Respiratory system problems are very common in clinical practice with many of the patients visiting the doctor having problems related to breathing, including shortness of breath.
Shortness of breath is usually brought on by a problem with the functioning of the heart or the lungs.
In this article, we will look at health conditions that may cause you to feel short of breath at night. Shortness of breath at night is a very specific symptom, often a pointer to one of a few conditions that may be affecting you.
Asthma is a long-term inflammatory disease of the airways due to hyperresponsiveness of the airway. The airway is made up of the mouth, nose and nostrils, larynx, pharynx, trachea, and the bronchus.
Asthma specifically affects the bronchial tree – an extension of the airway that connects directly with the lungs. Airway hyperresponsiveness is due to an exaggerated response to numerous stimuli or agents.
Some common triggers are –
- Emotional stress
- Cold air
- Viral disease
- Pollution: exhaust fumes, tobacco smoke, dust, vapor.
- Drugs, food additives and food preservatives (Aspirin, NSAIDs, Beta blockers)
- Perimenstrual (catamenial asthma)
- Gastroesophageal reflux disease
When exposed to a trigger agent (called allergens), the muscles of the bronchus respond and suddenly shorten or close up. Subsequently, there is a swelling of the covering of the airway caused by cells of the immune system which narrows the airway, restricting the amount of air that can pass through.
This causes the typical symptoms seen in asthma:
- Shortness of breath
- Chest tightness, usually at night or early in the morning
These symptoms are reversible either spontaneously or with treatment. In asthma, shortness of breath at night often suggests a severe form of asthma.
Asthma is a common disease – the commonest reason why people present at emergency rooms for shortness of breath. It affects approximately 130 million people worldwide. It is slightly more common in boys than girls and, after puberty, women slightly more than men.
The chances of having asthma symptoms are particularly higher at night. This is because the airways tend to narrow at night which triggers nighttime coughing, and sometimes, shortness of breath. Your sleeping position may also cause you to accumulate secretions in the airways, predisposing you to nighttime attacks.
Having repeated nighttime attacks if you already have an asthma diagnosis is a pointer to a severe form of asthma and/or poor control with medications.
2. Congestive Heart failure
Difficulty with breathing at night is a very common and specific symptom of heart failure. The heart is responsible for pumping blood around the whole body. The cells which make up the body require oxygen and nutrients found in the blood to live and function.
When the heart is unable to fill up with blood or pump out the blood at the pace and blood pressure the body requires, then it is in failure.
Difficulty with breathing at night as a result of heart failure is often accompanied by other symptoms such as:
- Chest tightness
- An uneasy feeling when lying flat
- Feeling tired after a walk or after mild exercises
- Waking up at night with severe shortness of breath after lying flat for a while
- Bouts of coughing, wheezing, and a feeling of being suffocated at night
- Swelling in the ankles or feet which is brought on by prolonged standing or at the end of the day
It often builds up gradually over time, progressively worsening as the days go by. The severity of symptoms in heart failure varies from person to person, as well as their body’s response to the heart’s inability to function as it should.
Heart failure is caused by inborn heart diseases, infections, uncontrolled hypertension, drugs, inflammation, and infections.
3. Chronic Obstructive Pulmonary Disease
This refers to a group of diseases that causes airway narrowing. Unlike asthma, the damage is irreversible and develops over a number of years. COPD causes airway blockage leading to:
- Shortness of breath (which may come on or be worse at night)
- Mucus production
It is caused by tobacco smoke in the majority of cases but genetic and environmental factors also play a role in the development of COPD.
This is the infection of the lungs. It is mostly caused by viruses or bacteria, with variable severity. In the United States, Pneumonia is the leading cause of hospitalizations.
Pneumonia causes you to have shortness of breath, among other things like a fever and cough. It is particularly common in young children and adults over 65.
5. Pulmonary Embolism
Blood clots are formed within blood vessels after a prolonged period of immobility. Clots are also formed in some people with blood that is “stickier or thicker” than normal.
Symptoms of pulmonary embolism often occur on after a long flight, after prolonged sitting in some individuals, after surgery and in people with deep vein thrombosis (DVT). Symptoms include:
- Shortness of breath which may occur at night
- Cough which may be productive of blood-stained sputum or actual blood
- Severe chest pain
6. Panic Disorder
Individuals with anxiety and hyperventilation disorders often experience shortness of breath during attacks. In some cases, the attacks occur at night, waking the individual from sleep with a feeling of suffocation.
This is a normal but exaggerated reaction by your body to a situation it deems “unsafe”. Other symptoms like chest tightness, a pounding heart, excessive sweating, shaky limbs, and easy fatiguability often follows attacks.
