Chest
Volume 124, Issue 1, July 2003, Pages 133-140
Journal home page for Chest

Clinical Investigations
Masses
Orthopnea and Tidal Expiratory Flow Limitation in Patients With Euthyroid Goiter

https://doi.org/10.1378/chest.124.1.133Get rights and content

Background

Nontoxic goiters can cause extrathoracic upper airway obstruction and, if large, may extend into the thorax, causing intrathoracic airway obstruction. Although patients with goiter often report orthopnea, there are few studies on postural changes in respiratory function in these subjects.

Purpose

The aim of this study was to investigate the postural changes in respiratory function and the presence of flow limitation (FL) and orthopnea in patients with nontoxic goiter.

Methods

In 32 patients with nontoxic goiter, respiratory function was studied in seated and supine position. Expiratory FL was assessed with the negative expiratory pressure method. Goiter-trachea radiologic relationships were arbitrarily classified as follows: grade 1, no evidence of tracheal deviation; grade 2, tracheal deviation present in lateral and/or anteroposterior plane but with tracheal compression < 20%; and grade 3, tracheal deviation present with compression > 20%. Subgroups were considered according to this classification and occurrence of orthopnea and FL.

Results

In all three groups of patients, the average maximal expiratory flow at 50% of FVC/maximal inspiratory flow at 50% of FVC ratios were > 1.1, suggesting the presence of upper airway obstruction. Grade 3 patients had a significantly lower expiratory reserve volume and maximal expiratory flow at 25% of FVC and higher airway resistance and 3-point FL score than patients with grade 1 and grade 2. The prevalence of orthopnea was highest in patients with grade 3 (75%, as compared to 18% in the grade 1 group). In patients with orthopnea, the prevalence of intrathoracic goiter was also higher (78%, vs 21% in patients without orthopnea).

Conclusion

There is a high prevalence of orthopnea in patients with goiter, especially when the location is intrathoracic and causes a reduction of end-expiratory lung volume and flow reserve in the tidal volume range, promoting FL especially in supine position. Obesity is a factor that increases the risk of orthopnea in patients with goiter.

Section snippets

Patients

A cross-sectional study was carried out on 32 consecutive outpatients (12 male) with nontoxic goiter. The diagnosis was made at the Endocrinology Unit, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy, by ultrasonography and/or nuclear imaging of the thyroid, and by measuring thyrotropin, free tri-iodothyronin, and free thyroxin concentrations. A classification of goiter based on clinical examination has been provided by Thillu14 for the World Health Organization; for this study, only

Results

Tables 1, 2 show the anthropometric, clinical, and baseline respiratory function data for all 32 patients and three subgroups stratified according to the 3-point goiter effect on the trachea. All subgroups included a few obese patients (BMI > 30). Static lung volumes, total lung capacity (TLC), functional residual capacity (FRC), residual volume (RV), as well as FVC were, on average, lower in group C than in groups A and B, though the difference was significant only in the case of ERV between

Discussion

The main finding of the present study is that tidal FL, as reflected by the 3-point FL score, is the strongest risk factor for reported orthopnea in patients with euthyroid goiter, and that this phenomenon is enhanced by concurrent obesity. Orthopnea probably results from increased inspiratory work in supine position due to increased inspiratory resistance, elastance of respiratory system (Ers) and, more importantly, intrinsic positive end-expiratory pressure caused by dynamic hyperinflation.

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