肺血栓栓塞症的诊断和治疗.ppt

肺血栓栓塞症的诊断和治疗,肺血栓栓塞症相关名词及定义,肺血栓栓塞症诊断与治疗指南（草案）中的有关名词肺血栓栓塞症(pulmonarythromboembolism,PTE)肺栓塞(pulmonaryembolism,PE)肺梗死(pulmonaryinfarction,PI)深静脉血栓形成(deepvenousthrombosis,DVT)静脉血栓栓塞症(venousthromboembolism,VTE)VTE=DVT+PTE其他相关名词遗传性易栓症、慢性血栓栓塞性肺动脉高压、经济仓综合征、肺动脉原位血栓形成、特发性肺动脉高压、家族性肺动脉高压、出血性肺不张其他类型肺栓塞气体栓塞、脂肪栓塞、羊水栓塞、粟粒性肺栓塞（肿瘤、虫卵）、其他（菌栓、药栓）,脂肪栓塞(fatembolismsyndrome,FES),定义：长管状骨骨折等严重创伤后脂肪滴阻塞肺循环或脑循环等其他微血管而引起的临床症候群。主要临床表现为呼吸衰竭、脑功能障碍及淤斑。病理生理：肺血管的机械性梗阻和肺间质的“生物化学性”炎症反应。,Fatembolismina58-year-oldwomanwhopresentedwithsuddendyspnea.Thepatienthadundergoneintramuscularinjectionofsomefattymaterialsintothebuttockseveraldaysearlier.,(a)Radiographshowsbilateralground-glassareasofincreasedopacity.,(b)Thin-section(1-mmcollimation)CTscanobtainedattheleveloftheaorticarchshowswidespreadpatchyground-glassattenuationandconsolidation.,羊水栓塞(amnioticfluidembolism,AFE),原因：妊娠期羊水中胎儿产物进入母体循环而引起。途径：分娩时羊水经宫颈内膜血管静脉撕裂部位;胎盘早剥和剖宫产时损及胎盘附着部位的静脉窦;子宫损伤或子宫撕列部位。病理生理：肺血管栓塞;变态反应;凝血机制障碍。,(a)Radiographshowsbilateralwidespreadairspaceconsolidation.Endotrachealintubationwasperformed.,AFEina40-year-oldwoman.Thepatientexperiencedsuddenrespiratorydistressshortlyaftergivingbirthbycaesareansection.,(b)Onafollow-upradiographobtained3dayslater,theextentoftheparenchymalareasofincreasedopacityhasdecreased.Achesttubewasinsertedintotherightpleuralspacetorelievetherightpleuraleffusion.,DVT-PTE的流行病学,发病率和患病率西方国家：DVT和PTE的年发病率分别为1.0和0.5美国：PTE年新发病例数650，000-700，000中国：阜外心血管病医院900例连续尸检：11.0（段以上PTE）易患因素年龄与性别、血栓性静脉炎、静脉曲张、心肺脑血管疾病、创伤、肿瘤、制动、妊娠和口服避孕药、遗传因素、肥胖、吸烟等,TableRiskFactorsforVTESurgeryTrauma(majororlowerextremity)Immobility,paresisMalignancyCancertherapy(hormonal,chemotherapy,orradiotherapy)PreviousVTEIncreasingagePregnancyandthepostpartumperiodEstrogen-containingoralcontraceptionorhormonereplacementtherapySelectiveestrogenreceptormodulatorsAcutemedicalillnessHeartorrespiratoryfailureInflammatoryboweldiseaseNephroticsyndromeMyeloproliferativedisordersParoxysmalnocturnalhemoglobinuriaObesitySmokingVaricoseveinsCentralvenouscatheterizationInheritedoracquiredthrombophilia,2004年9月ACCP第7次抗栓会议共识,TableAbsoluteRiskofDVTinHospitalizedPatients*PatientGroupDVTPrevalence,%Medicalpatients1020Generalsurgery1540Majorgynecologicsurgery1540Majorurologicsurgery1540Neurosurgery1540Stroke2050Hiporkneearthroplasty,hipfracturesurgery4060Majortrauma4080Spinalcordinjury6080Criticalcarepatients1080*RatesbasedonobjectivediagnostictestingforDVTinpatientsnotreceivingthromboprophylaxis.,2004年9月ACCP第7次抗栓会议共识,附表部分病种DVT-PTE的患病情况,国内资料,488例住院脑卒中患者,下肢DVT总体检出率21.7%.493例骨科住院患者(创伤394人,关节置换92人,脊柱损伤52人),下肢DVT总体检出率为25.5%.,DVT-PTE的诊断率犹如冰山一角，尚需各临床和医技功能科室的共同努力！,无声的杀手VTE,LowdiagnosticrateofPE,PTE的临床表现,病史VTE易患因素家族性症状体征,PTE的一般性检查,动脉血气分析：低氧、呼减ECG：窦速、SIQIIITIII,V3RV5R、V1的S波升支顿挫、粗钝和切迹，V1V3的T波倒置、ST段压低等等胸片心脏彩超：直接和间接征象深静脉超声D-二聚体（D-dimer）,PTE的ECG改变,PTE的ECG改变,case1takenonhospitaladmissionshowswell-marginatedopacitiesovertherightupperandmiddlelungzones,linearopacitiesovertherightlowerzone,andabluntedrightcostophrenicsulcus.,X线胸片(一),X线胸片(二),case2takenonhospitaladmissionshowsawedge-shaped,pleural-basedopacitywithitsapexdirectedtowardthehilumintheleftmid-lungzone,ahomogenousopacityoccupyingtheleftlowerzone,andbluntingoftheleftcostophrenicsulcus.,深静脉超声,PTE的确诊检查,肺动脉造影（PAA）CT肺动脉造影（CTPA）V/Q扫描磁共振肺动脉造影（MRPA）,肺动脉造影,CTPA(一),Incase1Thecontrast-enhancedspiralCTscanofthepatienttakenonhospitaladmissionrevealsintraluminalfillingdefectsinbothinterloberpulmonaryarteries,multiloculatedpleuraleffusions,andatelectaticareasintheleftlowerlobe.,CTPA(二),Incase2takenonhospitaladmissionrevealsanintraluminalfillingdefectintherightmainpulmonaryartery,multiloculatedeffusions,andatelectasisinboththeposteriorandparamediastinalregionsoftherightlung.,CTPA(三),CTVshowslargelow-attenuationthrombifillingtheleftcommoniliacvein(arrow).,CTPAshowsmultifocallow-attenuationemboli(arrows)insegmentalandsubsegmentalarteriesintherightlowerlobe.,CTscaninapatientwithCTEPHshowsapleurabasedwedge-shapedscarintherightupperlobecausedbypriorinfarction.,Lunginfarction,V/Q扫描,定性诊断：高度可能性大于或等于2个肺段灌注缺损，肺通气显像和X胸片均未见异常;或灌注缺损区大于异常的肺通气显像或X胸片；大于或等于2个亚肺段（或一个肺段）的肺灌注缺损，肺通气显像和X胸片无明显异常。中度可能性低度可能性,多发性肺栓塞,MRPA,Acutepulmonaryembolismina41-year-oldwoman.Coronalgadolinium-enhancedthree-dimensionalpulmonaryMRangiogramshowsalargeembolus(arrows)intheproximalrightinterlobarartery.,Chronicpulmonaryembolismina55-year-oldman.,(a)Chestradiographshowsenlargementofthecentralpulmonaryarteriesalongwithcardiomegaly.,(b)CTPAobtainedatthelevelofthebronchusintermediusshowseccentricthrombusalongthemedialmarginofthenarrowedrightinterlobarpulmonaryartery(arrows).,(c)V/Qscan(rightposteriorobliqueview)showsmultisegmentaldefects,whichdidnotmatchthefindingsseenonaventilationlungscanobtainedwithTc-99mTechnegas,(d)Pulmonaryarteriogramshowsabruptcutoffinroundedfashion(pouchingdefect)ofthelowerlobararteries(arrow).,(e)Photographshowsorganizedembolifillingtheenlargedcentralpulmonaryarteries.(arrows).,PTE的治疗,抗凝治疗溶栓治疗介入治疗,抗凝治疗,药物监测特殊情况下的抗凝治疗：妊娠和哺乳、围手术期、恶性肿瘤抗凝治疗的终止。,各种LMWH的推荐用法,依诺肝素钠（克塞）：100IU/kg,Q12h达肝素钠（法安明）：100IU/kg,Q12h那屈肝素钙（速避凝）：Q12h50kg,0.4ml;5059kg,0.5ml;6069kg,0.6ml;7079kg,0.7ml;8089kg,0.8ml;90kg,0.9ml.,BodyWeight-BasedDosingofIVHeparin（ACCP第六次抗栓会议共识）,GuidelinesforAnticoagulation:UnfractionedHeparin（ACCP第六次抗栓会议共识）,DurationofTherapy（ACCP第六次抗栓会议共识）,长期抗凝华法令,用法、监测、疗程、副作用常见影响华法令作用的药物和疾病：加强作用：乙胺碘呋酮、广谱抗生素、洛伐他汀、流感疫苗、奥美拉唑、扑热息痛、甲硝唑和甲状腺激素等；甲亢、老年、心衰、肝病、发热、维生素K缺乏、恶性肿瘤等。抑制作用：巴比妥类、口服避孕药、利福平和肾上腺皮质激素等；甲减、肾病综合征和遗传性华法令耐药等。,抗凝治疗的紧急终止,肝素：半衰期1.5小时，硫酸鱼精蛋白1mg可中和不少于100u的肝素，通常只需半量。华法令：半衰期约42小时，维生素K115mg口服或静注，24小时内能终止抗凝。紧急情况输新鲜冰冻血浆或补充维生素K依赖性凝血因子。LMWH：半衰期约6小时，每0.6mg鱼精蛋白可中和速避凝0.1ml,溶栓治疗,适应症溶栓方案：尿激酶12小时溶栓方案、重组组织型纤溶酶原激活剂2小时溶栓方案等其他问题：DVT、咯血、二次溶栓、妊娠、症状性PTE护理,介入治疗,适应症与并发症；方案的选择；腔静脉滤器的应用。肺动脉导管溶栓机械破碎滤器置入,左肺动脉栓子去除,下腔静脉滤网,CTEPHContrast-enhancedCTscaninapatientwithCTEPHshowsbronchialarterycollaterals.NotethattheenlargedmainpulmonaryarteryhasalargerdiameterthantheAO.,谢谢！