PULMONARY EMBOLISMPULMONARY EMBOLISM

PROF. DR. YESARİ PROF. DR. YESARİ

KARTER KARTER

Pulmonary Embolism: Impaction of material into branches of the pulmonary arterial bed

Mortality- 50 000 death/year

(decreasing)

Hospitalisation: 300-600 000/year

Male>Female

American Africans

old > young

RISK FACTORS - inherited

- acquired

Inherited Risk FactorsFamily History (+)

Acquired risk factor (-)

Prior deep venous thrombosis

Inherited Risk Factors (2) -Antithrombin III deficiency

-Protein C deficiency

-Protein S deficiency

-Protein C resistance (Factor V Leiden)

-Hyperhomocystinemi

-Abnormal fibrinogen

-Abnormal fibrinolytic system

Acquired Risk Factors-surgery or trauma of pelvis/lower extremities

-immobilization

-surgery with >30 min general anesthesia

-local tissue trauma and vessel destruction

-pregnancy especialy in the puerperism and

after cesarian section

-estrogen therpy

Acquired Risk Factors (II) -Age > 40

-Malignity

-Obesity

-Heart Failure

-Myocard infarction

Acquired Risk factors (III)

-Prior DVT -Nephrotic Syndrome -Antiphospholipid Syndrome -PNH -Waldenström

Thromboembolic risk of the patient

-Risk of the patient (acquired / inherited)

-Risk of the clinical condition

Diagnose-Young patient

-Family history (+)

-Acquired risk factors (-)

___ inherited

Symptoms

-Chest pain -Pleuritic pain

-Dyspnea -Cough

-Hemoptysis -Syncope

Laboratory

Standart test

ECG

Chest rontgenography

Arterial blood gases

Echocardiography

Imaging venous thrombus

Imaging pulmoner emboli

Standart tests

-Leucocytosis (infarctuse)

-ESR increases

-D-Dimer increases

low---- Exclusion of PE

ECG

Nonspesific changes

-Massive emboli-----RV load

Differential diagnosis -Myocardial infarctuse

-Accelere atrial rythm

Typical findings -RV strain

-T (-) and or ST elevation (V1-3)

-P pulmonale (right axis)

-S1Q3T3

Chest Radiography

Usually nonspesific

Not sensitive or specific

Proximal, large segmental artery

Multiple small segmental artery

Chest Radiography (II)

-Atelectasis

-Elevation of the hemidiaphragm

-Pleural efusion

-Dilatation of the main branches of PA

-Paranchymal densities

(in the lower lung fields, pleural based)

-Zones of oligemia

Arterial Blood Gases

Acute PaCO2 decreases

Massive PaO2 decreases

Submassive Normal / Nearnormal

Echocardiography

-Shows emboli in main pulmonary arteries, but not in lober and segmentary arteries

-Dilated hypokinetic RV

-Distorsion of the interventricular septum in diastole

-Tricuspid regurgitation associated with increase in systolic pressure in pulmonary artery

Deep Vein Thrombosis

-90% of PE originates from DVT

(poplitea or proximal leg veins)

-leg pain or swelling

-Homan’s sign

-signs of infection in subcutan veins

Deep Vein Thrombosis

-Phlebography

-Doppler

Imaging pulmonary emboli

-Chest radiography

-Ventilation-Perfusion Lung Scan

-Pulmonary angiography

-hCT

-MR angiography

Ventilation-Perfusion Lung Scan

Perfusion (-) and Ventilation (+)

---PE

Perfusion (N) and Clinical sym and signs (N)

----PE excluded

Low probability PVLS and low probability of

clinical sym and signs

----PE excluded

High probability PVLS and high probability of

clinical symp and signs

---- Anticoagulation

Clinical Probability of acute PE

-High Probability (80-100%)

Risk factors (+) Dyspnea

Tachypnea Chest pain

Radiology (+) PaO2 decreases

P (A-a)O2 increases

-Intermediate Probability (20-79%)

-Low Probability (1-19%)

Risk Factors (-)

Clinical and laboratory findings can

be explained

• DDichotomous clinical probability assesment:ichotomous clinical probability assesment:

