复旦大学附属中山医院 呼吸科暨呼吸病研究所 上海市重点学 Pulmonary Thromboembolism Jing ZHANG(张静),MD,PhD zhang jing @zs-hospital shcn Department of Pulmonary medicine Zhongshan Hospital Fudan University MBBS project, Zhongshan Hospital
MBBS project, Zhongshan Hospital Pulmonary Thromboembolism Jing ZHANG (张静), MD, PhD zhang.jing@zs-hospital.sh.cn Department of Pulmonary Medicine Zhongshan Hospital Fudan University
OUTLINE Understand the historical context of pulmonary emboli Comprehend the pathophysiology and know some common risk factors Be aware of the clinical features of pe and have a basic understanding of various diagnostic test Gain a therapeutic approach to the treatment of Pe and discuss a simplified method in the work up of pe MBBS project, Zhongshan Hospital
MBBS project, Zhongshan Hospital OUTLINE • Understand the historical context of pulmonary emboli • Comprehend the pathophysiology and know some common risk factors • Be aware of the clinical features of PE and have a basic understanding of various diagnostic test • Gain a therapeutic approach to the treatment of PE and discuss a simplified method in the workup of PE
Definition When venous emboli become dislodged from their site of origin, they embolize to the pulmonary arterial circulation or, paradoxically to the arterial circulation through a patent foramen ovale About 50% of pts with pelvic or proximal leg deep venous thrombosis have pe Isolated calf or upper extremity venous thrombosis pose a lower risk for PE MBBS project, Zhongshan Hospital
MBBS project, Zhongshan Hospital Definition • When venous emboli become dislodged from their site of origin, they embolize to the pulmonary arterial circulation or, paradoxically to the arterial circulation through a patent foramen ovale — About 50% of pts with pelvic or proximal leg deep venous thrombosis have PE — Isolated calf or upper extremity venous thrombosis pose a lower risk for PE
Epidemiology A Common disorder and potentially deadly Five million cases of venous thrombosis each year 10% of these will have a pe 10%Will die: Untreated mortality rate of 20%-30% Highest incidence in hospitalized patients a hard diagnosis to make Correct diagnosis is made in only 10-30% of cases Up to 60% of autopsies will show some evidence of past PE Plummets to 5% with timely intervention MBBS project, Zhongshan Hospital
MBBS project, Zhongshan Hospital Epidemiology • A Common disorder and potentially deadly — Five million cases of venous thrombosis each year — 10% of these will have a PE — 10% will die: Untreated mortality rate of 20% - 30% — Highest incidence in hospitalized patients • A hard diagnosis to make — Correct diagnosis is made in only 10-30% of cases — Up to 60% of autopsies will show some evidence of past PE — Plummets to 5% with timely intervention
Emboli origination 90-95% of pulmonary emboli originate in the deep venous system of the lower extremities other rare locations include Uterine and prostatic veins Upper extremities Renal veins Right side of the heart MBBS project, Zhongshan Hospital
MBBS project, Zhongshan Hospital Emboli origination • 90-95% of pulmonary emboli originate in the deep venous system of the lower extremities • Other rare locations include — Uterine and prostatic veins — Upper extremities — Renal veins — Right side of the heart
Risk Factors CHE Venous stasis Malignancy Prior dvt obesity ·Age>70 ° Estrogen/OCP ° Prolonged Bed Rest ° Pregnancy(esp3 Immobilization months post partum) Surgery requiring Lower ext injury 30 minutes general Previous anesthesia thrombophlebitis Orthopedic surgery Coagulopathy Stroke MBBS project, Zhongshan Hospital
MBBS project, Zhongshan Hospital Risk Factors • CHF • Malignancy • Obesity • Estrogen/OCP • Pregnancy (esp 3 months post partum) • Lower ext injury • Previous thrombophlebitis • Coagulopathy • Venous Stasis • Prior DVT • Age > 70 • Prolonged Bed Rest • Immobilization • Surgery requiring > 30 minutes general anesthesia • Orthopedic Surgery • Stroke
Virchow's triad Rudolf virchow postulated more than a century ago that a triad of factors predisposed to venous thrombosis Local trauma to the vessel wall Hypercoagulability Stasis of blood flow It is now felt that pts who suffer a Pe have an underlying predisposition that remains silent until a acquired stressor occurs MBBS project, Zhongshan Hospital
MBBS project, Zhongshan Hospital Virchow’s Triad • Rudolf Virchow postulated more than a century ago that a triad of factors predisposed to venous thrombosis — Local trauma to the vessel wall — Hypercoagulability — Stasis of blood flow • It is now felt that pts who suffer a PE have an underlying predisposition that remains silent until a acquired stressor occurs
Impairment in coagulant regulation Factor v leiden mutation Protein c deficiency Protein S deficiency Antithrombin deficiency Prothrombin gene mutation a20210 Anticardiolipin antibodies ° Lupus anticoagulant ° Hyperhomocystinemia MBBS project, Zhongshan Hospital
MBBS project, Zhongshan Hospital Impairment in coagulant regulation • Factor V Leiden mutation • Protein C deficiency • Protein S deficiency • Antithrombin deficiency • Prothrombin gene mutation A20210 • Anticardiolipin antibodies • Lupus anticoagulant • Hyperhomocystinemia
Pathophysiology Increased pulmonary vascular resistance Impaired gas exchange Alveolar hyperventilation Increased airway resistance Decreased pulmonary compliance MBBS project, Zhongshan Hospital
MBBS project, Zhongshan Hospital Pathophysiology • Increased pulmonary vascular resistance • Impaired gas exchange • Alveolar hyperventilation • Increased airway resistance • Decreased pulmonary compliance
Right Ventricular Dysfunction Progressive right heart failure is the usual immediate cause of death from pe As pulmonary vascular resistance increases, right ventricular wall tension rises and perpetuates further right ventricle dilation and dysfunction Interventricular septum bulges into and compresses the normal left ventricle MBBS project, Zhongshan Hospital
MBBS project, Zhongshan Hospital Right Ventricular Dysfunction • Progressive right heart failure is the usual immediate cause of death from PE • As pulmonary vascular resistance increases, right ventricular wall tension rises and perpetuates further right ventricle dilation and dysfunction • Interventricular septum bulges into and compresses the normal left ventricle