An Overview of Orthopnea

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

An important goal in treating a person with heart failure is to eliminate orthopnea entirely. 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.

Symptoms

When a person is experiencing orthopnea, the dyspnea usually occurs within a minute or so of lying down. Similarly, if the person then sits up or elevates his or her head, the shortness of breath typically resolves quickly. So, for a person who has 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 who have orthopnea usually end up propping themselves up in order to get some sleep. Sometimes it just takes an extra pillow or two to get rid of the symptom; other people may find they have to sleep while sitting up in a chair. 

In fact, healthcare providers usually characterize the severity of orthopnea by asking their patient how many pillows he/she needs in order to fall asleep. The practitioner will then typically record 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 that occurs 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. Rather, they are awakened later on, usually from a sound sleep, with an episode of severe dyspnea that causes them to immediately sit or stand up for relief. In addition to dyspnea, patients with PND also often experience palpitations, severe wheezing, coughing, and a sense of panic.

Clearly, 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.

Causes

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 normally quite minor, and in most people, it has no effect whatsoever on breathing.

However, people with congestive heart failure have a substantial amount of excess fluid in the body, 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 cause. Sometimes people with asthma or chronic bronchitis will have more breathing problems while lying down. The symptoms of wheezing and shortness of breath that occur with these conditions, however, 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 a shifting of the abdominal mass when recumbent, which can impinge on lung capacity. 

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

Diagnosis 

In most cases, making the diagnosis of orthopnea is pretty straightforward. Healthcare providers ask patients about nocturnal dyspnea, and whether they are able to 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 that they get short of breath when lying flat; they may just feel more comfortable with their heads elevated. This is why practitioners will often ask about how many pillows you routinely use. 

If a person describes orthopnea to a practitioner, the healthcare provider will ask follow-up questions to begin to pin down the cause. For instance, symptoms consistent with heart failure, sleep apnea, asthma, or bronchitis should be elicited. A thorough physical examination, to uncover 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 the large majority of cases, after performing a complete medical history and physical examination, and doing a non-invasive test or two, the cause of the orthopnea will become apparent.

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

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

A Word From Verywell

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