Reviews and feature article
Sleep and allergic disease: A summary of the literature and future directions for research

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Atopic diseases, such as asthma and allergic rhinitis, are common conditions that can influence sleep and subsequent daytime functioning. Children and patients with allergic conditions from ethnic minority groups might be particularly vulnerable to poor sleep and compromised daytime functioning because of the prevalence of these illnesses in these groups and the high level of morbidity. Research over the past 10 years has shed light on the pathophysiologic mechanisms (eg, inflammatory mediators) involved in many atopic diseases that can underlie sleep disruptions as a consequence of the presence of nocturnal symptoms. Associations between nocturnal symptoms and sleep and poorer quality of life as a result of missed sleep have been demonstrated across studies. Patients with severe illness and poor control appear to bear the most burden in terms of sleep impairment. Sleep-disordered breathing is also more common in patients with allergic diseases. Upper and lower airway resistance can increase the risk for sleep-disordered breathing events. In patients with allergic rhinitis, nasal congestion is a risk factor for apnea and snoring. Finally, consistent and appropriate use of medications can minimize nocturnal asthma or allergic symptoms that might disrupt sleep. Despite these advances, there is much room for improvement in this area. A summary of the sleep and allergic disease literature is reviewed, with methodological, conceptual, and clinical suggestions presented for future research.

Section snippets

Effect of allergic disease on sleep: Pathophysiologic mechanisms

A large area of focus on sleep quality in patients with allergic diseases involves pathophysiologic mechanisms related to illness that might influence symptoms that can disrupt the sleep process. To briefly summarize, asthma and AR symptoms are frequently experienced during nighttime hours because of many factors, including a dip in cortisol levels at night that affects inflammatory cytokines and other mediators.21 In addition, nighttime disturbances, such as airway obstruction in patients with

Nonadherence to treatment

If patients with allergic disease do not adhere to treatment recommendations for medication use, whether it be daily use of topical corticosteroids30 or controller asthma medications31 or avoid using rescue medication, this can result in increased symptoms during the nighttime hours and disrupted sleep. Thus, the importance of consistent medication use is crucial for high-quality sleep in patients with atopic diseases. Poor trigger control associated with AR and asthma in the home environment

Sleep disruption: Asthma

Results from a few cross-sectional studies indicate that atopic diseases, such as asthma, can affect sleep quality through the disruption of sleep, likely in part because of the presence of nocturnal symptoms.33 In one study including children with asthma, data from 1 night of polysomnography indicated that the primary sleep abnormality associated with nocturnal asthma symptoms is interruption in the continuity of sleep by frequent awakenings.34 These sleep disruptions caused by nighttime

Future directions for research

The current literature on sleep and allergic disease supports many of the proposed associations depicted in our conceptual model (Fig 1). Some areas have received more attention than others. For example, much is known about the pathophysiologic mechanisms that contribute to allergic symptoms that occur during the night and might disrupt sleep in patients with allergic diseases. Although studies have furthered our understanding of the effect of these conditions on sleep quality, there are many

Conclusions

In summary, sleep impairment associated with allergic diseases, such as asthma, AR, and AD, can have a significant effect on the patient's quality of life and functioning in specific areas. The sleep disturbance can be caused by congestion, symptoms of the underlying disease, and inflammatory cytokines and other mediators that can directly disturb sleep and cause daytime somnolence, fatigue, decreased cognitive and psychomotor abilities, and increased difficulty concentrating.91 More research

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    Supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (R01 HD057220 to D.K.M.).

    Disclosure of potential conflict of interest: T. Craig is an Interest Section Leader for the American Academy of Allergy, Asthma & Immunology; is a board member for the American College of Allergy, Asthma & Immunology and the Joint Council of Allergy, Asthma & Immunology; has consultant arrangements with CSL Behring, Dyax, and Viropharma; has provided expert testimony in a case related to anaphylaxis; has received grants from Viropharma, CSL Behring, Shire, Dyax, Pharming, Forrest, Genentech, Merck, and GlaxoSmithKline; has received payment for lectures from Viropharma, CSL Behring, Dyax, Merck, Novartis, Shire, and Teva; and has received payment for development of educational presentations from the Vietnam Education Foundation. C. A. Esteban has received a grant from the National Institute of Child Health and Human Development. The rest of the authors declare that they have no relevant conflicts of interest.

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