肺栓塞的诊治课件

1、肺动脉栓塞的诊治制作XGHRH敬请指正肺动脉栓塞的诊治制作敬请指正基本概念肺栓塞是以各种栓子阻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，包括肺血栓栓塞症，脂肪栓塞综合征，羊水栓塞，空气栓塞等。肺血栓栓塞症为来自静脉系统或右心的血栓阻塞肺动脉或其分支所致疾病。肺梗死为肺动脉发生栓塞后，其支配区的肺组织因血流受阻或中断而发生坏死。基本概念肺栓塞是以各种栓子阻塞肺动脉系统为其发病原因的一组疾肺栓塞的现状发病率高：仅次于CAD和HBP。易漏诊及误诊：警惕性不高，漏诊率高。不经治疗死亡率高：达20%-30%。明确诊疗者死亡率明显下降：可降至2-8% 。 肺栓塞的现状发病率高：仅次于CAD和H

2、BP。EpidemiologyThere is no accurate data for pulmonary embolism because we has limit knowledge of it. In the United States, it is responsible for about 2.3 new cases per 10,000 persons and 50,000 deaths every year.EpidemiologyThere is no accura流行病学Arch.Intern.Med.154:861,1994流行病学Arch.Intern.Med.154:

3、861,19生存率比较Arch.Intern.Med.154:861,19941.0123生存率比较Arch.Intern.Med.154:861,1Risk Factors for DVT/Pulmonary Embolism （Essential）抗凝血酶缺乏蛋白C缺乏先天性异常纤维蛋白原血症V因子基因突变血栓调节蛋白纤溶酶原缺乏高半胱氨酸血症异常纤溶酶原血症抗心肌碱脂抗体蛋白S缺乏纤溶酶原激活抑制剂过量因子缺乏前凝血酶20210A突变Risk Factors for DVT/PulmonaryRisk Factors for DVT/Pulmonary Embolism （Second）

4、创伤/骨折外科手术卒中制动高龄恶性肿瘤+化疗中心静脉导管肥胖慢性静脉机能不全心力衰竭吸烟长途旅行妊娠/产后期口服避孕药克隆病、狼疮抗凝剂肾病综合征假体表面粘滞性过高血小板异常Risk Factors for DVT/Pulmonary深静脉血栓形成原因 分类血流滞缓小腿肌肉静脉丛血栓形成髂股静脉血栓形成静脉壁损伤原发性髂肌静脉血栓形成继发性髂股静脉血栓形成高凝状态股青肿深静脉血栓形成原因 分类血流滞缓小腿肌肺血栓与深静脉血栓肺血栓与深静脉血栓肺栓塞的大体解剖观肺栓塞的大体解剖观肺栓塞的显微镜下观肺栓塞的显微镜下观肺栓塞的病理生理肺血管阻塞，神经体液因素或肺动脉压力感受器的作用，引起肺血管阻力增

5、加；肺血管阻塞肺泡死腔气体交换肺泡通气低氧血症V/Q单位气体交换面积二氧化碳刺激性受体反射性兴奋（过度换气）支气管收缩，气道阻力增加肺水肿、肺出血、肺泡表面活性物质减少，肺顺应性降低。肺栓塞的病理生理肺血管阻塞，神经体液因素或肺动脉压力感受器的肺栓塞后右心功能不全的病生肺栓塞冠状动脉灌注右心室氧需右心室壁张力右心室排血量右心室氧供左心室排血量肺动脉压力右心室后负荷解剖阻塞 神经体液作用右心室扩张/功能不全 右心室缺血室间隔移向左心室低血压体循环灌注左心室前负荷肺栓塞后右心功能不全的病生肺栓塞冠状动脉灌注右心室氧需肺栓塞后肺血流动力学变化 前毛细血管高压 血管床减少 支气管收缩 小动脉血管收缩

6、侧支血管的形成支气管-肺动脉吻合形成 肺内动静脉分流 血流改变： 血流重分布 Westermark征肺栓塞后肺血流动力学变化Westermark征呼吸动力学改变 过度通气： 肺动脉高压 顺应性下降 肺不张 气道阻力增加 ： 局限性低碳酸血症 化学介质 呼吸动力学改变临床分型大面积PE(massive PE)：休克和低血压；动脉收缩压1.5mm、avF有Qs波，但无Qs波QRS轴900或不确定肢导联低电压、avF的T波倒置或V1V4T波倒置心电图表现不完全性或完全性右束支传导阻滞图12000年8月27日（急诊）ECG大致正常2000年8月29日（门诊）ECG示IRBBB SQTV1V2T波倒置V

