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Shortness of Breath When Lying Down Symptom, Causes & Questions

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Written by
Carina Ryder, MS, BSN.
Certified Nurse Midwife, Takoma Park Gynecology
Last updated March 24, 2022

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Shortness of breath when lying down, also known as orthopnea, can affect individuals when sleeping or awake. When experiencing difficulty breathing or wheezing when lying down, you may also have a cough or heart palpitations. Causes of shortness of breath at night when lying down include heart-related conditions like congestive heart failure, lung-related conditions like bronchitis, or mental health issues that can cause hyperventilation. Read below for more information on causes and treatment options.

8 most common causes

Congestive Heart Failure
Illustration of a health care worker swabbing an individual.
Restrictive Cardiomyopathy
Iron Deficiency Anemia
COPD
Illustration of various health care options.
Aortic Valve Regurgitation
Obstructive Sleep Apnea
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Hyperventilation syndrome
Illustration of various health care options.
Hypertrophic cardiomyopathy

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Difficulty breathing when lying down explained

Have you ever woken up at night, breathless, and need to sit up for relief? It's like waking up from a nightmare only to find that feeling of being smothered is real. Shortness of breath when lying down is also called "orthopnea," and can happen whether you are sleeping or awake. Orthopnea plagues people with heart and lung conditions and sleep apnea.

Common characteristics of shortness of breath when lying down

In describing their experiences, people with orthopnea have said, "When I lie down, I feel...":

  • Like I am hungry for air.
  • Uncomfortable when I breathe.
  • Like my chest is tightening.
  • Like I can't take a deep enough breath.
  • I am out of breath.
  • I have to work hard to breathe.
  • I am being smothered.

Most orthopnea is caused by an underlying heart or lung condition. However, there are other conditions that could be leaving you gasping for air.

What causes shortness of breath when lying down?

Cardiovascular causes

Under the following conditions, the heart is unable to pump effectively, and not enough oxygenated blood reaches your lungs, causing orthopnea.

  • Hypertrophic cardiomyopathy
  • Aortic valve regurgitation
  • Atrial fibrillation
  • Myocarditis

Pulmonary causes

Under these conditions, oxygen is not effectively transferred into your lungs, even if your heart is working well, causing orthopnea.

  • Bronchitis
  • Pneumonia
  • Chronic obstructive pulmonary disease (COPD)
  • Pulmonary embolism
  • Cystic fibrosis

Other causes

Some other possible conditions that may cause orthopnea include the following.

  • Sleep apnea: Sleep apnea is one of the bigger offenders. It is more often seen in men, smokers, people who are overweight or have a sinus abnormality. Sleep apnea is often what causes the snoring, snorting, and restlessness that forces your bedmate to sleep in the guest room.
  • Panic disorder
  • Anemia
  • Nasal congestion
  • Pregnancy
  • Gastrointestinal conditions
  • Allergies and anaphylaxis
  • Obesity
  • Traveling to high altitudes

This list does not constitute medical advice and may not accurately represent what you have.

Acute or worsening heart failure

Heart failure is a condition in which the heart can't pump enough blood to meet the body's needs. Heart failure does not mean that the heart has stopped or is about to stop working, but rather that the heart is not able to pump blood the way it should. Usually this happens when the heart has been damaged by another medical condition.

Rarity: Rare

Top Symptoms: fatigue, shortness of breath, chest pain, nausea, shortness of breath on exertion

Urgency: Emergency medical service

Dilated cardiomyopathy

MISSING

Rarity: Ultra rare

Top Symptoms:

Urgency: Hospital emergency room

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Restrictive cardiomyopathy

Restrictive cardiomyopathy refers to a set of changes in how the heart muscle functions. These changes cause the heart to fill poorly (more common) or squeeze poorly (less common). Sometimes, both problems are present.

You should seek immediate medical care at an ER, where an ultrasound can confirm the diagnosis, blood tests can determine the cause of the problem, and treatment is needed immediately to stabilize you.

Obstructive sleep apnea

Sleep apnea means "sleeping without breathing." It means the person briefly stops breathing during sleep and then abruptly wakes up due to lack of oxygen.

In obstructive sleep apnea, the airway becomes relaxed and collapses during sleep. In central sleep apnea, the part of the brain which controls breathing may fail to send out signals during sleep. In both cases, breathing is cut off and the patient is forced to wake up – sometimes hundreds of times per night.

