Pulmonary embolism,overview

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pulmonary embolism is one of the commonest cause of death

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  • 1. Pulmonary Embolism By Eman mahmoud M.D of chest diseases
  • 2. Pulmonary Embolism Embolism : Impaction of a thrombus or foreign matter in the pulmonary vascular bed.
  • 3. Epidemiology 2nd most common cause of unexpected death in most age groups. present in 60-80% of patients with DVT, more than 50 % them are asymptomatic. Account for 15 % of all postoperative deaths it is estimated that in the USA .100 000 people die each year of pulmonary embolism.
  • 4. Thrombotic EMBOLUS Non-thrombotic : Fat, Air, Tumour , Amniotic fluid.
  • 5. RISK FACTORS Bed rest Post-operative After severe blood loss and trauma COPD CHF Varicose veins Advancing age Obesity Post-partum Malignancy Travel of 4 hours or more Smoking 1ry polycythemia Oral contraceptives
  • 6. THROMBOPHILIA Acquired thrombophilia Inherited thrombophilias
  • 7. Hereditary factors Antithrombin III deficiency Protein C deficiency Protein S deficiency Factor V Leiden (most common genetic risk factor for thrombophilia) Plasminogen abnormality Plasminogen activator abnormality Fibrinogen abnormality Resistance to activated protein C
  • 8. Acquired thrombophilia This is mostly associated with the antiphospholipid syndrome (APS). APS is the combination of (LAC) with or without, (ACA), with a history of recurrent miscarriage and or thrombosis.
  • 9. Pathophysiology
  • 10. Clinical Features Size of the embolus and blood vessel occluded. State of the lung. Associated disease(s).
  • 11. PE, Clinical Features dyspnea (7585%) Pleuritic chest pain (5787%) cough (4053% ) Hemoptysis Syncope.
  • 12. Massive Pulmonary Embolism MPE collapse/hypotension unexplained hypoxia engorged neck veins Acut right heart failure
  • 13. Physical Signs Normal Tachypnea (respiratory rate >16/min) - 96% Rales - 58% Accentuated second heart sound - 53% Tachycardia (heart rate >100/min) - 44% Fever (temperature >37.8C) - 43% Diaphoresis - 36% S3 or S4 gallop - 34% Clinical signs and symptoms suggesting thrombophlebitis - 32% Lower extremity edema - 24% Cardiac murmur - 23% Cyanosis - 19%
  • 14. Clinical Probability of PE
  • 15. D-Dimer Degradation product produced by plasmin-mediated proteases of cross-linked fibrin. Blood D-dimer assay should only be considered following assessment of clinical probability. D-dimer assay should not be performed in those with high clinical probability of PE.
  • 16. D-dimer .Highly sensitive assays, such rapid ELISA assays, have high false positive rates but safely rule out VTE in outpatients presenting with a low clinical probability of PE. A negative D-dimer test reliably excludes PE in patients with low clinical probability; such patients do not require imaging for VTE.
  • 17. Ischemia-Modified Albumin levels A potential alternative to D-dimer testing is assessment of the ischemia-modified albumin (IMA) level. 93% sensitive and 75% specific for pulmonary embolism The positive predictive value of IMA, in particular, is better than D-dimer. However, it should not be used alone.
  • 18. Chest x-ray 14% Normal 68% Atelectasis 48% Pleural Effusion 35% Pleural based opacity 24% Elevated diaphragm 15% Prominent central pulmonary artery 7% Westermarks sign 7% Cardiomegaly 5% Pulmonary edema
  • 19. Elevated L H.Diaph
  • 20. Decreased vascularity (Westermark sign)
  • 21. (Hampton hump) The classic radiographic findings of pulmonary infarction a wedge-shaped, pleura-based triangular opacity with an apex pointing toward the hilus
  • 22. Atelectic band
  • 23. cardiac troponins Recently, cardiac troponins I and T have been shown to be associated with early mortality and a complicated hospital course in patients with PE. The assessment of cardiac plasma troponin levels revealed ventricular injury, especially in patients with massive PE who had hypotension or shock.
  • 24. B Natriuretic Peptide (BNP) BNP is a neurohormone secreted from the cardiac ventricles in response to dilatation or an increase of pressure. BNP levels may increase with right ventricle dysfunction when the patients is in bed and decrease with treatment. Serum brain natriuretic peptide levels of > 90 pg/mL have a sensitivity of 85% and a specificity of 75% for predicting adverse clinical outcomes
  • 25. Arterial blood gases Blood gases may increase the suspicion and contribute to the clinical assessment, but they are insufficient to permit proof or exclusion of PE.
  • 26. ECG In minor pulmonary embolism, the only finding is sinus tachycardia. In massive pulmonary embolism, evidence of right heart strain may be seen (rightward shift of the QRS axis, transient RBBB, T-wave inversion, SIQIIITIII pattern, P-pulmonale), but these signs are non-specific. The main value of ECG is exclusion other diagnoses, such as MI or pericarditis.
  • 27. S1 Q3 T3 Pattern
  • 28. Echocardiography RV dilatation RV size does not change from diastole to systole = hypokinesis D-shaped LV 40% of pts have RV abnormalities seen by ECHO
  • 29. Echocardiography Transthoracic echocardiography rarely enables direct visualisation of the pulmonary embolus but may reveal thrombus floating in the right atrium or ventricle. Transoesophageal echocardiography, it is possible to visualise massive emboli in the central pulmonary arteries.
  • 30. Lower extremity venous ultrasonography Advantages Portability May avoid further diagnostic imaging if positive Limitations Low sensitivity and risk of false positives No consistent protocol for technique Operator dependant