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Pulmonary Embolism:

an update management

อดิศร วงษา
รพ.พระมงกุฎเกล้ าฯ

ราชวิทยาลัยอายุรแพทย์วิชาการสัญจรจังหวัดอุบลราชธานี 2558
Topic to cover
What is pulmonary embolism?
Pathophysiology
Clinical manifestation
Investigation
Strategies management
Thai data
Summary
What is pulmonary embolism?

https://en.wikipedia.org/wiki/Pulmonary_embolism
Endothelial damage
Dysfunction
• Smoking Stasis
• Hypertension Immobilization
Injury
Polycythemia
• Surgery Virchow’s
• Trauma triad
• Catheter Hypercoaulability
Heriditary
• Factor V Leiden
• Antithrombin def
• Protien C //S def
Acquired
Rudolph Virchow • Cancer
• ChemoRx
• OCR/HRT
• pregnancy
Hemodynamic Mechanical
Main vessel
consequence occlusion
Virchow’s RV afterload segmental
triad vessel
Peripheral Chemical
vessel mediators
DVT Pleuritic CP

Reflex
bronchoconstriction
Pulmonary
embolism
V/Q
mismatch

Hypoxemia
Clinical manifestation
Pulmonary embolism (PE) has a wide variety
of presenting features, ranging from no
symptoms to shock or sudden death.
Dyspnea at rest or with exertion (73 %)
Pleuritic pain (44 %)
Cough (37 %)
Orthopnea (28 %)
Calf or thigh pain and/or swelling (44 %)
Wheezing (21 %)
Hemoptysis (13 %)
Clinical signs
Common presenting signs on examination include :
Tachypnea (54 %)
Calf or thigh swelling, erythema, edema,
tenderness, palpable cords (47 %)
Tachycardia (24 %)
Rales (18 %)
Decreased breath sounds (17 %)
Lound P2(15 %)
Jugular venous distension (14 %)
Fever, mimicking pneumonia (3 %)
Circulatory collapse is uncommon (8 %)
Hemodynamically unstable and stable
PE (massive or submassive)
Hemodynamically unstable PE is that which results in
hypotension.
Hypotension is defined as a SBP <90 mmHg for a period >15
minutes or that requiring vasopressors or inotropic support
and not explained by other causes
Hemodynamically stable PE is defined as PE that does not
meet the definition of hemodynamically unstable PE.
There is a spectrum of severity within this population
ranging from patients who present with small asymptomatic
PE to those who present with mild or borderline hypotension
that stabilizes in response to fluid therapy, or those who
present with right ventricle dysfunction (also known as
“intermediate” PE).
Approach to suspicious of PE
Hemodynamically stable, we suggest an approach
which combines clinical and pretest probability
assessment, D-dimer testing, and definitive
diagnostic imaging
Definitive imaging includes CT PA and V/Q
scanning
Hemodynamically unstable and in whom
definitive imaging is unsafe, bedside
echocardiography may be used to obtain a
presumptive diagnosis of PE
Chest radiography
EKG
Echocardiography

S D
V/Q scan
CTPA
U/S leg

Short axis Power Doppler image showing the right common femoral artery (RCFA) and the
non-compressible right femoral vein (RCFV), surrounded by hypoechogenic tissue
consisting of perivascular hematoma, at first suspected to represent deep vein thrombosis
(DVT).
Lønnebakken et al. Cardiovascular Ultrasound 2009 7:14
Head drop sign

How sick of this pt.?


Key factors contributing to haemodynamic collapse in acute pulmonary embolism
Clinical probability
of PE
0 points = 30-day
mortality risk 1.0%
(95% CI 0.0%–2.1%)
≥1 point(s) = 30-day
mortality risk 10.9%
(95% CI 8.5%–13.2%)

Class I: ≤65 points


very low 30-day mortality risk (0–1.6%) Class IV: 106–125 points
Class II: 66–85 points high mortality risk (4.0–11.4%)
low mortality risk (1.7–3.5%) Class V: >125 points
Class III: 86–105 points very high mortality risk (10.0–24.5%)
moderate mortality risk (3.2–7.1%)
Clinical
suspicious of PE

