WHO criteria : sPAP>4

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??? ??

• ????? ????
• ?????

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??? ???

• ??
• WHO criteria sPAPgt40 mmHg ??
• NIH Criteria mPAP at rest gt 25mmHg ?? gt 30mmHg
  at exercise
• ??
• ??? vs ???
• ????
• passive pulmonary venous hypertension
• hyperkinetic increased pulmonary blood flow
• obstructive thromboembolic pulmonary vascular
  disease
• obliterative vasculitis
• vasoconstricitive hypoxia
• idiopathic unknown

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??? ? ????(primary pulmonary hypertension)

• ????? ??? ???? ??? ??? ????? ?? ?? ??? ?? ??
• ???
• ??
• exertional dyspnea, exertional chest pain,
  syncope, edema
• ??? ??
• increased JVP, reduced carotid pulse, early
  palpable right ventricular lift, increased P2,
  P3, S4 of rt side, TR, MR, cyanosis, edema,
• ??
• ????, ???, ?? ???, prostacyclin, ?? ???

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??? ???????(venous thromboembolism)

• ???????(deep vein thrombosis)? ?????? ???? ???
  ?????? ??? ????? ?????? ??
• Virchows triad
• ?? ?? (local trauma to vessel)
• ??? ??(hypercoagulability)
• ????(stasis)

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???? ???(deep vein thrombosis)

• (1) ??? ???
• a. calf pain
• b. calf tenderness
• c. Homans' sign
• d. calf ?? leg swelling
• (2) ?? ??
• a. cellulitis
• b. heart failure with edema
• c. ruptured backer's cyst
• d. chronic venous insufficiency
• (3) ??
• a. duplex ultrasound(color doppler flow
  B-mode image)
• vein compressibility primary criteria
  of DVT
• b. impedance plethysmography
• c. contrast venography

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DVT? ?? ? ??
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????(pulmonary embolism)

• (1) ??(embolization)
• a. ???? ??? ??? 30-60?? ????? ????
• b. ??? calf? ?????? ???? ???? ????
• (2) ??? ??
• a. ??? ??? ??(increased pulmonary vascular
  resistance)
• b. ?? ????(impaired gas exchange)
• c. ?? ???(alveolar hyperventilation)
• d. ?? ?????(increased airway resistance)
• e. ???? ??(decreased pulmonary compliance)?
  ??? ???? ??

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• (4) ?? ? ??
• a. dyspnea(70-80), tachypnea, pleuritic
  chest pain, syncope, cyanosis, cough,
  hemoptysis
• b. tachycardia, low-grade fever, neck vein
  distension, P2??, hypotension,

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Clinical features

• 60-70 cases / 100000
• Breathlessness/tachypnea
• Pleuritic chest pain/hemoptysis
• Absence of another reasonable clinical
  explanation
• Presence of a major risk factor

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• a. Chest radiography
• a) Focal oligemia(Westermark's sign)
• b) Hamptom's hump
• c) right descending pulmonary artery?
  ??(Palla's sign)
• b. ???
• a) Sinus tachycardia, atrial fibrillation
  ?? atrial flutter? ??? ??
• b) right axis deviation
• c) right ventricular strain T-wave
  inversion in V4-V6
• c. ???????
• a) D(A-a)O2 ??
• b) PaO2 ??, PaCO2 ??
• e. duplex ultrasound
• f. ????? (Echocardiography)
• a) ??? ??? ???? ?? ??? ??
• b) ??? ??? ?? ??? ??

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D-dimer

• Sensitivities 87-98
• Specificity poor
• Qualititive red cell agglutination test
• Rapid quantitative ELISA
• MDA test
• D-dimer ELISA level (gt500ng/ml)
• b) negative predictive value? ??? ???? ??? ???
  ????

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• g. ? ?? ???? (ventilation/perfusion scan)

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? ?? ???? (ventilation/perfusion scan)

• Perfusion scan 99m Tc-macroaggregate albumin
• Ventilation scan 133Xe
• ?????? ????
• high probability
• (a) 2 large segmental mismatches(gt75)
• (b) 2 moderate segmental mismatches(25-75)?1
  ?? large
• segmental mismatch
• (c) 4 moderate segmental mismatch
• low probability
• (a) single moderate segmental mismatches
• (b) small segmental mismatches( 25)
• (c) any matching defects
• (d) nonsegmental defects

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• ??? ?? (Pulmonary angiography)
• a) intraluminal filling defect (definitive
  diagnosis)
• b) ??? ??? ???? V/P scan???? ??? ?? ?,
  ??? ???
• ? ?? ?? ??

