肺血栓栓塞

肺血栓栓塞,Pulmonary Thromboembolism,Definitions 定义 Risk Factor 危险因素 Pathology 病理学 Pathophysiology 病理生理学 Clinical Manifestations 临床表现 Laboratory Testing & Special Testing 实验室和特殊检查 Diagnosis & Differential diagnosis 诊断和鉴别诊断 Treatment 治疗,Definitions 定义,Pulmonary Embolism (PE) 肺栓塞 Pulmonary Thromboembolism (PTE) 肺血栓栓塞 Pulmonary Infarction (PI) 肺梗死 Venous Thromboembolism 静脉血栓栓塞,60% to 90% of PEs originate from DVT As a thrombus breaks free, it travels to the heart and obstructs branches of the pulmonary arterial tree. Large clots may remain lodged in the central pulmonary artery as saddle emboli, while small emboli may travel to peripheral sub segmental arteries.,Risk Factors 危险因素,Inherited,Acquired,Age Obesity SmokingOral contraceptives Pregnancy Surgery Trauma,History of DVT Hormonal therapyImmobility Central venous Catheter,Medical Conditions,Virchows Triad,Local trauma to the vessel wall 血管内皮损伤Hypercoagulability 高凝状态Stasis of blood flow 血流淤滞,Pathology 病理学,Both lungs in the majority of cases, the lower lobes often than upper lobes, and right lung often than the left lung 双侧多于单侧，右侧多于左侧，下肺多于上肺Right heart failure: acute pulmonary artery hypertension 右心衰：急性肺动脉高压Chronic pulmonary artery hypertension 慢性肺动脉高压Pulmonary infarction: more less 肺梗死,按栓子大小和部位可以分为,巨大肺栓塞 急性发作（几小时到24小时） 肺动脉干阻塞达50%以上或相当于两个或两个以上 的肺叶动脉阻塞 右心功能不全伴低血压或心源性休克 急性次大肺栓塞 不到两个肺叶动脉受阻 血压正常，可以出现右心功能不全 中等肺栓塞 肺段或亚肺段动脉栓塞 血压正常，无右心功能不全 小肺动脉栓塞 肺亚段及其分支栓塞 血压正常，无右心功能不全,Pathophysiology 病理生理学,Hemodynamic alternations 血流动力学变化Alternations in nervous and humoral mediators 神经体液介质变化Gas exchange alternations 气体交换变化,栓子堵塞肺动脉毛细血管前动脉压 肺循环阻力 肺血管床 肺动脉压 右心负荷 右心衰 ,血流动力学变化,肺血管內皮损伤 內皮素 血小板活化脫顆粒血管紧张素 二磷酸腺甘 5羟色胺 组织胺 前列腺素 血管收缩,神经体液介质变化,5-羟色胺, 血小板激活因子组织胺, 交感神神兴奋, 血栓素2支气管痉挛 肺血管通透性气道阻力 肺泡表面活性物质肺通气 肺萎缩, 肺不张 肺水肿, 肺出血呼吸困难,呼吸系统病理生理改变,PTE 栓塞部位 未栓塞部位 有通气无血流 高血流灌注 肺泡死腔 肺通气灌注比例失调,呼吸系统病理生理改变,Clinical Manifestations 临床表现,Symptoms 症状 Signs of respiratory and circulation system 呼吸系统和心脏体征Features of deep venous thrombsis 深静脉血栓的临床表现,Symptoms 症状,Dyspnea 呼吸困难Chest pain (pleuritic & angina-like) 胸痛Hemoptysis 咯血Cough 咳嗽Apprehension 烦躁不安Syncope 晕厥Abdominal pain 腹痛Fever 发热,Signs of respiratory system 呼吸系统体征,Tachypnea 16 breaths/min 呼吸急促Cyanosis 紫绀Wheezes/fine rales 哮鸣音/细湿罗音,Signs of circulation system 循环系统体征,Tachycardia (100 beats/min) 心率增快Arrhythmia 心律失常Accentuated S2 heart sound or splitted S2 heart sound 肺动脉瓣第二心音亢进或分裂Gallop rhythm 右心奔马律Jugular venous distention 颈静脉怒张Hepatomegaly 肝大Hypotension & shock 低血压和休克,Features of deep venous thrombsis深静脉血栓的临床表现,Leg swelling 下肢肿胀Leg pain 下肢疼痛Leg erythema 下肢红斑,Laboratory Testing & Special Testing实验室和特殊检查,General testing 一般检查Chest radiography 胸部X线片EKG 心电图Echocardiography 超声心动图Ventilation-perfusion scanning 通气/灌注扫描Spiral CT & CT angiography CT和CT 血管成像Pulmonary arteriography 肺动脉造影Examinations of DVT 深静脉血栓的检查,General testing 一般检查,A rise in counting of white blood cell, but less than 15x109/L 白细胞总数升高，但一般不超过15x109/LA rise in levels of ESR, LDH, CPK, AST, and FDP from pheraphe blood 血沉、血ESR, LDH, CPK, AST和 FDP升高,Arterial blood gas analysis血气分析,ABG?,PaO2 下降PaCO2 降低pH,A-a Gradient,Alveolar arterial oxygen gradient148-1.2(PaCO2) - PaO2Gradient 15-20 is considered abnormalDone at Room air 肺泡-动脉血氧分压差增大,D-Dimer D-二聚体,Fibrin degradation product 纤维蛋白降解产物Elevated