Orthopnea is a condition that causes breathing difficulties when an individual is lying down. It usually happens at night when the person is going to sleep. People with orthopnea usually experience tightness in the chest and being oxygen-deficit. The shortness of breath is due to lying down whether in a supine, recumbent, or prone position.
Orthopnea itself is not a serious condition, but may signal an underlying medical illness such a progressive heart failure. For this reason, it is quite important to consult a doctor when you experience frequent orthopnea.
When a person is lying down, there is an increased pressure in the veins that connect the heart to the lungs. It would be difficult for the lungs to properly function, thereby leading to shortness of breath in an individual. Other symptoms associated with orthopnea include intermittent pain in the chest and edema in lower extremities.
People who are overweight have higher chances of experiencing orthopnea. Even pregnant women are equally at risk of developing this condition, which is why the proper monitoring of the signs and symptoms of orthopnea is important.
Orthopneic Positions That Cause Shortness of Breath
Orthopnea can only be experienced in certain positions. The following positions are different variations of orthopnea:
- Supine Position - In this position, an individual is lying down facing upward.
- Left or Right Lateral Recumbent Position - In this particular position, an individual is lying down facing sideways.
- Prone Position - The individual is lying down facing downward.
People with orthopnea may feel better by placing many pillows under their head. Orthopnea can be relieved by changing to an upright position. The condition can also be accompanied by swelling of the feet and ankles. Excess fluid accumulation in the lungs may also cause orthopnea. Blood volume gets redistributed from the feet and legs to the lungs when the person is in the prone position. For people whose hearts are pumping normally, this is not a problem. However, people with heart problems may suffer from breathing issues since their heart is not capable of accommodating extra fluid.
"Orthopnea" is derived from the Greek words "orthos" and "pnoe", which means "straight" and "breathing" respectively. People with the following conditions may also experience orthopnea:
To properly diagnose and treat the condition, you should see a doctor even though your breathing becomes normal after sitting.
Types of Orthopnea
There are many types of orthopnea, but the following are the most common:
- Pediatric Orthopnea - This kind of orthopnea occurs in infants to children below the age of 12. Due to an improper lying down position, children may have a hard time breathing.
- Orthopnea During Pregnancy - In pregnant women, the following conditions may cause orthopnea:
Aside from a difficulty in breathing, the typical symptoms of orthopnea include:
- Persistent coughing
- Intermittent tightness in the chest region
- Swelling of the ankles and feet
- Pedal edema
- Paroxysmal nocturnal dyspnea
- Pressure in the Veins - In orthopnea, there is an increased pressure in the veins. These veins transport oxygen to the heart from the lungs. In the heart, blood is pumped from the left ventricle to the aorta. From there, the oxygen-rich blood is distributed throughout the body. However, the ventricles cannot pump an adequate amount of blood to the aorta and there would also be an insufficient amount of blood being distributed throughout the body. Hence, pressure tends to increase in the veins that carry oxygenated blood to the left ventricle, which then leads to shortness of breath in people with orthopnea.
- Anxiety - People who experience anxiety attacks are also at risk of developing orthopnea. Due to intense fear, people get chest pains and are unable to properly sleep at night.
- Upper Respiratory Tract Infections - Orthopnea can also be caused by a congested nose and inflamed tonsils. Thus, even simple illnesses can be associated with orthopnea.
- Heart Disease - Cardiac conditions such as hypertensive heart disease and congestive heart failure may be related to orthopnea. Most hypertensive patients have a weak heart, which is not capable of pumping much blood throughout the body. Blood volume gets redistributed in a lying down position. Thus, pumping blood away from the lungs becomes challenging for the heart, thereby causing shortness of breath. In congestive heart failure, a similar experience is felt by the patient while in a lying down position.
- Pulmonary Heart Disease - Another medical condition that may cause orthopnea is pulmonary heart disease. In this cardiac condition, the right ventricle of the heart fails due to high blood pressure in the arteries. It can cause wheezing, coughing, and a difficulty in breathing. The patient may need oxygen therapy to support breathing and to relieve symptoms of orthopnea.
First, the patient's airway breathing and circulation are examined. A physical examination is done along with taking the patient's medical history. The following signs may indicate the severity of the condition:
- Altered mental status
- Unstable dysrhythmia
- Absence of breathing sounds
- Tracheal deviation
- Chest wall indrawing
To quantify the degree of orthopnea, a number of scales may be used. The scale may rate from 1 to 10. The description is associated with the number on the scale. MRC breathlessness scale may be used alternatively. Based on which circumstances orthopnea arises, five different grades are there on the scale.
To determine the exact cause of orthopnea a number of laboratory tests may help. D-dimer is a test used to rule out pulmonary embolism, but if the test is positive, then it is not of much value. To rule out congestive heart failure, there must be low levels of brain natriuretic peptide (BNP). However, if there are increased levels of BNP, then the condition may be due to advanced age, acute coronary syndrome (ACS), renal failure, or a large pulmonary embolism.
To rule out pulmonary edema, pneumothorax, or pneumonia, a chest X ray will be helpful. To evaluate pulmonary embolism, intravenous radiocontrast with spiral computed tomography can be used.
Normally, discomfort can be relieved by adjusting the height of the pillows or by keeping the upper body elevated while sleeping. To make the breathing process easier, most people with orthopnea prefer keeping their upper body in an elevated position. However, this is only a temporary solution. Over a period of time, an underlying disease may worsen. Ask your doctor about the most appropriate treatment for your condition.
Some of the treatment options available are:
- Anti-inflammatory medications
- Open-heart surgery
To get rid of excess fluid, diuretics can be given. To decrease the accumulation of fluid, doctors may recommend a reduced consumption of foods high in sodium. Certain medications may be given for muscle strength. These medications would help the heart to pump more blood from the left ventricle. Thus, the pressure on the veins is reduced leading to fewer symptoms of orthopnea.
Vasodilators may also help increase the width of the veins. These drugs reduce the pressure on the veins and allow the blood to flow more freely.
Fluid Overload Treatment
In the case of orthopnea, doctors usually recommend a low-sodium diet since sodium may contribute to fluid overload. Excess sodium and water can be eliminated from the body by taking diuretics. However, diuretics tend to become ineffective over a period of time. It is one of the reasons why many people are hospitalized for additional treatment.
A fluid overload treatment includes:
- Intravenous Medications - They include loop diuretics.
- Vasodilators - Increase the blood flow by increasing the diameter of the blood vessels.
- Inotropic Medications - With each contraction, these medications cause the heart to pump more blood.
Doctors may also recommend ultrafiltration if the fluid overload is not relieved by medications. In ultrafiltration, the excess fluid is pumped out of the blood by using a small machine.
Orthopnea is often a symptom of the condition called pulmonary edema. In this condition, fluid accumulates in the lungs due to increased pressure.
Another complication associated with orthopnea is heart failure. The pulmonary circulation may be overloaded in patients who suffer from congestive heart failure. The symptoms are usually improved when the person changes to an erect position.