Insomnia symptoms and asthma control-Interrelations and importance of comorbidities

[Management of patients with insomnia and polymorbidity. A draft of the clinical guidelines]

Insomnia is a serious and widespread public health problem, but is often undetected and patients do not receive needed treatment. Insomnia is often comorbid with other diseases and conditions, such as arterial hypertension, type 2 diabetes mellitus, pain syndromes, anxiety and depressive disorders, etc. A separate problem is drug-induced insomnia, when patients develop symptoms due to other diseases treatments. Insomnia has a negative effect on the prognosis of comorbid diseases, including an increased risk of death, more severe disease, and decreased quality of life. The presence of sleep disorders makes it difficult to effectively treat the underlying disease, so clinical guidelines draft for the evaluation and treatment of insomnia in multimorbid patients is proposed. Diagnostic methods are reviewed and recommendations are given for the treatment of acute and chronic insomnia and features of the treatment of insomnia in multimorbid patients. A clinical algorithm has been proposed to determine treatment tactics in multimorbid patients.

Revisiting Asthma Obstructive Sleep Apnea Overlap: Current Knowledge and Future Needs

Asthma and obstructive sleep apnea are highly prevalent conditions with a high cost burden. In addition to shared risk factors, existing data suggest a bidirectional relationship between asthma and OSA, where each condition can impact the other. Patients with asthma often complain of sleep fragmentation, nocturnal asthma symptoms, daytime sleepiness, and snoring. The prevalence of OSA increases with asthma severity, as evidenced by multiple large studies. Asthma may lower the threshold for arousal in OSA, resulting in the hypopnea with arousal phenotype. Epidemiologic studies in adults have shown that OSA is associated with worse asthma severity, increased frequency of exacerbation, and poor quality of life. The current literature assessing the relationship among OSA, asthma, and CPAP therapy is heavily dependent on observational studies. There is a need for randomized controlled trials to minimize the interference of confounding shared risk factors.

Socioeconomic status and sleep health: a narrative synthesis of 3 decades of empirical research

STUDY OBJECTIVES

This review aims to assess the association between socioeconomic status (SES) and sleep health in the general population and the mediating effects of lifestyle and mental and physical health in this relationship.

METHODS

Observational studies testing the independent association between objective or subjective SES indicators and behavioral/physiological or clinical sleep health variables in the general population were included. PubMed/MEDLINE was searched for reports published from January 1990 to December 2019. The direction of effect was used as the primary effect measure, testing the hypothesis that low SES is associated with poor sleep health outcomes. Results are presented in the form of direction effect plots and synthesized as binomial proportions.

RESULTS

Overall, 336 studies were identified. A high proportion of effects at the expected direction was noted for measures of sleep continuity (100% for sleep latency, 50-100% for awakenings, 66.7-100% for sleep efficiency), symptoms of disturbed sleep (75-94.1% for insomnia, 66.7-100% for sleep-disordered breathing, 60-100% for hypersomnia), and general sleep satisfaction (62.5-100%), while the effect on sleep duration was inconsistent and depended on the specific SES variable (92.3% for subjective SES, 31.7% for employment status). Lifestyle habits, chronic illnesses, and psychological factors were identified as key mediators of the SES-sleep relationship.

CONCLUSIONS

Unhealthy behaviors, increased stress levels, and limited access to health care in low-SES individuals may explain the SES-sleep health gradient. However, the cross-sectional design of most studies and the high heterogeneity in employed measures of SES and sleep limit the quality of evidence. Further research is warranted due to important implications for health issues and policy changes.

CITATION

Papadopoulos D, Etindele Sosso FA. Socioeconomic status and sleep health: a narrative synthesis of 3 decades of empirical research. J Clin Sleep Med. 2023;19(3):605-620.

[Management of patients with insomnia and polymorbidity: expert consensus]

Sleep disorders are becoming increasingly important due to the high comorbidity with other diseases and a significant impact on the patient's quality of life. Insomnia is the most common sleep disorder both in the general population and in patients with multimorbid pathology. Its prevalence in the general population is 6-15%, while in patients with somatic diseases it increases up to 20-40% and can reach 90% in patients with comorbid mental disorders. Another problem is the development of drug-induced insomnia. Insomnia has negative impact on the prognosis of comorbid diseases, including an increased risk of death, more severe disease, and a worse quality of life. The presence of sleep disorders makes it difficult to effectively treat the underlying disease, so it is extremely important to identify and correct these disorders in the early stages, therefore recommendations for the diagnosis of insomnia in polymorbid patients are proposed. Modern methods of treating acute and chronic insomnia and features of insomnia treatment in polymorbid patients are also discussed.

