pulmonary embolism

Pulmonary embolismPulmonary embolism

Pulmonology Refresher Pulmonology Refresher CourseCourse

27 May 201127 May 2011

Dr. JM NelDr. JM Nel

Department of Critical CareDepartment of Critical Care

IncidenceIncidence

Pulmonary embolism (PE)Pulmonary embolism (PE)

– In 1% of patients admitted to hospitalIn 1% of patients admitted to hospital– Accounts for Accounts for 5%5% of in of in hospital deathshospital deaths

– Common mode of deathCommon mode of death CancerCancer StrokeStroke

– Most common Most common cause of cause of death in pregnancydeath in pregnancy

EtiologyEtiology

MajorityMajority (75%) (75%)

Propagation of Propagation of lower lower limb DVTlimb DVT

Other (rare)Other (rare)

Amniotic fluidAmniotic fluid PlacentaPlacenta AirAir FatFat TumourTumour Septic emboli (from Septic emboli (from

endocarditis endocarditis affecting tricupid or affecting tricupid or pulmonary valves)pulmonary valves)

Risk factorsRisk factors SurgerySurgery

– Major abdominal/ pelvic Major abdominal/ pelvic surgerysurgery

– Hip/ knee surgeryHip/ knee surgery– Post- operative intensive Post- operative intensive

carecare

ObstetricsObstetrics– Pregnancy/ puerperiumPregnancy/ puerperium

Cardiorespiratory diseaseCardiorespiratory disease– COPDCOPD– Congestive cardiac failureCongestive cardiac failure– Other disabling diseaseOther disabling disease

Lower limb problemsLower limb problems– FractureFracture– Varicose veinsVaricose veins– Stroke/ spinal injuryStroke/ spinal injury

Malignant diseaseMalignant disease– Abdominal pelvicAbdominal pelvic– Advanced/ metastaticAdvanced/ metastatic– Concurrent chemotherapyConcurrent chemotherapy

MiscellaneousMiscellaneous– Increasing ageIncreasing age– Previous proven VTEPrevious proven VTE– ImmobilityImmobility– Thrombotic disordersThrombotic disorders– TraumaTrauma

Clinical featuresClinical features

Clinical features varyClinical features vary

DIFFICULT DIAGNOSISDIFFICULT DIAGNOSIS

ASK 3 QUESTIONSASK 3 QUESTIONS

– Is the presentation consistent with PE ?Is the presentation consistent with PE ?

– Does the patient have risk factors for Does the patient have risk factors for PE ?PE ?

– Is there another diagnosis that can Is there another diagnosis that can explain the patients presentation ?explain the patients presentation ?

– Acute massive PEAcute massive PE

– Submassive PESubmassive PE

– Acute small/ medium PEAcute small/ medium PE

Acute massive PEAcute massive PE

SymptomsSymptoms

CollapseCollapse Central chest painCentral chest pain Severe dyspnoeaSevere dyspnoea

SignsSigns

Major circulatory Major circulatory collapsecollapse

– TachycardiaTachycardia– HypotensionHypotension– Increased JVPIncreased JVP– Loud P2Loud P2– Parasternal heaveParasternal heave– RV gallop rhythmRV gallop rhythm

Severe cyanosisSevere cyanosis

Acute small/medium PEAcute small/medium PE

SymptomsSymptoms

Pleuritic chest painPleuritic chest pain Restricted breathingRestricted breathing HaemoptysisHaemoptysis

SignsSigns

TachycardiaTachycardia Pleural rubPleural rub Raised Raised

hemidiaphragmhemidiaphragm CracklesCrackles EffusionEffusion Low- grade feverLow- grade fever Normal BPNormal BP

Submassive PESubmassive PE

WHAT’S THAT ???WHAT’S THAT ???

