OVERVIEW Pulmonary Embolism (PE) or Venous thromboembolism (VTE) is a condition in which a sudden blockage in the arteries of the lungs.

The culprit for this blockage is usually due to a blood clot that has traveled from the vein in leg to the lungs. PE is a very serious condition and if undetected can damage the lungs, other body organs and cause death. Pulmonary is closely linked with another condition called Deep vein thrombosis (DVT). DVT is a blood clot that forms in a vein in the leg or lower. When blood begins to thicken and clumps together is called a blood clot. Lucignani & Pistolesi reports, Pulmonary embolism (PE) has an annual incidence rate of 23-69 per 100,000 population and is the third most common cause of cardiovascular death(522). PATHOLOGY CONDITION Pulmonary Embolism is not a disease; it is a condition that usually develops as a blood clot within the deep vein located in the thigh or lower leg. There are risk factors that have been linked to this condition for instance if patients are immobile for long periods or if a patients suffers from deep venous thrombosis (DVT) in their legs and left undetected. Patients currently suffering from kidney disease or failure increases your risk at become a PE candidate. In an article written by Carol Headley and Shelia Melander discuss the likelihood of patients with chronic kidney disease, Not only do patients with kidney disease have a higher incidence of VTE and pulmonary embolism, but the risk is further delineated to include an increased incidence for development of massive pulmonary embolism. Kidney dysfunction has been recognized to be one of the three co-morbidities (kidney disease, congestive heart failure, and reduced left ventricular systolic ejection fraction) associated with development of massive pulmonary embolism (Headley & Melander 128). Although very rare there have been cases that link oral contraceptive pills to PE. I personally know of a patient recently diagnosed with PE from continuous use of oral contraceptive pills. Unfortunately I am not allowed to discuss their medical history. The Clinical and Applied Thrombosis/Hemostasis presented a rare case of a young woman taking oral contraceptives pills for less than 2 months and diagnosed to have massive deep venous thrombosis and bilateral pulmonary embolism( Charafeddine et al. 594). SIGNS & SYMPTOMS The signs & symptoms for PE are more objective than subjective. Patients usually experience dyspnea (shortness of breath), chest pains (patients claims the pains are similar to having a heart attack or they experience tightness), and continuous cough as though they are not gathering enough air or the may began coughing up blood. Potential PE candidates could also experience asthmatic symptoms such as wheezing or develop swelling in one leg a result of DVT. They could also experience a light cyan skin coloring and paroxysmal tachycardia. For some patients depending on pre-existing disorders or illnesses patients can experience light-headedness or fainting. DIAGNOSIS PE and DVT cannot be tested off one diagnostic test alone. Many tests must be run to rule of other diseases or disorders. The type of Diagnostic test ran depends on the signs and symptoms displayed on the patient and what diagnostic equipment is available. There are other signs PE but for most patients the signs go unrecognized by physicians Despite decades of exploration of new diagnostic methods and treatments, PE is

still often missed because affected patients present with non-specific signs and symptoms (Lucignani, Pistolesi 522). Electrocardiogram An electrocardiogram is a painless test that checks the electrical activity of your heart.

