Sleep and asthma; Why do we usually go dodgy at night?

[EmmaF91]

Hi everyone

I thought I’d do an ‘infomercial’ today about why asthmatics can be worse at night! (I was asked privately if I could think of triggers that would cause night flares so have also added these in!)

SIGNS OF ISSUES

Now we all know that waking up at night is a bad sign for asthma, but did you know that waking up earlier than normal, waking symptomatic at usual time or waking absolutely shattered may also be signs of asthma issues during the night? I know personally I don’t always wake when my asthma is bad, however I might wake up with my alarm absolutely shattered test my PF and it’s down at 40% (I am lucky that I have a reliable PF). You CAN sleep through the issue and not recognise it, especially if your PF has recovered slightly by the time you wake (for reasons I will go into later 😉). You also may not wake completely or have ‘asthma’ dreams. I have semi woken multiple times, innately knew I needed my pump, taken 2 puffs and fallen immediately back to sleep - and only realised it wasn’t a dream cause the pump was still in my hand in the morning... I call them zombie wake ups cause I’m awake but not really aware 😅. Equally asthma dreams - another friend of mind can have dreams where she can feel the issues in her sleep (apparently she usually dreams that she’s in hospital with an asthma attack 😅) but it doesn’t necessarily wake her up! So basically if you wake fully, wake early, have zombie wake ups, asthma dreams or wake shattered all the time, then you should mention this to your doctor, as they can all be early signs of issues before they start affecting you during the day!

WHY THIS HAPPENS (the pathophysiology of night symptoms 😉😅)

You naturally produce more mucus and less cortisol (your natural steroid from your adrenal gland) at night - it’s linked to your circadian rhythm. Most people find that this usually starts around 10pm/12am ish and finishes around 6/8am ish depending on the individual. On top of this most people have a witching hour(s) where this can be worse, which again can be different for everyone! My worse time is usually 2-4am but my friend’s is 12-2.

But basically everything slows down at night, so more mucus, less cortisol and then we lie down! Lying down can cause both comorbidites to get worse, such as post nasal drip (esp if you sleep on your back), or reflux. But on top of this lying down changes how your airways ‘sit’... most people find that lying on their back makes breathing harder, whilst lying on their side easier (whoever this can change from person to person!) however the ‘easiest’ position to breathe in is leaning forwards... a position the complete opposite to sleep! However this will explain why people can have issues at bed time, especially when they have been dodgy (even mildly) throughout the day!

NIGHTTIME TRIGGERS

Is dust an issue for you? If so try washing your sheets and hooving more often! Sheets and carpets can hoard dust and it’s easy to forget that!

Also keep your window shut (if it’s been open) as some plants release pollen at night. Also don’t forget that if you are triggered by temperature changes, opening the window will (usually) let in colder air which for some may be a problem. Conversely if you find humidity and heat triggering and usually sleep with your window shut, maybe try opening it to see if that helps!

OTHER THINGS TO THING ABOUT

Meds!!! It won’t affect many, but it’s something that cropped up with me so I’ll add it here! Those on aminophylline/theophylline tablets, who find they keep waking at the same time of night, then having issues at the same time of day - go get your levels checked! I went 3 weeks with a 4 am wake up and 4 pm flare, and had 4 trips to hospital with it before someone thought to do a blood level check. I was untherapeautic! They upped the dose and suddenly that stopped happening 😅😂.

Now as I said before, night symptoms are not a good sign, so if you get them you should speak so someone about it, to get yourself back under control (also remember 3x reliever doses a week means you are uncontrolled, so if you’re needing to do that at night let them know!)! If you want to discuss it before you speak to your GP (or whoever you see!) the AUK helpline nurses are great and can be reached on 0300 2225800 M-F 9-5. Alternatively their WhatsApp service is 07378 606728.

AUK have done a good write up on their webpage here; asthma.org.uk/advice/living... if you want to read more!

[Lysistrata Administrator Community Ambassador]

Thanks Emma! This is all really useful to know, and AUK's page is really good too.

I went for ages where it felt like if you didn't wake up, take your peak flow and find it had dropped and then take your inhaler, it didn't 'count'. I'd get asked really specific questions about my night-time symptoms by drs/asthma nurses and it felt like if I didn't answer them 'correctly' I would be told well that can't possibly be asthma, you would wake up, you can't sleep through it etc.

Seeing that waking up in the morning with symptoms, being able to fall back asleep while still having asthma (on AUK's page), feeling shattered or like you haven't slept, and not fully waking with asthma can all indicate night time issues is so good to read to confirm this isn't just me!

My brain is a complete idiot at night frankly, and I have been known to semi wake up and spend 15 minutes wondering what this weird sensation in my chest is (when it is asthma symptoms I've had many many times before) and another 15 to realise that there is this thing called a blue inhaler which can actually help (yes this has happened!)

I definitely get the weird dreams which I see as my brain's attempt to make sense of the sensations. The top favourite themes are hospital (usually with a weird twist) and diving. (I have never dived and no one would let me do it now, but my brain goes 'oh breathing is funny, maybe you are underwater'. One time my dream self had run out of oxygen in the dream tank, but decided to ignore this because she wanted to chase some sharks. I eventually woke up SOB. Dream self should have a Darwin Award 😂😂)

I often find that if I had daytime symptoms I will have a better night if I take reliever before going to bed, even if I don't need it at that moment. If I ignore symptoms during the day and especially in the evening, it usually comes back to bite me at night; if I have treated things in the evening however I will usually have a better night unless I'm really struggling.

