It’s the end of a long day and you’re ready for bed. Your head hits the pillow, and suddenly, you can’t take deep breaths. The feeling of not getting enough air in every time you lie down is uncomfortable, and can be unsettling or even downright scary—especially if you’ve never felt it before. If this scenario describes your nightly routine, you could be dealing with something called orthopnea.

People with orthopnea become breathless when they lie on their backs, but breathe easily as soon as they sit up or stand. This makes it different from other conditions that involve difficulty breathing like:

• Dyspnea (shortness of breath, regardless of position)
• Platypnea (shortness of breath when upright)
• Trepopnea (shortness of breath when lying on your side)

But it’s not just shortness of breath that comes with orthopnea. You may have other symptoms like tightness or chest pain when lying down, wheezing or coughing, or heart palpitations, according to the Cleveland Clinic. And while this may sound like anxiety (who hasn’t had racing thoughts at night?), orthopnea is often a separate issue that points to an underlying health condition.

It’s important to see your doctor if you’re short of breath while lying down, says Panagis Galiatsatos, MD, MHS, a pulmonologist and director of the Tobacco Treatment Clinic at Johns Hopkins Bayview Medical Center. This is especially true if it comes with other symptoms that feel different than a bout of stress.

Read on to learn more about the causes and treatment options for orthopnea—so you can breathe more comfortably while dozing off.

9 causes of orthopnea

Orthopnea is typically caused by an underlying health problem that either creates fluid buildup around the lungs or prevents the lungs from fully expanding and taking in air. Some of these medical conditions include the following, per Dr. Galiatsatos and the Cleveland Clinic:

You may be dealing with congestive heart failure

Congestive heart failure is a chronic condition that can develop in four different stages. The most common symptoms are irregular heart beat, shortness of breath, and chest pain, but it can also cause you to feel short of breath at night as your head hits the pillow. This is because heart failure can cause excess fluid to accumulate around your lungs—leading to breathing issues. Over time, heart failure can also weaken your heart muscle. When your heart isn’t strong enough, it can’t pump extra blood that goes to the lungs when you lie down, per the Cleveland Clinic.

People most at risk for congestive heart failure include the following, per the Cleveland Clinic:

• Those over age 65
• Those who use tobacco, cocaine, or alcohol
• Those who have a sedentary lifestyle
• Those with high blood pressure or coronary artery disease
• Those who’ve had a heart attack
• Those with a family history of heart failure

How to treat it:

Treating orthopnea from heart failure will depend on the severity of the condition. For some people, lifestyle changes and certain medications (like those for high blood pressure or other heart conditions) are enough. Others may need to wear a device called a pacemaker to help improve their heart function, or even get surgery to open blocked arteries, per the Cleveland Clinic. If you have other heart-related symptoms with orthopnea, talk to your doctor to evaluate your heart failure risk.

You may have pulmonary hypertension

Pulmonary hypertension (PH) is a type of high blood pressure that affects the arteries—i.e., the blood vessels that bring oxygen-rich blood from your heart to your lungs. While this most often causes shortness of breath while active, it can also cause shortness of breath while resting or lying down in more severe cases, per the Cleveland Clinic. Other signs include the following:

• Chest pain or pressure
• Dizziness
• Bluish lips or face
• Racing heart beat

Unlike regular high blood pressure (which often has no symptoms, per the Mayo Clinic), PH can cause noticeable symptoms that you’re more likely to feel in certain situations (like during physical activity or when lying down at night and trying to relax). It’s also more common as you age, if it runs in your family, if you smoke, or if you’ve been exposed to environmental irritants for prolonged periods (like asbestos or smoke), per the National Library of Medicine (NLM).

How to treat it:

Like with heart failure, treatment for PH depends on how severe the condition has become. Conservative treatments involve limiting salt in your diet and getting regular exercise. In more serious cases, a person may need oxygen therapy or surgery. PH is also often diagnosed through echocardiograms, X-rays, and/or certain blood tests, per the Cleveland Clinic.

You’ve been dealing with COPD

COPD—or chronic obstructive pulmonary disease—is a group of diseases, including chronic bronchitis and emphysema, that causes chronic inflammation in your lungs, which can make it hard to breathe even while you are lying down. The most common cause of COPD is smoking or secondhand smoke, and other symptoms include the following, per the Cleveland Clinic:

• A persistent cough with mucus
• Wheezing
• Difficulty taking deep breaths (sometimes you can’t take a deep breath without coughing)

Women, people over 65, those who’ve worked with chemicals, or those who’ve had many respiratory infections in childhood are at a higher risk for developing COPD, per the Cleveland Clinic.

