Depressive symptoms, quality of sleep, and disease control in women with asthma

Association between lung function and sleep disorder symptoms in a community-based multi-site case-finding study

Obstructive airway disease is associated with sleep disturbances. We aimed to assess the relationship between lung function and sleep disorder symptoms using cross-sectionally collected data between March 2017 and August 2021 from the Undiagnosed Chronic Obstructive Pulmonary Disease and Asthma Population study, a prospective community-based multi-site case-finding study. Undiagnosed Chronic Obstructive Pulmonary Disease and Asthma Population study participants with respiratory symptoms but without diagnosed lung disease who completed spirometry and the Global Sleep Assessment Questionnaire were included. We conducted multivariate linear regression models for forced expiratory volume in 1 s, forced vital capacity and forced expiratory volume in 1 s/forced vital capacity by Global Sleep Assessment Questionnaire responses adjusted for confounders. The same models were employed to examine respiratory symptoms, as reported on the St George's Respiratory Questionnaire and Chronic Obstructive Pulmonary Disease Assessment Test, by Global Sleep Assessment Questionnaire responses. Logistic regression models were used to assess the association of undiagnosed obstructive airway disease with sleep symptoms. Amongst 2093 adults included in the study, 48.3% were female and the median age was 63 years (interquartile range 53-72). Two-hundred and five (9.79%) subjects met spirometry criteria for undiagnosed chronic obstructive pulmonary disease, and 191 (9.13%) for undiagnosed asthma. There were no significant associations between spirometry measures and sleep symptoms (p > 0.5), controlling for age, sex, body mass index, smoking and comorbidities. Those with undiagnosed asthma were more likely to report insomnia "at least sometimes" versus "never" (odds ratio 2.58, 95% confidence interval: 1.27-6.19, p = 0.02). Respiratory symptoms were associated with sleep symptoms, with significant (p < 0.05) increases in St George's Respiratory Questionnaire and Chronic Obstructive Pulmonary Disease Assessment Test scores in those reporting most sleep symptoms. Overall, we found an association between undiagnosed asthma and insomnia, and between respiratory and sleep disorder symptoms.

Prevalence and determinants of insomnia among patients living with asthma in Northwest Ethiopian University specialised hospitals: Multicentre cross-sectional study

OBJECTIVE

The study was aimed to determine the prevalence and contributing factors of insomnia among patients with bronchial asthma.

DESIGN

A multicentre cross-sectional survey was used.

SETTING

This study was carried out from January to March 2022 in three university comprehensive specialised hospitals in Northwest Ethiopia.

PARTICIPANTS

422 patients with bronchial asthma were approached of which 93.8% completed the survey.

OUTCOMES

The degree of asthma control and the severity of insomnia were evaluated using the Asthma Control Test and Insomnia Severity Index (ISI), respectively. The characteristics of the participants were presented, arranged and summarised using descriptive statistical analysis, and correlations between predictors and outcome variables were examined using logistic regression. The cut-off point was a p value of 0.05.

RESULTS

Participants' ages ranged from 33.6 to 65.2 years on average. Just under three-fourths (71.4%) of the participants had at least one episode of insomnia as per the ISI measurement (score ≥10). The odds of insomnia episodes were about 5.4 and 1.93 times higher in patients with uncontrolled asthma and partially controlled asthma status, with adjusted OR (AOR)=5.4 (95% CI 4.4 to 6.79, p<0.001) and AOR=1.93 (95% CI 1.21 to 4.11, p<0.001), respectively.

CONCLUSION

Insomnia episodes were substantially higher in bronchial patients with asthma. Insomnia is accompanied by asthma severity, and uncontrolled asthma and partially controlled asthma status are the two most determining factors for experiencing sleep disturbance. Furthermore, a prospective follow-up study must determine the real association found between insomnia and asthma control.

Systematic Review of Physical Activity, Sedentary Behaviour and Sleep Among Adults Living with Chronic Respiratory Disease in Low- and Middle-Income Countries

Abstract

Physical activity (PA), sedentary behaviour (SB) and sleep are important lifestyle behaviours associated with chronic respiratory disease (CRD) morbidity and mortality. These behaviours need to be understood in low- and middle-income countries (LMIC) to develop appropriate interventions.

