I can't breat right

[mb011]

Hello, for about a month now I have had quite a bit of trouble breathing.

I am going on my own observations about myself here, but, I don't really think it's shortness on breath necessarily, but it feels more like some type of almost 'mechanical' issue in my breathing.

When this started, I got a very, very annoying heavy and tight feeling in my chest that hasn't gone away since it started.  I have noticed that often times, it is better when I am sitting down or laying down, and worse when I stand up strait.

However, having said that, I do not notice any 'serious' increase in the symptoms during exercise---for example, today I was able to exercise for an hour of my usual moderate intensity cardio and although I struggled with deep breaths the whole time (like a brick wall in the middle of my chest, and some kind of rubber grip feeling around my lower ribs), it didn't hinder me or make me have to stop exercising...it just made me very uncomfortable and struggling to breath past the "brick wall" in my chest.

Now that my exercise is over and I'm sitting back down, it's not gone, but I'm more comfortable generally.  I know that if I stand up strait right now, it will be worse.  So, it's made worse by standing up strait and better by sitting or laying, but it certainly doesn't go away when sitting, just more fluctuations I guess.

4 months ago, I weighed 260 lbs.  I lost 20 lbs down to 240 by diet and exercise, and that's when this started suddenly one day.  After I lost 20 lbs.  I didn't have the symptoms at all before.   Oh yes, and I am a 38 year old male with no known health problems.

My doctor took a chest xray and some basic lab tests, and he said there is nothing wrong.  However, there clearly is something wrong and I was wondering if you might know where to look or if I should see another type doctor, or if you have ever heard of anything like this before?  Thanks for your input, I really appreciate it.

[mb011]

Also, by checking for this condition in a pulmonary function lab,  are you referring to a standard pulmonary function test, or something else?

[mb011]

Hello again, thank your for the most thorough response, I really appreciate it.  

In the meantime, I was just wondering, Do you mean to say that in this condition, generally speaking, that the pulse oximeter would have to have a low reading when sitting or standing up?   I will take this info. to my doctor.....my pulse oximeter reading was 95% while siting at my doctors office.  (My doctors office is at 800 feet above sea level)

[David Tinkelman, M.D.]

I am not an alarmist but what you describe, “struggling to breath past the ‘brick wall’ in my chest.” is worrisome and leads me to believe that you should have further evaluation, by either a heart specialist (cardiologist) or a lung specialist (pulmonologist), without further delay.  I suggest that you share this message with your doctor, especially if you have good rapport with him.

By your description you have experienced two major symptoms:  1) “a heavy and tight feeling in my chest that hasn't gone away since it started”, and “made worse by standing up strait and better by sitting or laying, but it certainly doesn't go away when sitting”, and 2) “a struggle with deep breaths” during exercise.”  It is my impression that your symptoms, “the brick wall in my chest” and the struggle with deep breaths are predictably worse when standing and relieved significantly by lying down.

There is a medical condition that is called Platypnia in which a person experiences shortness of breath with a reduction in blood oxygen level when standing erect, that is relieved by lying down when oxygen levels return to normal.  I cannot diagnose your condition by E-mail.  I can only say that it seems to bear some resemblance to this condition.  It is one that can easily checked by your doctors,  in a pulmonary function laboratory, at a hospital or clinic.

The importance of the diagnosis of platypnia can be associated with some other serious conditions, most importantly of the heart or large blood vessels.  These abnormalities are not always readily apparent on Chest X-ray.

The following are reports from the medical literature and are written in medical language.  I do not expect you to be familiar with any of this.  I provide it to be shared with your doctors.

I am intrigued by the information you have provided. The most important message I wish to convey to you is that your symptoms may be a sign of serious disease of your heart and blood vessels and that you would be wise to seek further medical attention to determine if it is or is not.

Good luck

1. “Dyspnea (shortness of breath) that worsens in the upright position (i.e., platypnea) may be related to orthodeoxia, a decrease in arterial blood oxygen pressure (Po2) in the upright position, which occurs with cirrhosis, pulmonary arteriovenous malformations, or interatrial shunts.[70–73]

2. Chest 2000; 118:871–874

“In fact, diagnosis can be erratic and usually pulmonary embolism is suspected. Breathing 100% oxygen is good test, showing usually insufficient rise in the arterial oxygen pressure. Then, the most powerful and simplest examination is contrast transesophageal echocardiography showing the interatrial defect and the right-to-left shunting, sometimes only after Valsalva maneuvers.

