1PULMONARY EMBOLISM

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All you wanted to know about Pulmonary embolus
but were Afraid to Ask
Dennis Bowie
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OBJECTIVES

• To synthesize information from a of sources
• To stimulate interest
• Learn about diagnosis and Treatment of Pulmonary
  Embolism
• Use probabilities to solve problem
• Tell you what you must know, Should know, could
  know

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Case I Mrs. P.E.

• 72 yr. Old female
• CC SOB Weakness
• 4-5 days ago noted weakness sudden onset of
  SOB Aggrevated by exertion lying flat

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Case I Mrs. P.E.

• Noted increased swelling of legs
• unable to ambulate because of weakness and
  dizzyness
• No cough, fever or chest pain

5
Case I Mrs. P.E.

• Past Hx Hypertension Osteoarthritis
  Goitre on a diuretic Total Hip
  repair 2.5 wks. ago
• O/E Pulse 104 irregular irreg. RR 22,
  B.P. 116/ 60 Temp. 38.1

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Case I Mrs. P.E.

• ? Peripheral cyanosis
• coarse crackles L anterior chest
• breath sounds both bases
• JVP 6 cm. With inspiration
• ?S4, Increased P2
• Liver increased 19 cm

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Case I Mrs. P.E.

• ABGs pH 7.48 PaO2 52 PaCO2 29
• ECG S1 Q3 T3non specific Twave ST changes
• Chest X-ray decrease lung volumes with some
  atelectasis at bases

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A WORD OF ADVICE FROM A FELLOW-ANGEL
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PULMONARY EMBOLISM

• 30 Mortality for untreated Pulmonary embolism
• 50,000 - 100,000 individuals die prematurely per
  year in U.S.
• Diagnosis crosses most Specialties

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DIAGNOSIS

• Based on
• Relevant SYMPTOMS SIGNS
• Associated RISK FACTORS
• Probability of ALTERNATIVE Diagnosis
• OBJECTIVE Confirmation

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PULMONARY EMBOLISM

• What are the risk factors for pulmonary embolism
  and or DVT

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Risk factors in those with Acute DVT / PE

• Obesity
  37.8
• Hx venous thromboembolism 26.0
• Cancer
  22.3
• Bed rest gt 5 days
  12.0
• Major Surgery
  11.2

• Risk factor n 1231
  
• Age gt 40 years
  88.5

Anderson FA et. Al J Vasc Surg 1992
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Risk factors in those with Acute DVT / PE

• Risk factor n 1231
• CHF
  8.2
• Varicose veins 5.8
• Fracture hip or leg 3.7
• Estrogen 2.0
• Stroke
  1.8

Anderson FA et. Al J Vasc Surg 1992
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Risk factors in those with Acute DVT / PE

• Multiple trauma 1.1
• childbirth
  1.1
• Myocardial infarction 0.7
• one or more risk factors 96.3
• two or more risk factors 76.0
• Three or more risk factors 39.0

Anderson FA et. Al J Vasc Surg 1992
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PULMONARY EMBOLISM

• 90 of clinically important PE results from leg
  DVT
• 96 of patients with DVT or PE have one or more
  risk factors
• The risk increases in proportion to the of risk
  factors

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Proportion of patients clinically suspected DVT
in whom Dx. Was confirmed increases with the of
risk factors

• of DVT risk factors Confirmed DVT()
• 0
  11
• 1
  24
• 2
  36
• 3
  50
• 4 or more 100

Arch Surg 1982
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RISK FACTORS (uncommon)

• Deficiencies Protein C or S Antithrombin
  III deficiency
• Resistance to protein C activating
• Factor V Leiden polymorphism
• Homocystinuria
• Polycythemia rubra vera
• SLE, Béchets, nephrotic syn.

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PULMONARY EMBOLISM

• What are the SYMPTOMS and SIGNS of Pulmonary
  embolism?

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PULMONARY EMBOLISM SYMPTOMS

• Chest Pain 88 - pleuritic
  74 -non pleuritic 14
• Dyspnea 85

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PULMONARY EMBOLISM SYMPTOMS

• Apprehension 59
• Cough 53
• Hemoptysis 30
• Syncope 13

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PULMONARY EMBOLISM SIGNS

• Tachypnea 92
• Crackles 58
• Tachycardia 44
• Fever 43
• Increased P2 53
• Phlebitis 32

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FREQUENCY of SX. Signs

• Proven PE
• Dyspnea 73
• Pleuritic pain 66
• Cough 37
• Leg pain 26
• Hemoptysis 13

No PE
72
59
36
24
8
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FREQUENCY of SX. Signs
No PE
Proven PE
68

• Tachypnea 70
• Tachycardia 35
• Temperature gt 38.5 7
• Signs DVT 11
• A-a difference 86

