1、彭文鸿 解放军306医院呼吸内科,急性肺栓塞（PE）诊治进展,基本概念,肺栓塞（pulmonary embolism,PE):是以各种栓子堵塞肺动脉系统为其发病原因的一组疾病或临床综合征的总称，包括肺血栓栓塞、脂肪栓塞、羊水栓塞、空气栓塞等。肺血栓栓塞症（pulmonary thromboembolism, PTE):是指来源于静脉系统或右心血栓堵塞肺动脉或其分枝引起肺循环障碍的临床和病理生理综合征。肺动脉血栓形成（pulmonary thrombosis）指肺动脉病变基础上（如肺血管炎、白塞氏病等）原位血栓形成，多见于肺小动脉，并非外周静脉血栓脱落所致，临床不易与肺栓塞相鉴别。,基本概念,深
2、静脉血栓形成（deep venous thrombosis,DVT): 纤维蛋白、血小板、红细胞等血液成份在深静脉管腔内形成凝血块（血栓）。静脉血栓栓塞症（venous thrombolism,VTE): PTE 和DVT是同一疾病过程中两个不同阶段， 统称为VTE.,从PTE到VTE,PTE: pulmonary thromboembolism 肺血栓栓塞症DVT: deep venous thrombosis 深静脉血栓形成VTE: venous thromboembolism 静脉血栓栓塞症 VTE = PTE + DVT 强调VTE观 概念的转变与防治策略的选择,The inciden
3、ce of physical signs,96% have tachypnea (respiratory rate 16/min) 58% develop rales 53% have an accentuated second heart sound 44% have tachycardia (heart rate 100/min) 43% have fever (temperature 37.8C) 36% have diaphoresis 34% have an S 3 or S 4 gallop 32% have clinical signs and symptoms suggesti
4、ng thrombophlebitis 24% have lower extremity edema 23% have a cardiac murmur 19% have cyanosis,Original Geneva Score,Age: 60 79 years (1 point) 80+ years (2 points) Previous DVT or PE (2 points)Recent surgery within 4 weeks (3 points)Heart rate 100 beats per minute (1 point)PaCO2 (partial pressure o
5、f CO2 in arterial blood): 35mmHg (2 points) 35 - 39mmHg (1 point) PaO2 (partial pressure of O2 in arterial blood): 6.0 - High (probability 59% based on pooled data) Score 2.0 to 6.0 - Moderate (probability 29% based on pooled data) Score 4 - PE likely. Consider diagnostic imaging. Score 4 or less -
6、PE unlikely. Consider D-dimer to rule out PE.,Wells Score for DVT,Variable Score Active cancer 1 point Paralysis, paresis, or recent plaster immobilization of the lower extremity 1 point Recently bedridden for more than three days or major surgery within four weeks 1 point Localized tenderness along
7、 the distribution of the deep venous system 1 point Entire leg swollen 1 point Calf swelling by more than 3 cm when compared with the asymptomatic leg 1 point Pitting edema - greater in the symptomatic leg 1 point Collateral superficial veins nonvaricose 1 point Alternative diagnosis as likely or mo
8、re possible than that of DVT -2 points,Modified Wells Score (Canadian score) for clinical probablity of PE is:,Variable Score Clinical signs of DVT +3 points Alternative diagnosis less probable than PE +3 points Heart rate 100 bpm +1.5 points Immobilization or surgery 6 indicates a high probability
9、of PE.,肺栓塞,静脉血栓栓塞症Venous thromboembolism: DVT & PE,深静脉血栓DVT,肺栓塞PTE,https:/ that originated in the femoral vein of the leg, removed from a pulmonary artery,Large thrombus in the femoral vein of the leg,PE的常见症状,呼吸困难 最常见，约占84%90%。胸痛 约占70%咯血 约占30%惊恐 约占55%咳嗽 约占37%晕厥 约占13%,体格检查,一般检查 低热，约占43%呼吸频率增快，约占70%窦速
10、，约占44%紫绀，约占19%多汗，约占11%下肢静脉紫肿低血压，少见。提示为大块PE,心血管系统体征,主要是急、慢性肺动脉高压和右心功能不全的表现。53%有肺动脉第二音亢进。可出现颈静脉充盈，搏动增强，是PE重要的体征，也是右心功能改变的重要窗口。,呼吸系统体征,气管移向患侧隔肌上移病变部位叩诊浊音肺野可闻及干湿罗音,血浆D-二聚体的应用,包括 D-二聚体,D-二聚体,血浆D-二聚体的应用,D-Dimer的排除诊断价值,血浆D-二聚体检查 小于500g/L，有排除诊断的价值。,PULMONARY EMBOLISMDIAGNOSIS,EKGThe classic findings of righ
11、t heart strain and acute cor pulmonale are tall, peaked P-waves in lead II (P-pulmonale), right axis deviation, right bundle branch block, an S1-Q3-T3 pattern or atrial fibrillationOnly 20% of patients with proven PE have any of these classic ECG abnormalities,心电图EKG,V1-V4的T波改变和ST段异常；部分病人出现SIQIIITII
