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Pulmonary Embolism

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Pulmonary Embolism Dr Felix Woodhead Consultant Respiratory Physician Pulmonary Embolism Part of VTE Potentially fatal Can complicate hospital admission Preventable ... – PowerPoint PPT presentation

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Title: Pulmonary Embolism


1
Pulmonary Embolism
  • Dr Felix Woodhead
  • Consultant Respiratory Physician

2
Pulmonary Embolism
  • Part of VTE
  • Potentially fatal
  • Can complicate hospital admission
  • Preventable
  • Tests poor

3
Risk factors
  • Surgery
  • Abdominal
  • Lower limb
  • Obstetric
  • Malignancy
  • Previous VTE

4
Clinical Probability
  • Wells score
  • Geneva criteria
  • Is a major risk factor present? 1
  • Is there no other explanation? 1
  • Score
  • 2 High probability
  • 1 Intermediate probability
  • 0 Low probability

5
D-dimer
  • Only useful if NEGATIVE
  • ? by many things (including pregnancy and
    infection)
  • Used only after assessment of clinical
    probability
  • Not used if high clinical probability

6
Imaging
  • CTPA in most places
  • V/Q
  • only if normal CXR and no cardiopulmonary disease
  • Intermediate scan requires follow-up imaging
    (CTPA)
  • Doppler USS if DVT (no need for resp imaging)

7
Screening for thrombophilia/cancer
  • Thrombophilic abnormality occurs in 25-50 VTE
  • Usually interacts with environment (esp
    oestrogens), and risk is multiplicative
  • Does not predict risk of recurrence
  • Screen for cancer with bloods, clinical picture
    and CXR only

8
Treatment
  • Thrombolysis only in massive PE (circ collapse)
  • Thrombolysis controversial if RV impairment
  • Anticoagulate with LMWH then warfarin for
  • 4-6/52 if associated with temporary risk factor
  • 3/12 if no risk factor (BTS), US recommend 6/12
  • ?unfractionated heparin initial bolus

9
Pulmonary Arterial Hypertension
  • Dr Felix Woodhead
  • Consultant Respiratory Physician

10
Findings
  • Exertional breathlessness
  • Exertional chest pain and presyncope
  • Normal radiology if idiopathic
  • Normal PFTs if idiopathic
  • ? systolic PAP on echo only if TR

11
Defined by RHC
  • mPAP
  • gt 25 mmHg at rest (normal 12-16 mmHg)
  • gt 30 mmHg on exertion
  • Cardiac Output
  • Cardiac Index (CO/height2)
  • Pulmonary Vascular Resistance

12
Causes
  • Left ventricular impairment (PCWP gt 15)
  • LVF
  • Mitral valve disease
  • Increased pulmonary blood flow (L?R shunt) ?
    Eisenmengers syndrome
  • Hypoxaemia (cor pulmonale)
  • Chronic Thromboembolic (CTEPH)
  • HIV
  • CTD (SSc etc)
  • Idiopathic (IPAH)

13
Investigations
  • PFTs
  • CTPA
  • Echo ( bubbles)
  • 6 minute walk
  • Right Heart Catheter
  • (traditional) pulmonary angiogram

14
Treatment
  • Treatment of associated causes
  • LV disease
  • O2 for cor pulmonale
  • Warfarin (for all)
  • Calcium channel blockers little used now
  • Endothelin receptor blockers Bosentan,
    sitaxentan
  • PDE4 antagonists Sildenafil etc
  • Prostaglandins
  • Nebulised
  • Continuous IV via Hickman line

15
Sleep medicine
  • Dr Felix Woodhead
  • Consultant Respiratory Physician

16
Obstructive sleep apnoea/hypopnoea Sx
  • Periodic reduction of airflow at night
  • Caused by ostruction (cf central apnoea) due to
    reduced muscle tone in a suceptible airway
    (obesity)
  • Apnoea no airflow for 10 s
  • Hypopnoea 50 airflow in 10 s
  • AHI (apnoea/hypopnoea index) no of events/hr
  • AHI
  • 5-14 mild
  • 15-30 moderate
  • gt30 severe

17
Symptoms
  • Sleepiness (daytime hypersomnolence)
  • Epworth Sleepiness Score
  • Witnessed apnoeas
  • Nocturia
  • Hypertension
  • Reduced concentration
  • Reduced libido
  • Tendency to cor pulmonale, esp in COPD

18
Diagnosis
  • Overnight oximetry
  • Good screening esp in obese
  • Cannot be used to exclude OSAHS
  • Limited PSG
  • Useful initial test in young, non-obese
  • Full PSG

19
Treatment
  • Only if symptomatic
  • AHI gt15, desat index gt10/hr
  • Nasal CPAP
  • fixed
  • Autotitrating device

20
Domiciliary NIV
  • For ventilatory failure
  • Other treatments
  • Low flow O2 (with care)
  • Treatment of sleep disordered breathing
  • Hallmark of ventilatory failure is ?pCO2
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