Massive PEMassive PE

RV Strain/dilatationRV Strain/dilatation Low BPLow BP

RV Strain/dilatationRV Strain/dilatation Normal BPNormal BP

InvestigationsInvestigations

CXRCXR

ECGECG

Arterial blood gasArterial blood gas

D- dimerD- dimer

Heart sonarHeart sonar

Other biomarkersOther biomarkers

ImagingImaging

Investigations: Chest x- rayInvestigations: Chest x- ray

High index of suspicion if normal CXRHigh index of suspicion if normal CXR– Acute dyspnoec and hypoxemic patientAcute dyspnoec and hypoxemic patient

Exclude differential diagnosesExclude differential diagnoses Heart failureHeart failure PneumoniaPneumonia PneumothoraxPneumothorax

Investigations: Chest x- rayInvestigations: Chest x- ray

Radiographic Radiographic appearancesappearances

– Pulmonary opacitiesPulmonary opacities

– Wedge shaped Wedge shaped opacityopacity

– Horizontal linear Horizontal linear opacitiesopacities

– Pleural effusionPleural effusion

– Oligaemia of lung Oligaemia of lung fieldfield

– Enlarged pulmonary Enlarged pulmonary arteryartery

– Elevated Elevated hemidiaphragmhemidiaphragm

Investigations: Chest x- rayInvestigations: Chest x- ray Acute massive PEAcute massive PE

Usually normalUsually normal OligaemiaOligaemia

Acute small/ medium PEAcute small/ medium PE

Pleuropulmonary opacitiesPleuropulmonary opacities Pleural effusionPleural effusion Linear shadowsLinear shadows Raised hemidiaphragmRaised hemidiaphragm

Investigations: ECGInvestigations: ECG

Common but non- specificCommon but non- specific

Most commonMost common– Sinus tachycardiaSinus tachycardia

Exclude other differential diagnosesExclude other differential diagnoses– Acute myocardial infarctionAcute myocardial infarction– PericarditisPericarditis

Investigations: ECGInvestigations: ECG

Massive/Submassive Massive/Submassive PEPE– Acute cor pulmonaleAcute cor pulmonale

S1 Q3 T3S1 Q3 T3 T- wave inversionT- wave inversion RBBBRBBB P-wave pulmonaleP-wave pulmonale Right axisRight axis

Small/ medium PESmall/ medium PE

Sinus tachycardiaSinus tachycardia

Investigations: A- blood gasInvestigations: A- blood gas

Typical A- blood gasTypical A- blood gas

Low PaO2Low PaO2 Normal or low PaCO2Normal or low PaCO2

Investigations: D- dimerInvestigations: D- dimer

Degradation productDegradation product

Positive D- dimerPositive D- dimer– High negative High negative

predictive valuepredictive value

– Screening test for PEScreening test for PE

– ELISA based D-dimer ELISA based D-dimer superior sensitivitysuperior sensitivity

Other causes for Other causes for elevationelevation

Myocardial infarctionMyocardial infarction Pneumonia/InfectionPneumonia/Infection SepsisSepsis PregnancyPregnancy MalignancyMalignancy Hospitalised patientsHospitalised patients ElderlyElderly TraumaTrauma

Investigations: Heart sonarInvestigations: Heart sonar Massive/Submassive PEMassive/Submassive PE

Acute dilatation of the right Acute dilatation of the right heartheart

Pulmonary hypertensionPulmonary hypertension Thrombus can be seenThrombus can be seen

LOOK FOR:LOOK FOR:

RV RV DYSFUNCTIONDYSFUNCTION

RV DYSFUNCTION

•RV enlargement•Hypokinesis of free wall•Leftward septal shift•PHT

Investigations: Other Investigations: Other biomarkersbiomarkers

Cardiac troponinCardiac troponin

Risk stratificationRisk stratification

Elevated in massive Elevated in massive PEPE

– 6-12 hours after 6-12 hours after symptomssymptoms

Pro-BNPPro-BNP

Increases with Increases with ventricular ventricular stretchingstretching

But also elevated in But also elevated in other causes of other causes of PHT/congestive PHT/congestive heart failureheart failure

