Respiratory function in thyroid disease
- Douglas C Johnson, MD
Douglas C Johnson, MD
- Associate Professor, Department of Medicine
- Tufts University School of Medicine
Many thyroid diseases can lead to pulmonary problems, including hypothyroidism, hyperthyroidism, nodular goiter, and thyroid cancer. Both hypothyroidism and hyperthyroidism cause respiratory muscle weakness and decrease pulmonary function. Hypothyroidism reduces respiratory drive and can cause obstructive sleep apnea or pleural effusion, while hyperthyroidism increases respiratory drive and can cause dyspnea on exertion. Compression of the trachea, which may be positional, can occur with nodular goiters and thyroid cancer, and the latter can metastasize to the lungs.
Depressed ventilatory drive — Some patients with hypothyroidism have alveolar hypoventilation . In the extreme case of myxedema coma, there can be marked hypercapnia . Severe hypothyroidism is associated with marked depression in hypoxic ventilatory drive and hypercapnic ventilatory drive, whereas less severe hypothyroidism (T4 [levothyroxine] replacement therapy stopped for three weeks) causes a moderate reduction in hypoxic ventilatory drive (figure 1 and figure 2) [3,4]. In one small study, the depression in hypoxic ventilatory drive, but not hypercapnic ventilatory drive, significantly improved with T4 therapy . In another study, parenteral thyroid hormone replacement therapy for one week improved hypoxic and hypercapnic ventilatory responses in the subset of hypothyroid patients with pretreatment blunted responses .
Respiratory muscle weakness — Skeletal muscle myopathy occurs with hypothyroidism ; in animal studies, the proportion of type 1 fibers of the diaphragm and intercostal muscles decreased four weeks after total thyroidectomy . Respiratory muscle strength is reduced in patients with hypothyroidism, and improves with treatment; the reduction is caused by both a myopathy and neuropathy. In a study of six patients, maximal expiratory and inspiratory pressures were reduced and improved with treatment . In a study of 43 hypothyroid patients, respiratory muscle weakness correlated with the degree of hypothyroidism . The degree of weakness is usually mild to moderate, but there have been case reports of patients with marked weakness . With treatment, respiratory muscle strength improves [8,9].
Pulmonary function — Carbon monoxide diffusing capacity (DLCO) may be low and increase during treatment; in one study, the mean value was 63 percent of the predicted value before and 93 percent during . The reasons for the low DLCO and its improvement are unclear.
Non-obese hypothyroid patients have normal lung volumes, whereas obese hypothyroid patients have moderate reductions in vital capacity and lung volumes. Studies of hypothyroidism and pulmonary function and respiratory muscle strength have not reported DLCO values, but vital capacity improved with T4 treatment [8,9].
- WILSON WR, BEDELL GN. The pulmonary abnormalities in myxedema. J Clin Invest 1960; 39:42.
- NORDQVIST P, DHUNER KG, STENBERG K, ORNDAHL G. Myxoedema coma and carbon dioxide-retention. Acta Med Scand 1960; 166:189.
- Zwillich CW, Pierson DJ, Hofeldt FD, et al. Ventilatory control in myxedema and hypothyroidism. N Engl J Med 1975; 292:662.
- Ladenson PW, Goldenheim PD, Ridgway EC. Prediction and reversal of blunted ventilatory responsiveness in patients with hypothyroidism. Am J Med 1988; 84:877.
- Khaleeli AA, Griffith DG, Edwards RH. The clinical presentation of hypothyroid myopathy and its relationship to abnormalities in structure and function of skeletal muscle. Clin Endocrinol (Oxf) 1983; 19:365.
- Johnson MA, Olmo JL, Mastaglia FL. Changes in histochemical profile of rat respiratory muscles in hypo- and hyperthyroidism. Q J Exp Physiol 1983; 68:1.
- Ashtyani H, Hochstein M, Bhatia G, Zawislak W. Respiratory muscle force in patients with hypothyroidism (abstract). Am Rev Respir Dis 1986; 133:A191.
- Siafakas NM, Salesiotou V, Filaditaki V, et al. Respiratory muscle strength in hypothyroidism. Chest 1992; 102:189.
- Laroche CM, Cairns T, Moxham J, Green M. Hypothyroidism presenting with respiratory muscle weakness. Am Rev Respir Dis 1988; 138:472.
- Pandya K, Lal C, Scheinhorn D, et al. Hypothyroidism and ventilator dependency. Arch Intern Med 1989; 149:2115.
- Sachdev Y, Hall R. Effusions into body cavities in hypothyroidism. Lancet 1975; 1:564.
- Manolis AS, Varriale P, Ostrowski RM. Hypothyroid cardiac tamponade. Arch Intern Med 1987; 147:1167.
- Lange K. Capillary permeability in myxedema. Am J Med Sci 1944; 208:5.
- Gottehrer A, Roa J, Stanford GG, et al. Hypothyroidism and pleural effusions. Chest 1990; 98:1130.