How to treat it:

COPD has various stages and each one will likely require a different level of care. Quitting smoking (if you do smoke) is one of the best things you can do to help kickstart recovery. Other treatment methods include lifestyle changes (i.e., nutritious meals, daily exercise, hydration, and proper sleep) and taking medications. COPD medications include some of the following, per the Cleveland Clinic:

• Bronchodilators: medications that relax your airways
• Corticosteroids: medications that reduce inflammation in your lungs
• Supplemental oxygen: a portable oxygen tank if your levels are low

You have overweight

Orthopnea can also happen in people with overweight or obesity. Extra weight may make it difficult for your diaphragm (the muscle that sits under the lungs and helps you breathe, per the NLM) to fully expand, which creates a sensation of shortness of breath. You may especially feel this when you are lying down, as pressure builds on your chest. Not everyone with overweight will have orthopnea; it may only happen if you specifically carry weight around your chest and upper abdomen.

How to treat it:

Reducing your chances of orthopnea may involve maintaining a healthy weight for your body size. You and your doctor can discuss different weight-loss goals or whether weight loss is right for you. Lifestyle adjustments like eating nutrient-dense foods and getting daily exercise can be helpful. In some cases, people may benefit from taking certain medications or surgery.

Your lungs have fluid buildup

Pulmonary edema is a condition that involves fluid building up in the lungs. It’s often related to congestive heart failure, but it can be from other non heart-related issues like viral illnesses, kidney disease, smoke, or lung injury, per the Mayo Clinic. This condition also often comes with other symptoms like the following, per the Mayo Clinic:

• Pressure on your chest that makes it hard to breathe
• An irregular heart beat
• A cough that produces mucus (sometimes you can’t even take a deep breath without coughing)

How to treat it:

Treating the underlying cause of pulmonary edema is one of the best ways to treat shortness of breath. Taking medications that support your heart and getting extra oxygen (through a mask or tube in the nose) are also common treatment options, per the Cleveland Clinic.

You have a case of severe pneumonia

A strong case of pneumonia can trigger orthopnea. It’s typically caused by a bacterial, viral, or fungal infection in your lungs. It can even happen as a result of viruses like COVID-19 or RSV (respiratory syncytial virus), per the American Lung Association. Not only does it create breathing problems—including shallow breathing when sleeping—but it can also cause a fever and cough with yellow, green, or bloody mucus.

How to treat it:

If your pneumonia is caused by bacteria, your doctor will prescribe a course of antibiotics. If it’s caused by a virus, your doctor may prescribe antiviral medications, but the first line of treatment is often just symptom management (think: staying hydrated, controlling your fever with medication, etc.) and plenty of rest. If you struggle to breath, experience confusion or an inability to think clearly, or have chest pain, you should go to the emergency room, according to the Cleveland Clinic. With severe cases, you may be treated in the hospital with supplemental oxygen therapy, per the American Lung Association.

Your diaphragm is weak

Your shortness of breath may be more of a structural issue within your body than a condition, per se. Case in point: You may have a weak diaphragm, which may make it hard to fully inhale and exhale when you breathe. Tumors, injuries, certain autoimmune diseases (like arthritis or multiple sclerosis), or other conditions can be to blame for weakness or even diaphragm paralysis, per the Cleveland Clinic.

How to treat it:

Diaphragm paralysis is often treated with supplemental oxygen or a ventilator if you can’t breathe well on your own. In some cases, it can be treated with a pacemaker to regulate breathing, per Columbia Surgery.

You have sleep apnea

Sleep apnea is a disorder that happens when a person repeatedly stops breathing while they sleep. It’s either caused by a blockage of your airway (obstructive sleep apnea) or an issue with your brain’s ability to control breathing (central apnea). Whichever type you have, you’re more likely to have trouble breathing when you lie on your back. You may also have paroxysmal nocturnal dyspnea—a sensation of shortness of breath that wakes you up from a sound sleep, per the National Institutes of Health (NIH).

Over time, sleep apnea may also weaken your heart, increasing the risk of heart failure, per the American Heart Association (AHA). And as we learned, heart failure also raises your odds of orthopnea.

How to treat it:

There are lots of ways to treat sleep apnea, depending on the type and severity. For some, maintaining a healthy weight or changing their sleeping position can be helpful. Others may need to take medicine or use devices like a CPAP machine to keep their airway open while they sleep, per the Cleveland Clinic.