Detects myocardial dysfunction

Detects myocardial injury

Investigations: Other Investigations: Other biomarkersbiomarkers

Normal levels:

•Low risk of death/complications

Increased levels:

•Cannot predict early death

•RISK ASSESSMENT

•Do not dictate need for early thrombolysis

Investigations: ImagingInvestigations: Imaging

V/Q scansV/Q scans– If normalIf normal

Excludes PEExcludes PE

– If underlying chronic cardiopulmonary If underlying chronic cardiopulmonary pathology (COPD, congestive cardiac pathology (COPD, congestive cardiac failure)failure) Majority of scan indeterminateMajority of scan indeterminate

Investigations: ImagingInvestigations: Imaging

CT pulmonary angiographyCT pulmonary angiography– Difficult to detect small peripheral emboliDifficult to detect small peripheral emboli

Duplex doppler of legsDuplex doppler of legs– DVT in legDVT in leg

Pulmonary angiographyPulmonary angiography– Gold standardGold standard

ManagementManagement

General measuresGeneral measures

AnticoagulationAnticoagulation

Thrombolytic therapyThrombolytic therapy

Caval filtersCaval filters

Management: GeneralManagement: General

Oxygen for Oxygen for hyoxaemic patientshyoxaemic patients– Keep arterial oxygen Keep arterial oxygen

saturation > 90%saturation > 90%

AnalgesicsAnalgesics– OpiatesOpiates

Careful in hypotensive Careful in hypotensive patientspatients

Avoid diuretics and Avoid diuretics and vasodilatorsvasodilators

Treat hypotensionTreat hypotension– IVI fluidsIVI fluids– Inotropic agents of Inotropic agents of

limited valuelimited value

Confirmed PE

ECHORV dysfunction

Low riskNon-massive PE

Anticoagulate

HemodynamicallyStable ?

LMWHUFH

Massive PE

Thrombolysis if no contra-indicationAnticoagulate

Submassive PE

Management: Management: AnticoagulationAnticoagulation

Start immediatelyStart immediately

– High or intermediate High or intermediate probability of PEprobability of PE

Low molecular weight Low molecular weight heparin scheparin sc

– ClexaneClexane– Give according to Give according to

weightweight– Reduces mortality in PEReduces mortality in PE– Reduces the Reduces the

propagation of clot and propagation of clot and risk of further embolirisk of further emboli

– Give at least 5 daysGive at least 5 days– Start WarfarinStart Warfarin– Stop Clexane when INR Stop Clexane when INR

is > 2is > 2

Management: Management: AnticoagulationAnticoagulation

Duration of Warfarin therapyDuration of Warfarin therapy– If underlying prothrombotic risk or If underlying prothrombotic risk or

previous emboliprevious emboli For lifeFor life

– If identifiable and reversible risk factorIf identifiable and reversible risk factor 3 Months3 Months

– If idiopathic If idiopathic 6 Months6 Months

Management: Thrombolytic Management: Thrombolytic therapytherapy

Acute massive pulmonary embolismAcute massive pulmonary embolism– Patient shockedPatient shocked– Improves outcomeImproves outcome

If normal BPIf normal BP– Unsure if advantage above heparinUnsure if advantage above heparin

High risk of High risk of intracranial haemorrhageintracranial haemorrhage– Screen patient for haemorrhagic riskScreen patient for haemorrhagic risk

Management: Caval filtersManagement: Caval filters

Filter inserted in inferior vena cavaFilter inserted in inferior vena cava Below origin of renal vesselsBelow origin of renal vessels

IndicationsIndications Recurrent PE despite adequate Recurrent PE despite adequate

anticoagulationanticoagulation Contraindication to anticoagulationContraindication to anticoagulation

