Orthopnea and Your Health

Orthopnea is the symptom of dyspnea (shortness of breath) that occurs when a person is lying flat. It is considered an important symptom mainly because it is often a sign of worsening heart failure, but other medical conditions can also cause it. For this reason, anyone who experiences orthopnea should always be evaluated by a healthcare provider.

In this article, learn the causes and symptoms of orthopnea along with its diagnosis and treatment.

Symptoms of Orthopnea

When experiencing orthopnea, the dyspnea usually occurs within a minute or so of lying down. Similarly, if the person sits up or elevates his or her head, the shortness of breath typically resolves quickly. So, for a person with this symptom, there is little doubt that it is related to a change in position. 

In addition to the dyspnea (or sometimes, instead of overt shortness of breath), a person with orthopnea can also experience coughing or wheezing brought on by lying down. 

People with orthopnea usually prop themselves up to sleep. Sometimes, an extra pillow or two is all it takes to relieve the symptoms; others may find they must sleep sitting in a chair. 

Healthcare providers usually characterize the severity of orthopnea by asking their patients how many pillows they need to fall asleep. The practitioner typically records the answer in the patient’s medical record as “two-pillow orthopnea” or “three-pillow orthopnea.” Healthcare providers keep track of this information because worsening orthopnea is often a sign that underlying heart failure is also worsening.

Related Symptoms

A symptom similar to orthopnea, and one that is also strongly associated with heart failure, is paroxysmal nocturnal dyspnea or PND. Like orthopnea, PND is a type of shortness of breath that occurs in relation to sleep. Both orthopnea and PND are related to fluid redistribution within the body during sleep, but PND is a more complex condition than “simple” orthopnea.

Generally, people who have PND do not notice dyspnea right after lying down. Instead, they are awakened later on, usually from a sound sleep, with an episode of severe dyspnea that causes them to sit or stand up for relief immediately. In addition to dyspnea, patients with PND also often experience palpitations, severe wheezing, coughing, and a sense of panic.

PND is a far more dramatic event than orthopnea. It is thought that some additional mechanism (aside from simple fluid redistribution) is taking place in people with PND, most likely related to changes in the brain’s respiratory center that may be associated with heart failure.

Recently, healthcare providers have recognized another kind of symptom in people with heart failure that is also related to fluid redistribution: “bendopnea,” or dyspnea caused by bending over.

What Is the Main Cause of Orthopnea?

When anyone lies down flat, gravity causes a redistribution of fluid within the body. Typically, lying down causes some of the fluid in the lower part of the body, particularly the legs and the organs of the abdomen, to gravitate into the chest area. This redistribution of fluid is usually quite minor, and in most people, it does not affect breathing at all.

However, people with congestive heart failure have a substantial amount of excess fluid in their bodies, and when this additional fluid is redistributed, the weakened heart may be unable to perform the additional work necessary to keep it from accumulating in the lungs. As a result, pulmonary congestion—and early pulmonary edema—may occur, and shortness of breath results. 

Heart failure is not the only cause of orthopnea, but it is by far the most common. Sometimes, people with asthma or chronic bronchitis have more breathing problems while lying down. The symptoms of wheezing and shortness of breath that occur with these conditions usually do not disappear rapidly after sitting up but take more time to resolve. 

Sleep apnea can also produce symptoms similar to orthopnea or, more often, to PND. 

Orthopnea has also been reported as a symptom in people who have paralysis of one or both diaphragm muscles (breathing muscles).

Severe obesity can cause orthopnea, not by a redistribution of fluid but rather by shifting the abdominal mass when recumbent, which can impinge on lung capacity. 

Orthopnea has also been seen in people with large goiters (thyroid gland enlargement), which can obstruct airflow in the upper airways when lying down. 

Diagnosing Orthopnea

In most cases, making the diagnosis of orthopnea is pretty straightforward. Healthcare providers ask patients about nocturnal dyspnea and whether they can sleep while lying flat as part of a routine medical evaluation. 

Many people who have orthopnea will deal with the symptom subconsciously by adding a pillow or two. They may not even realize they get short of breath when lying flat; they may just feel more comfortable with their heads elevated. This is why practitioners often ask how many pillows you routinely use. 

If a person describes orthopnea to a practitioner, the healthcare provider will ask follow-up questions to pinpoint the cause. For instance, symptoms consistent with heart failure, sleep apnea, asthma, or bronchitis should be elicited. A thorough physical examination to uncover the physical signs of these kinds of medical problems will also help to determine the cause. 

Additional testing is often needed to diagnose the cause of orthopnea. An echocardiogram, pulmonary function tests, or sleep studies are commonly obtained. In most cases, the cause of the orthopnea will become apparent after a complete medical history, physical examination, and a non-invasive test or two.

Because worsening orthopnea is often an early sign of worsening heart failure, anyone with heart failure (and their significant others) should pay attention to this symptom and even to the number of pillows they are using. Early intervention, when symptoms are relatively mild, can avoid a heart failure crisis and prevent the need for hospitalization.

Treatment of Orthopnea

An important goal in treating a person with heart failure is to eliminate orthopnea. Most cardiologists will consider lingering orthopnea to be a sign that a person’s heart failure may be inadequately treated and is usually considered a reason to be more aggressive with therapy.

Treating orthopnea requires identifying and treating the underlying cause. In most cases, orthopnea is due to heart failure, and (as noted) an essential goal in treating heart failure should be to eliminate orthopnea. 

Summary

Orthopnea is usually a manifestation of pulmonary congestion that can occur in people with heart failure or other medical conditions. The onset of orthopnea or changes in its severity can indicate essential changes in the severity of heart failure. Other significant medical conditions can also cause orthopnea, so this symptom should always be reported to your healthcare provider.

Orthopnea is diagnosed primarily through a consultation with a healthcare professional and may include tests like an echocardiogram, lung function tests, or sleep studies. Treating orthopnea is achieved by treating the underlying medical condition.