Allergists vary in how they perform sleep assessments
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Key takeaways:
- Most respondents to a survey by the American College of Allergy, Asthma and Immunology said they ask their adult patients with asthma about their sleep often or almost all the time.
- More than 60% of respondents said they often or almost always assess sleep in children who snore.
- Most respondents said they do not plan on using a sleep assessment tool because they had insufficient information or time.
Although patients with asthma and other atopic conditions experience higher risks for sleep disorders, allergists vary in how they address their patients’ sleep, according to findings presented in a research letter.
Standardized and easy-to-use assessment tools may help reconcile these differences, Fatima S. Khan, MD, attending physician in the division of allergy and immunology at Ann & Robert H. Lurie Children’s Hospital of Chicago, and Zachary W. Marshall, MD, physician in the McGovern Allergy and Asthma Clinic in Bellaire, Texas, wrote in Annals of Allergy, Asthma & Immunology.
The ACAAI Respiratory and Sleep-Related Breathing Disorders Committee developed and distributed an email questionnaire to ACAAI members about their awareness and assessment of sleep disturbances among their patients.
Responses were given on a 5-point descriptive scale including “almost all the time,” “often,” “occasionally,” “rarely” and “never.” The committee received 102 valid questionnaires between Sept. 30 and Oct. 8, 2021.
According to the survey, 90% of respondents saw adult and pediatric patients. Also, 46% had been in practice for more than 20 years, 32% between 6 and 20 years and 18% for less than 5 years. Locations included suburban (54%), urban (24.5%) and inner city (15.7%) practices, with most in small group, self-employed or academic settings.
Adult patient treatment
With 92 respondents completing the questions pertaining to adults, most said they asked about sleep in adults with asthma often or almost all the time, whereas approximately 10% said they rarely or never did.
More than 60% said they discussed treatment for obstructive sleep apnea (OSA) with their patients, with 1% rarely discussing treatment. Also, 41% never ordered sleep studies, approximately 15% rarely ordered them and approximately 43% ordered them occasionally, often or almost all the time.
Most often, respondents asked patients with asthma about their sleep, with 74% asking all the time. Patients with rhinosinusitis and those with atopic dermatitis followed as the next two groups most often asked about their sleep. Patients with chronic urticaria and contact dermatitis were asked less often, and approximately 48% of respondents said they rarely asked patients with food allergies about their sleep.
For patients who snore, 55% of respondents recommended intranasal corticosteroids (INS) almost all the time, and 43% occasionally or often recommended them.
Similarly, 9% of respondents recommended first-generation antihistamines almost all the time, 61% recommended them often or occasionally, and 23% recommended them rarely in adults with atopic dermatitis, chronic urticaria and contact dermatitis.
The respondents with more than 10 years of practice experience were significantly more likely to ask adults often or almost all the time about possible OSA compared with respondents with less experience (OR = 4.3; 95% CI, 1.6-11.2).
These more experienced allergists also were significantly more likely to order overnight sleep studies often or almost all the time for adults with suspected OSA (OR = 9.5; 95% CI, 2.4-42.5).
Pediatric patient treatment
Among the 86 respondents who completed the questions about pediatric patients, more than 60% said they often or almost always assessed sleep in the children who snore, and 86% recommended INS for them.
Despite data showing benefits of montelukast for children with sleep-disordered breathing and adenoid enlargement, 32% rarely and 13% never recommended the treatment for children who snore, with only 8% recommending the medication almost all the time.
Also, 48% did not order any sleep studies when they suspected sleep apnea, with 73% using first-generation antihistamines occasionally, often or all the time and 94% occasionally, often or always referring patients to a sleep specialist.
Overall findings
The sleep of patients with food allergies was assessed the least, and most respondents rarely assessed sleep in patients with chronic urticaria, AD, contact dermatitis or food allergies regardless of age.
Most respondents did not plan on using a sleep assessment tool, primarily because of insufficient information and time. But variable clinical manifestations may limit physician recognition, the researchers noted, even though there are associations between atopic conditions and sleep disturbances among patients of all ages.
According to the researchers, allergists need information to guide them in using valid tools that they could incorporate into their practices easily, particularly as the lack of sensitive and specific pediatric screening tools further complicates sleep assessments in children.
Allergists and patients alike, the researchers concluded, would benefit from increased awareness of sleep disorders in patients of all ages with atopic diseases and from standardized assessment tools that are easy to use.
Perspective
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This is an interesting and much-needed writeup about sleep considerations for patients with allergy. I was surprised at the high rate of insufficient sleep that a CDC survey found for children (34%) and adolescents (75%). That is significant and underappreciated, I believe. Although it was a small sample size (3.3% response rate), it sheds light on a very important issue.
It wasn’t so surprising to me that many clinicians fail to ask about adequate sleep among their allergy patients. Sleep is probably not a major consideration when practitioners are focusing on diagnoses and treatment. With insufficient sleep being such a problem in the pediatric population as the CDC reports, it makes me wonder how aware pediatricians are of this.
Because we’re accustomed to ask about nighttime cough and wheezing with asthmatics, it is not surprising that respondents inquired most often about sleep in patients with asthma (74% all the time) but less often in those with chronic urticaria/dermatitis and food allergies. The discomfort of those with chronic skin allergies may not be fully appreciated by some specialists (perhaps those with less experience), but these patients often have significant nighttime pruritis that interrupts their sleep.
The difference between those who have been in practice more than 10 years and those in practice less time to ask about obstructive sleep apnea was interesting, likely reflecting the experience one gets in a practice rather than what’s learned in school, residency or fellowship.
I think this report underscores the need for more studies in the awareness, effects and treatment of sleep deprivation. Considering the negative effects of poor sleep, including the reduction of mental clarity and coping mechanisms that can lead to increased stress and potential mental illness, sleep is a necessary topic about which clinicians should inquire.
In my practice, I have the sleep question in the review of systems on my template, so I always ask about sleep with my new patients. I don’t ask about sleep often with my established patients, but after seeing the prevalence in the numbers by the CDC, I will try to ask about it more often.
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