Difficulty Breathing When Lying Down (Orthopnea)

What orthopnea is

Doctors often ask, "How many pillows do you sleep on?" because the number of pillows someone needs to breathe comfortably measures how severe orthopnea is ("two-pillow" or "three-pillow orthopnea"). Some people end up sleeping in a recliner.

Two related patterns are worth knowing:

Why lying down makes breathing harder

When you lie flat, around 250 to 500 ml of blood moves from the legs and abdomen into the chest. A healthy heart pumps it on. A weak heart cannot, so pressure rises in the lung blood vessels and fluid seeps into the lungs, making them stiff and wet. Lying down also lets the abdomen push up on the diaphragm, which reduces lung volume, especially with obesity or a swollen abdomen.

Causes

Heart failure

Heart failure is the most important cause. Other signs include breathlessness on exertion, swollen ankles and legs, tiredness, rapid weight gain from fluid, and a night cough. Orthopnea in heart failure means the fluid is significant and treatment may need adjusting. Underlying causes include heart attacks, high blood pressure, valve disease such as aortic stenosis, cardiomyopathy and atrial fibrillation.

Fluid on the lungs (pulmonary edema)

Sudden severe orthopnea with frothy sputum and crackling breathing is acute pulmonary edema, an emergency often caused by a heart attack, a severe spike in blood pressure or a heart valve failure.

COPD and asthma

People with COPD often find it easier to breathe sitting forward, and may be breathless lying flat because the diaphragm works less efficiently. Asthma tends to worsen at night, causing cough and wheeze in the early hours.

Pleural effusion

A pleural effusion is fluid between the lung and chest wall, from heart failure, infection, cancer or other causes. A large effusion compresses the lung. Lying on the affected side may be more comfortable.

Obesity and obesity hypoventilation

Excess weight on the chest and abdomen restricts the lungs when lying flat. Obesity hypoventilation syndrome causes shallow breathing during sleep, with morning headaches and daytime sleepiness. It often overlaps with sleep apnea.

Weakness of the diaphragm

Paralysis or weakness of the diaphragm, from nerve injury, ALS or muscle disease, causes marked breathlessness on lying flat because the abdominal contents push into the chest unopposed. Breathing may look "paradoxical", with the belly moving inward on breathing in.

Acid reflux

Reflux can trigger coughing, wheezing and a choking feeling when lying down, particularly after a late meal.

Other causes

• Large amounts of fluid in the abdomen (ascites) from liver disease or cancer
• Late pregnancy, when the uterus pushes up on the diaphragm
• Panic attacks at night
• Sleep apnea, which causes waking with gasping or choking, but is not true orthopnea

How doctors find the cause

Your doctor will ask how many pillows you use, whether you wake gasping, how far you can walk, and about ankle swelling, weight gain, chest pain, cough and heart or lung disease. They will listen to your heart and lungs, check your neck veins and ankles, and measure oxygen levels. Tests often include:

• BNP or NT-proBNP blood test: a normal result makes heart failure unlikely
• ECG
• Chest X-ray: fluid, enlarged heart, effusion or lung disease
• Echocardiogram: heart pumping and valve function
• Spirometry: for COPD or asthma
• Sleep study or diaphragm tests in selected cases

Treatment

Treatment depends on the cause:

• Heart failure: diuretics (water pills) remove excess fluid quickly and often relieve orthopnea within days. Long-term medicines that strengthen the heart and improve survival are added, along with salt and fluid guidance and daily weighing.
• COPD and asthma: inhalers, pulmonary rehabilitation and treatment of flare-ups.
• Pleural effusion: draining the fluid and treating its cause.
• Obesity hypoventilation and sleep apnea: CPAP or bilevel breathing support at night, and weight loss.
• Reflux: avoid eating within 3 hours of bed, raise the head of the bed, and use acid-reducing medicine.

What you can do now

• Sleep propped up on pillows or with the head of the bed raised.
• If you have heart failure, weigh yourself every morning and report sudden gains.
• Follow your fluid and salt advice, and take medicines as prescribed.
• Avoid large meals and alcohol late in the evening.

Propping yourself up is a way to cope, not a fix. If you find you need more pillows than before, tell your doctor.

Frequently asked questions

Why do I get short of breath when lying down?

The most common reason is heart failure, where fluid shifts into the lungs when you lie flat. COPD, obesity, fluid around the lungs, diaphragm weakness and acid reflux can also cause it. New breathlessness lying down should be checked by a doctor.

Is orthopnea always heart failure?

No, but heart failure is the most common and important cause, so doctors check for it first. Lung disease, obesity, diaphragm problems and reflux can cause similar symptoms. A BNP blood test and an echocardiogram help tell them apart.

What is the difference between orthopnea and sleep apnea?

Orthopnea is breathlessness felt while awake as soon as you lie flat. Sleep apnea causes pauses in breathing during sleep, with snoring, choking or gasping awakenings and daytime sleepiness. Both can occur together, especially with obesity and heart failure.

When is shortness of breath lying down an emergency?

Call 911 or your local emergency number if you are breathless even sitting up, cannot speak in full sentences, have chest pain, cough up pink frothy sputum, or your lips turn blue. These suggest fluid on the lungs or another serious problem.

Does sleeping on more pillows help?

Yes, raising your head and chest reduces fluid shifting into the lungs and eases breathing. However, needing more pillows is a sign your condition may be worsening, so tell your doctor rather than relying on pillows alone.