PrognosisPrognosis

Lowest recurrence after operationLowest recurrence after operation

If right ventricular dysfunctionIf right ventricular dysfunction Risk of cardiogenic shockRisk of cardiogenic shock Increased risk of deathIncreased risk of death

If pulmonary hypertension and right If pulmonary hypertension and right ventricular dysfunction after 6 weeksventricular dysfunction after 6 weeks

Increased risk to develop right heart failure over next Increased risk to develop right heart failure over next 5 years5 years

Pulmonary Embolism:Pulmonary Embolism:Case StudiesCase Studies

Pulmonary embolism Pulmonary embolism

Case Presentation 1:Case Presentation 1:– 64 year old male 64 year old male – Previous hip surgery 20 days agoPrevious hip surgery 20 days ago– Sudden dyspnoeaSudden dyspnoea– Pleuritic chest painPleuritic chest pain– HypoxicHypoxic– BP 130/80BP 130/80– Clinically DVTClinically DVT

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

PneumoniaPneumonia

PneumothoraxPneumothorax

Musculoskeletal chest painMusculoskeletal chest pain

ASK 3 QUESTIONSASK 3 QUESTIONS

– Is the presentation consistent with PE ?Is the presentation consistent with PE ?

– Does the patient have risk factors for Does the patient have risk factors for PE ?PE ?

– Is there another diagnosis that can Is there another diagnosis that can explain the patients presentation ?explain the patients presentation ?

WHAT NOW ???WHAT NOW ???

CXRCXR– Exclude differential diagnosesExclude differential diagnoses

Heart failureHeart failure PneumoniaPneumonia PneumothoraxPneumothorax

High index of suspicion High index of suspicion if if normal CXRnormal CXR– Acute dyspnoeac and hypoxaemic Acute dyspnoeac and hypoxaemic

patientpatient

ECG ECG – Exclude other differential diagnosesExclude other differential diagnoses

Acute myocardial infarctionAcute myocardial infarction PericarditisPericarditis

Most commonMost common– Sinus tachycardiaSinus tachycardia

Arterial bloodgasArterial bloodgas

Low PaO2Low PaO2

D- dimerD- dimer

POSITIVEPOSITIVE

HeartsonarHeartsonar

NORMALNORMAL

Massive/Submassive PEMassive/Submassive PE

– Acute dilatation of the Acute dilatation of the right heartright heart

– Pulmonary hypertensionPulmonary hypertension– Thrombus can be seenThrombus can be seen

Alternative diagnosesAlternative diagnoses

– Left ventricular failureLeft ventricular failure– Aortic dissectionAortic dissection– Pericardial tamponadePericardial tamponade

Duplex doppler of legsDuplex doppler of legs

DVT in legDVT in leg

V/Q scanV/Q scan

PULMONARY EMBOLISMPULMONARY EMBOLISM

Pulmonary embolism: Pulmonary embolism: ManagementManagement

General measuresGeneral measures– Oxygen for all hyoxaemic patientsOxygen for all hyoxaemic patients

Keep arterial oxygen saturation > 90%Keep arterial oxygen saturation > 90%

AnticoagulationAnticoagulation– Clexane 80mg bd scClexane 80mg bd sc

Give at least 5 daysGive at least 5 days

– WarfarinWarfarin

– Stop Clexane when INR is > 2Stop Clexane when INR is > 2

HOW LONG DO I HOW LONG DO I TREAT THIS TREAT THIS PATIENT WITH PATIENT WITH WARFARIN ???WARFARIN ???