7. Gastroesophageal reflux disease
Gastroesophageal reflux disease (or GERD) is a condition in which acid from the stomach goes back up into the esophagus. This is commonest at night when affected individuals lay flat in bed.
It is characterized by heartburn and if acid refluxes into the trachea (or windpipe), it causes a cough and/or shortness of breath.
In obese individuals, there are changes to normal respiration. They often have smaller lung volumes and require greater effort to take in breaths at a depth and rate necessary for normal health.
They also have difficulty breathing when laying down because the chief muscle of breathing – the diaphragm is unable to compress the abdominal organs as much as necessary.
9. Sleep apnea
When we sleep, our muscles are more relaxed – including the muscles of the airway. Normally, the throat muscles are relaxed during sleep but open wide enough to allow air to pass through to the lungs without causing any problems with breathing.
Sleep apnea is a condition in which breathing pauses during sleep because of narrowed or blocked airways. Shortness of breath occurs several times during the night in people with sleep apnea, leading to poor quality of sleep.
In affected individuals, they also have a history of loud snoring, difficulty with prolonged sleeping, and daytime sleeping (often at work). If symptoms are severe, surgery is undertaken to correct this.
Being physically fit is a healthy way to live. It reinvigorates your body and mind, enabling you to function properly and remain energized for activities of daily living. While it is quite important to exercise, exercising for too long, especially after a long break can be considered going too far.
When this happens, you are left very tired and fatigued with body aches and in some cases, shortness of breath, which is worse at night when you lie down. At this time, the chest and abdominal muscles are sore and painful, making breathing difficult.
Being unfit for a long period may also cause similar symptoms, especially when a simple but seemingly grueling task is completed, like using the stairs or running in an emergency.
This is the lack of adequate red blood cells or hemoglobin in the body. Red cells contain hemoglobin, the oxygen-carrying component, which supplies all the cells of the body with oxygen. Anemia is majorly due to:
- Blood loss
- Increased breakdown of red cells by the body
- Low production of red cells in the body or production of defective red cells
In anemia, the body tries to compensate for the reduction in oxygen levels by increasing heart rate, blood pressure, and respiratory rate. In some cases (considerable anemia or prolonged anemia), one may be short of breath, especially at night.
Besides feeling breathless, individuals with anemia may have other symptoms like easy fatiguability, dizziness, chest pain, cold hands and feet, tiredness, and pale skin.
12. Other Disease Conditions
Other lung problems like lung cancer, croup, lung fibrosis, interstitial lung disease, mesothelioma, pneumothorax, tuberculosis, and sarcoidosis may also cause you to become breathless at night.
A heart attack or an abnormality in heart rhythm may also cause you to become breathless at night. Insect bites or stings may also cause a severe allergic reaction leaving you short of breath.
Particularly in children, inhalation of toys or other foreign objects which may clog their airway is an important cause of shortness of breath at night. This is because they may rapidly deteriorate, leading to more serious problems.
Some people are breathless after doing strenuous exercises or during a bout of illness. Others have difficulty with breathing and consequently shortness of breath from doing normal day to day activities like walking, running or climbing the stairs.
If you are breathless at night – or at any other time of the day, that is not normal. You should see your doctor as soon as possible, especially if you have one or more of the following:
- Sudden onset of breathlessness
- Swelling in your feet and ankles
- Breathlessness after a long flight
- Difficulty in breathing brought on when you lie flat
- Bluish discoloration of your lips and/or fingers
- Fever or chills with difficulty in breathing
- Breathlessness that does not go away after rest
- Noisy breathing described as a wheeze or a higher pitched noise (called stridor)
Your doctor will take a full history of your symptoms in order to determine the cause. The severity, onset, duration, character, periodicity and other symptoms accompanying your shortness of breath are specific points your doctor will consider. Your doctor will also examine you.
Thereafter, the doctor’s impression of your symptoms will lead him/her to request for investigations or tests. Investigations ordered for are variable and may include blood and electrolyte tests, echocardiogram, chest scans or x-rays as well as lung function tests.
Treatment in itself varies. It is dependent on the cause of your symptoms. In some cases, you may require medications, chest physiotherapy, and avoidance of allergens. In other cases, surgery may be necessary.
The best way to avoid unsavory outcomes when you have shortness of breath at night (or at any time of the day) is to go to your doctor. Preventing a recurrence of symptoms or a severe outcome is tailored to specific underlying diseases causing you to have shortness of breath at night.
For example, asthmatics and individuals with congestive heart failure are required to use their medications as prescribed. Your doctor may also recommend that you make lifestyle modifications like quitting smoking, losing weight or avoiding allergens, depending on the underlying cause of your breathlessness.
The goal is to prevent a recurrence of symptoms and to ensure that the quality of life is near normal.
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