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J Allergy Clin Immunol. 2011 Nov;128(5):977-82.e1-2. doi: 10.1016/j.jaci.2011.07.018. Epub 2011 Sep 8.

Most nocturnal asthma symptoms occur outside of exacerbations and associate with morbidity.

Collaborators (152)

Szefler SJ, Larsen G, Spahn J, Liu A, Jain N, Leo H, Macomber B, Mjaanes C, Song B, Sundström D, Breese K, White M, Morgan K, Grumann A, Spears G, Markson J, Barter J, Patterson K, Sorkness CA, Lemanske RF, Moss MH, Krawiec ME, Allen DB, Blotz K, Garibay S, Miller K, Eversoll H, Clark A, Kelly Schanovich K, Kelley R, Zeiger RS, Heldt G, Mellon MH, Schatz M, Friedman NJ, Christiansen SC, Jalowayski AA, Hoffman H, Harden K, Nelle C, Rodriguez E, Jenson E, Galbreath L, Strunk RC, Bacharier LB, Bloomberg GR, Corry JM, Oliver-Welker T, Morgan V, Hodgdon K, Caldwell W, Moseid C, Martinez FD, Morgan WJ, Guilbert TW, Mark JD, Brown MA, Goodwin J, Celaya M, Valencia A, Lawless J, Weese R, Radford S, Hall W, Taussig LM, Kiley J, Taggart V, Weinmann G, Zheng G, Chinchilli VM, Mauger D, Paul I, Graff G, Boehmer S, Phillips B, Doty L, Dyer AM, Texter L, Schmidt J, Rawa P, Ferrari L, Whisler S, Arminavage P, Beers B, Miller L, Potteiger J, Schell L, Olexovitch S, Simmons V, Tran T, Milner L, Moore B, Sutton A, Boat TF, Bailey WC, Kay Garcia M, Kercsmar CM, Key LL Jr, Tonascia J, Wilfond B, Ballard P, Davis CE, McLean DE, Shapiro G, O'Byrne P, Liu M, Taussig LM, Taggart VS, Szefler SJ, Lemanske RF, Zeiger RS, Strunk RC, Martinez FD, Chinchilli VM, Lemanske RF, Szefler SJ, Martinez FD, Zeiger RS, Chinchilli VM, Sorkness CA, Strunk RC, Guilbert T, Mauger D, Szefler S, Phillips B, D S, Schmidt J, Blotz K, Garibay S, Miller K, Morgan W, Heldt G, Larsen G, Sorkness CA, Spahn JD, Graff G, Hodgdon K, Kelley R, Radford S, Rodriguez E, Doty L, Evans R, Lennon J, Sanders L, Grella V, Ferrari L, Martinez FD, Szefler SJ, Lemanske RF, Chinchilli VM, Mauger DT, Phillips B.

Author information

Department of Pediatrics, Washington University School of Medicine and St Louis Children's Hospital, St Louis, MO 63110, USA.



Although nocturnal awakenings help categorize asthma severity and control, their clinical significance has not been thoroughly studied.


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.


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.


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.


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.

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