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12
11
78
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ECG FINDINGS

• Sinus Tachycardia 43
• T wave inversion 40
• ST segment depression 33
• Low voltage 16
• L axis 12
• S1 Q3 T3 11
• ST elevation 11
• R Bundle Branch Block 11
  

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X-RAY FINDINGS

• Diaphragm elevation 41
• Consolidation 40
• Pleural effusion 28
• Distended prox. Pulm art. 23
• Atelectasis 20
• Oligemia 15

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Diagnosis P.E. predictive score

• Clin. Symptoms of DVT 3.0
• No alternative diagnosis 3.0
• Heart rate gt 100 1.5
• immob. Or Surg. In lt 4 wks 1.5
• Previous DVT/ PE 1.5
• Hemoptysis 1.0
• Malignancy 1.0

Wells, Anderson, Rodger, Ginsberg,
Kearon,Gent,Turpie Bormanis, WeitzChamberlain,Bowi
e,Barnes,Hirsh Thromb.Haemost. 2000 416
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Diagnosis P.E. predictive score

• Low probability lt 2.0Moderate Prob. 2 -
  6High gt 6
• Patients with lt 4 had 7.8 incid. PE
• lt 4 and a negative D dimer 1.7 - 2.2 This
  combination was in 46 of population studied.

Wells, Anderson, Rodger, Ginsberg,
Kearon,Gent,Turpie, Bormanis, Weitz,
Chamberlain, Bowie,Barnes,Hirsh Derivation of a
simple clinical model to categorize patients
probability of pulmonary embolism increasing the
models utility with the SimpliRED D-dimer
Thromb.Haemost. 2000 416
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Geneva Score
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Geneva Score
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DIAGNOSIS

• Based on
• Relevant SYMPTOMS SIGNS
• Associated RISK FACTORS
• Probability of ALTERNATIVE Diagnosis
• OBJECTIVE Confirmation

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DIFFERENTIAL DIAGNOSIS

• CHF
• Asthma / COPD exacerbation
• Pneumothorax
• Pneumonia
• Shock
• Pleural disease
• Chest wall Pain

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DIFFERENTIAL DIAGNOSIS

• Myocardial infarction
• Pericarditis
• 1 or metastatic ca.
• Hyperventilation syndrome
• Infradiaphragmatic processe.g. cholecystitis,
  splenic infarction

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Diagnosis Pulmonary Embolism

• How do you confirm the diagnosis?

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Diagnosis Objective Confirmation

• Documentation of clot in the leg by Compression
  Ultrasound or Impedance Platysmography or
  Intravenous Venogram
• 1st Test Compr. Ultrasound

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Diagnosis Objective Confirmation

• Since the treatment for DVT and PE is the same,
  the demonstration of clot in the leg is
  sufficient for the diagnosis of Pulmonary
  Embolism

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Diagnosis Objective Confirmation

• Pulmonary Angiogram(GOLD STANDARD)
• expensive
• Technically more difficult requiring skilled
  personnel
• More risk for side effects
• Not always available

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VENTILATION / PERFUSION SCANS

• Normal lung scan means
• no perfusion defects
• the perfusion matches the ventilation scan

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VENTILATION / PERFUSION SCANS

• High Probability lung scan
• gt 1 lung segmental or greater perfusion defects
  with normal ventilation
• or gt 2 large subsegmental defects (gt75 of a
  segment) with normal ventilation

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CAUSES OF ABNORMAL V/Q SCANS

• INTRALUMINAL
• Clots
• Fat emboli
• Tumor
• Vasculitis or vascular stenosis
• Parasites
• Fungi

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CAUSES OF ABNORMAL V/Q SCANS

• EXTRA LUMINAL
• Tumor
• Adenopathy
• Vascular structures
• REGIONAL HYPOXIC VASOCONSTRICTION
• Reactive airways
• Mucous plugs or Foreign body
• VASCULAR RESISTANCE
• CHF
• Pneumonia

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VENTILATION / PERFUSION SCANS

• Non-High Probability
• Ventilation -perfusion defects that did not
  qualify as high or normal

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DIAGNOSTIC PROCESS
No Treatment
Treatment
Test threshold
Treatment threshold
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GENERAL RULES

• CONSIDER WITH EACH PATIENT
• Risk OF MISSING Diagnosis
• Risk OF PROCEDURE or COST
• Risk OF TREATMENT

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DIFFERENTIAL DIAGNOSIS

• CHF
• Asthma / COPD exacerbation
• Pneumothorax
• Pneumonia
• Shock
• Pleural disease
• Chest Pain

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D-dimer

• A degradation product of of crosslinked fibrin
• High number of conditions that activate
  coagulation fibrinolysis e.g. Surgury,
  inflammation, cancertrauma.
• Has a high negative predictive value R/O PE in
  low clinical probability