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.

Clinical Remission of Asthma and Allergic Rhinitis - in a Longitudinal Population Study

BACKGROUND

Although asthma and allergic rhinitis are chronic diseases, some patients experience periods of remission. Information on prognostic factors associated with the remission of asthma and allergic rhinitis is valuable in resource prioritization. This study investigated factors associated with the clinical remission of asthma and allergic rhinitis.

METHODS

In the Respiratory Health In Northern Europe (RHINE) study, data was collected with questionnaires in stage one (RHINE I, 1989-1992) and two follow-ups (RHINE II, 1999-2001 and RHINE III, 2010-2012) from Sweden, Norway, Denmark, Iceland and Estonia. Clinical remission was defined as having reported asthma or allergic rhinitis in RHINE I or RHINE II but not in RHINE III.

RESULTS

Of 13,052 participants, 975 (7.5%) reported asthma in RHINE I or RHINE II, and 3379 (25.9%) allergic rhinitis. Clinical remission of asthma and allergic rhinitis was found in 46.4% and 31.8%, respectively. Living in Estonia (OR (95% CI) 2.44 (1.22-4.85)) and living in an apartment (1.45 (1.06-1.98)) were related to remission of asthma, while subjects reporting allergic rhinitis (0.68 (0.51-0.90)), asthma onset ≤ 12 years of age (0.49 (0.35-0.68)), receiving treatment with antibiotics for respiratory illness (0.64 (0.47-0.87)) were less likely to have asthma remission. Factors related to a higher likelihood of remission of allergic rhinitis were no asthma at baseline, age ≥ 58 years in RHINE III, allergic rhinitis onset after 12 years of age, living in rural areas as a child, having only a primary school education and not being pregnant.

CONCLUSION

Clinical remission was found in almost one-half of those with asthma and one-third of persons with allergic rhinitis. Coexisting allergic symptoms were associated with less clinical asthma remission. Age, asthma symptoms and environmental factors in childhood, such as living in a rural area, were found to influence the clinical remission of allergic rhinitis.

Asthma and asthma-related comorbidity: effects on nocturnal oxygen saturation

STUDY OBJECTIVES

Nocturnal symptoms are very common in asthma, which is associated with worse sleep quality. The nocturnal oxygen saturation may be decreased in asthma; however, whether this association is dependent on nocturnal asthma symptoms, lung function, coexisting obstructive sleep apnea (OSA), or other asthma-related comorbidities is unknown. The objective of this study was to examine the effects of asthma, OSA, lung function, airway symptoms, and asthma-related comorbidities on the nocturnal oxygen saturation in a cross-sectional community-based population study.

METHODS

In total, 395 women and 392 men underwent overnight polysomnography, performed spirometry, and completed questionnaires on airway symptoms and asthma-related comorbidities.

RESULTS

Participants with asthma (n = 88) had a lower nocturnal oxygen saturation than those without asthma (93.8% vs 94.3%, P = .01) also after adjusting for comorbidity, age, body mass index, and smoking status (coefficient -0.38; CI -0.67, -0.10; P < .01). The nocturnal oxygen saturation was lower among participants with wheezing, nocturnal chest tightness, fixed airflow limitation, gastroesophageal reflux, obesity, and OSA than in those without these conditions. The associations between lower oxygen saturation and wheezing, forced expiratory volume in 1 second, gastroesophageal reflux, and apnea-hypopnea index were significant also after adjusting for age, sex, body mass index, and smoking status. Participants with both wheezing and OSA had a significantly lower nocturnal oxygen saturation (92.5 ± 0.5%) than participants with wheezing only (94.3 ± 0.3%) and OSA only (93.6 ± 0.2% %) (P < .01).

CONCLUSIONS

Participants with asthma displayed a lower mean oxygen saturation during sleep, which could not be explained only by coexisting OSA or obesity. Also, asthma symptoms and lung function were associated with lower nocturnal oxygen saturation. The lower oxygen saturation seen in asthma is hence multifactorial in origin and is a result of the combination of symptoms, lung function, and comorbidity.

CITATION

Sundbom F, Janson C, Ljunggren M, Lindberg E. Asthma and asthma-related comorbidity: effects on nocturnal oxygen saturation. J Clin Sleep Med. 2022;18(11):2635-2641.

