Disallowed Key Characters.

TOPIC OUTLINE
SUMMARY
INTRODUCTION
HYPOTHYROIDISM
Depressed ventilatory drive
Respiratory muscle weakness
Pulmonary function
Respiratory failure
Pleural effusions
Obstructive sleep apnea
Pulmonary hypertension
HYPERTHYROIDISM
Increased ventilatory drive
Respiratory muscle weakness
Pulmonary hypertension
GOITER
THYROID CANCER AND THE LUNG
SUMMARY
REFERENCES

GRAPHICS View All

FIGURES
Vent responses to hypoxia
Vent responses to hypercapnia
Effect of T4 on sleep apnea

RELATED TOPICS
Clinical manifestations and evaluation of obstructive or substernal goiter
Diagnostic approach to and treatment of goiter in adults
Flow-volume loops
Radioiodine treatment of differentiated thyroid cancer
Respiratory function in thyroid disease
Official reprint from UpToDate
www.uptodate.com 2013 UpToDate
Print | Back
Respiratory function in thyroid disease
Author
Douglas C Johnson, MD

Section Editor
Douglas S Ross, MD
Deputy Editor
Jean E Mulder, MD
Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Mar 2013. | This topic last updated: Oct 19, 2012.
INTRODUCTION 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.
HYPOTHYROIDISM
Depressed ventilatory drive Some patients with hypothyroidism have alveolar hypoventilation [ 1 ]. In
the extreme case of myxedema coma, there can be marked hypercapnia [ 2 ]. Severe hypothyroidism is
associated with marked depression in hypoxic ventilatory drive and hypercapnic ventilatory drive,
whereas less severe hypothyroidism (thyroxine replacement therapy stopped for three weeks) causes a
moderate reduction in hypoxic ventilatory drive ( figure 1 and figure 2 ) [ 3 ]. In one study, patients with
hypothyroidism had little increase in minute ventilation with PO2 values of 40 mmHg. The depression in
hypoxic ventilatory drive, but not hypercapnic ventilatory drive, improves with thyroxine therapy.
Respiratory muscle weakness Skeletal muscle myopathy occurs with hypothyroidism [ 4 ]; in animal
studies, the proportion of type 1 fibers of the diaphragm and intercostal muscles decreased four weeks
after total thyroidectomy [ 5 ]. 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 [ 6
]. In a study of 43 hypothyroid patients, respiratory muscle weakness correlated with the degree of
hypothyroidism [ 7 ]. The degree of weakness is usually mild to moderate, but there have been case
reports of patients with marked weakness [ 8 ]. With treatment, respiratory muscle strength improves [ 7,8
].
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 [ 1 ]. 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 thyroxine treatment [ 7,8 ].
Respiratory failure Hypothyroidism should be considered in patients with respiratory failure who are
difficult-to-wean. In a study of 121 ventilator-dependent patients, four were found to have severe
hypothyroidism [ 9 ]; weaning was aided by treatment with thyroxine.
Pleural effusions Pleural and also pericardial and peritoneal effusions can occur in patients with severe
chronic hypothyroidism [ 10,11 ]. The effusions are exudates, indicative of increased capillary
permeability [ 12 ]. Among patients with hypothyroidism, however, most pleural effusions have causes
other than the hypothyroidism alone [ 13 ].
Obstructive sleep apnea Obstructive sleep apnea is more common among patients with
hypothyroidism. In one study of 11 patients with newly diagnosed hypothyroidism, nine had marked sleep