• PE likely > 4PE likely > 4

• Pe unlikely < 4 or = 4Pe unlikely < 4 or = 4

• PE likely--------h CTPE likely--------h CT• ------normal----exclude------normal----exclude• ------findings (+)----PE------findings (+)----PE• ------indeterminate----LE US ------indeterminate----LE US • PAPA• PE unlikely-----D-dimer(+)PE unlikely-----D-dimer(+)• -------h (CT)-------h (CT)• D-dimer(-)D-dimer(-)• -------exclude PE-------exclude PE•

Pulmonary Angiography

Gold standart

İmages PE in subsegmental and peripheral arteries

hCT-two dimensional angiographic image

-specifity 90%

-dimension of the emboli

-mediastinal and parenchymal patologies

MR Angiography

Sensitivity-70 – 90 %

Specifity- 77 – 100 %

(Central arteries)

Also asseses RV function

Treatment

-to prevent death

-to reduce morbidity

-to prevent pulmoner hypertension

progresing due to thromboemboli

Treatment (II)

Supportive

-Oxygen

-IV liquid

-Vasopressors

Anticoagulation

-unfractioned heparin

-LMWH

-Thrombolysis

-Embolectomy

Unfractioned Heparin

IV 5000 U bolus + 30-35 000 U/kg

aPTT- twice the control value

-Thrombocytopeni

early: thrombocyte agregation

slight, reveresible, no need to stop

late: antibodies against trombocytes

arterial and venous thromboemboli

-Osteopeni

LMWH

-long acting

-less binding to plasma protein

-greater bioavailibity

-no need monitorisation

Prognosis

-Mortality rate – 30%

-Depends on associated pathology

-Resolution – 5 days 36%

2 weeks 52%

3 months 73%

Pulmonary hypertension

recurrent microemboli (rare)

Secondary prevention

UFH + oral anticoagulan (6 months)

LMWH SC + oral anticoagulan (6 months )

LMWH (pregnancy)

Recurrance / unknown origin / permanantly increased risk (throughout life)

Thrombolysis

Massive pulmoner emboli with

hemodynamic instability

-streptokinase

-urokinase

-t-PA

**serious bleeding

REFERENCES:REFERENCES:

• Agnelli G. Anticoagulation in the prevention and treatment of Agnelli G. Anticoagulation in the prevention and treatment of pulmonary embolism.Chest 1995. 107;39-44.pulmonary embolism.Chest 1995. 107;39-44.

• BellWR,Simon TL; DeMets DL. The clinical features of massive and BellWR,Simon TL; DeMets DL. The clinical features of massive and submassive pulmonary embolism. Am J Med 1977; 62: 355-360.submassive pulmonary embolism. Am J Med 1977; 62: 355-360.

• Braunwald E. Pulmonary embolism. Braunwald’s heart disease. Braunwald E. Pulmonary embolism. Braunwald’s heart disease. Braunwald (ed)Philedalphia. WB Saunders 1992 .562-1568.Braunwald (ed)Philedalphia. WB Saunders 1992 .562-1568.

• Herold CJ, Bankier AA, Burghaiber OC, Minar E, Watzke HH. Pulmonary Herold CJ, Bankier AA, Burghaiber OC, Minar E, Watzke HH. Pulmonary Embolism. Comprehensive Pulmonary Medicine. Albert R, Spiro S, Jett J Embolism. Comprehensive Pulmonary Medicine. Albert R, Spiro S, Jett J (eds). Harcaurt Brace and Company Limited London 1999. 50.1-50.12(eds). Harcaurt Brace and Company Limited London 1999. 50.1-50.12

• Hyers TH . Diagnosis of pulmonary embolism. Thorax 1995; 50: 930-Hyers TH . Diagnosis of pulmonary embolism. Thorax 1995; 50: 930-932.932.

• Lane D, Manucci PM, Bauer KA, et al. Inherited thrombophilia: Part Lane D, Manucci PM, Bauer KA, et al. Inherited thrombophilia: Part I.Thromb Haemost 1996;76: 651-662.I.Thromb Haemost 1996;76: 651-662.

• Remy -Jerden M, Remy J,Deschildre F. Diagnosis of pulmonary Remy -Jerden M, Remy J,Deschildre F. Diagnosis of pulmonary embolism with spiral CT: comparison with pulmonary angiography and embolism with spiral CT: comparison with pulmonary angiography and scintigraphy. Radiology 1996; 200(3):699-706.scintigraphy. Radiology 1996; 200(3):699-706.