has a complaint of excessive day time sleepiness.
She says she has not been sleeping well, she
says she has trouble going to sleep and staying asleep.
She says once a week she will abruptly wake up from sleep and have coughing fits and feel short of breath. Her husband says she sounds like she is wheezing . She uses her albuterol inhaler upon waking up and this resolves her symptoms.
You suspect she has nocturnal asthma causing her moderate persistent asthma symptoms.
You assess her for possible triggers including OSA, GERD, and allergic Rhinitis/Sinusitis.
She says she does not wake up and gasp for air nor has a choking sensation, she does not have any burning substernal or epigastric pain, and she does not have nasal drip symptoms.
You prescribe her a Long Acting Beta Agonist ( LABA ),
she returns for a follow up and she now reports night time awakenings of 1 time a month and feels better!
So What If ?
What if the patient did not have a prior diagnosis of asthma?
- Then symptoms of cough or unexplained dyspnea will need evaluation with spirometry/pulmonary function tests possible methacholine challenge to assess for bronchospastic disease
What if the patient wakes up gasping for air and a choking sensation?
- Suspect OSA and order a sleep study
What if the patient reports acid reflux symptoms?
- Start empiric PPI 2x daily for 3 months
What if the patent was taking NSAIDS or Aspirin or Beta Blockers?
- Then you would suspect drug induced asthma
What if she was having symptoms at work and feels better at home or on vacations?
- Then you suspect exposure to irritants and Occupational Asthma
- You would request spirometry/ peak flows before and after work exposure
What if She was also Pregnant with Asthma?
- Then you would perform spirometry to evaluate pregnancy dyspnea from asthma dyspnea
Then you would perform regular Spirometry monitoring to assess disease control
What if you look up her nose and see this?
- You suspect Allergic Rhinitis (pale boggy, edematous nasal turbinate with secretions ) and prescribe leukotriene inhibitor and glucocorticoid nasal sprays
Case Clues - Nocturnal Asthma
- She has day time sleepiness, due to night time awakenings with cough / wheezing
- Her symptoms improve with Albuterol ( SABA)
- She does not snore or gasp for air ( R/O OSA)
- She does not have epigastric pain or burning substernal chest pain ( R/O GERD)
Notable Notes - Nocturnal Asthma
- Nocturnal symptoms of cough and wheezing owning to frequent nighttime awakenings
- Improves with albuterol ( SABA)
-Treat with adding long acting beta agonist ( LABA )
- Assess and R/O Common Triggers:
1. Obstructive Sleep Apnea
- Narrowing of the small airways also leads to more irritation and contraction of the smooth muscle worsening asthma symptoms
2. Uncontrolled GERD:
- Can lead to aspiration of gastric contents into the lung leading to Uncontrolled/ Difficult to control Asthma in the setting of moderate to severe asthma GERD induces cough and increases frequency of exacerbations
3. Rhinitis/ Sinusitis:
- Irritants / allergens / Infections cause inflammation and mucous production which irritates the airway
The Differentials ( Why Not ? )
Why not Obstructive Sleep Apnea?
- This Patient will wake up gasping , have a sensation of choking and a bedside partner reports apnea periods
- Symptoms resolve as soon as they wake up
- Will need a formal sleep study to diagnose and rule out
Why Not GERD ?
- This patient will wake up with a cough + epigastric pain + burning chest pain
- This is a potential trigger of nocturnal asthma so look for symptoms of uncontrolled GERD in the setting of moderate to severe asthma will need empiric PPI 2X / Day x 3 months
- Symptoms worse not only at night but while laying supine
- Symptoms resolve with a trial of acid reduction ( PPIs )
- If silent GERD (so no symptoms) may contribute to asthma that is difficult to control then PH monitoring may be needed prior to Rx of PPI
Know it for the Boards - Nocturnal Asthma!
- Nocturnal Awakenings and Symptoms resolve with Short Acting Beta Agonist ( SABA )
- Treat with a Long Acting Beta Agonist ( LABA)
- Rule out theTriggers:
1. OSA
2. GERD
3. Allergic Rhinitis/Sinusitis
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