Purpose

Where and how have free-living PA, SB and sleep data been collected for adults living with CRD in LMIC? What are the free-living PA, SB and sleep levels of adults living with CRD?

Patients and Methods

The literature on free-living PA, SB and sleep of people living with CRD in LMIC was systematically reviewed in five relevant scientific databases. The review included empirical studies conducted in LMIC, reported in any language. Reviewers screened the articles and extracted data on prevalence, levels and measurement approach of PA, SB and sleep using a standardised form. Quality of reporting was assessed using bespoke criteria.

Results

Of 89 articles, most were conducted in Brazil (n=43). PA was the commonest behaviour measured (n=66). Questionnaires (n=52) were more commonly used to measure physical behaviours than device-based (n=37) methods. International Physical Activity Questionnaire was the commonest for measuring PA/SB (n=11). For sleep, most studies used Pittsburgh Sleep Quality Index (n=18). The most common ways of reporting were steps per day (n=21), energy expenditure (n=21), sedentary time (n=16), standing time (n=13), sitting time (n=11), lying time (n=10) and overall sleep quality (n=32). Studies revealed low PA levels [steps per day (range 2669-7490steps/day)], sedentary lifestyles [sitting time (range 283-418min/day); standing time (range 139-270min/day); lying time (range 76-119min/day)] and poor sleep quality (range 33-100%) among adults with CRD in LMIC.

Conclusion

Data support low PA levels, sedentary lifestyles and poor sleep among people in LMIC living with CRDs. More studies are needed in more diverse populations and would benefit from a harmonised approach to data collection for international comparisons.

The prevalence of sleep disturbance among asthmatic patients in a tertiary care center

Sleep disturbances are commonly reported by patients with asthma. However, the prevalence of sleep disturbance and its association with the level of asthma control is unknown. The primary objective was to determine the prevalence of sleep disturbance among Saudi adult asthmatic patients attending pulmonary clinics at King Abdulaziz Medical City (KAMC). The study also aimed to compare sleep quality between controlled and uncontrolled asthma patients. The study was carried out in the outpatient pulmonary clinics at KAMC and utilized a cross-sectional survey. The survey included five different questionnaires: asthma control test and questionnaires related to the quality of sleep (Pittsburgh sleep quality index [PSQI], Epworth sleepiness scale [ESS], Berlin questionnaire [a measure of obstructive sleep apnea risk], and insomnia severity index [ISI]). Among the 200 asthma patients, 66% suffered from poor sleep quality (PSQI > 5), 43% were at high risk for obstructive sleep apnea, 25% had excessive daytime sleepiness (ESS > 10), and 46.5% had significant clinical insomnia (ISI ≥ 10). Poor sleep quality was less common in patients with well-controlled asthma (37%) compared to those with partially controlled asthma (78%) and uncontrolled asthma (82%) (p < 0.001). Poor sleep quality was common among patients with asthma, particularly those with suboptimal levels of asthma control. Further studies are needed to better understand the interaction between these two conditions.

Characteristics of Asthma-related Nocturnal Cough: A Potential New Digital Biomarker

Introduction

The nature of nocturnal cough is largely unknown. It might be a valid marker for asthma control but very few studies characterized it as a basis for better defining its role and its use as clinical marker. This study investigated prevalence and characteristics of nocturnal cough in asthmatics over the course of four weeks.

Methods

In two centers, 94 adult patients with physician-diagnosed asthma were recruited. Patient-reported outcomes and nocturnal sensor data were collected by a smartphone with a chat-based study app.

Results

Patients coughed in 53% of 2212 nights (range: 0–345 coughs/night). Median coughs per hour were 0 (IQR 0–1). Nocturnal cough rates showed considerable inter-individual variance. The highest counts were measured in the first 30 min in bed (4.5-fold higher than rest of night). Eighty-six percent of coughs were part of a cough cluster. Clusters consisted of a median of two coughs (IQR 2–4). Nocturnal cough was persistent within patient.

