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Differential diagnosis for orthopnea and paroxysmal nocturnal dyspnoea (PND)

Common and important causes of orthopnoea and paroxysmal nocturnal dyspnoea (PND) for doctors and medical students

Pulmonary oedema due to congestive (chronic) left ventricular failureSuggested by: dyspnoea, displaced apex beat, third heart sound, bilateral basal fine crackles.
Confirmed by: CXR appearances. Impaired left ventricular (LV) function on echocardiogram. Abnormal ECG reflecting underlying heart disease
COPDSuggested by: smoking history, cough and sputum. Pursed lip breathing, use of accessory muscles, reduced breath sounds, wheezes. Chest hyperinflation. Reduced peak flow rate.
Confirmed by: CXR: radiolucent lungs. Spirometry: reduced FEV, reduced FEV1/FVC ratio, <12% reversibility, hypoxia ± increased arterial PCO (rarely, reduced α 1-antitrypsin levels).
AsthmaSuggested by: wheeze or dry cough. Other specific triggers to breathlessness. Other allergies. Past history of similar attacks unless first presentation.
Confirmed by: reversibility following bronchodilator treatment, and symptomatic response to treatment.

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