apnea [ 14 ], with 72 episodes per hour; the number decreased to 13 episodes per hour after treatment with
thyroxine for 3 to 12 months, without weight loss ( figure 3 ). A study from Taiwan [ 15 ] found a lower
incidence of obstructive sleep apnea among newly diagnosed hypothyroid patients (5 of 20); unsuspected
hypothyroidism was present in 2 of 65 (3 percent) patients with newly diagnosed obstructive sleep apnea.
Possible mechanisms for obstructive sleep apnea in patients with hypothyroidism include depressed
ventilatory drive and narrowing of the airway due to enlargement of the tongue, pharynx, or larynx due to
mucinous edema (myxedema).
Pulmonary hypertension Thyroid dysfunction, primarily mildly elevated TSH consistent with
subclinical hypothyroidism, is common among patients with idiopathic pulmonary hypertension [ 16,17 ],
and autoimmune thyroid disease has been found increased among patients with pulmonary hypertension [
18 ].
HYPERTHYROIDISM
Increased ventilatory drive Hyperthyroidism is associated with an increased ventilatory drive in
response to hypoxemia and hypercapnia. With exercise, hyperthyroid patients are more dyspneic than
normal subject controls for the same level of work, but there is no difference in dyspnea for the same level
of ventilation [ 19 ]. Thus, increased ventilatory drive seems to account for dyspnea on exertion in
hyperthyroid patients [ 19 ]. The mechanism for increased ventilatory drive is uncertain, but betaadrenergic blockade reduces it to normal, suggesting that adrenergic stimulation plays a role [ 19 ].
Respiratory muscle weakness Hyperthyroidism causes respiratory muscle weakness [ 20,21 ]. In a
study of 20 hyperthyroid patients, both maximal expiratory and inspiratory pressures fell with increasing
degrees of hyperthyroidism [ 21 ]. Respiratory muscle force increased to normal after treatment.
Hyperthyroidism can also cause abnormalities in pulmonary function, with reductions in FEV1 and vital
capacity that improves with treatment [ 21,22 ].
Pulmonary hypertension Pulmonary hypertension, a known complication of neonatal thyrotoxicosis,
has also been reported in adults with hyperthyroidism, with over 70 percent of cases occurring in women [
23-26 ]. The mechanism of pulmonary hypertension in these patients is unclear, but pulmonary pressures
drop with institution of medical therapy for the hyperthyroidism [ 23,24 ].
GOITER Retrosternal goiters have the greatest part of their mass within the chest. They are found in 2
to 6 percent of patients undergoing thyroidectomy [ 27 ], and comprise 5 to 11 percent of all mediastinal
tumors resected at thoracotomy [ 28 ]. Larger cervical or retrosternal goiters can cause tracheal
compression with symptoms of cough, nocturnal dyspnea, wheezing, and stridor [ 29 ]. While most
retrosternal goiters are in the anterior mediastinum, they can occur in the posterior mediastinum, as well [
30 ]. The effect of goiters on flow-volume loop studies of upper airway patency can be positional, with
findings of upper airway obstruction present only in the supine position [ 31,32 ]. (See "Clinical
manifestations and evaluation of obstructive or substernal goiter" and "Flow-volume loops" .)
Patients with large goiters causing symptoms related to pressure on the trachea, esophagus, or great
vessels are usually treated by thyroidectomy, but radioiodine therapy will result is some decrease in goiter
size. (See "Diagnostic approach to and treatment of goiter in adults" .)
THYROID CANCER AND THE LUNG Thyroid cancer can metastasize to the lung. In a study of
1127 patients, 101 (9 percent) had pulmonary metastases [ 33 ]. The incidence of pulmonary metastasis
was lowest in patients with papillary carcinoma (9 percent), compared with that in patients with follicular
(13 percent) or Hrthle-cell (25 percent) carcinoma. However, since papillary carcinoma is much more
common, it was the most common cause of pulmonary metastases (69 percent), as compared with
follicular carcinoma and Hrthle-cell carcinoma.
Pulmonary metastases are often treated with radioiodine therapy [ 34,35 ]. It is unusual for there to be
pulmonary damage with radioiodine therapy for lung metastases of thyroid cancer, but radiation

pneumonitis can occur [ 34 ]. (See "Radioiodine treatment of differentiated thyroid cancer" .)

SUMMARY Many thyroid diseases can lead to pulmonary problems, including hypothyroidism,
hyperthyroidism, nodular goiter, and thyroid cancer.
Hypothyroidism reduces respiratory drive, causes respiratory muscle weakness, and can cause
obstructive sleep apnea and pleural effusion. (See 'Hypothyroidism' above.)
Hyperthyroidism is associated with an increased ventilatory drive in response to hypoxemia and
hypercapnia, which is perceived by the patient as dyspnea, particularly with exertion.
Hyperthyroidism may also cause respiratory muscle weakness and pulmonary hypertension. (See
'Hyperthyroidism' above.)
Larger cervical or retrosternal goiters can cause tracheal compression with symptoms of cough,
nocturnal dyspnea, wheezing, and stridor. (See 'Goiter' above and "Clinical manifestations and
evaluation of obstructive or substernal goiter", section on 'Clinical presentation' .)
Papillary, follicular, and Hrthle-cell thyroid cancer can metastasize to the lung. (See 'Thyroid
cancer and the lung' above.)
Use of UpToDate is subject to the Subscription and License Agreement .