Conclusion

To the best of the authors’ knowledge, this study is the first to describe prevalence and characteristics of nocturnal cough in asthma over a period of one month, demonstrating that it was a prevalent symptom with large variance between patients and high persistence within patients. Cough events in asthmatics were 4.5 times more frequent within the first 30 min in bed indicating a potential role of positional change, and not more frequent during the early morning hours. An important next step will investigate the association between nocturnal cough and asthma control.

Relationship between the Asthma Control Test (ACT) and other outcomes: a targeted literature review

BACKGROUND

The Asthma Control Test (ACT) has been used to assess asthma control in both clinical trials and clinical practice. However, the relationships between ACT score and other measures of asthma impact are not fully understood. Here, we evaluate how ACT scores relate to other clinical, patient-reported, or economic asthma outcomes.

METHODS

A targeted literature search of online databases and conference abstracts was performed. Data were extracted from articles reporting ACT score alongside one or more of: Asthma Control Questionnaire (ACQ) score; rescue medication use; exacerbations; lung function; health-/asthma-related quality of life (QoL); sleep quality; work and productivity; and healthcare resource use (HRU) and costs.

RESULTS

A total of 1653 publications were identified, 74 of which were included in the final analysis. Of these, 69 studies found that improvement in ACT score was related to improvement in outcome(s), either as correlation or by association. The level of evidence for each relationship differed widely between outcomes: substantial evidence was identified for relationships between ACT score and ACQ score, lung function, and asthma-related QoL; moderate evidence was obtained for relationships between ACT score and rescue medication use, exacerbations, sleep quality, and work and productivity; limited evidence was identified for relationships between ACT score and general health-related QoL, HRU, and healthcare costs.

CONCLUSIONS

Findings of this review suggest that the ACT is an appropriate measure for overall asthma impact and support its use in clinical trial settings. GlaxoSmithKline plc. study number HO-17-18170.

Relationship between neuroticism and sleep quality among asthma patients: the mediation effect of mindfulness

OBJECTIVE

The aims of this study were to investigate the prevalence of sleep disturbance; to validate the associations between neuroticism, mindfulness, and sleep quality; and to further examine whether mindfulness mediates the relationship between neuroticism and sleep quality among asthma patients.

METHODS

This study was conducted with 193 asthma patients from outpatient clinics. They completed questionnaires including the neuroticism subscale of the Big Five Inventory (BFI), the Pittsburgh Sleep Quality Index (PSQI), and the Mindful Attention Awareness Scale (MAAS). Structural equation model was used to analyze the relationships among neuroticism, mindfulness, and sleep quality, with mindfulness as a mediator.

RESULTS

The mean global PSQI score was 7.57 (SD = 3.25), and 69.9% of asthma patients reported poor sleep quality (cutoff score > 5). Structural equation model analysis showed that neuroticism was significantly associated with global PSQI scores (β = 0.198, P = 0.006), and mindfulness (β = - 0.408, P < 0.001), respectively; mindfulness was associated with global PSQI scores (β = - 0.250, P = 0.006). Furthermore, mindfulness mediated the relationship between neuroticism and global PSQI scores, in which the mediation effect was 0.102 (- 0.408 × - 0.250), and the bootstrapped 95% CI did not include zero (0.032, 0.208, P = 0.021).

CONCLUSIONS

Sleep disturbance is a serious health concern among asthma patients. This study illuminated the latent mediating mechanism of mindfulness on neuroticism and sleep quality, and implied that intervention and prevention programs on mindfulness might be beneficial in improving sleep quality in asthma patients.

Prevalence of nocturnal cough in asthma and its potential as a marker for asthma control (MAC) in combination with sleep quality: protocol of a smartphone-based, multicentre, longitudinal observational study with two stages

INTRODUCTION

Nocturnal cough is a burdensome asthma symptom. However, knowledge about the prevalence of nocturnal cough in asthma is limited. Furthermore, prior research has shown that nocturnal cough and impaired sleep quality are associated with asthma control, but the association between these two symptoms remains unclear. This study further investigates the potential of these symptoms as markers for asthma control and the accuracy of automated, smartphone-based passive monitoring for nocturnal cough detection and sleep quality assessment.