Heterogeneous Condition of Asthmatic Children Patients: A Narrative Review

Currently, asthma represents the most common chronic disorder in children, showing an increasingly consistent burden worldwide. Childhood asthma, similar to what happens in adults, is a diversified disease with a great variability of phenotypes, according to genetic predisposition of patients, age, severity of symptoms, grading of risk, and comorbidities, and cannot be considered a singular well-defined disorder, but rather a uniquely assorted disorder with variable presentations throughout childhood. Despite several developments occurring in recent years in pediatric asthma, above all, in the management of the disease, some essential areas, such as the improvement of pediatric asthma outcomes, remain a hot topic. Most treatments of the type 2 (T2) target phenotype of asthma, in which IL-4, IL-5, and IL-13 modulate the central signals of inflammatory reactions. Although, there may be an unresolved need to identify new biomarkers used as predictors to improve patient stratification using disease systems and to aid in the selection of treatments. Moreover, we are globally facing many dramatic challenges, including climate change and the SARS-CoV2 pandemic, which have a considerable impact on children and adolescent asthma. Preventive strategies, including allergen immunotherapy and microbiome evaluation, and targeted therapeutic strategies are strongly needed in this population. Finally, the impact of asthma on sleep disorders has been reviewed.

Chronic lung diseases and sleep

Sleep is vitally important part of our life. Its quality and quantity influence all physiological processes in our organism. The relationship between the lung diseases and sleep is bidirectional - the lack of quality sleep worsens the compensation and the course of the diseases and in the same time chronic lung diseases are negatively affecting sleep quality. The coexistence of the sleep disordered breathing and lung disorders is another important issue to discuss. In case of chronic obstructive pulmonary disease the overlap with sleep disordered breathing is characterized by higher prevalence of hypercapnia and overall worse prognosis. Moreover, there is a growing body of evidence about possible links of sleep disordered breathing to lung fibrosis and tumors. The complex healthcare in patients with respiratory diseases should not omit sleep examination.

Developments in the field of allergy in 2020 through the eyes of Clinical and Experimental Allergy

While 2020 will be remembered for the global coronavirus pandemic, there were also important advances in the field of allergy. In this review article, we summarize key findings reported in Clinical and Experimental Allergy during 2020. We hope this provides readers with an accessible snapshot of the work published in our journal during this time.

Characterisation of insomnia as an environmental risk factor for asthma via Mendelian randomization and gene environment interaction

Asthma is a complex disease that is reportedly associated with insomnia. However, the causal directionality of this association is still unclear. We used asthma and insomnia-associated single nucleotide polymorphisms (SNPs) and genome-wide association study (GWAS) summary statistics to test the causal directionality between insomnia and asthma via Mendelian randomization (MR) analysis. We also performed a cross-trait meta-analysis using UK Biobank GWAS summary statistics and a gene–environment interaction study using data from UK Biobank. The interaction of genetic risk score for asthma (GRS_asthma) with insomnia on asthma was tested by logistic regression. Insomnia was a risk factor for the incidence of asthma, as revealed by three different methods of MR analysis. However, asthma did not act as a risk factor for insomnia. The cross-trait meta-analysis identified 28 genetic loci shared between asthma and insomnia. In the gene–environment interaction study, GRS_asthma interacted with insomnia to significantly affect the risk of asthma. The results of this study highlight the importance of insomnia as a risk factor of asthma, and warrant further analysis of the mechanism through which insomnia affects the risk of asthma.

Insomnia and Daily Function in Older Adults With Asthma

The current study examined the prevalence of insomnia and its relationship with daily function in older adults with asthma. Data on 278 older adults with asthma (aged ≥60 years) from the 2005-2008 National Health and Nutrition Examination Survey were analyzed. Insomnia was present in 40% of the study sample and was associated with a greater number of activities of daily living (ADL) and instrumental ADL (IADL) limitations. In multivariate analyses accounting for covariates including depressive symptoms, insomnia was not associated with having at least two ADL/IADL limitations. However, those with co-occurring insomnia and depressive symptoms were more likely to have at least two ADL/IADL limitations compared to those with either condition singly. Insomnia in the presence of depressive symptoms may impede one's ability to perform ADL/IADL. Current findings suggest that assessment and treatment of insomnia and depression in older adults with asthma may be important for maintaining active, independent living. [Journal of Gerontological Nursing, 46(11), 28-36.].

Inference of causal relationships between sleep-related traits and 1,527 phenotypes using genetic data

STUDY OBJECTIVE

Sleep is essential for both physical and mental health, and there is a growing interest in understanding how different factors shape individual variation in sleep duration, quality and patterns, or confer risk for sleep disorders. The present study aimed to identify novel inferred causal relationships between sleep-related traits and other phenotypes, using a genetics-driven hypothesis-free approach not requiring longitudinal data.