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or V/Q scan
Angiogram
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Data to define Test Treatment Thresholds

• Mortality Untreated 30
  Treated 8
• Angiography Sensitivity 90
  Specificity 95
  Mortality 0.5
  Morbidity 3
• Anticoagulent Mortality 1.4
  Morbidity 16

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Role of Spiral CT Scan

• Easily done non invasive test with few
  complications
• Requires proper equipment and experienced readers
• Rarely cannot perform e.g. allergy, SVC syn.
  Renal insufficiency, Approximately 10-13
• Sensitivity 90, specificity 95, with
• multidetector CT in experienced hands

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Perfusion/Ventilation Lung Scanning (V/Q scan)

• There are 3 V/Q lung scan patterns
• 1. A normal perfusion scan rules out PE.
• 2. Most patients with a high probability
  scan (defined as one or more, segmental or
  larger, perfusion defects with relatively
  preserved ventilation) have PE and they can
  generally be treated without further testing.

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Perfusion/Ventilation Lung Scanning (V/Q scan)

• There are 3 V/Q lung scan patterns
• 3. All other lung scan patterns (which,
  unfortunately, includes 60 of all the scans) are
  nondiagnostic. These nondiagnostic patterns
  include
• low probability, non high probability,
  intermediate probability, and
• indeterminate probability,
• Further testing is required in patients with this
  V/Q scan pattern.

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Advantages of V/Q Lung Scans include

• 1. a normal V/Q scan rules out PE
• 2. the radiation dose is low
• 3. iodine-based contrast is not used

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Limitations of V/Q Lung Scans include

• 1. the majority of V/Q scans are nondiagnostic
• 2. V/Q scans do not help to identify an
  alternate diagnosis in the large proportion of
  patients who dont have PE.
• 3. high cost

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Spiral/Helical CT (SCT)

• There are 3 SCT patterns
• 1. No PE seen and an alternate diagnosis is
  found. This group does not require any further
  investigation for VTE.
• 2. Definite PE is detected in a segmental
  or larger pulmonary artery.
• 3. Patients with normal SCT, technically
  inadequate scans, and scans that report
  subsegmental PE are all considered
  nondiagnostic. Further testing is required in
  patients with these SCT patterns.

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Advantages of SCT include

• 1.ability to directly visualize emboli
• 2.high accuracy for large emboli (segmental or
  larger)
• 3.potential to provide the alternate diagnosis
  in patients who dont have PE

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Limitations of SCT include

• 1.Filling defects confined to subsegmental
  vessels are not diagnostic
• 2.Contrast must be given (problematic in
  patients with renal insufficiency or a history of
  contrast allergy)
• 3.A normal SCT does not rule-out small PE
• 4.Significant radiation (equivalent to 500 chest
  x-rays)

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Venous Imaging in Suspected PE

• Since almost all pulmonary emboli arise from DVT,
  a useful strategy in some patients with suspected
  PE is to look for the presence of DVT using
  Duplex ultrasound (DUS).
• If the DUS of the proximal veins is positive, the
  patient requires treatment (the treatment of
  proximal DVT and PE is the same).
• If the DUS is negative, the risk of recurrent PE
  in the short term is very low.
• Repeating the DUS testing in 5-7 days and 12-14
  days is a safe strategy in suspected PE with
  nondiagnostic lung imaging.

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1.Should I start with lung imaging (V/Q scan,
SCT) or with DUS?

• Start with Lung Imaging
• 1.No leg symptoms
• 2.Lung test likely to be normal
• 3.Lung test likely to be positive

• Start with DUS
• 1. Leg symptoms /signs compatible with DVT
• 2.Recent leg injury/surgery
• 3.Pregnancy

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2. If I start with lung imaging, should it be a
P/V scan or spiral CT?

• Choose V/P Scan
• 1.Normal CXR
• 2.Patient is otherwise healthy
• 3.SCT is contraindicated(because of contrast
  allergy or renal failure)

• Choose SCT
• 1.Abnormal CXR
• 2.Respiratory disease
• 3.Critical care patient
• 4.Suspect massive PE

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TREATMENT of PULMONARY EMBOLISM

• Both Pulmonary embolism and DVT are treated the
  same
• An adequate level of anticoagulation is
  essentional
• Patients will have variable effect of
  anticoagulents
• Treatment requires monitoring

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TREATMENT of PULMONARY EMBOLISM

• Bolus of 5-10,000 units of (unfractionated)
  HEPARIN maintenance dose with heparin nomogram
• Low Molecular Weight Heparin if patient is
  hemodynamically stable

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Heparin Nomogram
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Treatment of Pulm. Embolism

• Various manufacturers of PTT testing reagents
  and lots from same company may have different
  therapeutic ranges