METHODS AND ANALYSIS

The study is a multicentre, longitudinal observational study with two stages. Sensor and questionnaire data of 94 individuals with asthma will be recorded for 28 nights by means of a smartphone. On the first and the last study day, a participant's asthma will be clinically assessed, including spirometry and fractionated exhaled nitric oxide levels. Asthma control will be assessed by the Asthma Control Test and sleep quality by means of the Pittsburgh Sleep Quality Index. In addition, nocturnal coughs from smartphone microphone recordings will be labelled and counted by human annotators. Relatively unrestrictive eligibility criteria for study participation are set to support external validity of study results. Analysis of the first stage is concerned with the prevalence and trends of nocturnal cough and the accuracies of smartphone-based automated detection of nocturnal cough and sleep quality. In the second stage, patient-reported asthma control will be predicted in a mixed effects regression model with nocturnal cough frequencies and sleep quality of past nights as the main predictors.

ETHICS AND DISSEMINATION

The study was reviewed and approved by the ethics commission responsible for research involving humans in eastern Switzerland (BASEC ID: 2017-01872). All study data will be anonymised on study termination. Results will be published in medical and technical peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03635710; Pre-results.

Development and Validation of Personalized Prediction to Estimate Future Risk of Severe Exacerbations and Uncontrolled Asthma in Patients with Asthma, Using Clinical Parameters and Early Treatment Response

BACKGROUND

Current level of asthma control can be easily assessed by validated instruments, but it is currently difficult to assess individuals' level of future risk.

OBJECTIVE

Develop, and validate, a risk prediction score for level of future risk, including patient characteristics and information on early treatment response.

METHODS

We used data of 304 adult patients with asthma from a 12-month primary care randomized controlled trial with 3-monthly assessments. With logistic regression we modeled the association between the level of future risk and patient characteristics including early treatment response. Future risk was defined as Asthma Control Questionnaire (ACQ) score of 1.5 or more at 12 months or the experience of at least 1 exacerbation during the final 6 months. We developed a risk prediction score on the basis of regression coefficients.

RESULTS

Performance of the risk prediction score improved, taking into account data on early treatment response (area under receiver-operating curve [AUROC] = 0.84) compared with a model containing only baseline characteristics (AUROC = 0.78). The score includes 6 easy-to-obtain predictors: sex, ACQ score and exacerbations in the previous year at baseline and at first follow-up, and smoking status and exacerbations in the previous 3 months (indicating early treatment response). External validation yielded an AUROC of 0.77. The risk prediction score classified patients into 3 risk groups: low (absolute risk, 11.7%), intermediate (47.0%), and high (72.7%).

CONCLUSIONS

We developed and externally validated a risk prediction score, quantifying both level of current asthma control and the guideline-defined future risk. Patients' individual risk can now be estimated in an easy way, as proposed but not specified, by asthma management guidelines.

Indicators of Asthma Control in Asthmatic Patients: Are they related to Depression?

BACKGROUND:

Many patients with chronic illnesses suffer from depression. A poorly controlled asthma that presents with repeated attacks of breathlessness is a recognised risk factor for bipolar disorders. On the other hand, depression can aggravate asthma symptoms.

AIM:

The aim of this study is to determine the indicators of the asthma control test (ACT) among the asthmatic patients who attend the outpatient clinic for follow-up and to investigate the relation between these indicators and clinical depression, using a standardised depression scale.

METHODS:

A total of 38 adult asthmatic patients (29 women, age 17–85 years), with variable levels of control, were assessed using the ACT and the Beck Depression Inventory (BDI). Data obtained were analysed with the Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL, USA) version 20. The association of depression with the various indicators of asthma control was analysed with the Chi-Square test. Statistical significance was determined at p< 0.05.

RESULTS:

The uncontrolled asthma is associated with depression in 37% of all participants compared to 0% in the well-controlled group (p = 0.002). Depression is significantly related to asthma interference with daily activities (p = 0.003), breathlessness (p < 0.001), night symptoms (p = 0.036), use of bronchodilators (p = 0.007), and poor compliance with medical treatment (p = 0.003). The poor educational attainment and comorbidities have significant relations to both uncontrolled asthma and clinical depression (p < 0.05).

CONCLUSION:

All indicators of the poor asthma control are associated with clinical depression. A significant proportion of the uncontrolled asthma patients suffers from depression. The possibility of improving asthma control with a pharmacological treatment of depression has to be considered.