Orthopnea

Orthopnea — difficulty breathing in the supine position — is a common symptom of cardiopulmonary disorders that produce dyspnea. It’s usually a subtle symptom; the patient may complain that he can’t catch his breath when lying down, or he may mention that he sleeps most comfortably in a reclining chair or propped up by pillows. Derived from this complaint is the common classification of two- or three-pillow orthopnea.

Orthopnea presumably results from increased hydrostatic pressure in the pulmonary vasculature related to gravitational effects in the supine position. It may be aggravated by obesity or pregnancy, which restricts diaphragmatic excursion. Sitting in an upright position relieves orthopnea by placing much of the pulmonary vasculature above the left atrium, which reduces mean hydrostatic pressure, and by enhancing diaphragmatic excursion, which increases inspiratory volume.

History and physical examination

Begin by asking about a history of cardiopulmonary disorders, such as myocardial infarction, rheumatic heart disease, valvular disease, asthma, emphysema, or chronic bronchitis. Does the patient smoke? If so, how much? Explore associated symptoms, noting especially complaints of coughing, nocturnal or exertional dyspnea, fatigue, weakness, loss of appetite, or chest pain. Does the patient use alcohol or have a history of heavy alcohol use?

When examining the patient, check for other signs of increased respiratory effort, such as accessory muscle use, shallow respirations, and tachypnea. Also note barrel chest. Inspect the patient’s skin for pallor or cyanosis and the fingers for clubbing. Observe and palpate for edema, and check for jugular vein distention. Auscultate the lungs for crackles, rhonchi, or wheezing. Also auscultate the heart. Monitor the patient’s oxygen saturation.

Medical causes

Chronic obstructive pulmonary disease (COPD)

COPD typically produces orthopnea and other dyspneic complaints, accompanied by accessory muscle use, tachypnea, tachycardia, and paradoxical pulse. Auscultation may reveal diminished breath sounds, rhonchi, crackles, and wheezing. The patient may also exhibit a dry or productive cough with copious sputum. Other features include anorexia, weight loss, and edema. Barrel chest, cyanosis, and clubbing are usually late signs.

Left-sided heart failure

Orthopnea occurs late in left-sided heart failure. If heart failure is acute, orthopnea may begin suddenly; if chronic, it may become constant. The earliest symptom of this disorder is progressively severe dyspnea. Other common early symptoms include Cheyne-Stokes respirations, paroxysmal nocturnal dyspnea, fatigue, weakness, and a cough that may occasionally produce clear or blood-tinged sputum. Tachycardia, tachypnea, and crackles may also occur.

Other late findings include cyanosis, clubbing, a ventricular gallop, and hemoptysis. Left-sided heart failure may also lead to signs of shock, such as hypotension, a thready pulse, and cold, clammy skin.

Mediastinal tumor

Orthopnea is an early sign of a mediastinal tumor, resulting from pressure of the tumor against the trachea, bronchus, or lung when the patient lies down. However, he may be asymptomatic until the tumor enlarges. Then it produces retrosternal chest pain, a dry cough, hoarseness, dysphagia, stertorous respirations, palpitations, and cyanosis. Examination reveals suprasternal retractions on inspiration, bulging of the chest wall, tracheal deviation, dilated jugular and superficial chest veins, and face, neck, and arm edema.

Special considerations

To relieve orthopnea, place the patient in semi-Fowler’s or high Fowler’s position; if this doesn’t help, have him lean over a bedside table with his chest forward. If necessary, administer oxygen via nasal cannula. A diuretic may be needed to reduce lung fluid. Monitor electrolyte levels closely after administering diuretics. Angiotensin-converting enzyme inhibitors should be used for the patient with left-sided heart failure, unless contraindicated. Monitor his intake and output closely.

An electrocardiogram, chest X-ray, pulmonary function tests, and an arterial blood gas analysis may be necessary for further evaluation.

A central venous line or pulmonary artery catheter may be inserted to help measure central venous pressure and pulmonary artery wedge pressure and cardiac output, respectively.

Pediatric pointers

Common causes of orthopnea in a child include heart failure, croup, cystic fibrosis, and asthma. Sleeping in an infant seat may improve symptoms for a young child.

Geriatric pointers

If the elderly patient is using more than one pillow at night, consider noncardiogenic pulmonary reasons for this, such as gastroesophageal reflux disease, sleep apnea, arthritis, or simply the need for greater comfort.

Book Source Details

• Book Title: Handbook of Signs & Symptoms (Third Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.

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Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Handbook of Signs & Symptoms (Third Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-402-1

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