7、3V4T波双向图12000年8月27日（急诊）ECG大致正常2000年8月Ventilation/Perfusion Lung ScanVentilation/Perfusion Lung ScaTHANK YOUSUCCESS2022/10/436可编辑THANK YOUSUCCESS2022/10/33PIOPED：肺扫描分类与肺动脉造影结果的比较肺扫描肺栓塞肺动脉造影阴性总数有无不肯定高度可疑1021417124中度可疑105217933364低度可疑391991262312接近正常/正常550274131总计25148024176931J Nucl Med 1993; 34: 1119

8、PIOPED：肺扫描分类与肺动脉造影结果的比较肺扫描肺栓塞肺肺扫描怀疑PE的患者约25可因肺灌注正常而否定诊断，而且不用抗凝治疗可能是安全的怀疑PE的患者约25具有高度的肺扫描结果，他们可能需要行抗凝治疗其余的患者需要进一步的诊断性检查，而这些检查是更广泛的诊断策略肺扫描怀疑PE的患者约25可因肺灌注正常而否定诊断，而且不典型肺栓塞 典型肺栓塞 不典型肺栓塞不典型肺栓塞It is high sensitivity but low specificity The differential diagnosis for a ventilation perfusion mismatch include

9、s: acute pulmonary embolus previous pulmonary embolus congenital vascular abnormalities vasculitis, bronchogenic carcinoma, radiation therapy,et al.It is high sensitivity but lowWhen a ventilation/perfusion scan does not fit into either the normal or high probability category, then we consider the s

10、tudy to be non-diagnostic and further investigation is required. The majority of cases fall into this category which is characterized by scans with subsegmental defects or defects of any size that match abnormalities on the chest x-ray or the perfusion scan. When a ventilation/perfusion A low probab

11、ility category has been suggested by a number of authors. However, as we can see from the PIOPED data this is not a particularly reliable category. Disagreement among experienced readers is common when perfusion defects are small and limit the utility of this category. This study was originally read

12、 as showing a small subsegmental defect. Without the arrow, this study has subsequently been called normal by a number of experienced readersA low probability category hasConclusionLung scans are sensitive exams that essentially rule out the diagnosis of pulmonary embolus when they are normal. Patie

13、nts with high probability lungs can often be treated without further workup. Those patients with non-diagnostic studies require further diagnostic investigation. ConclusionLung scans are sensCT of Pulmonary EmbolismPulmonary infarcts are more readily identified on CT. Modern CT scanners now have fas

14、ter acquisition times and are providing a detailed assessment of the lung parenchyma that is not available from the chest radiograph. The typical appearance of a pulmonary infarct on CT includes a pleural based density with convex borders and a linear strand at the apex of the triangle CT of Pulmona

15、ry EmbolismPulmoThe apex of the triangle is often truncated and not wedge shaped which corresponds to the normal configuration of a secondary lobule in the lung periphery. Low attenuation areas within the infarct represents viable lung. It is important to note, however, that this appearance is not s

16、pecific for pulmonary infarction. The differential diagnosis for this abnormality includes infarct, hemorrhage, pneumonia, fibrosis, neoplasia and edemaThe apex of the triangle is ofSince the clinical presentation of pulmonary embolus is usually non-specific, the findings on CT are often the first c

17、linical indication that the patient may be suffering from pulmonary embolus. In addition to visualizing the area of infarction we are often able to see the clot itself. Since the clinical presentatiCT has been show to be especially useful in the assessment of patients with chronic dyspnea and known

18、pulmonary artery hypertension. These patients are often difficult to diagnose as is exemplified by this patient with known sclerodema and pulmonary artery hypertension whose CT unexpectedly showed a large calcified clot in the right pulmonary artery. CT has been show to be especi肺动脉造影正常肺动脉肺动脉造影正常肺动脉

19、This selective study was done because of a perfusion defect in the left lower lobe on a ventilation perfusion scan. The first angiographic study was inconclusive. Therefore, a subselective study was done that demonstrated the clot with certainty. This selective study was done The most reliable signs