Older, overweight people are most susceptible, as is anyone with enlarged tonsils.

Symptoms include loud snoring; constant rousing during sleep; and constant daytime sleepiness.

Ongoing sleep apnea leads to very poor sleep quality with little REM sleep. This is very stressful and can lead to high blood pressure, stroke, and heart arrhythmias. The daytime drowsiness can lead to car accidents.

Diagnosis is made through physical examination and a sleep study.

Treatment consists of lifestyle changes and usually a CPAP (Continuous Positive Airway Pressure) machine, which allows the patient to experience much better sleep almost immediately.

Iron deficiency anemia

Iron deficiency anemia means that the body does not have enough iron to form hemoglobin, the protein in red blood cells that carries oxygen throughout the body.

The condition is caused by:

  • Acute blood loss through injury, surgery, or childbirth.
  • Chronic blood loss through an ulcer, overuse of aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs,) or heavy menstrual periods.
  • Inability to absorb dietary iron due to intestinal surgery or disease, or interference from certain medications.
  • A diet low in iron-supplying foods.

Symptoms include fatigue, shortness of breath, lack of endurance, and chest pain with rapid and irregular heartbeat.

If not treated, iron deficiency anemia can lead to heart disease because the heart has to pump extra blood to get enough oxygen to the tissues. Developmental problems in children can also occur.

Diagnosis is made through physical examination and blood tests.

Treatment includes a diet higher in iron-rich foods, such as red meat and dark green leafy vegetables, along with iron supplements. Severe cases may require hospitalization for blood transfusion and/or intravenous iron therapy.

Hyperventilation syndrome

Hyperventilation syndrome is a type of anxiety or panic attack, where the primary symptom is fast, shallow breathing that leads to a drop in carbon dioxide levels in the blood. This drops changes the body chemistry and causes the discomfort.

Any sort of fear or excitement that might provoke an anxiety attack can bring on hyperventilation syndrome.

Symptoms are worse in some patients than in others, but include anxiety; lightheadedness; pain and constriction in the chest; numbness and tingling of the extremities; and a feeling of suffocation.

It is important to seek treatment for hyperventilation syndrome, because the symptoms can be debilitating and interfere with quality of life.

Diagnosis is made through detailed patient history, as well as a complete physical examination and lab tests to rule out any other conditions.

Treatment involves showing that patient that, during an anxiety attack, simply breathing into a paper bag for a few minutes will ease the symptoms and allow recovery. Psychological counseling, with an emphasis on managing stress, is also helpful.

Rarity: Common

Top Symptoms: anxiety, shortness of breath, dizziness, racing heart beat, chest pain

Symptoms that always occur with hyperventilation syndrome: rapid, deep breaths

Symptoms that never occur with hyperventilation syndrome: shortness of breath after a few stairs

Urgency: Primary care doctor

Hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy (HCM) means "abnormal thickening of the heart muscle." This can interfere with the heart's ability to pump blood.

Most often, an inherited genetic mutation causes HCM. However, aging, high blood pressure, diabetes, or thyroid disease can sometimes bring it about.

Many people have no symptoms at all. Some have unexplained chest pain, shortness of breath, fainting, or the feeling of rapid, fluttering heartbeat, because the abnormally thick heart muscle interferes with normal heartbeat and causes an arrhythmia. Take the patient to the emergency room or call 9-1-1.

Untreated hypertrophic cardiomyopathy can lead to serious heart disease and even sudden cardiac arrest and death, especially in people under age 30.

Diagnosis is made through echocardiogram; electrocardiogram; treadmill stress test; and/or cardiac MRI.

Treatment involves medication to relax the enlarged heart muscle and slow the rapid pulse. Surgery to remove some of the thickened muscle may be done, or a defibrillator may be implanted.

Anyone with a family history of HCM should ask their medical provider about screening for the disease, which involves regular echocardiography.

Congestive heart failure

Congestive heart failure (CHF) is a form of heart failure that causes fluid to back up into the lungs and other tissue. Symptoms include trouble breathing and edema (swelling of ankles, hands).

You should schedule an appointment with your physician as soon as possible.

Chronic obstructive pulmonary disease (COPD)

Chronic obstructive pulmonary disease (COPD) is a progressive inflammation of the lungs that makes breathing difficult. It is caused by long-term exposure to irritating gases and/or dust particles, most often cigarette smoke.

