Dear Marion,

Your letter, for which I thank you, gives me the opportunity
for a correction. Orthopnea, difficult breathing in a horizontal
position, is characteristically a sign of left (not right) sided
heart failure.  Because the left ventricle is too weak to pump
it out, blood backs up in the lungs, causing pulmonary edema.
I suppose pulmonary hypertension would also cause accumulation
of fluid in the lungs and shortness of breath in the recumbent
position.  The high pulmonary blood pressure would then strain the
right ventricle, because it was required to exert more force to
expel the blood against a higher pressure.

My worm's eye view of the whole business is that with a normal
EKG and a normal chest X-ray, I'd play down the echocardiogram,
and not resort to a CT scan looking for pulmonary emboli. But
admittedly my cardio-pulmonary diagnostic judgment is fifty
years behind the times. I feel sorry for poor Dr. Skarda.
She's in a difficult profession, and I don't want to make
life harder for her. If you don't have to pay for it yourself,
and if you have the sense of humor to put up with the sleep
lab motel, and are able to ignore the results if they don't make
sense, I see no harm in the tests for obstructive sleep apnea.
You must, however, have enough sense not to let any one operate
on your nose or neck to cure some non-existent ailment. The
conventional treatment for obstructive sleep apnea is continuous
positive airway pressure, a mask with resistance to outflow,
which the patients wear at night. The apparatus makes them sleep
better and feel better the next day. How much is physiological
effect and how much is consequence of suggestion would be a
suitable subject for clinical research, which I doubt has been
done. The mask also is harmless if it makes you feel better and
doesn't cost too much. The happiness is to be free of significant
heart disease.

Jochen