What is the appropriate evaluation and management for a 55‑year‑old woman with wheezing that occurs when she lies down?

Evaluation and Management of Positional Wheezing in a 55-Year-Old Woman

This patient requires urgent evaluation for cardiac asthma (heart failure) as the primary concern, followed by assessment for gastroesophageal reflux disease (GERD) and nocturnal asthma, as wheezing specifically triggered by lying down is a red flag for left ventricular dysfunction rather than typical bronchial asthma. 1, 2

Initial Diagnostic Approach

Key Clinical Features to Assess

Cardiac vs. Pulmonary Differentiation:

• Orthopnea (inability to lie flat without breathlessness) strongly suggests cardiac asthma from congestive heart failure, where pulmonary vascular congestion and edema cause wheezing when supine 2
• Assess for paroxysmal nocturnal dyspnea (waking gasping for air 2-3 hours after lying down), peripheral edema, elevated jugular venous pressure, and history of hypertension or coronary disease 2
• Note that cardiac asthma patients typically have poor response to diuretics alone and limited effectiveness with bronchodilators or corticosteroids 2

GERD-Related Symptoms:

• Reflux is directly related to posture (bending or lying down), though evidence for reflux-related wheeze specifically is limited 1
• Ask about postprandial cough (occurs within 10 minutes after eating in 75% of reflux cough patients) and cough with phonation (talking, laughing—present in 90% of reflux cough) 1
• Absence of dyspepsia does NOT rule out reflux as the cause 1

Asthma Characteristics:

• True asthma symptoms are variable, intermittent, worse at night, and provoked by triggers including exercise 1
• However, asthma symptoms being "worse at night" refers to nocturnal awakening from bronchospasm, not specifically positional wheezing on lying down 1

Essential Objective Testing

Immediate Evaluation:

• Chest radiograph to evaluate for pulmonary edema, cardiomegaly, or mass lesions 3
• ECG and BNP/NT-proBNP if cardiac asthma suspected (not explicitly in guidelines but standard practice for heart failure evaluation)
• Spirometry with bronchodilator challenge when stable—measure FEV1 and peak expiratory flow (PEF) before and after short-acting beta-agonist 1

Diagnostic Criteria for Asthma:

• ≥20% variability in PEF amplitude with minimum 60 L/min change over 2 weeks is highly suggestive of asthma 1
• ≥15% increase in FEV1 after bronchodilator indicates reversible airflow obstruction 1
• Critical caveat: Normal spirometry between episodes does not exclude asthma, but repeatedly normal values with persistent symptoms makes asthma diagnosis doubtful 1

Management Algorithm

If Cardiac Asthma is Confirmed:

• Optimize heart failure management as primary intervention—this is fundamentally different from bronchial asthma treatment 2
• Bronchodilators and corticosteroids have limited effectiveness in cardiac asthma 2
• Consider cardiology referral for comprehensive heart failure management

If Bronchospasm is Documented:

• Trial of short-acting beta-agonist (albuterol 2.5-5 mg nebulized or 200-400 μg via metered-dose inhaler) 4, 1
• Measure response objectively with pre- and post-treatment PEF or FEV1 4
• Important pitfall: Do NOT use albuterol for cough or wheeze without documented bronchospasm—it provides no benefit in non-bronchospastic conditions 4

If GERD is Suspected:

• Empiric trial of proton pump inhibitor therapy (though not detailed in provided guidelines)
• Lifestyle modifications: elevate head of bed, avoid late meals, weight loss if indicated 1

If No Bronchospasm Documented:

• Do NOT prescribe bronchodilators—they are ineffective and inappropriate 4
• Consider ipratropium bromide for cough suppression if cough is prominent without bronchospasm 4
• Investigate alternative causes: upper airway obstruction, vocal cord dysfunction, mass lesions 1, 5

Critical Pitfalls to Avoid

• Never assume all wheezing equals asthma—cardiac disease, GERD, and upper airway obstruction can all present with wheezing 2, 5, 6
• Positional wheezing specifically when lying down is NOT typical of bronchial asthma and should prompt cardiac evaluation first 2
• Wheezing can be an unreliable indicator of airway obstruction severity—some patients with severe obstruction have minimal wheeze ("silent chest") 1
• First-dose supervision is essential if beta-agonists are prescribed, especially in this age group, as they may precipitate angina 1, 4
• Review all medications, particularly ACE inhibitors, which can cause or potentiate cough and wheeze (median resolution time 26 days after discontinuation, but may take up to 40 weeks) 1

Additional Considerations

• Assess for stress incontinence if cough is prominent—55% of women with chronic cough report urinary incontinence, which may be a major concern 1
• Consider advanced imaging (CT chest) if patient is over 40 years with significant tobacco history and new-onset wheezing to evaluate for malignancy 3
• Upper airway obstruction should be ruled out if there is dysphonia, inspiratory stridor, or monophonic wheezing loudest over central airways 1