Chest X-Ray This diagnostic test is used to photograph the heart, lungs, arteries, ribs, etc. This method is used when the patient is experiencing dyspnea. To rule out any other disorders that share similar characteristics as PE, Cloutier explains A normal film in patients with severe, acute dyspnea without wheezing is very suspicious for PE. The CXR is more helpful in excluding other conditions that mimic PE, such as pneumothorax, pneumonia, left-sided heart failure, tumor, rib fracture, massive pleural effusion and lobar collapse (346). In reviewing the CXR, radiologists look for the presence of the Pallas sign, Westermark sign or the Hamptons Hump. The Pallas sign is when the right descending pulmonary artery is enlarged. The Westermark sign show large emboli affect the arrangement of the blood vessels within a lobe or the entire lung. The Westermark sign is also present when a patient has pulmonary embolus due to damage of a lung. The Hamptons Hump is a hollow wedge-shaped obscurity located towards the edge of the lung pointing toward the Hilum. Arterial Blood Gas (ABG) The arterial blood gas is a test used by Pulmonologists, where a small amount of blood is extracted from an artery. The test measures arterial oxygen tension, carbon dioxide tension, arterial oxyhemoglobin and the acidity. It is also use to check the gas exchange across the alveolar capillary membrane. In establishing a PE diagnoses the Arterial Blood Gas test should be done, Cloutier explains, Characteristic changes associated with PE include a reduced arterial oxygen pressure and an arterial carbon dioxide pressure that is normal or reduced because of hyperventilation. Arterial oxygen pressure may be normal in a patient with a minor pulmonary embolus but is almost never normal in patients with massive pulmonary emboli when more than 50% of the pulmonary circulation is obstructed suddenly (Cloutier, 345).

Diagnostic Imaging
Ventilation/Perfusion Scan or (V/Q) Scan Lung Ventilation A scan used to detect the ventilation in the small airways by having the patient inhale a radioactive gas or aerosol. Perfusion Scan A scan used to detect the oxygen and blood flow through the lungs with the assistance of a radioactive substance. V/Q scanning is an indirect study of embolism because it shows perfusion abnormality. defects in tracer uptake when inhaled into the lungs are reported as normal, near normal or indication low moderate or high probability for PE(Cloutier,346). Pulmonary Angiography This type of test requires trained specialist and may not be readily available in all of the hospitals. With this test a catheter is thread through to the thigh or arm to reach the blood vessels within the lungs. A contrast dye is injected through the vessels. The specialist takes x-ray photographs that later reveal the blood flow through the vessels in the lungs. The catheter will be use to remove the clot or clots if found in the blood vessels. In a article written by Cloutier she states, Pulmonary angiogram is considered the gold standard for the diagnosis of PE to which sensitivity and specificity of all other radiographic methods for diagnosis of PE have been compared (347). This test should be run only if all other image tests are inconclusive.

Spiral Computed Tomography Angiography (CTA) A new technique for vascular imaging that provides better accuracy in angiography with minimum risks to the patients. For this device the patient lies within a x-ray tube and the spiral CT scanner rotates continuously at a constant rate gathering the data using high resolution and delivered in cross sectional images. High-resolution helical (spiral) CT angiography is gaining wide acceptance as first-line imaging for the detection of PE. The sensitivity and specificity of the test may be as high as 100%. Following the injection of contrast, the entire chest can be scanned for abnormalities (Cloutier, 347). Chest Computed Tomography Angiogram The Chest Computed Tomography Angiogram is a test used by Radiologist to examine the blood vessels located across the chest. The test involves injecting a contrast material through a catheter along with MRI and CT to view pictures of the major blood vessels throughout the body. Its used to identify aneurysms in the aorta, detect disease in the arteries to the kidneys and in this case examine pulmonary arteries in the lungs to detect Cloutier states in her review, PE. PIOPED II studied patients with suspected PE and concluded that CT angiography was as accurate as invasive pulmonary angiography for the diagnosis of acute PE (Cloutier, 347). Ultrasound When attempting to look for blood clots in the legs, physicians will most likely choose the Ultrasound. This is to check the blood flow in your vein. TREATMENT Medicines The medications use to treat patients with Pulmonary Embolism includes: Anticoagulants Anticoagulants are used when attempting to prevent coagulation. Tapson comments, Anticoagulants clearly improves survival among patients with symptomatic pulmonary embolism, but the risk of recurrent, nonfatal venous thromboembolism is estimated at 5% to 10% during the first year after diagnosis (TapsonV, 1038). The current available anticoagulants are heparin and warfarin. Heparin is given to patients when they require immediate response to preventing the clotting. This particular drug is usually delivered directly with a needle. Warfarin is another drug used to kill rats, prevent clotting or prevent further expansion of clotting. This particular drug in delivered orally in a pill. It usually takes a few days for this drug to take effect. Clot dissolvers Clot dissolvers are used when attempting to dissolve clots quicker. These particular drugs are used for life threatening cases because the risk factors in using this drug can cause sudden and severe bleeding. Vena cava filter There are cases where surgical procedures can be used to treat Pulmonary Embolism; the vena cava filter method is one option. By inserting a filter with the use of a catheter into the inferior vena cava towards your heart this filter can catch and prevent any blood clots from moving through the blood stream toward the lungs. The filters installed can be installed permanently or retrievable if the patient is no longer in danger of clots. Clot removal This procedure is for patients that have very large clots in their lungs and they are going into shock. A thin catheter can be threaded through the blood vessels and the clot suctioned out. Attempting to remove a clot this way is not only difficult but it isnt always successful.