[Junglechicken]

Emma, as always your posts are so informative. I’ve always been a bad sleeper and never quite settle. Usually wake to covers on the floor along with pillows that I’ve thrown around at night during sleep. I often wake feeling more tired than I was prior to sleep. My first attack in a long time happened at 2am.

I do have asthma dreams about an ongoing wheeze that won’t stop. I always put it down to anxiety over my asthma rather than physical symptoms. Maybe I have been having issues and not realised.

[AirIsUnderrated]

Thank you, that’s very interesting.

I wake up at 2:45am most mornings but usually not noticeably SOB. I sleep on my left side, and night-time and mornings are usually better for me. I get worse after lunch until bedtime. That doesn’t tick the boxes for either silent reflux or asthma, both of which I’m being treated for. Now that I’m taking Omeprazole, the reliever inhaler always helps which is the biggest reason for my asthma diagnosis. They can’t do spirometry tests any more because of Covid.

Does that mean I’m just weird or that I might not have asthma after all?

[twinkly29 in reply to AirIsUnderrated]

I suspect it's probably just a weird habit thing (not a conscious one!) - there must be a gazillion reasons for waking in the night. I wake frequently for asthma but not every time I wake up is related to that. A bit like I cough when my asthma is a pain but not every cough is asthma related.

[AirIsUnderrated in reply to twinkly29]

I agree, I don't think the waking is necessarily related to asthma, although that specific time is new since my breathing problems began. Peri-menopause is far more likely to be the cause of the night waking in general.

I am confused though, why I'm better at night when the two possible diagnoses that I have are both supposed to be worse at night. It makes me wonder whether there's something else going on that we haven't worked out yet. Or whether not all asthma sufferers are worse at night?

[Lotti_321-]

Zombie wake ups, I’m so glad this is actually a thing. I thought I was going round the bend. I get it so much, wake have my inhaler than drop to sleep straight away! I can always tell when my asthma isn’t great as even if I don’t wake up during the night I don’t feel refreshed.

[Gareth57]

Thanks that’s really interesting, I’ve always thought I had reasonably well controlled asthma, I have few flares and haven’t woken up at night for many years, but I often wake feeling shattered. I will be checking my peak flow again on a regular basis!

[hilary39]

All great points! Good resource for the archives

[mjrminor]

Thanks for this. I've been having terrible night time asthma recently, complete with weird anxiety dreams that wake me up to find I'm short of breath. My asthma nurse has now added Beconase to go with the usual Fostair and Montelukast as we realised it's being caused by post nasal drip. I'm seeing an improvement already.

[Mogget]

Thanks for this Emma, especially the bit about theophylline, as I’ve never had a blood test to check my levels. I wake up pretty much every night with asthma trouble (it’s been like this for 2yrs 🙄) but do have a good consultant who is doing his best to help me. With severe asthma though he described treatment as being in the realm of art and not science 😆

[Wheezycat]

Interesting! I often feel tired in the morning, at present as well, but I am pretty certain it is not asthma related. I also dream a lot, but it has seemed to me that is possibly caused by the medication. But for those times, for me especially in the winter months, when I am always tired it is good to bear what you say in mind.

One more night time thing: I am prone to a cough caused by throat irritation. This has been with me for years. It often wakes me at night. But it is not a typical asthma cough. However, after years often being disturbed by it at night, I now know it is linked to asthma as it is often eased by my reliever. For years I occasionally sought help for it, but got nowhere, and then my asthma became a thing. That was when a GP noticed and joined together dots. So if any of you have a throat cough it could still be asthma linked.

[MissNyxiie]

I have had trouble sleeping for years, im a very light sleeper, never sleep the whole night and dont stop with the toilet trips. I occasionally wake coughing or tight chested between 12 and 3 am I have noticed and sometimes when I get up between 5 and 8 depending on the day. I mentioned this to the respiratory team when I stayed in hospital for a night in april and all they said was it was likely I had sleep apnea. Which I have had an assessment for last week, and the type of dreams I have and everything suggests it might be this and not asthma in the night. I always wake up groggy and very tired in the morning. I have real trouble getting up most mornings. But now have to wait for a year for another appointment for tests. My asthma is poorly controlled, so dont know now if night time symptoms are asthma or sleep apnea.

[daleboy3]

Wash duvet covers & sheets weekly to reduce dust on the bed linen & replace the pillow for a new one this will help reduce intake of dust partials during the night.

Check you don’t have moss growing on your roof top as this can release tiny air born mould particals that drift down past bedroom windows in the night, this can trigger asthma attacks, a net curtain could help trap this mould so it’s not breathed in as you sleep, buy a negative ion emission device to make dust drop down in the bedroom, this stops dust floating in the air, some air purifiers have carbon filters built in to catch dust this should help for a better nights sleep

[ninelives]

Thank you so much -hadmt twigged that my theophylline levels could be to blame bless you ,will get them checked .

I also have "dreams" of asthma attacks and wake up with them -also aware in my sleep that I am not breathing -and feel my heart rate slowly dropping -quite unpleasant!

[lucia_m]

This is really interesting Emma, thank you. I have loads of asthma dreams - last night I dreamt I was coughing for what seemed like hours. A common one is dreaming that I'm taking loads of ventolin but not getting relief, or that I need ventolin but something is stopping me from being able to take it. I don't always wake up with these, although I often do (usually about 3am). If I wake up earlier than usual (5.30-6) I'm usually wheezy then too.