- Rajagopal KR, Abbrecht PH, Derderian SS, et al. Obstructive sleep apnea in hypothyroidism. Ann Intern Med 1984; 101:491.
- Lin CC, Tsan KW, Chen PJ. The relationship between sleep apnea syndrome and hypothyroidism. Chest 1992; 102:1663.
- Li JH, Safford RE, Aduen JF, et al. Pulmonary hypertension and thyroid disease. Chest 2007; 132:793.
- Curnock AL, Dweik RA, Higgins BH, et al. High prevalence of hypothyroidism in patients with primary pulmonary hypertension. Am J Med Sci 1999; 318:289.
- Chu JW, Kao PN, Faul JL, Doyle RL. High prevalence of autoimmune thyroid disease in pulmonary arterial hypertension. Chest 2002; 122:1668.
- Badesch DB, Wynne KM, Bonvallet S, et al. Hypothyroidism and primary pulmonary hypertension: an autoimmune pathogenetic link? Ann Intern Med 1993; 119:44.
- Small D, Gibbons W, Levy RD, et al. Exertional dyspnea and ventilation in hyperthyroidism. Chest 1992; 101:1268.
- McElvaney GN, Wilcox PG, Fairbarn MS, et al. Respiratory muscle weakness and dyspnea in thyrotoxic patients. Am Rev Respir Dis 1990; 141:1221.
- Siafakas NM, Milona I, Salesiotou V, et al. Respiratory muscle strength in hyperthyroidism before and after treatment. Am Rev Respir Dis 1992; 146:1025.
- Mier A, Brophy C, Wass JA, et al. Reversible respiratory muscle weakness in hyperthyroidism. Am Rev Respir Dis 1989; 139:529.
- Lozano HF, Sharma CN. Reversible pulmonary hypertension, tricuspid regurgitation and right-sided heart failure associated with hyperthyroidism: case report and review of the literature. Cardiol Rev 2004; 12:299.
- Soroush-Yari A, Burstein S, Hoo GW, Santiago SM. Pulmonary hypertension in men with thyrotoxicosis. Respiration 2005; 72:90.
- Thurnheer R, Jenni R, Russi EW, et al. Hyperthyroidism and pulmonary hypertension. J Intern Med 1997; 242:185.
- Nakchbandi IA, Wirth JA, Inzucchi SE. Pulmonary hypertension caused by Graves' thyrotoxicosis: normal pulmonary hemodynamics restored by (131)I treatment. Chest 1999; 116:1483.
- Marvisi M, Zambrelli P, Brianti M, et al. Pulmonary hypertension is frequent in hyperthyroidism and normalizes after therapy. Eur J Intern Med 2006; 17:267.
- deSouza FM, Smith PE. Retrosternal goiter. J Otolaryngol 1983; 12:393.
- Benjamin SP, McCormack LJ, Effler DB, Groves LK. Primary tumors of the mediastinum. Chest 1972; 62:297.
- Lamke LO, Bergdahl L, Lamke B. Intrathoracic goitre: a review of 29 cases. Acta Chir Scand 1979; 145:83.
- Shahian DM, Rossi RL. Posterior mediastinal goiter. Chest 1988; 94:599.
- Meysman M, Noppen M, Vincken W. Effect of posture on the flow-volume loop in two patients with euthyroid goiter. Chest 1996; 110:1615.
- Sundaram P, Joshi JM. Flow volume loops: postural significance. Indian J Chest Dis Allied Sci 1998; 40:201.
- Birring SS, Patel RB, Parker D, et al. Airway function and markers of airway inflammation in patients with treated hypothyroidism. Thorax 2005; 60:249.
- Samareh Fekri M, Shokoohi M, Gozashti MH, et al. Association between anti-thyroid peroxidase antibody and asthma in women. Iran J Allergy Asthma Immunol 2012; 11:241.
- Samaan NA, Schultz PN, Haynie TP, Ordonez NG. Pulmonary metastasis of differentiated thyroid carcinoma: treatment results in 101 patients. J Clin Endocrinol Metab 1985; 60:376.
- Samuel AM, Unnikrishnan TP, Baghel NS, Rajashekharrao B. Effect of radioiodine therapy on pulmonary alveolar-capillary membrane integrity. J Nucl Med 1995; 36:783.
- Samuel AM, Rajashekharrao B, Shah DH. Pulmonary metastases in children and adolescents with well-differentiated thyroid cancer. J Nucl Med 1998; 39:1531.
- Depressed ventilatory drive
- Respiratory muscle weakness
- Pulmonary function
- Respiratory failure
- Pleural effusions
- Obstructive sleep apnea
- Pulmonary hypertension
- Increased ventilatory drive
- Respiratory muscle weakness
- Pulmonary hypertension
- AUTOIMMUNE THYROID DISEASE
- THYROID CANCER AND THE LUNG