REFERENCES
1. WILSON WR, BEDELL GN. The pulmonary abnormalities in myxedema. J Clin Invest 1960;
39:42.
2. NORDQVIST P, DHUNER KG, STENBERG K, ORNDAHL G. Myxoedema coma and carbon
dioxide-retention. Acta Med Scand 1960; 166:189.
3. Zwillich CW, Pierson DJ, Hofeldt FD, et al. Ventilatory control in myxedema and hypothyroidism.
N Engl J Med 1975; 292:662.
4. 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.
5. 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.
6. Ashtyani, H, Hochstein, M, Bhatia, G, Zawislak, W. Respiratory muscle force in patients with
hypothyroidism (abstract). Am Rev Respir Dis 1986; 133:A191.
7. Siafakas NM, Salesiotou V, Filaditaki V, et al. Respiratory muscle strength in hypothyroidism.
Chest 1992; 102:189.
8. Laroche CM, Cairns T, Moxham J, Green M. Hypothyroidism presenting with respiratory muscle
weakness. Am Rev Respir Dis 1988; 138:472.
9. Pandya K, Lal C, Scheinhorn D, et al. Hypothyroidism and ventilator dependency. Arch Intern Med
1989; 149:2115.
10. Sachdev Y, Hall R. Effusions into body cavities in hypothyroidism. Lancet 1975; 1:564.
11. Manolis AS, Varriale P, Ostrowski RM. Hypothyroid cardiac tamponade. Arch Intern Med 1987;
147:1167.
12. Lange, K. Capillary permeability in myxedema. Am J Med Sci 1944; 208:5.
13. Gottehrer A, Roa J, Stanford GG, et al. Hypothyroidism and pleural effusions. Chest 1990; 98:1130.
14. Rajagopal KR, Abbrecht PH, Derderian SS, et al. Obstructive sleep apnea in hypothyroidism. Ann
Intern Med 1984; 101:491.
15. Lin CC, Tsan KW, Chen PJ. The relationship between sleep apnea syndrome and hypothyroidism.
Chest 1992; 102:1663.
16. Li JH, Safford RE, Aduen JF, et al. Pulmonary hypertension and thyroid disease. Chest 2007;
132:793.
17. 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.

18. Chu JW, Kao PN, Faul JL, Doyle RL. High prevalence of autoimmune thyroid disease in
pulmonary arterial hypertension. Chest 2002; 122:1668.
19. Small D, Gibbons W, Levy RD, et al. Exertional dyspnea and ventilation in hyperthyroidism. Chest
1992; 101:1268.
20. McElvaney GN, Wilcox PG, Fairbarn MS, et al. Respiratory muscle weakness and dyspnea in
thyrotoxic patients. Am Rev Respir Dis 1990; 141:1221.
21. Siafakas NM, Milona I, Salesiotou V, et al. Respiratory muscle strength in hyperthyroidism before
and after treatment. Am Rev Respir Dis 1992; 146:1025.
22. Mier A, Brophy C, Wass JA, et al. Reversible respiratory muscle weakness in hyperthyroidism. Am
Rev Respir Dis 1989; 139:529.
23. 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.
24. Soroush-Yari A, Burstein S, Hoo GW, Santiago SM. Pulmonary hypertension in men with
thyrotoxicosis. Respiration 2005; 72:90.
25. Thurnheer R, Jenni R, Russi EW, et al. Hyperthyroidism and pulmonary hypertension. J Intern Med
1997; 242:185.
26. Nakchbandi IA, Wirth JA, Inzucchi SE. Pulmonary hypertension caused by Graves' thyrotoxicosis:
normal pulmonary hemodynamics restored by (131)I treatment. Chest 1999; 116:1483.
27. deSouza FM, Smith PE. Retrosternal goiter. J Otolaryngol 1983; 12:393.
28. Benjamin SP, McCormack LJ, Effler DB, Groves LK. Primary tumors of the mediastinum. Chest
1972; 62:297.
29. Lamke LO, Bergdahl L, Lamke B. Intrathoracic goitre: a review of 29 cases. Acta Chir Scand 1979;
145:83.
30. Shahian DM, Rossi RL. Posterior mediastinal goiter. Chest 1988; 94:599.
31. Meysman M, Noppen M, Vincken W. Effect of posture on the flow-volume loop in two patients
with euthyroid goiter. Chest 1996; 110:1615.
32. Sundaram P, Joshi JM. Flow volume loops: postural significance. Indian J Chest Dis Allied Sci
1998; 40:201.
33. 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.
34. Samuel AM, Unnikrishnan TP, Baghel NS, Rajashekharrao B. Effect of radioiodine therapy on
pulmonary alveolar-capillary membrane integrity. J Nucl Med 1995; 36:783.
35. Samuel AM, Rajashekharrao B, Shah DH. Pulmonary metastases in children and adolescents with
well-differentiated thyroid cancer. J Nucl Med 1998; 39:1531.
Topic 7865 Version 3.0
2013 UpToDate, Inc. All rights reserved. | Subscription and License Agreement | Release: 21.4 C21.36
Licensed to: Southeast Alabama Med Ctr | Support Tag: [0503-61.234.146.186-DA858D2583S244013.14]
Respiratory function in thyroid disease

