Orthopnea

Orthopnea (Greek from ortho, straight + pnoia, breath) is dyspnea which occurs when lying flat, causing the person to have to sleep propped up in bed or sitting in a chair. Orthopnoea is a symptom of heart failure. It can also occur in those with asthma and chronic bronchitis, as well as those with sleep apnea or panic disorder. The condition is often due to left ventricular failure and/or pulmonary edema. It is also associated with Polycystic Liver Disease.

Patients with orthopnoea often complain of waking up suddenly during the night 'unable to breathe' if they have slipped down from their pillows into the supine position. They may run to the window to 'get some air'.

It is commonly measured according to the number of pillows needed to prop the patient up to enable breathing (Example: "3 pillow orthopnea").

See also: Paroxysmal Nocturnal Dyspnea which means that a patient wakes up short of breath.

Epidemiology and Demographics
Orthopnea indicates heart failure in almost 95% of cases.

Pathophysiology
When a patient lies flat, pulmonary and venous pressure increases due to increase in venous return to the lungs.

Differential Diagnosis
Othopnea is often observed among patients with left heart failure the causes of which are included in the list below.

In alphabetical order.

Left Ventricular Failure
Most Common Causes:
 * Aortic regurgitation
 * Aortic stenosis
 * Hypertension
 * Mitral regurgitation
 * Myocardial ischemia

Expanded List of Causes:
 * Atrial fibrillation
 * Alcoholism
 * Anemia
 * Angina
 * Aortic regurgitation
 * Aortic Stenosis
 * Arteriovenous fistula
 * Beriberi
 * Cardiac aneurysm
 * Cardiomyopathy
 * Constrictive pericarditis
 * Drugs, toxins
 * Hypertension
 * Hyperthyroidism
 * Hypovolemia
 * Hypoxia
 * Mediastinal tumors
 * Mitral Regurgitation
 * Myocardial Infarction
 * Paget's Disease
 * Pancoast's Tumor
 * Pericardial effusion
 * Pericardial tamponade
 * Perimyocarditis
 * Protein deficiency
 * Restrictive cardiomyopathy
 * Rupture of the papillary muscles
 * Sepsis
 * Superior Vena Cava Thrombosis

History and Symptoms

 * Note onset, persistance and associated symptoms

Heart
An S3 gallop may be heard if LV failure is present

Lungs
Rales will likely be present

Laboratory Findings

 * Labs include:
 * pulse oximetry
 * arterial blood gas

Electrocardiogram
Should be performed to exclude MI, RV strain, LV hypertrophy and cardiomyopathy

Chest X Ray
Should be obtained to assess extent of pulmonary edema

Echocardiography or Ultrasound

 * Reveals any structure problems of the heart, valves and LV function

Other Diagnostic Studies

 * Pulmonary function tests
 * BNP to distinguish CHF

Treatment
Supplemental oxygen

Acute Pharmacotherapies

 * CHF
 * nitrates
 * loop diuretics
 * IV morphine
 * ACE inhibitors
 * digoxin

Valve disease:
 * ACE inhibitors
 * beta blockers


 * Asthma
 * Albuterol


 * COPD
 * Inhaled vasodilators

Indications for Surgery

 * Valve disease
 * valve replacement
 * valve balloon


 * Pleural effusion
 * thoracentesis

Acknowledgements
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