Nocturnal asthma medical therapy

• Overnight nasal continuous positive airway pressure (nCPAP) abolishes nocturnal oxygen desaturation and offers improvement in nocturnal asthma control.^[1][2][3]
• Gastroesophageal reflux contributes little to the nocturnal worsening of asthma^[4][5][6] and hence, should be based upon symptoms of reflux and not based upon the worsening of asthma. However, if a patient complained of metallic taste in the mouth or unexplained infiltrates on chest x-ray, the possibility of reflux with aspiration should be considered.
• Specific inspiratory muscle training improves the inspiratory muscle strength and endurance. This can result in the improvement of asthmatic symptoms and medication consumption by asthmatics.^[7]

• Inhaled long-acting bronchodilator such as salmeterol has shown to improve sleep quality and may be beneficial for patients who remain symptomatic despite anti-inflammatory therapy and environmental control.^{[8][9][10][11]}
• Similar bronchodilation and good symptomatic control of nocturnal asthma may be achieved by both oral beta2 agonists such as extended release albuterol tablet and inhaled long-acting bronchodilator such as inhaled salmeterol.^[12][13]
• Sustained-release theophylline preparations alter the inflammatory cell number and function secondary to the leukotriene B4-mediated mechanism. Research has demonstrated this can provide better bronchial airflow levels overnight and stabilize nocturnal pulmonary function.^{[14][15][16][17][18][19]} Among the drugs, inhaled salmeterol and oral theophylline, only a small benefit in sleep quality, quality of life, and daytime cognitive function was observed with salmeterol; however, no major clinical advantage was noted.^[20]
• In patients with nocturnal asthma, the timing and dose of steroid alters both the inflammatory milieu and spirometric decline that is associated with nocturnal worsening of asthma.^[21] Long-term administration of corticosteroids at 8 A.M. and 3 P.M. was found to be more effective to control asthma and enhance peak expiratory flow rate values.^[22][23][24]
• Inhalation method of administration of steroids, cromolyn and nedocromil has shown to be beneficial in reducing the morning dips and improving the mean peak expiratory flow rate value.^{[25][26][27][28]}
• 5-lipoxygenase inhibitors such as zafirlukast and montelukast, have shown to significantly decrease the levels of LTB4 and improve FVE1 that is usually worsened in patients with nocturnal asthma.^[29][30][31]
• Inhaled short-acting anticholinergic drugs, that affect vagal blockade have shown to provide little benefit on the overnight fall in pulmonary function seen in patients with nocturnal asthma.^[32]

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