20、 of pulmonary embolus are: An Intraluminal filling defect An Abrupt termination of a branch vessel The most reliable signs of pulConclusionAngiography is most accurate in segmental and larger sized arteries. The reproducibility of readings is subsegmental and smaller vessels is poor. Angiography is

21、a safe procedure that is most accurate when imaging emboli that lodge in segmental or larger arteries. ConclusionAngiography is most The Diagnosis Algorithm Plasma D-Dimer AssayNormal to Near-NormalLow or Intermediate ProbabilityHigh ProbabilityClinical AssessmentLow ProbabilityIntermediate or High

22、ProbabilityAngiographyPositiveNegative 500mg/L 500mg/LUltrasonogramNo DVTDVTLung ScanThe Diagnosis Algorithm PlasmaInterpretation CriteriaHigh Probability (80-100% likelihood for PE ):Greater than or equal to 2 large mismatched segmental perfusion defects or the arithmetic equivalent in moderate or

23、large and moderate defects. Intermediate Probability (20-80% likelihood for PE ):1. One moderate to 2 large mismatched perfusion defects or the arithmetic equivalent in moderate or large and moderate defects. 2. Single matched ventilation-perfusion defect with a clear chest radiograph . 3. Difficult

24、 to categorize as low or high, or not described as low or high. 4. Nonsegmental perfusion defects (e.g., cardiomegaly, enlarged aorta, enlarged hila, elevated diaphragm). 5. Multiple matched V/Q abnormalities, even when relatively extensive, are low probability for PE . The prevalence of PE in patie

25、nts with extensive matched V/Q defects and no CXR abnormality was 14% (low probability). J Nucl Med 1995; 36: 2380-2387Interpretation CriteriaHigh PLow Probability (0-19% likelihood for PE ) Perfusion defects matched by ventilation abnormality provided that there are: (a) clear chest radiograph and

26、(b) some areas of normal perfusion in the lungs. Extensive matched V/Q abnormalities are appropriate for low probability, provided that the CXR is clear.Any perfusion defect with a substantially larger chest radiographic abnormality. Any number of small perfusion defects with a normal chest radiogra

27、ph. J Nucl Med 1995; 36: 2380-2387Low Probability (0-19% likelihDiagnostic Criteria for Clinically Suspected Pulmonary EmbolismPulmonary embolism absentNegative pulmonary angiogranNormal or near-normal lung scanD-dimer level50女/男比例4：11：1临床经过进行性恶化稳定一段时间后恶化肺灌注扫描无节段性灌注缺损节段性或大片灌注缺损肺动脉收缩压60mmHg50女/男比例急性P

28、E的治疗一般处理：送入监护病房，加强生命体征的监护防止栓子脱落，绝对卧床情感支持对症治疗：如咳嗽、发热等急性PE急性PE的治疗一般处理：急性PE呼吸循环支持治疗一般患者均采用经鼻导管或面罩吸氧治疗低氧血症无创伤性或经气管插管机械通气治疗呼吸衰竭，避免气管切开。尽量减少正压通气对循环的不种影响。急性PE呼吸循环支持治疗一般患者均采用经鼻导管或面罩吸氧治疗低氧血症溶栓治疗的适应证栓塞面积超过2个肺叶血管者合并休克或低血压者合并右心功能不全者排除禁忌证者急性PE溶栓治疗的适应证栓塞面积超过2个肺叶血管者急性PE溶栓禁忌证绝对禁忌证活动性内出血近期的自发性颅内出血相对禁忌证大手术、分娩、器官活检或不能

29、压迫的血管穿刺史（10天内）2月内缺血性中风10天内胃肠道出血15天内严重外伤1月内神经外科或眼科手术控制不好的重度高血压近期心肺复苏血小板100000/mm3，PT50%怀孕细菌性心内膜炎糖尿病出血性视网膜病变溶栓禁忌证绝对禁忌证活动性内出血近期的自发性颅内出血肺动脉栓塞的溶栓及抗凝治疗12小时溶栓法：4400u/Kg尿激酶溶于100ml于不少于10分钟静推2200u/Kg尿激酶溶于250ml用12小时维持每46小时监测APTT，当其降到正常2倍时，加用低分子肝素钙（0.1ml/10Kg，每天二次，皮下注射)同用华法令，35天后监测INR，当重复为1.52倍二天时，停用低分子肝素，维持剂量华法令6周6月，同时监测INR2小时溶栓法：尿激酶2万u/Kg溶于250ml用2