Symptoms may take years to develop. They include a chronic cough with mucus (sputum), wheezing, chest tightness, fatigue, constant colds, swollen ankles, and cyanosis (blue tinge to the lips and/or fingernails.) Depression is often a factor due to reduced quality of life.

Treatment is important because there is a greater risk of heart disease and lung cancer in COPD patients. Though the condition cannot be cured, it can be managed to reduce risks and allow good quality of life.

COPD is commonly misdiagnosed and so careful testing is done. Diagnosis is made through patient history; physical examination; lung function tests; blood tests; and chest x-ray or CT scan.

Treatment involves quitting smoking and avoiding exposure to other lung irritants; use of inhalers to ease symptoms; steroids; lung therapies; and getting influenza and pneumonia vaccines as recommended.

Aortic valve regurgitation

The aorta is the large blood vessel which leads directly out of the heart. If the heart's aortic valve – which controls the flow of blood out of the heart and into the aorta – does not close tightly between heartbeats, some of the blood flows backward into the heart instead of out into the aorta.

This condition may be present at birth or develop through calcium deposits that build up as a person ages. Other causes are illnesses such as endocarditis, rheumatic fever, or lupus.

Symptoms may take years to develop and include fatigue and lightheadedness; chest pain and shortness of breath during exercise; swollen feet and ankles; and irregular, fluttering heartbeat.

Aortic valve regurgitation can lead to heart failure, which is life-threatening. If the above symptoms are present, the person should see a medical provider as soon as possible.

Diagnosis is made through patient history, physical examination, chest x-ray, stress tests, echocardiogram, and electrocardiogram.

Treatment involves lifestyle changes; some medications; and sometimes surgery to repair or replace the aortic valve.

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Treatment for trouble breathing at night/when lying down

When to see a doctor

Completely treating orthopnea requires treating the condition that is causing it. The following may specifically be recommended or you can ask your physician about them.

  • CPAP: A continuous positive airway pressure machine can help you breathe during sleep.
  • Ask if there is a dental device that could help you

At-home treatments

Even if your shortness of breath when lying down cannot be cured, there are many steps you can take to limit how severe it is. If you are experiencing relatively benign (not life-threatening) orthopnea, one of the best practices is to avoid sleeping or lying flat on your back. Understandably, this can be a difficult adjustment for back sleepers. You might fall asleep on your side, but that doesn't mean you will stay on your side. An unusual approach to help you stay off your back is to attach tennis balls to the back of your nightshirt. You can actually buy one pre-made if you prefer. You can also try the following.

  • Sleep in a semi-reclined position
  • Wear nasal strips
  • Lose weight: There are many health professionals out there who can help you achieve this goal if you are struggling.

When it is an emergency

Seek immediate medical care if you have orthopnea and any of the following.

  • Heart attack symptoms: Such as chest pain, nausea, profuse sweating, back, neck, or arm pain
  • Severe shortness of breath: Especially if you're unable to talk
  • Are having an allergic reaction (no matter how minor)

Questions your doctor may ask about shortness of breath when lying down

  • Have you been feeling more tired than usual, lethargic or fatigued despite sleeping a normal amount?
  • Any fever today or during the last week?
  • Do you have a cough?
  • Do you notice your heart beating hard, rapidly, or irregularly (also called palpitations)?

Self-diagnose with our free Buoy Assistant if you answer yes on any of these questions.

Hear what 1 other is saying
Persistent coughPosted December 29, 2019 by F.
Male, age 31. For about six weeks now I’ve had a persistent cough. I was treated with two antibiotics, and felt better briefly. However, days after the antibiotics ended I developed symptoms again. Currently, I am have difficulty breathing and coughing up yellow mucus, mostly at night while trying to sleep or when I lie down. What could cause such a resistant and persistent cough with these symptoms?
Dr. Rothschild has been a faculty member at Brigham and Women’s Hospital where he is an Associate Professor of Medicine at Harvard Medical School. He currently practices as a hospitalist at Newton Wellesley Hospital. In 1978, Dr. Rothschild received his MD at the Medical College of Wisconsin and trained in internal medicine followed by a fellowship in critical care medicine. He also received an MP...
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References

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  5. Best Positions to Reduce Shortness of Breath. Lung Institute. Published March 10, 2018. Lung Institute Link.