TOPIC OUTLINE
SUMMARY
INTRODUCTION
HYPOTHYROIDISM
Depressed ventilatory drive
Respiratory muscle weakness
Pulmonary function
Respiratory failure

Pleural effusions
Obstructive sleep apnea
Pulmonary hypertension
HYPERTHYROIDISM
Increased ventilatory drive
Respiratory muscle weakness
Pulmonary hypertension
GOITER
THYROID CANCER AND THE LUNG
SUMMARY
REFERENCES

GRAPHICS View All

FIGURES
Vent responses to hypoxia
Vent responses to hypercapnia
Effect of T4 on sleep apnea

RELATED TOPICS
Clinical manifestations and evaluation of obstructive or substernal goiter
Diagnostic approach to and treatment of goiter in adults
Flow-volume loops
Radioiodine treatment of differentiated thyroid cancer
Official reprint from UpToDate
www.uptodate.com 2013 UpToDate
Print | Back
Respiratory function in thyroid disease
Author
Douglas C Johnson, MD
Section Editor
Douglas S Ross, MD
Deputy Editor
Jean E Mulder, MD
Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Mar 2013. | This topic last updated: Oct 19, 2012.
INTRODUCTION 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.
HYPOTHYROIDISM

Depressed ventilatory drive Some patients with hypothyroidism have alveolar hypoventilation [ 1 ]. In
the extreme case of myxedema coma, there can be marked hypercapnia [ 2 ]. Severe hypothyroidism is
associated with marked depression in hypoxic ventilatory drive and hypercapnic ventilatory drive,
whereas less severe hypothyroidism (thyroxine replacement therapy stopped for three weeks) causes a
moderate reduction in hypoxic ventilatory drive ( figure 1 and figure 2 ) [ 3 ]. In one study, patients with
hypothyroidism had little increase in minute ventilation with PO2 values of 40 mmHg. The depression in
hypoxic ventilatory drive, but not hypercapnic ventilatory drive, improves with thyroxine therapy.
Respiratory muscle weakness Skeletal muscle myopathy occurs with hypothyroidism [ 4 ]; in animal
studies, the proportion of type 1 fibers of the diaphragm and intercostal muscles decreased four weeks
after total thyroidectomy [ 5 ]. 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 [ 6
]. In a study of 43 hypothyroid patients, respiratory muscle weakness correlated with the degree of
hypothyroidism [ 7 ]. The degree of weakness is usually mild to moderate, but there have been case
reports of patients with marked weakness [ 8 ]. With treatment, respiratory muscle strength improves [ 7,8
].
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 [ 1 ]. 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 thyroxine treatment [ 7,8 ].
Respiratory failure Hypothyroidism should be considered in patients with respiratory failure who are
difficult-to-wean. In a study of 121 ventilator-dependent patients, four were found to have severe
hypothyroidism [ 9 ]; weaning was aided by treatment with thyroxine.
Pleural effusions Pleural and also pericardial and peritoneal effusions can occur in patients with severe
chronic hypothyroidism [ 10,11 ]. The effusions are exudates, indicative of increased capillary
permeability [ 12 ]. Among patients with hypothyroidism, however, most pleural effusions have causes
other than the hypothyroidism alone [ 13 ].
Obstructive sleep apnea Obstructive sleep apnea is more common among patients with
hypothyroidism. In one study of 11 patients with newly diagnosed hypothyroidism, nine had marked sleep
apnea [ 14 ], with 72 episodes per hour; the number decreased to 13 episodes per hour after treatment with
thyroxine for 3 to 12 months, without weight loss ( figure 3 ). A study from Taiwan [ 15 ] found a lower
incidence of obstructive sleep apnea among newly diagnosed hypothyroid patients (5 of 20); unsuspected
hypothyroidism was present in 2 of 65 (3 percent) patients with newly diagnosed obstructive sleep apnea.
Possible mechanisms for obstructive sleep apnea in patients with hypothyroidism include depressed
ventilatory drive and narrowing of the airway due to enlargement of the tongue, pharynx, or larynx due to
mucinous edema (myxedema).
Pulmonary hypertension Thyroid dysfunction, primarily mildly elevated TSH consistent with
subclinical hypothyroidism, is common among patients with idiopathic pulmonary hypertension [ 16,17 ],
and autoimmune thyroid disease has been found increased among patients with pulmonary hypertension [
18 ].
HYPERTHYROIDISM
Increased ventilatory drive Hyperthyroidism is associated with an increased ventilatory drive in
response to hypoxemia and hypercapnia. With exercise, hyperthyroid patients are more dyspneic than