Thrombolytic Therapy This procedure is similar to the clot removal on instead of suctioning out the clot the physician injects a clot dissolver into the blood vessels directly or through a catheter. This method should only be used if patient experiences cardiogenic shock due to pulmonary embolism.

PROGNOSIS The end result for patients with pulmonary embolism is determined by the size and number of clots found within the arteries and their cardiopulmonary status. Although PE is a potentially fatal, if detected in time the patients recovery from PE is good, according to Tapson, the 3-month overall mortality rate has been reported to be about 15 to 18 %( 1042). Patients that have pre-existing illnesses such as kidney disease, heart disease or lung disease will pose a problem in detecting PE. By the time the patients experience decline in pulmonary or cardic outputs over 50% of their arteries could be obstructed. According to Tracy Cardin, A higher risk of mortality, 25% was noted among patients with cancer and recurrent pulmonary embolismpatients who are hospitalized for a medical condition other than pulmonary embolism, and are subsequently diagnosed with pulmonary embolism during hospitalization, have a higher fatality rate(32% vs 15%) than those admitted with a primary diagnosis of PE(311).

Lucignani G, Pistolesi M. Diagnosing pulmonary embolism: clinical problem or methodological issue?. European Journal Of Nuclear Medicine & Molecular Imaging [serial online]. March 2009;36(3):522-528. Available from: Health Source: Nursing/Academic Edition, Ipswich, MA. Accessed February 25, 2012. Cloutier L. Diagnosis of Pulmonary Embolism. Clinical Journal Of Oncology Nursing [serial online]. June 2007;11(3):343-348. Available from: Health Source: Nursing/Academic Edition, Ipswich, MA. Accessed February 25, 2012. Chavan A., Galanski M., Olbricht C.J., Prokop M. Spiral CT Angiographycan we forget about arteriography to diagnose renal artery stenosis? Nephrol Dial Transplant. 1996 : 11 Editorial Comments; 1227-1235. Available from: Nephrology Dialysis Transplantation/ Oxford University Press Accessed March 5, 2012. Headley C, Melander S. When It May Be a Pulmonary Embolism. Nephrology Nursing Journal [serial online]. March 2011;38(2):127-152. Available from: Health Source: Nursing/Academic Edition, Ipswich, MA. Accessed February 25, 2012. Charafeddine K, Mahfouz R, Ibrahim G, Taher A, Hoballah J, Taha A. Massive pulmonary embolism associated with Factor V Leiden, prothrombin, and methylenetetrahydrofolate reductase gene mutations in a young patient on oral contraceptive pills: a case report. Clinical And Applied Thrombosis/Hemostasis: Official Journal Of The International Academy Of Clinical And Applied Thrombosis/Hemostasis [serial online]. October 2010;16(5):594-598. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed March 6, 2012. Tapson V. Acute Pulmonary Embolism. New England Journal Of Medicine [serial online]. March 6, 2008;358(10):1037-1052. Available from: Health Source: Nursing/Academic Edition, Ipswich, MA. Accessed February 25, 2012. Cardin T, Marinelli A. Pulmonary embolism. Critical Care Nursing Quarterly [serial online]. October 2004;27(4):310-324. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed March 7, 2012.