Myxedema in Crisis: A Case-Based Review of Myxedema Coma With Respiratory Failure

Introduction: Myxedema coma is a life-threatening syndrome involving multiple organ systems. Respiratory failure—often with hypoxemia and/or hypercapnia —is a major cause of morbidity and mortality. ATA guidelines highlight hypoventilation as a key manifestation, yet ICU-specific management guidance is lacking. This study reviews treatment methods and aims at reducing the length of stay, morbidity, and mortality.


Methods: PubMed and Google Scholar databases were searched using PRISMA guidelines. Keywords used were “myxedema coma”, “respiratory failure”, “mechanical ventilation”, and “case report”. Two independent reviewers extracted data. Inclusion criteria were single-patient case reports of adults (> 18 years) with confirmed myxedema, requiring mechanical ventilation, and providing sufficient data. Extracted data included demographics, presenting features, serum TSH and free T4 levels, form of mechanical ventilation, treatment forms and dosing, outcomes, ICU length of stay, and identified causes of respiratory failure.


Results: 22 case reports were included in the study. The median age was 64 years, with 55% females. All had low T4; TSH was elevated in all cases except one case of central hypothyroidism. Features of respiratory distress (45.5%), bradycardia (50%), and altered mentation (63.6%) were the most common presentations. Most patients (91%) required intubation. IV levothyroxine was used in 81% cases; 14% received it via NG or PO use, and one patient received only IV triiodothyronine. 95% of patients received steroids in varying forms and dosages. The mortality rate was 14%. Of the surviving patients, 53% had prolonged ICU stays (>/=10 days).


Conclusions: Our literature review highlights the clinical variability and management complexity of myxedema complicated by respiratory failure. Treatments varied widely, with different forms, routes, and dosing of thyroid hormone supplementation. The choice of steroids and dosing lacked consistency as well. These discrepancies throw light on the lack of standardized ICU guidelines for the management of respiratory failure in the setting of myxedema. Given the high ICU burden, prolonged ICU stays, and mortality risk, there is a clear need for evidence-based protocols to improve outcomes in this critically ill population.