,PulmonaryHypertention,WANGJinxiang,RespiratoryDepartmentofBeijingLuheHospital,PulmonaryHypertention,ClassificationFunctionalClassificationDiagnosticPrecedureTherapy,Classification,2003,VinicePulmonaryarterialhypertension(PAH)PulmonaryhypertensionwithleftheartdiseasePulmonaryhypertensionassociatedwithlungdiseaseand/orhypoxPulmonaryhypertensionduetochronicthromboticand/orembolicdiseaseMiscellaneous,Pulmonaryarterialhypertension(PAH)1.1.Idiopathic(IPAH)1.2.Familial(FPAH)1.3.Associatedwith(APAH):1.3.1.Collagenvasculardisease1.3.2.Congenitalsystemic-to-pulmonaryshunts1.3.3.Portalhypertension1.3.4.HIVinfection1.3.5.Drugsandtoxins1.3.6.Other(thyroiddisorders,glycogenstoragedisease,Gaucherdisease,hereditaryhemorrhagictelangiectasia,hemoglobinopathies,myeloproliferativedisorders,splenectomy)1.4Associatedwithsignificantvenousorcapillaryinvolvement1.4.1Pulmonaryveno-occlusivedisease(PVOD)1.4.2Pulmonarycapillaryhemangiomatosis(PCH),Pulmonaryhypertensionwithleftheartdisease2.1.Left-sidedatrialorventricularheartdisease2.2.Left-sidedvalvularheartdisease,Pulmonaryhypertensionassociatedwithlungdiseaseand/orhypoxemia3.1.Chronicobstructivepulmonarydisease3.2.Interstitiallungdisease3.3.Sleep-disorderedbreathing3.4.Alveolarhypoventilationdisorders3.5.Chronicexposuretohighaltitude3.6.Developmentalabnormalities,Pulmonaryhypertensionduetochronicthromboticand/orembolicdisease4.1.Thromboembolicobstructionofproximalpulmonaryarteries4.2.Thromboembolicobstructionofdistalpulmonaryarteries4.3.Non-thromboticpulmonaryembolism(tumor,parasites,foreignmaterial),MiscellaneousSarcoidosishistiocytosis-XLymphangiomatosiscompressionofpulmonaryvessels(adenopathy,tumor,fibrosingmediastinitis),FunctionalClassification（WHO,2004,Chest）,ClassI:PatientswithPHwithoutlimitationofusualactivityClassII:PatientswithPHwithslightlimitationofusualphysicalactivityClassIII:PatientswithPHwithmarkedlimitationofusualphysicalactivityClassIV:PatientswithPHwithinabilitytoperformanyphysicalactivitywithoutsymptomsandwhomayhavesignsofrightventricularfailure,A.NewYorkHeartAssociationfunctionalclassification*Class1:Nosymptomswithordinaryphysicalactivity.Class2:Symptomswithordinaryactivity.Slightlimitationofactivity.Class3:Symptomswithlessthanordinaryactivity.Markedlimitationofactivity.Class4:Symptomswithanyactivityorevenatrest.B.WorldHealthOrganizationfunctionalassessmentclassificationClassI:PatientswithPHbutwithoutresultinglimitationofphysicalactivity.Ordinaryphysicalactivitydoesnotcauseunduedyspneaorfatigue,chestpain,ornearsyncope.ClassII:PatientswithPHresultinginslightlimitationofphysicalactivity.Theyarecomfortableatrest.Ordinaryphysicalactivitycausesunduedyspneaorfatigue,chestpain,ornearsyncope.ClassIII:PatientswithPHresultinginmarkedlimitationofphysicalactivity.Theyarecomfortableatrest.Lessthanordinaryactivitycausesunduedyspneaorfatigue,chestpain,ornearsyncope.ClassIV:PatientswithPHwithinabilitytocarryoutanyphysicalactivitywithoutsymptoms.Thesepatientsmanifestsignsofright-heartfailure.Dyspneaand/orfatiguemayevenbepresentatrest.Discomfortisincreasedbyanyphysicalactivity,Classification（ContrastofNYHAandWHO）,Hemodynamicclassification,Mild:mPAP2635mmHgModerate:mPAP3645mmHgsevere:mPAP46mmHg,EssentialEvaluationContingentEvaluationHistoryandphysicalexamination；TransesophagealechoChestx-ray；EchowithbubblestudyElectrocardiogram；CTchesthighresolutionPulmonaryfunctiontesting；PulmonaryangiogramVentilation-perfusionscan；ArterialbloodgasTranstho