You can have an asthma attack while you are asleep. This is formally known as nocturnal asthma, which refers to the regular worsening of symptoms during sleeping hours. Experiencing these flare-ups indicates that your asthma is not optimally controlled, affecting both your quality of sleep and overall health. Symptoms often become pronounced enough to wake a person from deep sleep.
Why Asthma Symptoms Worsen at Night
The body’s internal 24-hour cycle, known as the circadian rhythm, is one of the primary drivers behind the nighttime worsening of asthma symptoms. During the early morning hours, typically between 2 a.m. and 4 a.m., hormonal shifts naturally occur that predispose the airways to constriction. This timing corresponds with the lowest point of the body’s natural bronchodilators, cortisol and epinephrine.
Cortisol is a hormone that suppresses inflammation, and its concentration decreases significantly during sleep. Epinephrine helps keep the airway muscles relaxed and open, and its reduced level diminishes this bronchodilating effect. Simultaneously, the body’s production of inflammatory mediators, such as histamine, often peaks during these same hours.
The physical act of lying flat also contributes to increased symptoms by affecting lung mechanics and mucus drainage. In a horizontal position, mucus accumulates, and postnasal drip from the sinuses is more likely to flow down the back of the throat, irritating the bronchial tubes. Lying down can slightly decrease lung volume and increase airway resistance, making breathing more difficult. The parasympathetic nervous system, which controls rest and digestion, becomes more dominant at night, causing natural airway narrowing.
The bedroom environment often harbors triggers that exacerbate nighttime symptoms. Dust mites, a common allergen, thrive in bedding, pillows, and mattresses, leading to prolonged exposure while sleeping. Pet dander, if animals sleep in or near the bedroom, settles on surfaces and is inhaled throughout the night. Breathing in cool, dry air can also irritate the sensitive lining of the airways, triggering spasms and coughing.
Underlying health issues that are mild during the day can become problematic at night due to the reclining position. Gastroesophageal Reflux Disease (GERD) allows stomach acid to be easily regurgitated into the esophagus when lying flat. This acid can be inhaled into the airways, causing irritation and triggering a reflex bronchospasm that leads to coughing and wheezing. These physiological and environmental factors often work together, making the cumulative effect on the airways during sleep much worse than during the day.
Recognizing Symptoms of a Nighttime Attack
A nocturnal asthma event typically begins with symptoms that mirror a daytime attack but are often more intense because they interrupt the sleep cycle. The most common immediate signs that wake a person are persistent, hacking coughing fits and a distinct wheezing sound, which is a high-pitched whistle caused by air moving through narrowed airways. These are accompanied by shortness of breath and a feeling of pressure or tightness across the chest.
Even if the symptoms are not severe enough to cause a dramatic awakening, nocturnal asthma can still be indicated by disruptions to sleep quality. A person may wake up briefly multiple times during the night without recalling the symptoms that caused the arousal. This fragmented and poor-quality sleep leads to noticeable consequences during the day.
Daytime indicators include fatigue, difficulty concentrating, and irritability, even after a full night of rest. The need to use a short-acting rescue inhaler more than twice a month during the night strongly indicates uncontrolled nocturnal symptoms. If symptoms require rescue inhaler use, this signifies a significant event that should be discussed with a healthcare provider.
Immediate Actions During a Nocturnal Attack
If you are woken by an asthma attack, follow your established Asthma Action Plan. The first step is to sit up straight, as this position helps maximize lung capacity and ease breathing. Immediately use your short-acting beta-agonist (SABA) rescue inhaler, which should always be kept on the bedside table for easy access.
Take one puff of the rescue medication, taking a slow, deep breath, and hold it for a few seconds before exhaling. Wait 30 to 60 seconds and repeat the puff if you do not feel immediate relief. Repeat this process for up to 10 puffs in a severe attack, following your doctor’s instructions. Focusing on slow, controlled breathing helps prevent panic, which can tighten chest muscles and worsen the attack.
Seek emergency medical attention if the rescue medication fails to provide relief after the maximum recommended doses, or if your symptoms worsen. Signs that require an emergency call include difficulty speaking in full sentences, a bluish tint to the lips or fingernails, or exhaustion.
Strategies for Prevention and Management
Prevention of nocturnal asthma requires achieving better overall asthma control with a healthcare provider. This often involves adjusting the timing or dosage of long-term controller medications. A doctor may recommend taking an inhaled corticosteroid or a combination inhaler later in the day to ensure peak effectiveness coincides with the early morning hours. Leukotriene modifiers also block inflammatory chemicals that contribute to nighttime airway narrowing.
Environmental control within the bedroom is a long-term strategy for reducing triggers. Since dust mites are common culprits, several steps should be taken:
- Encasing mattresses and pillows in allergen-proof covers.
- Washing all bedding weekly in hot water (at least 130°F or 54°C) to kill dust mites.
- Keeping pets out of the bedroom to minimize exposure to dander.
- Using a high-efficiency particulate air (HEPA) filter to remove airborne allergens and irritants.
- Keeping the room comfortably warm, as cold air can trigger bronchospasm.
- Using a dehumidifier to maintain humidity below 50%, discouraging mold and dust mite growth.
Addressing underlying conditions contributes to managing nocturnal symptoms. If GERD is suspected or diagnosed, a doctor may recommend lifestyle changes, such as avoiding large meals, caffeine, or alcohol within three hours of bedtime. Treating acid reflux with medication, or managing chronic sinus issues that cause postnasal drip, can significantly reduce irritation that triggers nighttime attacks.
Maintaining a written Asthma Action Plan is necessary for long-term management. This plan details daily medication use, instructs on monitoring peak flow readings, and provides clear steps for adjusting medication based on worsening symptoms. Adhering strictly to your controller medication schedule, even when feeling well, maintains a stable level of airway protection for preventing attacks during sleep.