12、I；不完全的右束支传导阻滞、肺性P波、电轴右偏和顺钟向转位。常见窦速。,PULMONARY EMBOLISMDIAGNOSIS,EKG with S1-Q3-T3,血气分析BLOOD GAS,低氧血症、低碳酸血症、PA-aO2 增大。部分患者的血气正常。肺血管床堵塞15%20%即可出现氧分压下降。,超声心动检查,间接征象：右室扩张为71%100%，右肺动脉内径增加72%，左室径变小38%，室间隔左移及矛盾运动42%以及肺动脉压增高等。直接征象：右心血栓可有两个类型：活动、蛇样运动的组织和不活动、无蒂及致密的组织。发生PE前者98% ，后者40%。 超声心动图检查对可疑非高危PE的诊断意义不大，
13、敏感性有限（60%70%，特异性90%左右），而且阴性结果也不能排除PE。对于这部分非高危PE患者，超声的主要作用是预后分层，中危，抑或低危。 当临床评估结果与无创影像检查结果不一致时，可考虑肺动脉造影检查。,外周血管超声检查,探测到较大的下肢深静脉血栓作为临床DVT患者的最初检查减少对肺部影像学检查的需要,Venous Ultrasonography,Relies on loss of vein compressibility as the primary criterionAbout 1/3 of pts will have no imaging evidence of DVTClot m
14、ay have already embolizedClot present in the pelvic veins (U/S usually inadequate)Workup for PE should continue even if dopplers (-) in a pt in which you have a high clinical suspicion,放射性核素肺通气/灌注扫描 作为疑有PE患者的标准筛选检查，其特异性有一定的限度，可有假阳性。,螺旋CT血管造影术,特别是电子束CT，可以直接看到肺动脉内的血栓。表现为血管内的低密度充盈缺损。可清晰地探测位于主、叶及段肺动脉内的栓
15、子。对于在亚段及一些远端肺动脉内的栓子，SCT的敏感性是有限的。SCT敏感性为53%89%，特异性为78%100%。直接征象有：半月形或环形充盈缺损，完全梗阻，轨道征等；间接片象有：主肺动脉及左右肺动脉扩张，血管断面细小、缺支、马赛克片、肺梗死灶、胸膜改变等。,X线胸片,斑片状浸润、肺不张、膈肌抬高、胸腔积液、尤其以胸膜为基底凸面朝向肺门的圆形致密阴影（Hampton征），以及扩张的肺动脉伴远端肺纹理稀疏（Westermark征）对PTE诊断有重要价值，但不特异。,CXR,Initial CXR usually normal.May progress to show atelectasis,
16、plueral effusion and elevated hemidiaphram.Hamptons hump and Westermark sign are classic findings but are not usually present.,PULMONARY EMBOLISMDIAGNOSIS,Chest X-ray: virtually always normalmay show Westermarks sign, a dilatation of the pulmonary vessels proximal to an embolism, sometimes with a sh
17、arp cutoffrare late finding is Hamptons hump, a triangular or rounded pleural-based infiltrate with the apex pointed toward the hilum, frequently located adjacent to the diaphragm,Chest X-ray findings:,Band atelectasis (1 point) Elevation of hemidiaphragm (1 point) The score obtained relates to the
18、probability of the patient having had a pulmonary embolism (the lower the score, the lower the probability):8 points indicates a high probability of PE,Hampton hump sign: Refers to a homogeneous wedge-shaped consolidation in the lung periphery with a base contiguous to a visceral pleural surface and
19、 a rounded convex apex directed toward the hilum; associated with pulmonary infarct,Westermark sign: Refers to an area of o!igemia with minimal change in lung volume distal to a large PE; this regional oligemia is caused either by mechanical obstruction to blood flow by the clot or by reflex vasocon
20、striction,Radiographic Eponyms- Hamptons Hump, Westermarks Sign,Westermarks Sign,Hamptons Hump,CXR,Hamptons Hump consists of a pleura based shallow wedge-shaped consolidation in the lung periphery with the base against the pleural surface.,PULMONARY EMBOLISMDIAGNOSIS,Westermarks Sign,PULMONARY EMBOL
21、ISMDIAGNOSIS,Hamptons Hump,PE with hemorrhage or pulmonary edema,PE with effusionand elevated diaphragm,V/Q Scan,Ventilation-perfusion scanning is a radiological procedure which is often used to confirm or exclude the diagnosis of pulmonary embolism. It may also be used to monitor treatment.Ventilat