In the observation, the therapeutic option chosen was surgical closure of the interatrial defect. We clearly recommend transcatheter PFO/ASD closure, as it was performed successfully in all our patients but one. The procedure is safe, simple, and effective without need of general anesthesia.

We hope that publication of this observation in CHEST will heighten awareness of platypnea-orthodeoxia syndrome. Postural change in dyspnea and/or hypoxemia should lead to transesophageal echocardiography to depict the interatrial right-to-left shunt and to propose subsequent transcatheter closure as the procedure of choice for relief of platypnea-orthodeoxia. In fact, the true incidence of this syndrome remains to be stated, taking into account the high prevalence of PFO in the normal population,
and a registry of this condition would be of interest.”

3. A Case of Orthodeoxia Caused by an Atrial Septal Aneurysm*
Satya S. Acharya, MD and Ritha Kartan, MD, FCC  CHEST September 2000 vol. 118 no. 3 871-874
The orthostatic nature of the desaturation was again documented with arterial blood studies while the patient was receiving 100% oxygen by nonrebreather facemask. In supine position, the Po2 level was 99 mm Hg and the oxygen saturation rate was 97%; while sitting, the Po2 dropped to 38 mm Hg and oxygen saturation to 75%. A transesophageal echocardiogram (TEE) disclosed a probable fenestrated atrial septum with an aneurysm and a bidirectional shunting that was confirmed by cardiac catheterization in supine position. In the case described herein, the patient had an atrial septal defect with an aneurysm.
Incidences of platypnea-orthodeoxia have also been described in patients with acute organophosphorous poisoning,20 amiodarone-induced lung toxicity,21 bronchogenic or laryngeal carcinoma,2324 cryptogenic fibrosing alveolitis,25 or autonomic nervous system dysfunction.26 An elongated ectatic aorta27 and an aortic aneurysm28 have also been reported to cause orthodeoxia.
Most cases of platypnea/orthodeoxia described in the literature have been corrected with surgical correction of the shunt, as occurred with our patient. Other treatments for orthodeoxia include prednisone for pericardial effusion following coronary artery bypass graft, and opiate therapy in elderly patients.14 Treatment with almitrine bismesylate has been shown to potentiate the normal pulmonary hypoxic vasoconstriction, thereby reducing the development of respiratory dead spaces.29
Conclusion:  During the administration of TEE in the supine position, we observed an atrial septal aneurysm coexisting with an atrial septal defect. We suspect upright posture worsened the shunt. Dehydration exacerbated the shunt leading to its discovery.
Greater awareness of orthodeoxia and the necessity of documenting orthostatic changes in saturation levels in all cases of severe hypoxemia are urged. Orthostatic desaturation should prompt further workup and facilitate early recognition of potentially treatable causes. TEE is the ideal technique for septum evaluation and diagnosis of platypnea-orthodeoxia.

4.Authors Full NameBaptista, Rui. da Silva, Antonio Marinho. Castro, Graca. Monteiro, Pedro. Providencia, Luis A.
InstitutionServico de Cardiologia, Hospitais da Universidade de Coimbra, Portugal. ***@****

TitleAscending aortic aneurysm and patent foramen ovale: a rare cause of platypnea-orthodeoxia.
SourceRevista Portuguesa de Cardiologia. 30(4):445-50, 2011 Apr.

Abstract:  Platypnea-orthodeoxia is a rare syndrome characterized by dyspnea and hypoxia induced by the upright position and relieved by the supine position. Several factors related to atrial anatomy can facilitate shunting through an atrial septal defect; in many cases, the syndrome is associated with patent foramen ovale and right-to-left shunt, and has also been linked to aortic aneurysm. We present a case of platypnea-orthodeoxia syndrome in a 61-year-old woman with patent foramen ovale and ascending aortic aneurysm.