What is Nocturnal Asthma?

Asthma is a chronic lung disease that causes shortness of breath, wheezing, chest tightness, and cough. More than 25 million adults and children live with asthma in the United States.

People with nocturnal asthma, or nighttime asthma, experience symptoms while sleeping. This can disrupt sleep. It can also make managing asthma more difficult. Up to 60% of asthma patients are estimated to have nocturnal asthma.

An asthma attack at night is a sign of uncontrolled asthma. If you experience asthma symptoms at night more than two times per month, make an appointment with a doctor. You may want to see an asthma specialist, such as an allergist or pulmonologist.

A person sits on a bed in a dimly lit room, head in hands, appearing thoughtful or stressed. A lamp glows on a bedside table next to an alarm clock. Battling nocturnal asthma under the calming yet somber blue walls adds to the night's quiet struggle for breath.

What causes nocturnal asthma?

What causes nocturnal asthma is not completely understood. However, several factors can make asthma more severe at night.

When you breathe in, the lungs transport oxygen into the bloodstream. From there it is carried to the rest of the body. When you breathe out, the lungs send the waste, or carbon dioxide, out of the bloodstream. How well this process works varies – it is part of the body’s natural circadian rhythm. The circadian rhythm is your internal clock. It regulates the body over a 24-hour period.

Lungs work best during the day, with peak lung function at about four in the afternoon. Studies show lung function drops by 4 a.m., especially in people with asthma. The fluctuation is usually less than 10 percent in most people. But people with asthma can have up to a 50 percent variation from day to night.

The body’s inner clock, or circadian rhythm, affects hormones such as adrenaline, cortisol, and melatonin. The hormones change throughout the day and can trigger nighttime asthma symptoms.

  • Adrenaline is naturally lower during the night. It helps to relax and keep the airways open.
  • Cortisol also goes down at night, and this can affect airway narrowing and worsen asthma symptoms.
  • Melatonin is higher at night and is associated with a decrease in lung function.

The circadian rhythm can also affect levels of airway inflammation. This leads to nighttime asthma symptoms.

In addition, mucus from post-nasal drip, allergens, and cold air can trigger nighttime asthma attacks.

In the blue-lit room, a woman sits on her bed, resting her head with a tired expression. Wearing a long-sleeved top, she appears to be exhausted from lack of sleep because of night time asthma.

What are nocturnal asthma symptoms?

Nighttime asthma symptoms mirror daytime asthma symptoms, but are usually worse. People with nocturnal asthma often experience:

  • coughing
  • shortness of breath
  • wheezing
  • chest tightness

These symptoms can occur just before or even during sleep, and can lead to poor sleep quality. The nocturnal symptoms can cause irritability and tiredness and may also worsen asthma symptoms during the day.

Nocturnal asthma can be very serious. An asthma attack at night can be fatal. Shockingly, over half of all deaths from asthma attacks happen between midnight and 8 am.

Daytime effects of nocturnal asthma

Nocturnal asthma and allergy symptoms go beyond the bedroom. Children with nighttime asthma miss more school days than healthy kids. It can also cause parents to miss work. School and work performance can suffer when the family can’t sleep.

Children with nocturnal asthma often perform poorly in school. Research suggests these children score lower on memory and timed tests. They often have an inability to concentrate, listen and problem solve. Poor sleep from asthma can include morning headaches and mood changes. They may have an increased risk of getting colds and the flu.

Nocturnal asthma triggers

Physiological changes that occur during sleep contribute to nocturnal asthma. But there are other nighttime asthma triggers, including:

  • Mucus and postnasal drip. At night, people often experience increased mucus production, sinus drainage and acid production. This fluid and acid can trigger asthma symptoms and make asthma at night worse.
  • Sleep position. Sleeping on your back can allow fluids to pool in breathing passages. This can trigger nocturnal asthma.
  • Comorbid conditions. Gastroesophageal reflux disease (GERD), acid reflux, obstructive sleep apnea, allergic rhinitis, and obesity are common comorbid conditions and can make asthma worse.
  • Allergens. Exposure to indoor allergens, such as dust mites, pet dander, or mold, can trigger symptoms.
  • Cold air. Sleeping with air conditioning on or with a window open can trigger symptoms. Cool air is a common asthma trigger.
  • Smoking. Cigarette smoke is a known trigger, whether it’s from smoking before bedtime or from secondhand smoke.
Two tween boys sleeping in the morning after being up all night with asthma issues.

How do you treat nocturnal asthma?

Make sure to take your asthma medications daily. Treatment may include:

  • Quick-relief inhalers. These open airways to relieve asthma symptoms. They can be taken at the first sign of asthma symptoms for quick relief, even at night. There is also a quick-relief inhaler available that can relieve symptoms and also reduce airway inflammation.
  • Controller medications (anti-inflammatory). These reduce and prevent lung inflammation. They include inhaled corticosteroids (ICS), long-acting inhaled beta2-agonists (LABA) and long-acting muscarinic antagonists (LAMA). Controller medications are taken every day, not just when you have symptoms.
  • Leukotriene modifiers. Theseblock the action of leukotrienes, chemicals involved in immune responses that lead to inflammation and tightening of the airways.
  • Combination inhalers. These include more than one asthma medication in one device. For example, a combination inhaler may include ICS and LABA. Another combination is ICS and LAMA.
  • Biologics target the specific cells and pathways that cause inflammation and asthma symptoms. These medications treat severe asthma.