III-V
 suspectedhigh-risk acute PE (presence of shock or hypotension), emergent
computed tomography (CT) angiography or bedside transthoracic
echocardiography is recommended for diagnostic purposes (Class I).
Pulmonary angiography may be considered in unstable patients referred
directly to a catheterization laboratory to exclude acute coronary
syndromes (Class IIb).
 suspectedacute PE without shock or hypotension, use of a validated risk
stratification scheme (e.g., Modified Well’s or Revised Geneva scores) should
be employed (Class I).
 If
pretest probability is low or intermediate, D-dimer test should be used in
outpatient and emergency department settings (Class I). Low pretest
probability and a negative D-dimer test excludes acute PE (Class I). D-dimer
testing is not recommended in patients with a high pretest probability for
acute PE (Class III).
 NormalCT angiography excludes PE in patients with low or intermediate
pretest probability (Class I). Normal perfusion lung scintigram (V/Q scan)
excludes acute PE (Class I).
 Lower limb compression ultrasound with a proximal deep venous thrombosis
(DVT) in a patient with a clinically suspected PE confirms the diagnosis of
acute PE (Class I).
 acutePE patients without shock or hypotension, use of the PESI or sPESI score
can be considered to distinguish between low- and intermediate-risk PE
(Class IIa). Similarly, assessment of the right ventricle with echocardiography
or CT, along with assessment of myocardial injury (usually troponin testing),
can be considered for further risk stratification (Class IIa).
 patients with high-risk acute PE (shock or hypotension), initial therapy
should include intravenous anticoagulation with unfractionated heparin
(Class I) and thrombolytic therapy (Class I). Surgical pulmonary embolectomy
is recommended in patients with a contraindication to thrombolysis or when
thrombolytic therapy has failed (Class I).
 Intermediate- or low-risk acute PE, initiation of parenteral
anticoagulation is recommended (Class I). Use of low molecular weight
heparin (LMWH) or fondaparinux is recommended for most patients (Class I).
In parallel to parenteral anticoagulation, treatment with warfarin
(international normalized ratio [INR] goal 2-3) is recommended (Class I).
 Rivaroxaban (15 mg twice a day for 3 weeks, then 20 mg daily) or apixaban (10
mg twice a day for 7 days, then 5 mg twice a day) are alternatives to the
combination of parenteral and warfarin anticoagulation (Class I for both).
 Inplace of warfarin, dabigatran (150 mg twice a day, 110 mg twice a day for
patients ≥80 or taking verapamil) is recommended following the acute phase
of parenteral anticoagulation (Class I).
 Neworal anticoagulants (dabigatran, rivaroxaban and apixaban) are not
recommended in patients with severe renal impairment (Class III)
Oral anticoagulant
 oral anticoagulant ชนิดใหม่ที่ สามารถใช้ในการรักษา acute PE อาทิเช่น
 dabigatran ซึ่งเป็น direct thrombin inhibitor สามารถใช้ได้ภายหลัง bridging therapy
ใน acute phase treatment และยังใช้ตอ ่ เนือ
่ งได้ใน early maintenance phase และ
long-term prevention เพื่อ ป้องกันการกลับเป็น VTE ซ้้าโดยไม่เพิม ่ ความเสีย
่ งต่อการเกิด
เลือดออกเมือ
่ เทียบกับ warfarin
 rivaroxaban และ apixaban เป็นยาในกลุม่ direct factor Xa inhibitor ซึ่งสามารถ ใช้
แทน bridging therapy ได้และยังสามารถใช้ตอ ่ เนือ
่ งได้ใน early maintenance phase
กระทัง่ ถึง long-term prevention โดยไม่เพิม
่ ความเสีย ่ งในการเกิดเลือดออกเมือ
่ เทียบกับ
การรักษามาตรฐานเช่นกัน
 U.S. FDA ได้ให้การรับรอง dabigatran, rivaroxaban และ apixaban เพือ ่ ใช้ในการรักษา
acute PE และป้องกันการเกิด VTE ซ้้า ข้อดีของยากลุม
่ ใหม่นค ี้ อ