3 Months3 Months

Duration of Warfarin Duration of Warfarin therapytherapy– If underlying If underlying

prothrombotic risk or prothrombotic risk or previous emboliprevious emboli For lifeFor life

– If If identifiableidentifiable and and reversible risk factorreversible risk factor 3 Months3 Months

– If idiopathic If idiopathic 6 Months6 Months

Case Presentation 2:Case Presentation 2:– 28 year old lady28 year old lady– Oral contraceptivesOral contraceptives– 10 hour flight10 hour flight– Sudden dyspnoeaSudden dyspnoea– BP 90/40BP 90/40– Loud P2/ Increased JVPLoud P2/ Increased JVP– HypoxicHypoxic

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS Massive pulmonary embolismMassive pulmonary embolism

Myocardial infarctionMyocardial infarction

Pericardial tamponadePericardial tamponade

Aortic dissectionAortic dissection

CXRCXR

NORMALNORMAL

ECGECG– S1 Q3 T3S1 Q3 T3– RBBBRBBB

Arterial bloodgasArterial bloodgas– Low PaO2Low PaO2

D- dimerD- dimer– POSITIVEPOSITIVE

HeartsonarHeartsonar– Right ventricular dilatationRight ventricular dilatation– Increased pulmonary pressureIncreased pulmonary pressure

CT pulmonary angiographyCT pulmonary angiography

MASSIVE PULMONARY EMBOLISMMASSIVE PULMONARY EMBOLISM

General measuresGeneral measures Oxygen for all hypoxaemic patientsOxygen for all hypoxaemic patients

– Keep arterial oxygen saturation > 90%Keep arterial oxygen saturation > 90% Treat hypotension with IVI fluidsTreat hypotension with IVI fluids

Thrombolytic therapyThrombolytic therapyRV dilatationRV dilatationLow BPLow BP

Complications of thrombolytic Complications of thrombolytic therapytherapy

Intracranial haemorrhageIntracranial haemorrhage Haemorrhage at other sitesHaemorrhage at other sites AnaphylaxisAnaphylaxis

Case Presentation 3:Case Presentation 3:– 28 year old lady28 year old lady– Oral contraceptivesOral contraceptives– 10 hour flight10 hour flight– Sudden dyspnaeSudden dyspnae– BP 130/80BP 130/80– Loud P2/ Increased JVPLoud P2/ Increased JVP– HypoxicHypoxic

CXRCXR

NORMALNORMAL

ECGECG– S1 Q3 T3S1 Q3 T3– RBBBRBBB

Arterial bloodgasArterial bloodgas– Low PaO2Low PaO2

D- dimerD- dimer– POSITIVEPOSITIVE

HeartsonarHeartsonar– Right ventricular dilatationRight ventricular dilatation– Increased pulmonary pressureIncreased pulmonary pressure

CT pulmonary angiographyCT pulmonary angiography

PULMONARY EMBOLISMPULMONARY EMBOLISM

Patient has Patient has normal BPnormal BP

Patient has Patient has RV strainRV strain

SUBMASSIVE PULMONARY EMBOLISMSUBMASSIVE PULMONARY EMBOLISM

Confirmed PE

ECHORV dysfunction

Low riskNon-massive PE

Anticoagulate

HemodynamicallyStable ?

LMWHUFH

Massive PE

Thrombolysis if no contra-indicationAnticoagulate

Submassive PE

Associated with rapid resolution of Associated with rapid resolution of radiographic abnormalityradiographic abnormality

No reduction in mortality !!!No reduction in mortality !!!– In In submassive PEsubmassive PE

Indicated only in Indicated only in hemodynamically hemodynamically unstable patients !!!unstable patients !!!– SBP < 90mmHg or drop of 40mmHg for at SBP < 90mmHg or drop of 40mmHg for at

least 15 minutesleast 15 minutes

– Best if given in 48 hours, still benefit after 14 Best if given in 48 hours, still benefit after 14 days (if still symptomatic)days (if still symptomatic)

All must be followed by therapeutic All must be followed by therapeutic anticoagulationanticoagulation

To thrombolise or not to thromboliseTo thrombolise or not to thrombolise

THAT REMAINS THE QUESTION !!!THAT REMAINS THE QUESTION !!!

pulmonary embolism

blood gastypical

patients presentation

blood gaslow pao2normal

presentation consistent

normal cxracute dyspnoec

low paco2investigations

submassive pemassive

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