normal subject controls for the same level of work, but there is no difference in dyspnea for the same level
of ventilation [ 19 ]. Thus, increased ventilatory drive seems to account for dyspnea on exertion in
hyperthyroid patients [ 19 ]. The mechanism for increased ventilatory drive is uncertain, but betaadrenergic blockade reduces it to normal, suggesting that adrenergic stimulation plays a role [ 19 ].
Respiratory muscle weakness Hyperthyroidism causes respiratory muscle weakness [ 20,21 ]. In a
study of 20 hyperthyroid patients, both maximal expiratory and inspiratory pressures fell with increasing
degrees of hyperthyroidism [ 21 ]. Respiratory muscle force increased to normal after treatment.
Hyperthyroidism can also cause abnormalities in pulmonary function, with reductions in FEV1 and vital
capacity that improves with treatment [ 21,22 ].
Pulmonary hypertension Pulmonary hypertension, a known complication of neonatal thyrotoxicosis,
has also been reported in adults with hyperthyroidism, with over 70 percent of cases occurring in women [
23-26 ]. The mechanism of pulmonary hypertension in these patients is unclear, but pulmonary pressures
drop with institution of medical therapy for the hyperthyroidism [ 23,24 ].
GOITER Retrosternal goiters have the greatest part of their mass within the chest. They are found in 2
to 6 percent of patients undergoing thyroidectomy [ 27 ], and comprise 5 to 11 percent of all mediastinal
tumors resected at thoracotomy [ 28 ]. Larger cervical or retrosternal goiters can cause tracheal
compression with symptoms of cough, nocturnal dyspnea, wheezing, and stridor [ 29 ]. While most
retrosternal goiters are in the anterior mediastinum, they can occur in the posterior mediastinum, as well [
30 ]. The effect of goiters on flow-volume loop studies of upper airway patency can be positional, with
findings of upper airway obstruction present only in the supine position [ 31,32 ]. (See "Clinical
manifestations and evaluation of obstructive or substernal goiter" and "Flow-volume loops" .)
Patients with large goiters causing symptoms related to pressure on the trachea, esophagus, or great
vessels are usually treated by thyroidectomy, but radioiodine therapy will result is some decrease in goiter
size. (See "Diagnostic approach to and treatment of goiter in adults" .)
THYROID CANCER AND THE LUNG Thyroid cancer can metastasize to the lung. In a study of
1127 patients, 101 (9 percent) had pulmonary metastases [ 33 ]. The incidence of pulmonary metastasis
was lowest in patients with papillary carcinoma (9 percent), compared with that in patients with follicular
(13 percent) or Hrthle-cell (25 percent) carcinoma. However, since papillary carcinoma is much more
common, it was the most common cause of pulmonary metastases (69 percent), as compared with
follicular carcinoma and Hrthle-cell carcinoma.
Pulmonary metastases are often treated with radioiodine therapy [ 34,35 ]. It is unusual for there to be
pulmonary damage with radioiodine therapy for lung metastases of thyroid cancer, but radiation
pneumonitis can occur [ 34 ]. (See "Radioiodine treatment of differentiated thyroid cancer" .)
SUMMARY Many thyroid diseases can lead to pulmonary problems, including hypothyroidism,
hyperthyroidism, nodular goiter, and thyroid cancer.
Hypothyroidism reduces respiratory drive, causes respiratory muscle weakness, and can cause
obstructive sleep apnea and pleural effusion. (See 'Hypothyroidism' above.)
Hyperthyroidism is associated with an increased ventilatory drive in response to hypoxemia and
hypercapnia, which is perceived by the patient as dyspnea, particularly with exertion.
Hyperthyroidism may also cause respiratory muscle weakness and pulmonary hypertension. (See
'Hyperthyroidism' above.)
Larger cervical or retrosternal goiters can cause tracheal compression with symptoms of cough,
nocturnal dyspnea, wheezing, and stridor. (See 'Goiter' above and "Clinical manifestations and
evaluation of obstructive or substernal goiter", section on 'Clinical presentation' .)
Papillary, follicular, and Hrthle-cell thyroid cancer can metastasize to the lung. (See 'Thyroid
cancer and the lung' above.)

