Orthopnea is a symptom characterized by difficulty breathing when lying flat, which is relieved by sitting up or elevating the head. It is often associated with various cardiovascular and respiratory conditions.

Pathophysiology

Orthopnea occurs due to:

• Redistribution of fluid from the lower extremities to the lungs when lying flat
• Increased venous return to the heart
• Reduced functional residual capacity in the supine position

Causes

Cardiovascular:

• Congestive heart failure
• Coronary artery disease
• Valvular heart disease (especially mitral stenosis)
• Pericardial effusion

Respiratory:

• Chronic obstructive pulmonary disease (COPD)
• Asthma
• Pleural effusion
• Diaphragmatic paralysis

Other:

• Obesity
• Pregnancy
• Ascites

Clinical Presentation

• Difficulty breathing when lying flat
• Need for multiple pillows to sleep (quantified in “pillows”)
• Associated symptoms may include:
• Paroxysmal nocturnal dyspnea
• Cough
• Fatigue
• Edema

Diagnosis

• Detailed medical history
• Physical examination
• Chest X-ray
• Echocardiogram
• Pulmonary function tests
• Sleep study (if sleep apnea is suspected)

Treatment

Treatment is directed at the underlying cause:

Heart failure management:

• Diuretics
• ACE inhibitors or ARBs
• Beta-blockers
• Digoxin (in selected cases)

COPD/Asthma management:

• Bronchodilators
• Inhaled corticosteroids

General measures:

• Elevating the head of the bed
• Weight loss in obese patients
• Salt restriction