ื เป็น oral therapy ที่ไม่
จ้าเป็นต้องท้าการตรวจ เพื่อติดตามระดับของยา แต่ยามีขอ
้ จ้ากัดส้าหรับการใช้ใน ผู้ป่วยทีม ่ ี
การท้างานของไตบกพร่องค่อนข้างรุนแรง
บูรพา ปุสธรรม บทฟื ้ นฟูวชิ าการ
 Routine
use of systemic thrombolytic therapy is not recommended in
low- and intermediate-risk acute PE patients (Class III).
Thrombolytic therapy can be considered in patients with
intermediate- to high-risk acute PE with clinical signs of
hemodynamic decompensation (Class IIa).
 Patientswith low-risk acute PE should be considered for early
discharge and continuation of treatment at home if proper outpatient
care and anticoagulation therapy can be arranged (Class IIa).
 Routineuse of inferior vena cava (IVC) filters in patients with acute
PE is not recommended (Class III). IVC filters can be considered in
patients with a contraindication to anticoagulation (Class IIa) or with
recurrence of PE despite therapeutic anticoagulation (Class IIa).
 Anticoagulation should be given for 3 months in all patients
(Class I). Indefinite treatment is recommended for patients
with a recurrent unprovoked PE (Class I), and considered for
patients with a first unprovoked PE and low risk of bleeding
(Class IIa). In patients with acute PE and cancer, consider
administering weight-adjusted LMWH for the first 3-6
months (Class IIa).
 All patients with chronic thromboembolic pulmonary
hypertension (CTEPH) should be assessed for potential
operability by a multidisciplinary team (Class I), and should
receive life-long anticoagulation (Class I). Riociguat is
recommended for symptomatic CTEPH patients who are
inoperable (Class I).
Clinical characteristics and outcome of Thai
patients with acute pulmonary embolism
Cross-sectional study
OBJECTIVES:
To evaluate common risk factors, symptoms, signs, commonly used investigations,
treatment and outcome of Thai patients with APE.
To compare the clinical characteristics of non-massive and massive APE patients.
To identify the clinical characteristics and treatment that may predict the mortality of
massive APE.
MATERIAL AND METHOD:
All patients with confirmed APE diagnoses who were admitted to Siriraj Hospital,
Bangkok, Thailand between January 2001 and October 2005 were selected for
analysis in the present study. All APE patients' data, including demographics,
symptoms, signs, investigations, treatments, outcome and risk factors such as
malignancy, surgery, immobilization, and congenital thrombophilia, were recorded.
J Med assoc Thai, 2007 Nov;90 Suppl 2:59-67
RESULTS:
71 patients had a confirmed diagnosis of APE, 22 patients were male and 49 were
female. 14 patients were diagnosed with massive APE. The ages of patients varied
from 16 to 90 years old. The mean age was 50 +/- 2.2 years old. The most common
presenting symptoms and signs were dyspnea (92%), followed by tachypnea (63%)
and tachycardia (54%).
Idiopathic APE was found in 42.2% of the patients. Malignancy, especially
adenocarcinoma, was the most frequent risk factor (21%). The most frequent
radiographic abnormalities noted in the present study were pulmonary parenchymal
lesions (23.9%). Echocardiography findings were mostly elevated right ventricular
systolic pressure (RVSP), ranging from 18.5 to 98 mmHg (mean RVSP of 54.4 mmHg).
The most frequent diagnostic test used was ventilation-perfusion lung scan. Elevated
serum troponin-T seemed to be more frequent in the massive APE group. In the non-
survivor group, the author found hypotension and underlying malignancy statistically
significant different from the survivor group.
Clinical characteristics and outcome of Thai
patients with acute pulmonary embolism

