Orthopnea

Orthopnea is defined as difficulty breathing (dyspnea) while in the recumbent position. The dyspnea is due to increased venous return to the lungs while recumbent, resulting in increased pulmonary venous and capillary pressures. Elevating the head/chest toward an upright position relieves the dyspnea. Orthopnea implies left-sided heart failure in about 95% of cases.

Differential Diagnosis

• Congestive heart failure is the most common cause of orthopnea
  –Etiologies include uncontrolled HTN, pulmonary embolus, endocarditis, hyperthyroidism, pericardial disease, endocardial disease (e.g., valvular stenosis, insufficiency, rupture, endocarditis), and myocardial disease (e.g., MI, ischemia, arrhythmias)
• Aortic regurgitation
  –Most commonly due to rheumatic fever
• Cardiomyopathies
• Pleural effusion
  –Common causes: CHF, pneumonia, cancer, pulmonary embolus, connective tissue disease (e.g., SLE, rheumatoid arthritis), pancreatitis, renal or liver disease
• Aortic stenosis
  –Associated with angina, syncope, and CHF
• Mitral stenosis
  –Usually secondary to rheumatic heart disease (after 15–40 years)
  –Advanced cases result in pulmonary hypertension and right heart failure
  –Dyspnea is the most significant symptom
  –Classic triad: Diastolic rumble, opening snap, and loud first heart sound
• Congenital heart disease
  –May see failure to thrive, progressive CHF symptoms, cyanosis, and/or murmur
• Severe COPD and asthma
• Severe bilateral apical lung disease
• Bilateral diaphragmatic paralysis

Workup and Diagnosis

• Thorough history and physical exam
  –Note onset (sudden or chronic, progressive)
  –Timing (persistent or intermittent)
  –Associated symptoms (e.g., chest discomfort, syncope)
• Initial labs should include CBC, electrolytes, thyroid function tests, pulse oximetry (resting, ambulatory, and nocturnal), and chest X-ray
• Arterial blood gas will identify barriers to oxygen diffusion (increased A-a gradient), hypoxemia, and chronic hypercapnia
• ECG may reveal evidence of MI, right ventricular strain (e.g., due to mitral stenosis), left ventricular hypertrophy (e.g., aortic stenosis), low voltage (cardiomyopathy), and dysrhythmias
• BNP may be useful if the etiology is uncertain to distinguish CHF from other causes of dyspnea
• Pulmonary function tests may be indicated to identify restrictive or obstructive disease and barriers to diffusion
• Echocardiogram to establish a diagnosis of structural heart disease, valve disease, and LV dysfunction
• Consider cardiac catheterization to evaluate valve disease, cardiomyopathy, and congenital heart disease

Treatment

• Attention to airway, breathing, and circulation
• Administer supplemental O₂ as needed
• CHF: Decrease preload by venodilation and afterload by arteriodilation and volume removal, to improve forward blood flow and decrease symptoms; give nitrates (sublingual/IV), loop diuretics, IV morphine, ACE inhibitors, digoxin, spironolactone; treat refractory respiratory distress with CPAP, BiPAP, or intubation
• Valvular disease: Reduce blood pressure with an ACE inhibitor or β-blocker; surgery (balloon valvuloplasty, valve repair, or valve replacement) for severe disease
• Pleural effusion: Treat underlying cause; thoracentesis may be indicated; pleurodesis for recurrent effusions
• Asthma: Avoid triggers; bronchodilation with inhaled βagonists (e.g., albuterol) and anticholinergics (e.g., ipratropium); inhaled, oral, and/or IV steroids
• COPD: Inhaled bronchodilators (e.g., albuterol, ipratropium); systemic corticosteroids; antibiotics in severe exacerbations; mechanical ventilation

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

More About Causes of Breathing difficulties

• Back to symptom: Breathing difficulties: Introduction (review 2668 causes)
• Next Book Extract About Breathing difficulties: Tachypnea (In a Page: Signs and Symptoms)
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More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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