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spiral CT, MR angiography

• Superior specificity to VQ scan
• Quantitative assessment
• Alternative diagnosis
• Interobserver agreement

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????? ??

• ??? ??
• (a) ????, ????, ??? ??
• (b) ?????? ???? dobutamine??
• (c) ?? ?? ??? ?? ??? ?? ??? ?? ???
  ?????? ??? ??
• (d) heparin ??? ??? ? ?? ????? ??? ? ??? ???
  stocking? ??

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• ????
• a) heparin
• - coagulation factor Factor?a, Xa, IXa,
  XIa? XIIa? ???? ???
  Anti-thrombin ?? ???? ??? ?????.
• - ???? ?? ??? ???? ?? ??? clot? ???? ??
  endogenous fibrinolytic mechanism? ?????.
• - ?? ??? ??? ?? ????? ???.
• - aPTT? ??? 1.5-2? ??
• b) low-molecular-weight heparins
  fractionated heparin
• - ???? unfractionated heaprin?? ??
• - ???? ???? monitering?? ???? ?? ????? ??
• - heparin-induced thrombocytopenia?
  osteoporesis? ?? ????
• c) Wafarin
• - coagulation factors ?, ?, ?, ??
  gamma-caroxylation activation? ???? vitamine K
  antagonist
• - thrombotic state ?? ???? Protein C?
  Protein S ??? ??
  thrombogenic potential? ????.
• - protrombin time INR 2.0-3.0 ??

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• ???? ??? ? ??
• ??
• heparin ?? LMWheparin??
• - ???? ??, ??
• - protamine sulfate
• wafarin
• - Vitamine K 2.5-5mg subcutaneousa
• - cryoprecipitate ?? fresh-frozen plasma
• heparin-induced thrombocytopenia
• unfractionated heparin ??? ??????
  3-4?? ??
• ??? 5-10? ??? ?? ???? ???? ??? ????
• ???? ???? 50???? ????? 10,000/?? ?? ??
• hiparinoid? danaparoi ??
• wafarin skin necrosis
• protein C, vitamin K dependent
  anticoagulant? ??? ??? ??
• ??? ?? ????? ??, ??, ??? ????
• ??? heparin? ?????? ????

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?? ???(thrombolysis) a) ?? (a)
rapidly reverse right heart failure (b)
low rate of death rate and recurrent PTE b)
?? Cerebrovascular hemorrhage at any
time Nonhemorrhagic stroke ?? other
cerebrovascular event within the past 1yr
Marked hypertension(???gt180 and/or ???gt110)
Aortic dissection c) ??? epsilon
aminocaproic acid
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Thrombolysis

• Thrombolysis if the first line treatment for
  massive PE
• 50mg alteplace bolus
• Thrombolysis should not be used as first line
  treatment in non-massive PE

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• inferior vena caval filter
• a) ???
• (a) ??? ??? ?? ??? ?? ??
• (b) ???? ???? ???? ???? ???? ??
• (c) ?? ???? ???? ?? ???? ???? ????? ???
  ???
• (d) ???? ??? ??
• (e) active internal bleeding

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Testing for thrombophilia

• Anti-phospholipid syndrome
• Antithrombin III deficiency
• Factor V Leiden, protein C, S
• Under 50 years with recurrent PE
• Strong family history of proven VTE

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Investigation for occult cancer

• Clinical assessment
• Routine blood tests
• Chest radiography

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Fat embolism

• 1) ??
• ??? ??, ?? ??? ?? ? 12-24?? ?? ???? ???, ????
  ??? ?? ???
• 2) ??
• ??? traumatic fracture 72?? ?? ??? ?? ?? ? ??
• (1) Otherwise unexplained dyspnea, tachypnea,
  arterial
• hypoxemia, and diffuse alveolar infitrates on
  chest radiography
• (2) Otherwise unexplained confusion or other
  signs of cerebral dysfunction
• (3) Petechiae over the upper half of the body
• 3) ??
• supportive treatment
• high mortality

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Bronchiectasis
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??

• ??? ??
• Tuberculosis
• Measles
• Pertusis
• ??? ??
• Immotile cilia syndrome
• ?? ???
• ??? ??
• Foreign body
• Neoplasm

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???

• Coughing
• Purulent sputum
• Repeated respiratory infection
• Hemoptysis

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??

• Simple Chest X-ray
• HRCT

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??

• Antibiotics
• Chest physiotherapy
• Bronchodilator
• Surgery