title: Most nocturnal asthma symptoms occur outside of exacerbations and associate with morbidity.
abstract: BACKGROUND
  Although nocturnal awakenings help categorize asthma severity and control, their clinical significance has not been thoroughly studied.
  
  
  OBJECTIVE
  We sought to determine the clinical consequences of nocturnal asthma symptoms requiring albuterol (NASRAs) in children with mild-to-moderate persistent asthma outside of periods when oral corticosteroids were used for worsening asthma symptoms.
  
  
  METHODS
  Two hundred eighty-five children aged 6 to 14 years with mild-to-moderate persistent asthma were randomized to receive one of 3 controller regimens and completed daily symptom diaries for 48 weeks. Diary responses were analyzed for the frequency and consequences of NASRAs.
  
  
  RESULTS
  NASRAs occurred in 72.2% of participants at least once, and in 24.3% of participants, they occurred 13 or more times. The majority (81.3%) of nocturnal symptoms occurred outside of exacerbation periods and were associated the next day with the following events: albuterol use (56.9% of days preceded by nocturnal symptoms vs 18.1% of days not preceded by nocturnal symptoms; relative risk [RR], 2.3; 95% CI, 2.2-2.4), school absence (5.0% vs 0.3%; RR, 10.6; 95% CI, 7.8-14.4), and doctor contact (3.7% vs 0.2%; RR, 8.8; 95% CI, 6.1-12.5). Similar findings were noted during exacerbation periods (RRs of 1.7 for albuterol use, 5.5 for school absence, and 4.9 for doctor contacts). Nocturnal symptoms did not predict the onset of exacerbations.
  
  
  CONCLUSIONS
  Nocturnal symptoms requiring albuterol in children with mild-to-moderate persistent asthma receiving controller therapy occurred predominantly outside of exacerbation periods. Despite being poor predictors of exacerbations, they were associated with increases in albuterol use, school absences, and doctor contacts the day after nocturnal symptom occurrences.
authors.affiliation: Department of Pediatrics, Washington University School of Medicine and St Louis Children's Hospital, St Louis, MO 63110, USA. horner_k@kids.wustl.edu
authors.forename: Caroline C
authors.initials: CC
authors.lastname: Horner
authors.forename: David
authors.initials: D
authors.lastname: Mauger
authors.forename: Robert C
authors.initials: RC
authors.lastname: Strunk
authors.forename: Nora J
authors.initials: NJ
authors.lastname: Graber
authors.forename: Robert F
authors.initials: RF
authors.lastname: Lemanske
authors.forename: Christine A
authors.initials: CA
authors.lastname: Sorkness
authors.forename: Stanley J
authors.initials: SJ
authors.lastname: Szefler
authors.forename: Robert S
authors.initials: RS
authors.lastname: Zeiger
authors.forename: Lynn M
authors.initials: LM
authors.lastname: Taussig
authors.forename: Leonard B
authors.initials: LB
authors.lastname: Bacharier
mesh_terms: D000293:Adolescent; D000420:Albuterol / Q000031:analogs & derivatives / Q000627:therapeutic use*; D000730:Androstadienes / Q000627:therapeutic use; D018927:Anti-Asthmatic Agents / Q000627:therapeutic use; D001249:Asthma / Q000188:drug therapy* / Q000453:epidemiology*; D001993:Bronchodilator Agents / Q000627:therapeutic use*; D002648:Child; D004338:Drug Combinations; D005260:Female; D000068298:Fluticasone; D000068297:Fluticasone-Salmeterol Drug Combination; D006801:Humans; D008297:Male; D015995:Prevalence; D012890:Sleep
chemical_list: D000730:Androstadienes; D018927:Anti-Asthmatic Agents; D001993:Bronchodilator Agents; D004338:Drug Combinations; D000068297:Fluticasone-Salmeterol Drug Combination; D000068298:Fluticasone; D000420:Albuterol