CONCLUSION:
APE was not infrequent. Characteristics of APE patients in Thailand were not
different from previous reports in European countries. Malignancy seemed to
be the most frequent risk factors of APE in the present study population.
Troponin-T measurement may be useful to predict progression of APE.

J Med assoc Thai, 2007 Nov;90 Suppl 2:59-67


 January 1 and June 30, 2007. All attending anesthesiologists and nurse
anesthetists in 51 hospitals ranging from district (community) hospitals to
tertiary (regional or university) hospitals
 There were 12 out of 1996 incident reports of suspected PE in the
database (0.6% of 1996 incident reports) of the Thai AIMS with 41.7%
mortality rate. Majority of suspected PE during 24-hour perioperative
period cases occurred among, obstetric or orthopedic patients. Sudden
hypoxia, hypotension, and unconsciousness were major clinical
manifestations necessitating prompt cardiopulmonary support.
 prospective study evaluated the prevalence of thrombophilia
and venous thromboembolism after total knee arthroplasty in
patients who did not receive prophylactic treatment of VTE
 Results: The authors studied 100 patients, 94 primary TKA and
6 revisions TKA. 61% were positive for deep vein thrombosis.
Eleven patients with positive venograms showed bilateral
DVT, 12% had a proximal DVT, one was protein C deficiency, 9
were protein S deficiency, 18 were antithrombin III deficiency,
and 36 were positive study for FDP(D-dimer), However, no one
was found with factor V leiden.
 Odds ratio of protein S deficiency was 0.9506, Antithrombin III
deficiency was 0.7376, and FDP(Ddimer) was 1.229. The protein C
deficiency and factor V leiden was undetermined.
 Hospitalized patients diagnosed with acute pulmonary embolism at Srinagarind
Hospital between January 1, 2002 and October 31, 2009.
 Results: 169 patients were diagnosed with acute pulmonary embolism; 95 (56.2%)
females and 74 (43.8%) males. The mean age was 54.1 years (range, 18-85). 13%
presented with massive pulmonary embolism. The most common presentation was
dyspnea (65.1%). Arterial hypoxemia (88.8%) and sinus tachycardia (58.3%) were the
common initial clinical findings. 20%of chest radiograph were unremarkable.
 The most common etiology was cancer (62.1%), mostly solid malignancies (98/105) e.g.,
cholangiocarcinoma, gynecologic malignancy, and lung cancer. The 2nd and the 3rd
common etiologies were immobilization/stasis (8.3%) and connective tissue disease
(7.1%). After treatment, 58.6% of the patients improved while 21.3% died in hospital.
 The main therapeutic modality was anticoagulation. The treated group had better
outcomes than those receiving only supportive care. Only one patient underwent
thromboembolectomy but died. The complications during treatment were acute
respiratory failure (34.9%), shock (18.3%), and bleeding (6.5%).
ผู้ป่วยโรคมะเร็งทีม
่ าตรวจเอกซเรย์คอมพิวเตอร์ของช่องอกแบบฉีดสารทึบ
รังสี​ณ​โรง​พยาบาล​พระมงกุฎเกล้าในช่วงเดือนพฤษภาคม 2552​ ถึง​เดือน
ธันวาคม 2552
ผู้ป่วยทีเ่ ป็นโรคมะเร็งจ้านวนทัง ้ สิ้น​ 288​ คน​ที่มาตรวจเอกซเรย์
คอมพิวเตอร์ของช่องอกแบบฉีดสารทึบรังสี:ผูป ้ ว ่ ยชายจ้านวน​ 216​ คน​และ
หญิงจ้านวน 72 คน​และอายุเฉลีย ่ ของผูป ้ ว
่ ยเท่ากับ ​56 ปี​ ​พบภาวะหลอด
เลือดแดงปอดอุดตันจากลิม ่ เลือดจ้านวน​ 7​ คน(2.4%) โดยพบในผูป ้ ว
่ ย
กลุ่มมะเร็งปอดมากที่สด ุ คิดเป็นร้อยละ ​71
​ต้าแหน่งของหลอดเลือดแดงปอดทีม ่ กี ารอุดตันจากลิม ่ เลือดทีพ
่ บมากทีส ่ ุด
คือ​ segmental​ pulmonary​ artery​ คิดเป็นร้อยละ​ 39 ของจ้านวนเส้น
เลือดทีม ่ กี ารอุดตันทัง้ หมด​ และ​ พบน้อยทีส ่ ด
ุ ที่​ main​ pulmonary​ artery​
คิดเป็นร้อยละ11
Take home messages
Pulmonary embolism is not rare disease
Suspicious when sudden dyspnea, tachypnea,
tachycardia , hypoxemia, pleuritic chest pain
Risk factor: cancer, immobilization, hormone
Work up by classify patient into: stable or
unstable hemodynamic , high risk for mortality
and clinical probability for PE
All case treat for at least 3 month and
reassess by risk factor