Paroxysmal nocturnal dyspnea is a sudden attack of shortness of breath that awakens a patient from sleep, often with coughing, wheezing, diaphoresis, or chest discomfort. Relief usually follows sitting or standing, though attacks may recur every 2–3 hours.PND most commonly indicates left-sided heart failure and reflects mechanisms such as pulmonary venous congestion, interstitial fluid reabsorption, increased thoracic blood volume, or impaired left ventricular function that worsen in the recumbent position.

History and Physical Examination

History

• Clarify timing and frequency of nocturnal attacks.

• Ask if dyspnea also occurs with exertion or at rest.

• Determine associated symptoms: cough (clear or blood-tinged sputum), wheezing, chest tightness, palpitations, fatigue, or weakness.

• Inquire about orthopnea (number of pillows, sleeping in chair).

• Review history of myocardial infarction, coronary artery disease, hypertension, valvular disease, or cardiomyopathy.

• Ask about chronic lung disease (asthma, emphysema, bronchitis) or previous cardiac surgery.

• Explore presence of ankle swelling, jugular vein distention, or rapid weight gain.

Physical Examination

• Assess vital signs (pulse, blood pressure, respiratory rate, oxygen saturation).

• Observe for cyanosis, diaphoresis, and peripheral edema.

• Auscultate lungs for crackles, wheezes, or decreased air entry.

• Auscultate heart for gallops (S3/S4), murmurs, or irregular rhythms.

• Evaluate jugular venous pressure, hepatojugular reflux, and presence of clubbing or hemoptysis.

Medical causes of paroxysmal nocturnal dyspnea

Special considerations

• Prepare for investigations: chest X-ray, echocardiography, ECG/exercise testing, BNP, and cardiac blood pool imaging.

• During an episode, help patient sit upright or dangle legs to reduce venous return.

• Provide supplemental oxygen if hypoxemic and reassure the patient to lessen anxiety, which can worsen breathlessness.

Patient counseling

• Teach recognition of warning signs: increasing frequency of attacks, resting dyspnea, or edema.

• Advise on sodium and fluid restriction if prescribed.

• Emphasize adherence to medications (diuretics, ACE inhibitors, beta-blockers).

• Suggest elevating head of bed or using extra pillows to reduce nocturnal symptoms.

Pediatric pointers

• In children, PND usually indicates congenital heart disease with heart failure.

• Supportive measures: elevate head, provide calm reassurance, and ensure prompt evaluation by a pediatric cardiologist.

References

1. Berkowitz, C. D. (2012). Berkowitz’s Pediatrics: A Primary Care Approach (4th ed.). American Academy of Pediatrics.

2. Buttaro, T. M., Tybulski, J., Bailey, P. P., & Sandberg-Cook, J. (2008). Primary Care: A Collaborative Practice (pp. 444–447). Mosby Elsevier.

3. Colyar, M. R. (2003). Well-Child Assessment for Primary Care Providers. F.A. Davis.

4. McCance, K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2010). Pathophysiology: The Biologic Basis for Disease in Adults and Children. Mosby Elsevier.

5. Sommers, M. S., & Brunner, L. S. (2012). Pocket Diseases. F.A. Davis.