Clinical ReviewRhinitis and sleep
Introduction
Inflammatory disorders of the upper respiratory tract are prevalent in the general population. This is especially seen in developed countries. Allergic rhinitis affects up to 40% of the population, and its prevalence appears to be increasing. Recent estimates suggest that 20 to 40 million people in the United States are affected, including up to 40% of children. The disorder is not limited to the United States, with a European prevalence estimated to be 23%.1, 2, *3, 4, 5, *6
Nasal congestion is a prominent and troublesome symptom of both allergic and non-allergic rhinitis. Additional symptoms of allergic rhinitis include rhinorrhea, sneezing, and pruritus of the eyes, nose, and throat, particularly in patients with perennial allergic rhinitis (PAR).4 Typical sleep-related problems seen include sleep-disordered breathing, sleep apnea, and snoring, all of which are associated with nasal congestion/obstruction.7, 8, 9, 10
Allergic rhinitis can affect the mucous membranes of the nose, eyes, eustachian tubes, middle ear, sinuses, and pharynx and is usually triggered by immunoglobulin E in response to an allergen. Mediators involved in clinical symptoms include histamine, tryptase, chymase, heparin as well as leukotrienes. Non allergic rhinitis is a term used to describe a variety of diseases including, infectious, vasomotor, occupational, hormonal, gustatory, and drug induced rhinitis. In non-allergic etiologies, autonomic parasympathetic stimuli lead to localized nasal swelling and secretions.
Nasal congestion is a problem seen in both children and adults. This was noted in the recent publication of the “Pediatric Allergies in America Survey” which emphasized that congestion is the main symptom that affects children with rhinitis.11 A similar survey completed in over 7000 subjects of whom 89.3% were adults, demonstrated the burden of sleep disturbance in patients with rhinitis.12
Sleep disturbance is a significant problem for patients with rhinitis. In a recent survey of individuals with allergic rhinitis, 68% of respondents with PAR and 48% with seasonal allergic rhinitis (SAR) reported that their condition interfered with sleep.13 Sleep disturbance can be caused by the mechanical obstruction of nasal congestion. However, additional symptoms of rhinitis and the release of inflammatory mediators may influence sleep and resultant daytime fatigue and somnolence.
The socioeconomic burden of rhinitis is also significant. It is estimated that more than $6 billion were spent on prescription medications for allergic rhinitis in 2000.1, 2, 14 The socioeconomic costs of these disorders include the costs of treatment and the secondary cost of poor productivity, which results from the impact of symptoms on patient lives and the use of inappropriate therapies. A patient's quality of life is significantly affected by allergic rhinitis, which has been shown using generic health-related quality-of-life questionnaires, such as the Medical Outcomes Study Short Form Health Survey (SF-36), and disease-specific measures, such as the rhinoconjunctivitis quality of life questionnaire (RQLQ).15, 16, 17, 18, *19, 20, 21As noted above, these effects may not solely be related to the rhinitis itself, and in part, may be a consequence of sleep impairment.
Treatments that improve the symptoms of allergic rhinitis, particularly those that relieve nasal congestion, have been shown to improve patients’ sleep and quality of life. However, the data are limited that prove nasal congestion and its associated sleep disturbance is the only culprit. Thus, further research is warranted in this area. This review explores the importance of congestion in rhinitis. It also addresses the adverse effects of disturbed sleep on the quality of life of patients with rhinitis and how these effects can be reduced by therapies addressing the underlying problems affecting sleep.
Section snippets
How frequent is congestion in rhinitis?
With the prevalence of rhinitis being somewhere between 15 and 40% depending on methods used and populations surveyed and over 50% of these subjects having congestion as their main symptom it is understandable that congestion is a major concern. Even more concerning are the effects that congestion has on those that experience it. In a study reported by Stull et al.22 the mean proportional affect of nasal congestion on outcomes, as compared to 9 other rhinitis symptoms, was 73%. Therefore, as
Evidence of sleep impairment
As noted earlier, rhinitis is associated with sleep problems, daytime somnolence, and fatigue. The symptoms of allergic rhinitis, in particular nasal congestion, adversely affect sleep.23, 24 The degree of sleep impairment is utilized in the Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines to classify allergic rhinitis severity.11 Sleep disturbances associated with allergic rhinitis include sleep-disordered breathing (ranging from snoring to obstructive sleep apnea and/or hypopnea)
Mechanisms of sleep impairment
Identifying the mechanisms involved in sleep impairment in allergic rhinitis, is important in determining how to reduce the impact of the disease on patients. For example, the daytime fatigue experienced by patients with allergic rhinitis could be attributed to sleep impairment resulting from nasal congestion or other rhinitis symptoms*36, 37 or to the effects of inflammatory cytokines on sleep or producing fatigue directly.38 The current evidence suggests that symptoms and the underlying
Sleep impairment and quality of life
Individuals with allergic rhinitis suffer impaired cognitive function and reduced work productivity and performance.61, 62, 63 Allergic rhinitis can affect children’s learning ability and performance at school64 and cause somnolence and inability to concentrate in children.65 These effects may be a direct result of allergic symptoms but are likely to be exacerbated by sleep impairment.23, 64, 66 Sleep-disordered breathing and sleep disturbance are known to be directly associated with decreased
Effects of therapy
Therapies that reduce nasal congestion may improve sleep impairment and daytime sleepiness and, thereby, improve patients’ quality of life. In addition, those therapies that reduce inflammation, often those that also decrease congestion, may have a positive influence on quality of life by the reduction of inflammatory mediators, such as TNF, which can cause constitutional symptoms. Not all treatments for allergic rhinitis are effective in this respect.
Sedating antihistamines are contraindicated
Conclusions
Sleep impairment associated with rhinitis has a significant impact on patients’ quality of life. Nasal congestion, one of the most common and bothersome symptoms of these conditions, is thought to be a major cause of sleep impairment and sleep-disordered breathing. Recent research has suggested that the poor sleep associated with nasal congestion is an important therapeutic target. However, evidence exists that other rhinitis symptoms, inflammatory mediators released because of rhinitis can
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