What Is Orthopnea?

Medically Reviewed by Poonam Sachdev on January 01, 2024
Written by Paul Frysh
6 min read

photo of Orthopnea

Orthopnea means you have shortness of breath when you lie down that goes away as you sit or stand up. It usually comes on over time, but sometimes it can happen all of a sudden.

Orthopnea is a sign of excess fluid in your lungs. It's usually caused by a heart condition such as congestive heart failure.

What wakes you up is a lack of oxygen. Orthopnea isn’t the same as sleep apnea, when your throat relaxes while you sleep and blocks your airway. Orthopnea can happen if you're asleep or awake.

Orthopnea vs. Dyspnea

Dyspnea is a general term for shortness of breath. Orthopnea is a specific term for a type of dyspnea that happens when you're lying down. Orthopnea goes away when you sit or stand. A similar form of dyspnea is paroxysmal nocturnal dyspnea (PND). With this, you are awakened by shortness of breath after a couple of hours of sleep. It is also relieved by sitting up. 

If you have orthopnea, you may wheeze when you lie down or have a dry cough. These go away when you sit or stand. You also might be short of breath when you exercise or do normal household chores. Orthopnea can cause you to:

  • Feel more tired than usual
  • Have swollen feet and ankles
  • Gain weight suddenly
  • Need more pillows when you sleep
  • Have chest pain
  • Wake up breathless

Orthopnea usually happens because your heart isn’t strong enough to pump out all the blood sent from your lungs. This is called heart failure. Heart disease, cardiomyopathy, high blood pressure, lung disease, and other problems can cause this weakness.

Heart failure causes fluid to build up around your lungs and eventually seep in. But why is it worse when you lie down? When you have orthopnea, your lungs are like half-full bottles of water. Upright, there’s still a good amount of space above the water. On its side, the water distributes across the bottle. That’s what happens in your lungs with orthopnea when you lie down and why you feel short of breath.

When you lie down, blood moves from your legs and feet to your chest and belly area. A weak heart can’t pump out the extra blood. Because of this added pressure, your lungs might absorb even more fluid.

Conditions linked to orthopnea

Sleep apnea and snoring can produce orthopnea. Though less common, there are other non-heart-related conditions that can cause orthopnea such as: 

  • Acute respiratory distress syndrome (ARDS). You can get orthopnea after trauma or infection in your lungs.
  • High-altitude pulmonary edema (HAPE). This happens when you travel too quickly to or are too active at high altitudes (more than 8,000 feet).
  • Nervous system trauma. You might get orthopnea after an accident, seizure, or brain surgery.
  • Drug reaction. Drugs like cocaine or heroin or even over-the-counter ones like aspirin sometimes cause orthopnea.
  • Pulmonary embolism. A clot that travels from your leg to your lung may cause shortness of breath.
  • Toxins. Breathing in harmful or dangerous air, smoke, or other chemicals can damage your lungs.
  • Obesity. A large stomach may create pressure on the lungs or airway while you're lying down.
  • Diaphragm paralysis. Weakness or paralysis in the diaphragm, the muscle that controls your breathing, can trigger orthopnea. 
  • Pulmonary hypertension. High blood pressure in your lungs from heart disease may leave you short of breath.
  • Chronic obstructive pulmonary disease (COPD). This is inflammation in the lungs from conditions like emphysema and chronic bronchitis.

To diagnose orthopnea, your doctor might ask a lot of questions about your breathing, such as:

  • Do you cough or wheeze when you lie down?
  • Do you have chest pain?
  • Are you very short of breath when exercising?
  • Does it get better when you stand?
  • Are your symptoms getting worse over time?
  • How many pillows do you use to sleep comfortably? 

Your doctor could also do several tests to find out why you have fluid in your lungs. They can include::

  • X-rays. An image of your lungs is the first test your doctor will use to check for fluid in your lungs.
  • Blood tests. Your doctor will take some of your blood to see how much oxygen and carbon dioxide it has. They’ll also see if you have higher than normal levels of B-type natriuretic peptide (BNP). This substance points to whether a heart condition is behind the extra fluid.
  • An echocardiogram. For this test, the doctor will use a handheld wand to get pictures to help trace the beating action of your heart and the flow of blood through the valves.
  • Pulmonary function tests. These tests measure how well your lungs work. A common one is spirometry, which tests how much air your lungs can take in and how hard you can breathe out. Other procedures might include lung volume and exercise testing. 
  • Sleep studies. Sleep studies can find the causes of breathing-related sleep problems like orthopnea. You can take these tests overnight at a sleep clinic or with an at-home device.

If your doctor finds that you have orthopnea that’s due to a heart-related cause, they’ll likely suspect heart failure. Then they’ll figure out exactly what condition led to it in order to treat it.

In the short term, you may be able to ease your symptoms if you sit or stand, or raise your upper body with pillows. In addition to treating the condition causing your orthopnea, your doctor may give you in-home oxygen or prescribe a diuretic, a medicine that helps you get rid of extra fluid.

Heart failure

Left-sided heart failure is linked to orthopnea. When the bottom left chamber of your heart doesn't pump blood well, the vessels that carry blood from the lungs get backed up. If heart failure causes your orthopnea, your doctor will treat the source of it and encourage you to:

  • Control your blood pressure and blood sugar levels, if you have diabetes.
  • Eat a heart-healthy diet.
  • Stop smoking and limit alcohol.
  • Lose weight, if needed
  • Get enough sleep.
  • Exercise moderately.
  • Monitor any symptoms of heart failure such as swelling in your legs.

COPD

COPD (chronic obstructive pulmonary disease) is a term for several conditions that block the lungs' airways and make breathing difficult. Orthopnea is a symptom of COPD. COPD often results from many years of smoking, exposure to pollution, or inhaling other toxic materials. If you have COPD and you smoke, you should quit. 

Your doctor may prescribe oxygen therapy or medications that relieve your COPD symptoms right away or long-term by opening up your airways and treating flare-ups.

Effectively treating your orthopnea depends on what's causing it and how severe that condition is. Your doctor will do further testing and evaluation to find out what that may be. In the meantime, oxygen therapy, raising your position in bed, losing weight, and diuretic medicines may help relieve your orthopnea symptoms.

Orthopnea is the medical term for shortness of breath when lying down. When you lie down, excess fluid spreads across your lungs and makes it hard to breathe. Sitting or standing up relieves this congestion. If you find yourself needing multiple pillows to breathe comfortably at night, you should see your doctor. Orthopnea is almost always caused by a condition such as heart failure or chronic obstructive pulmonary disease (COPD). Treating that condition, as well as relieving your breathlessness with oxygen treatments and diuretic drugs and changing your sleeping position, can help you manage your orthopnea.

Which heart failure creates orthopnea?

When your heart's bottom left chamber doesn't pump blood well, the blood flows back into your lungs. This left-sided heart failure is linked to orthopnea.

What is the difference between sleep apnea and orthopnea?

People with sleep apnea have short bouts of shallow breathing or no breathing while they sleep. Orthopnea makes it hard to breathe while lying down. Certain conditions, like obesity or heart failure, put you at risk for sleep apnea and orthopnea.

What position is used for patients with orthopnea?

To relieve extreme shortness of breath, your doctor may suggest the orthopneic, or tripod, position. In a sitting position, you lean forward slightly with your arms on your knees or propped on a stack of pillows or a bed table. The orthopneic position allows your lungs to expand and your body to use other muscles to help you breathe.