To manage nighttime asthma, avoid triggers and treat other illnesses. Also, avoid using nasal sprays and inhalers with stimulants before bed. They can make falling asleep harder.

For people with allergic asthma, doctors may recommend allergen immunotherapy.

People with asthma should meet with an asthma specialist to develop an Asthma Action Plan. This plan can be used for both day and night symptoms.

Questions and Answers (Q&A) on Nocturnal Asthma

Below are some frequently asked questions about nocturnal asthma. If you have a specific question you’d like answered here, please Email Gary Fitzgerald, Senior Editor.

First, focus on good sleep habits or “sleep hygiene.” Go to bed at the same time every day. Make sure your room is dark and quiet. Avoid television, cell phones, or other electronic devices before bedtime. Don’t eat big meals before going to bed. Avoid alcohol and caffeine. Exercise during the day helps, too.

In addition to sleep hygiene, there is a lot you can do to manage asthma at night.

  • Take your controller medications every day as prescribed. Daily asthma medications prevent symptoms and reduce inflammation.
  • Keep a quick-relief inhaler at your bedside for nighttime asthma symptoms.
  • Keep the house at a comfortable temperature. A good temperature range is somewhere between 65 and 72 degrees.
  • Use a room dehumidifier.
  • Keep pets out of the bedroom. This will limit any animal dander – a common allergen – where you sleep.
  • Wash bedding (including stuffed animals) weekly in hot water to kill dust mites, another allergen.
  • Clean carpets in the bedroom several times a week to remove allergens and dust. Use a vacuum with a HEPA (High Efficiency Particulate Air) filter. Consider hardwood floors.
  • Use allergy-proof coverings on pillows and mattresses.
  • Eat a balanced diet and maintain a healthy weight. Don’t eat in the bedroom so you can keep critters and pests away from where you sleep.
  • Quit smoking. Do not allow smoking in your house.

Anyone with asthma can develop nocturnal asthma. Is your asthma worse at night? Do you ever wake up with chest tightness, wheezing, shortness of breath, or coughing?

If you experience these symptoms, you could have nocturnal asthma. Make an appointment with an asthma specialist to discuss treatment.

Nocturnal asthma may be harder to diagnose in children because they may not understand or report their symptoms. Parents should talk with their child’s doctor if there are frequent symptoms at night.

Yes. People with asthma who have nighttime symptoms may have poor asthma control. They are also at risk for severe or persistent asthma. Nocturnal asthma attacks are responsible for more than half of all deaths from asthma.

Asthma often worsens at night, causing wheezing. This could be from nocturnal asthma. It might be from GERD and acid reflux. If you experience wheezing, talk to your asthma doctor to discuss symptoms, causes and treatment options.

It is likely a combination of factors. It could be physiological changes that happen during sleep. It could be exposure to triggers before bed (pollen, mold or pet dander) or during sleep (dust mites).

Obstructive sleep apnea and asthma are closely related. Sleep apnea involves repeat episodes of upper airway collapse during sleep. Both conditions have shared risk factors, such as smoking, being overweight or GERD symptoms.

Sleep apnea can lead to nighttime episodes of…

  • snoring
  • pauses in breathing
  • gasping for air
  • coughing
  • gagging

Sleep apnea affects 18 million American adults. Studies show that people with asthma have a higher risk of developing sleep apnea than people who do not have asthma. Black, Hispanic/Latino and Asian Americans are at higher risk. People who are overweight are also at higher risk for sleep apnea.

If you or a loved one has asthma, watch for symptoms of sleep apnea. You may be prescribed a CPAP (continuous positive airway pressure) machine to help you breathe at night. Studies show this treatment may also improve asthma control.

The best sleeping position is the one that allows you to sleep without waking from symptoms. Some prefer sleeping on their back with a slight raise in their shoulders and head. (This position may not be helpful for people with obstructive sleep apnea, however.) Others find it more comfortable to sleep on their side with a pillow between their knees.

Sleeping on the stomach compresses the lungs and should be avoided.

If you have an asthma attack at night, the first thing to do is use your quick-relief inhaler or nebulizer. You can also try steam from a shower to see if it improves breathing. If your symptoms do not improve, seek emergency care.

Chronic nighttime cough “should not be ignored,” says William Berger, MD, board-certified allergist and medical advisory board member with Allergy & Asthma Network. Dr. Berger advises people with asthma to see an allergist or pulmonologist for nighttime asthma.

Reviewed by:
Bradley Chipps, MD, FACAAI, is a board-certified allergist and pediatric pulmonologist with Capital Allergy and Respiratory Disease Center in Sacramento, California. He earned his medical degree from University of Texas Medical Branch in Galveston in 1972. He is Past President of the American College of Allergy, Asthma and Immunology (ACAAI).