A practical approach to allergic rhinitis and sleep disturbance management.

Sleep quality can be significantly impacted by nasal congestion, a common symptom related to allergic rhinitis (AR). This may lead to decreased learning ability, productivity at work or school, and a reduced quality of life. A number of inflammatory cells and the release of inflammatory mediators lead to increased nasal congestion, causing disrupted sleep and subsequent daytime somnolence. Therefore, it is important to treat AR with medications that improve congestive symptoms without worsening sedation. Second-generation antihistamines and anticholinergic drugs are well tolerated but have little effect on congestion and therefore are limited in their ability to reduce AR-associated daytime somnolence. However, intranasal corticosteroids reduce congestion, improve sleep and sleep problems, and reduce daytime sleepiness, fatigue, and inflammation. Montelukast, a leukotriene receptor antagonist, has joined the approved therapies for AR. Montelukast significantly improves both daytime and nighttime symptoms. AR treatment should endeavor to improve daytime and nighttime symptoms, sleep, and productivity thereby improving quality of life.

How do topical nasal corticosteroids improve sleep and daytime somnolence in allergic rhinitis?

Therapy for rhinitis improves sleep quality and symptoms of daytime sleepiness. This improvement with therapy may be secondary to anti-inflammatory effects, leading to a reduction of inflammatory mediators, or to a mechanical reduction of congestion directly leading to improvement in sleep disturbance. We combined our data from 3 placebo-controlled studies of intranasal corticosteroids in patients with perennial rhinitis to determine whether a correlation between the reduction of congestion and improved sleep and daytime somnolence existed. The pooled data of budesonide, flunisolide, and fluticasone demonstrated significantly decreased nasal congestion, sleep problems, and sleepiness in treated patients. The data demonstrated a correlation between a reduction in nasal congestion and an improvement of sleep (P < .01) and daytime somnolence (P = .01). Thus, topical intranasal corticosteroids should be used to decrease nasal congestion and to improve sleep and daytime somnolence in patients manifesting these symptoms.

Asthma and the diver.

Self-contained underwater breathing apparatus (scuba) diving has grown in popularity, with nearly 9 million sport divers in the United States alone. Approximately 7% of the population has been diagnosed with asthma, which is similar to the percentage of divers admitting they have asthma. Numerous concerns exist regarding subjects with asthma who choose to participate in recreational diving. Among these concerns are pulmonary barotrauma, pneumomediastinum, pneumothorax, arterial gas embolism, ear barotrauma, sinus barotrauma, and dental barotrauma. Despite these concerns, a paucity of information exists linking asthma to increased risk of diving complications. However, it has long been the norm to discourage individuals with asthma from participating in recreational scuba diving. This article examines the currently available literature to allow for a more informed decision regarding the possible risks associated with diving and asthma. It examines the underlying physiological principles associated with diving, including Henry's law and Boyle's law, to provide a more intimate understanding on physiological changes occurring in the respiratory system under compressive stress. Finally, this article offers a framework for guiding the patient with asthma who is interested in scuba diving. Under the right circumstances, the patient with asthma can safely participate in recreational diving without apparent increased risk of an asthma-related event.

Nasal obstruction, the airway, and the athlete.

Rhinitis is a common condition that affects a significant proportion of the general population, as well as a high proportion of athletes. Nasal congestion is a predominate symptom of the late-phase reaction in allergic rhinitis and can have far-reaching effects that extend through the airway and beyond the nose. Rhinitis is often found in conjunction with asthma and is a risk factor for asthma. Nasal obstruction, which does not permit conditioning of inspired air by the nasal turbinates, may contribute to asthma symptoms and the development of asthma. These adverse conditions may be especially troublesome for the high-performance athlete who has increased nasal airflow turbulence and who competes under extreme conditions that may worsen rhinitis and asthma. Under the theory of the unified airway, an immune response induced in the nose may extend into the lungs via cytokines and other inflammatory mediators. Nasal congestion can significantly contribute to sleep dysfunction, leading to daytime fatigue and decreased performance. Treatment of allergic rhinitis can improve sleep and foster productivity. Control of rhinitis and nasal congestion, which is obtained by various therapies, may reverse lower airway tendency to bronchoconstriction.