Use of UpToDate is subject to the Subscription and License Agreement .

REFERENCES
1. WILSON WR, BEDELL GN. The pulmonary abnormalities in myxedema. J Clin Invest 1960;
39:42.
2. NORDQVIST P, DHUNER KG, STENBERG K, ORNDAHL G. Myxoedema coma and carbon
dioxide-retention. Acta Med Scand 1960; 166:189.
3. Zwillich CW, Pierson DJ, Hofeldt FD, et al. Ventilatory control in myxedema and hypothyroidism.
N Engl J Med 1975; 292:662.
4. 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.
5. 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.
6. Ashtyani, H, Hochstein, M, Bhatia, G, Zawislak, W. Respiratory muscle force in patients with
hypothyroidism (abstract). Am Rev Respir Dis 1986; 133:A191.
7. Siafakas NM, Salesiotou V, Filaditaki V, et al. Respiratory muscle strength in hypothyroidism.
Chest 1992; 102:189.
8. Laroche CM, Cairns T, Moxham J, Green M. Hypothyroidism presenting with respiratory muscle
weakness. Am Rev Respir Dis 1988; 138:472.
9. Pandya K, Lal C, Scheinhorn D, et al. Hypothyroidism and ventilator dependency. Arch Intern Med
1989; 149:2115.
10. Sachdev Y, Hall R. Effusions into body cavities in hypothyroidism. Lancet 1975; 1:564.
11. Manolis AS, Varriale P, Ostrowski RM. Hypothyroid cardiac tamponade. Arch Intern Med 1987;
147:1167.
12. Lange, K. Capillary permeability in myxedema. Am J Med Sci 1944; 208:5.
13. Gottehrer A, Roa J, Stanford GG, et al. Hypothyroidism and pleural effusions. Chest 1990; 98:1130.
14. Rajagopal KR, Abbrecht PH, Derderian SS, et al. Obstructive sleep apnea in hypothyroidism. Ann
Intern Med 1984; 101:491.
15. Lin CC, Tsan KW, Chen PJ. The relationship between sleep apnea syndrome and hypothyroidism.
Chest 1992; 102:1663.
16. Li JH, Safford RE, Aduen JF, et al. Pulmonary hypertension and thyroid disease. Chest 2007;
132:793.
17. 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.
18. Chu JW, Kao PN, Faul JL, Doyle RL. High prevalence of autoimmune thyroid disease in
pulmonary arterial hypertension. Chest 2002; 122:1668.
19. Small D, Gibbons W, Levy RD, et al. Exertional dyspnea and ventilation in hyperthyroidism. Chest
1992; 101:1268.
20. McElvaney GN, Wilcox PG, Fairbarn MS, et al. Respiratory muscle weakness and dyspnea in
thyrotoxic patients. Am Rev Respir Dis 1990; 141:1221.
21. Siafakas NM, Milona I, Salesiotou V, et al. Respiratory muscle strength in hyperthyroidism before
and after treatment. Am Rev Respir Dis 1992; 146:1025.
22. Mier A, Brophy C, Wass JA, et al. Reversible respiratory muscle weakness in hyperthyroidism. Am
Rev Respir Dis 1989; 139:529.
23. 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.
24. Soroush-Yari A, Burstein S, Hoo GW, Santiago SM. Pulmonary hypertension in men with
thyrotoxicosis. Respiration 2005; 72:90.
25. Thurnheer R, Jenni R, Russi EW, et al. Hyperthyroidism and pulmonary hypertension. J Intern Med

26.
27.
28.
29.
30.
31.
32.
33.
34.
35.

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.
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.
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.

Topic 7865 Version 3.0

2013 UpToDate, Inc. All rights reserved. | Subscription and License Agreement | Release: 21.4 C21.36
Licensed to: Southeast Alabama Med Ctr | Support Tag: [0503-61.234.146.186-DA858D2583S244013.14]