22、ion (V) Achieved by the inhalation of Technetium DTPA. DTPA is an elongated version of EDTA and is a heavy metal chelator. Ventilation is assessed under a gamma camera.Perfusion (Q) Achieved by injecting the patient with Technetium 99m, which is coupled with macro aggregated albumin (MAA). An embolu
23、s shows up as a cold area when the patient is placed under a gamma camera.,Abnormal V/Q Scan,Abnormal V/Q Scan,Perfusion,Ventilation,V/Q Scan Results,Likelihood of pulmonary embolism according to scan category and clinical probability in PIOPED study,Spiral CT,Spiral CT first introduced in 1990sIn o
24、lder CT scanners, the X-ray source would move in a circular fashion to acquire a single slice. Once the slice had been completed, the scanner table would move to position the patient for the next slice.In helical CT the X-ray source and detectors are attached to a freely rotating gantry. During a sc
25、an, the table moves the patient smoothly through the scanner. The name derives from the helical or spiral path traced out by the X-ray beam.,Spiral CT,Major advantage of Spiral CT is speed:Often the patient can hold their breath for the entire study, reducing motion artifacts.Allows for more optimal
26、 use of intravenous contrast enhancement.Spiral CT is quicker than the equivalent conventional CT permitting the use of higher resolution acquisitions in the same study time.Contraindicated in cases of renal disease.Sensitive for PE in the proximal pulmonary arteries, but less so in the distal segme
27、nts.,CT Angiogram,Quickly becoming the test of choice for initial evaluation of a suspected PE.CT unlikely to miss any lesion.CT has better sensitivity, specificity and can be used directly to screen for PE.CT can be used to follow up “non diagnostic V/Q scans.,CT Angiogram,Chest computed tomography
28、 scanning demonstrating extensive embolization of the pulmonary arteries.,DiagnosisSpiral CT/ Multislice,Ascending Aorta,Lt Pulmonary Artery,Main Pulmonary Artery,Rt Pulmonary Artery,Descending Aorta,Thrombus,Pulmonary embolism,This 62 y/o female presented with shortness of breath and an abnormal ch
29、est x-ray. A Spiral CT of the chest with IV contrast was performed. A filling defect in the right pulmonary artery consistent with a pulmonary embolus is demonstrated.,CT肺动脉造影（CTPA）,被广泛应用，可以安排急诊检查能准确地显示近端血栓和急性右心室扩张可以做定量分析，分析结果与临床严重程度的相关性直接显示血管内血栓，间接显示继发效应，楔形阴影或特征性的右心室改变当排除PTE时可能做出其它的正确诊断高质量CTPA检查阴性不
30、进行抗凝治疗是安全的,CT pulmonary angiography (CTPA) showing a saddle embolus and substantial thrombus burden in the lobar branches of both main pulmonary arteries.,CT pulmonary angiography (CTPA) showing a saddle embolus and substantial thrombus burden in the lobar branches of both main pulmonary arteries.,A
31、sian/Pacific Islanders (12.1M),450 - 600,000 episodes/year in US,Stein et al: Regional Differences in Rates of Diagnosis and Mortality of Pulmonary Thromboembolism; AJC 2004;93:1194-1197,2008年ESC新版指南取消临床分型，代之以危险分层。原因：急性肺栓塞严重程度与肺动脉内血栓的形态、分布和血栓量的多少不呈平行关系。急性肺栓塞的严重程度与急性肺栓塞早期（住院或发病后30天）死亡危险程度密切相关。,2008年急
32、性肺栓塞危险分层的主要指标临床特征休克 低血压a右心室功能不全 超声心动图示右心扩大运动减弱或压力负荷过重表现螺旋CT示右心扩大 BNP或NT-proBNP升高 右心导管术示右心室压力增大心肌损伤标志物 心脏肌钙蛋白T或I阳性a：低血压定义：收缩压40mmHg达15分钟以上，除外新出现的心律失常、低血容量或败血症所致低血压。,2008年急性肺栓塞危险分层早期死亡风险危险分层指标推荐治疗 临床表现右心室功能不全心肌损伤 （休克或低血压）高危+ a a 溶栓或栓子切除术(15%) 中危 + + (3-15) + 住院治疗 + 低危 (180 mmHg) 晚期肝病 感染性心内膜炎 活动性消化性溃疡,