METHODS

We used summary-level statistics from genome-wide association studies and the latent causal variable (LCV) method to screen the phenome and infer causal relationships between seven sleep-related traits (insomnia, daytime dozing, easiness of getting up in the morning, snoring, sleep duration, napping, and morningness) and 1,527 other phenotypes.

RESULTS

We identify 84 inferred causal relationships. Among other findings, connective tissue disorders increase insomnia risk and reduce sleep duration; depression-related traits increase insomnia and daytime dozing; insomnia, napping, and snoring are affected by obesity and cardiometabolic traits and diseases; and working with asbestos, thinner, or glues may increase insomnia risk, possibly through an increased risk of respiratory disease or socio-economic related factors.

CONCLUSION

Overall, our results indicate that changes in sleep variables are predominantly the consequence, rather than the cause, of other underlying phenotypes and diseases. These insights could inform the design of future epidemiological and interventional studies in sleep medicine and research.

Determinants of uncontrolled asthma among adult asthmatic patients on follow-up at chest clinic of Jimma medical center: unmatched case-control study

OBJECTIVE

To identify the determinants of uncontrolled asthma among asthmatic patients on follow-up at Jimma Medical Center.

METHODS

Institution-based case-control study was conducted on asthmatic patients who were on follow-up at the chest clinic of Jimma University Medical (JMC) from March to May 2020. A total of 59 cases and 118 controls (1: 2 ratio) were included in the study. Cases and controls were defined based on asthma control test (ACT) scores where those who had scores of ≤19 and above 19 were defined to be cases and controls, respectively.

RESULTS

Age of the patients [AOR: 2.78; 95% CI: 1.14, 6.81], age of the cases' residential houses [AOR: 3.65; 95% CI: 1.30, 10.28], presence of pets within the houses [AOR: 2.78; 95% CI: 1.29, 5.96], having rhinitis [AOR: 3.34; 95% CI: 1.17, 9.52], past asthma exacerbation [AOR: 2.38, 95% CI: 1.05, 5.40], non-adherence to treatment [AOR: 2.81; 95% CI: 1.30, 6.08] and smoking [AOR: 7.09; 95% CI: 1.84, 27.33] were found to be determinants of uncontrolled asthma.

CONCLUSIONS

Uncontrolled asthma results from multiple sociodemographic, environmental, clinical, and behavioral factors. Therefore, patients should be counseled on avoiding pets, maintenance of houses, adherence to treatment, quitting smoking, and early treatment-seeking for rhinitis and asthma exacerbation to improve asthma control comprehensively.

Developments allergy in 2019 through the eyes of Clinical and Experimental Allergy, Part II clinical allergy

In the second of two linked articles, we describe the development in clinical as described by Clinical & Experimental Allergy and other journals in 2019. Epidemiology, clinical allergy, asthma and rhinitis are all covered. In this article, we described the development in the field of allergy as described by Clinical and Experimental Allergy in 2019. Epidemiology, clinical allergy, asthma and rhinitis are all covered.

The impact of clinical and psychological factors on asthma control: the experience of a single asthma center in Poland

OBJECTIVE

The asthma control test (ACT) is commonly used to identify patients with uncontrolled asthma. The goal of this study was to determine whether clinical parameters such as asthma history and medications, exacerbation rate, comorbidities, lung function, and socioeconomic status are risk factors for uncontrolled asthma assessed with the ACT, and to evaluate the psychological status of controlled and uncontrolled asthmatics.

METHODS

Adult asthmatics (n = 104) were recruited from a single asthma center, Poland. Asthma control was assessed with the ACT, using <20 as the cutoff point for uncontrolled asthma. Data on clinical factors were collected and spirometry was performed. Patients completed the Asthma Quality of Life Questionnaire, General Health Questionnaire, Acceptance of Illness Scale, Life Orientation Test-Revised, and Eysenck's Personality Inventory.

RESULTS

Asthma was uncontrolled in 42.3% of patients. Asthma exacerbations in the preceding 12 months and high inhaled corticosteroid (ICS) doses were identified as independent risk factors for uncontrolled asthma. Uncontrolled asthmatics had a significantly worse psychological status than controlled asthmatics. The groups did not differ in terms of personality traits, but in the controlled asthma group numerous significant correlations between psychological factors and personality traits were observed. In the uncontrolled asthma group, however, the occurrence of correlations between personality traits and other psychological variables was rarer.

CONCLUSIONS

The study identified independent risk factors for uncontrolled asthma, namely, exacerbations in the recent 12 months and treatment with high-dose ICS. Uncontrolled asthmatics have a significantly worse psychological status than controlled asthmatics, irrespective of personality traits.