Your thyroid gland has enlarged

When your thyroid (the butterfly-shaped endocrine gland in your neck) is healthy, it is relatively small. If it gets enlarged—often from thyroid disease—you can develop something called a goiter. In some cases, a goiter can cause shortness of breath when lying down, though this isn’t super common. It’s more likely that severe hypothyroidism (when your thyroid doesn’t make enough hormone) causes your heart to weaken, which can lead to orthopnea, per Penn Medicine.

How to treat it:

Treatment for goiter will depend on what’s causing it and how it’s affecting your health. Some goiters go away on their own, while others require treatment approaches like medication, radioactive iodine therapy, or surgery, per Penn Medicine.

Other conditions associated with orthopnea

Many things can cause shortness of breath while lying down. This is why it can be tough to tell when you have orthopnea or some other medical issue. For example, you might find it hard to get air if you’re dealing with health conditions like:

• Anxiety
• Panic disorder (a type of anxiety)
• Asthma

The best way to differentiate is to ask yourself, do I feel better when I sit up? In the case with anxiety or asthma, the answer is probably no. The same shortness of breath you have with these problems will probably stick around whether you’re standing, sitting, or lying down. On the other hand, when it’s a true case of orthopnea, being upright will offer relief and allow you to breathe more deeply.

How is orthopnea diagnosed?

Diagnosis often starts with your doctor reviewing your symptoms. If they think orthopnea is the culprit, they’ll want to get a better look at your heart and lungs to see what underlying condition is causing it. They may recommend tests like the following, per the Cleveland Clinic:

• Chest X-ray: A quick, noninvasive test that uses radiation to create an image of your heart and/or lungs.
• Echocardiogram: A noninvasive ultrasound that uses high-frequency sound waves to generate pictures of your heart.
• Electrocardiogram (EKG): A quick, noninvasive test that uses temporary electrodes on your chest and limbs to track your heart’s electrical activity.
• Pulmonary function tests: Different kinds of noninvasive breathing tests that can measure how well your lungs exchange air, how well your lungs absorb oxygen into your blood, and how exercise affects your lungs (like if you get dyspnea after exercise).

Treatment for orthopnea

As we learned, orthopnea is usually a symptom of another medical condition. So the key to breathing better on your back is to treat the underlying cause, Dr. Galiatsatos says. Depending on the root issue, treatment options may call for things like:

• Lifestyle changes (like managing your weight, eating a wholesome diet, and getting daily exercise)
• Medication
• Supplemental oxygen
• Surgery (in severe cases)

As you treat the primary health problem, you can also do a few things to minimize your orthopnea symptoms. Sometimes a simple tweak to your sleeping position is all you need for a better night’s rest. For example, try using an adjustable mattress or foam wedge pillow to prop yourself up, according to the Cleveland Clinic. Being in an upright posture will help you breathe better, Dr. Galiatsatos says.

When to see a doctor

If you have shortness of breath while lying in bed that resolves once you get up, you’re likely dealing with a bout of anxiety or stress (which is equally valid and can be relieved, too, BTW.) But if your shortness of breath only happens when you’re horizontal, you should get help “immediately,” Dr. Galiatsatos says. Orthopnea “is an urgent issue,” he adds.

Again, feeling breathless on your back is usually a red flag for another serious medical problem, especially a cardiovascular-related one. “Never dismiss this symptom as it is often indicative of a weakened heart,” he says. See your doctor as soon as possible if you have:

• Shortness of breath when you lie on your back
• Tightness or pain in your chest
• Wheezing or coughing
• Heart palpitations

FAQ

What’s the best sleeping position if you have orthopnea?

Most people with orthopnea will find comfort by sleeping in an elevated or upright position, Dr. Galiatsatos says. Some ideas to help you breathe better (and snooze more soundly) include the following:

• Use a foam wedge or several pillows to prop up your upper body in bed
• Consider an adjustable mattress so you can raise the head of the bed
• Sleep upright on the couch or in a comfortable chair

If you try other positions and feel uncomfortable (think: chest pain when sleeping on your side, for example), try to stick with sleeping upright or on an inclined bed to breathe better. Or ask your doctor about the best position to sleep in.

What’s the difference between orthopnea and paroxysmal nocturnal disease (PND)?

Paroxysmal nocturnal dyspnea (PND) happens when shortness of breath wakes you up. Unlike orthopnea, PND only occurs while you’re asleep, according to the Cleveland Clinic. A combination of sleep apnea and PND could even make you wake up gagging in some cases.

On the other hand, people with orthopnea can lose their breath whenever they lie down, including when they’re wide awake (read: while binging Netflix, during an exam at your doctor’s office, in certain reclined yoga poses, etc.).

—reviewed by Jennifer Gilbert, MD, MPH