in many circumstances: Malignancy, surgery, inflammation 很多疾病出现D-dimer升高Negative D-dimer combined with low pre-test probablilty has negative predictive value of 99% D-dimer诊断PTE的阴性预测值为99%,D-Dimer contd,Pts with higher likelihood of PE need more extensive w/u even if d-dimer is normal.A positive test does nothing to increase the certainty of diagnosis of PTE 阳性结果并不能确定诊断,心电图 EKG,If ECG abnormalities are present, they may be suggestive of PTE, but the absence of ECG abnormalities has no significant predictive value 心电图正常不能除外PTEOnly 20% of patients with proven PTE have any of these classic ECG abnormalities 20% 的PTE患者心电图异常,The most common EKG abnormalities in the setting of PE are tachycardia and nonspecific ST-T wave abnormalities 窦性心动过速和非特异性ST-T异常最常见The classic findings of right 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 fibrillation 肺性P波；电轴右偏；右束支阻滯； ,EKG with ,Chest radiography 胸部X线片,CXRUsually reveals a nonspecific abnormality. 14% normal 胸部X线片特异性差， 仅14%出现正常Classic abnormalities include:Westermarks Sign - focal oligemiaHamptons Hump - wedge shaped densityEnlarged Right Descending Pulmonary Artery (Pallas sign 典型X线片：Westermark征和Hampton征,Westermarks Sign,Hamptons Hump,PE which appears like a mass,PE with effusionand elevated diaphragm,超声心动图,右心室扩大间隔左移左心室变小，呈字形右心室运动减弱肺动脉增宽三尖瓣返流肺动脉高压,Ventilation-perfusion scanning 通气/灌注扫描,Useful if the results are normal or near normalAs many as 40% of pts with high clinical suspicion for PE and low probability scans have a PE on angiogram 正常灌注扫描可除外PTE,Ventilation-perfusion scanning 通气/灌注扫描,Spiral CT & CT angiography CT和CT血管成像,Pulmonary Angiogram,Most specific test available for diagnosis of PE Can detect emboli as small as 1-2 mmMost useful when the clinical likelihood of PE differs substantially from the lung scan result or when the lung scan is intermediate probability,肺动脉造影显示正常左肺动脉,Examinations of DVT 深静脉血栓形成的检查,Contrast venography: a gold standard 静脉造影：金标准Duplex ultrasonography 超声多普勒Impedance plethysmography 静脉阻抗图测定放射性核素静脉造影,Diagnosis & Differential diagnosis诊断和鉴别诊断,重视发病诱因血栓性静脉炎长期卧床下肢和盆腔静脉血栓不活动（乘机、乘车）慢性心肺疾病手术、创伤恶性肿瘤、肥胖症血液病、妊娠、服避孕药,重要的临床线索,胸闷原因不明的劳力性呼吸困难不能解释的低热原有疾病的突然变化心力衰竭对洋地黄制剂反应差下肢静脉的检查双侧下肢周径相差1 CM,重视必要的检查,D-dimer阴性可以除外PTE 以心电图、胸片、动脉血气、心 脏和下肢静脉超声提出拟诊,Diagnostic Procedure,Suspected PE,Low Clinical Suspicion,Intermediate or High clinical suspicion,D- Dimer Level,Abnormal,CT Angiography,Normal,PE Excluded,Other Diagnosis,PE,No PE,Consider US of lower Extremities Vein,临床上怀疑肺栓塞,正常灌注显像 肺通气/灌注显像 高度可能性 治疗,不需治疗,不能诊断,肺动脉造影,有肺栓塞,低血压和/低氧血症,双下肢检查（DUS、IPG CV、MRI）,不存在DVT或不能诊断,继续做下肢检查或CV,诊断DVT 治疗,无肺栓塞 不需要治疗,临床情况稳定,Differential Diagnosis鉴别诊断,PTE is known as “the great masquerader”USA, MIPneumonia, bronchitisCHFAsthmaCostochondritis, Rib Fx,PneumothoraxPTE can coexist with other illnesses!,Treatment 治疗,General treatment 一般治疗Anticoagulation 抗凝治疗Thrombolytic therapy 溶栓治疗Pulmonary embolectomy 手术治疗Inferior vena cava filters 下腔静脉滤器植入,肺栓塞的药物治疗,PaO26065mmHg 面罩或插管给氧 机械通气（避免血流动力学方面的副作用） 低潮气量（7mlKg） 低液体负荷抗休克治疗： 多巴胺(dopamine) 阿拉明(Aramine),作用：快速溶解血栓, 恢复肺再灌注 阻止慢性肺栓塞的发展，降低肺高压指征：大块PTE(超过2个肺叶血管) PTE伴休克，原有心肺疾病的次大块栓塞引 起循环衰竭時间窗：症状发作2周內 2周以上可能有效禁忌证：活动性内出血和近期脑出血并发症：出血，发热，过敏反应,溶栓治疗,溶栓方案,1. SK: 25万 IU/ 30min, 以10万 IU/ h 持续24h 2. UK: 4400 IU/Kg/10min, 以2200 IU/Kg/ h 持续 12h (国內UK 2万 IU/K