Orthopnea is difficulty breathing while lying supine, a common symptom in cardiopulmonary disorders that produce dyspnea. Patients often report they breathe best when sitting upright, propped on pillows, or in a reclining chair. Clinically, orthopnea is sometimes described as two- or three-pillow orthopnea, depending on the number of pillows needed for comfortable breathing.

Pathophysiology

Orthopnea results from increased venous return and pulmonary hydrostatic pressure when lying supine, combined with restricted diaphragmatic excursion. Key mechanisms include:

1. Left-sided heart failure

   • Supine position increases venous return from the lower body.

   • The failing left ventricle cannot accommodate this increased preload, resulting in elevated left atrial and pulmonary venous pressures.

   • Increased pulmonary hydrostatic pressure causes pulmonary congestion and interstitial edema, impairing gas exchange and producing dyspnea.

   • Upright posture reduces venous return and hydrostatic pressure, relieving symptoms.

2. Chronic obstructive pulmonary disease (COPD)

   • Hyperinflated lungs in COPD limit diaphragmatic excursion, particularly in the supine position.

   • Supine positioning increases work of breathing and may worsen ventilation-perfusion mismatch, leading to orthopnea.

3. Mediastinal masses or tumors

   • Supine positioning allows tumors to compress the trachea, bronchi, or large vessels, impairing airflow and venous return.

   • Compression worsens respiratory mechanics and reduces oxygenation.

4. Obesity and pregnancy

   • Increased abdominal pressure in supine posture restricts diaphragmatic movement, reducing tidal volume and functional residual capacity.

History and Physical Examination

• History: Ask about cardiopulmonary diseases (myocardial infarction, valvular disease, asthma, COPD), smoking, alcohol use, and symptom patterns (dyspnea, fatigue, cough, nocturnal awakenings).

• Physical Examination:

  • Observe for use of accessory muscles, tachypnea, shallow breathing, and barrel chest.

  • Inspect skin for cyanosis or pallor and fingers for clubbing.

  • Palpate and inspect for peripheral edema, jugular vein distention.

  • Auscultate lungs (crackles, rhonchi, wheezing) and heart (gallops, murmurs).

  • Monitor oxygen saturation.

Medical causes

Special considerations

• Relieve orthopnea by placing the patient in semi-Fowler’s or high Fowler’s position; leaning forward over a bedside table may help.

• Administer oxygen if hypoxic.

• Diuretics may be required to reduce pulmonary congestion; monitor electrolytes.

• ACE inhibitors for left-sided heart failure unless contraindicated.

• Monitoring: intake/output, daily weight, oxygen saturation.

• Diagnostic studies: ECG, chest X-ray, pulmonary function tests, ABG, central venous pressure, pulmonary artery catheter if needed.

Patient counseling

• Teach the patient to report worsening dyspnea or edema.

• Discuss dietary and fluid restrictions for heart failure.

• Encourage daily weight tracking to detect fluid retention early.

Pediatric pointers

• Common causes: heart failure, croup, cystic fibrosis, asthma.

• Infants may benefit from sleeping in an infant seat or elevated position.

Geriatric pointers

• Multiple pillows at night may indicate noncardiogenic causes: sleep apnea, GERD, arthritis, or need for comfort.

• Consider comorbidities that affect lung compliance and diaphragmatic excursion.

References

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9. Mayo Clinic. Orthopnea. Rochester, MN: Mayo Foundation for Medical Education and Research; 2023. Available from: https://www.mayoclinic.org/symptoms/orthopnea

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