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TREATMENT of PULMONARY EMBOLISM

• Start oral anticoagulants in 24 -72 hrs. with ? 5
  day crossover with heparin
• Duration - 3 - 6 months if correctable cause
  e.g. surgery - indefinitely if no known cause
  or recurrent or ongoing risk e.g cancer

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TREATMENT of PULMONARY EMBOLISM

• Side effects of heparin
• abnormal bleeding especially if predisposed e.g.
  peptic ulcer disease
• Heparin induced trombocytopenia which is
  associated with increased clotting

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TREATMENT of PULMONARY EMBOLISM

• Low Molecular Weight Heparin
• increased half life
• Increased bioavailability
• low frequency of bleeding
• administered once a day
• less monitoring
• More Expensive

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TREATMENT of PULMONARY EMBOLISM

• THROMBOLYTIC THERAPY
• More rapid in effect
• Indicated in patients hemodynamically compromised
• No evidence to date it improves clinical outcomes
• increased bleeding.

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Case I Mrs. P.E.

• 72 yr. Old female
• CC SOB Weakness
• 4-5 days ago noted weakness sudden onset of
  SOB Aggrevated by exertion lying flat

73
Case I Mrs. P.E.

• Noted increased swelling of legs
• unable to ambulate because of weakness and
  dizzyness
• No cough, fever or chest pain

74
Case I Mrs. P.E.

• Past Hx Hypertension Osteoarthritis
  Goitre on a diuretic Total Hip
  repair 4 wks. ago
• O/E Pulse 104 irregular irreg. RR 22,
  B.P. 116/ 60 Temp. 38.1

75
Case I Mrs. P.E.

• ? Peripheral cyanosis
• coarse crackles L anterior chest
• breath sounds both bases
• JVP 6 cm. With inspiration
• ?S4, Increased P2
• Liver increased 19 cm

76
Case I Mrs. P.E.

• ABGs pH 7.48 PaO2 52 PaCO2 29
• ECG S1 Q3 T3non specific Twave ST changes
• Chest X-ray decrease lung volumes with some
  atelectasis at bases

77
Summary Approach to P.E.

• Asses pretest probability based on
• 1. RISK factors
• 2. Symptoms and signs (SOB, Chest Pain,
  syncope)
• 3. ECG and X-RAY Findings
• 4. Likelihood of ALTERNATIVE Dx. Consider
  WELLs criterion

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Summary Approach to P.E.

• CONFIRM DIAGNOSIS by
• Demonstration of DVT by US, Venogram
• High probability V/Q scan / CT scan
• Angiogram
• Treatment as untreated Mortality 30
• Heparin Regular or LMW heparin.

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Pulmonary Embolism

• Thrombosis Interest Group
• of Canada

http//www.tigc.org/english.htm
80

• Thats all folks

Remember Everyone is entitled to MY OPINION
BONNE JOURNEE
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Pulmonary Embolism visuals

• Dennis Bowie

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P.E. atelectasis
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P.E. effusion
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P.E. Hamptons Hump
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P.E. subsegmental defect
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Normal V/Q Scan
J. Galvin, M.D. J.Choi, B.S. The Diagnosis of P.
E. Virtual Hospitalhttp//www.vh.org/Providers
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High Probability V/Q Scan
J. Galvin, M.D. J.Choi, B.S. The Diagnosis of
P. E. Virtual Hospital http//www.vh.org /Provid
ers
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Pulm. Embolism CT
J. Galvin, M.D. J.Choi, B.S. The Diagnosis of P.
E. Virtual Hospitalhttp//www.vh.org/Providers
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Pulm. Embolism CT
J. Galvin, M.D. J.Choi, B.S. The Diagnosis of P.
E. Virtual Hospital http//www.vh.org/Providers
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Pulmonary Arteriogram
J. Galvin, M.D. J.Choi, B.S. The Diagnosis of P.
E. Virtual Hospital http//www.vh.org/Providers
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Pulmonary embolism
J. Galvin, M.D. J.Choi, B.S. The Diagnosis of P.
E. Virtual Hospitalhttp//www.vh.org/Providers
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OKAY EVERYBODY. TEA-TIME!!!
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Wells Score
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Diagnosis P.E.

• Dyspnea, Chest Pain, Fainting
• R.V. overload on ECG S1Q3,S1S2S3 ,T wave
  inversion R leadsTransient RBBB,
  Pseudoinfarction
• Chest X-ray changes, Oligemia, Prominent R hilar
  artery, Peripheral consolidation1 symptom plus
  1 other sign Found in 81 with PE 7 without

M. Miniati et al. Accuracy of Clinical assessment
in the diagnosis of Pulmonary Embolism Am. J.
Respir. Crit. Care Med. 159 864
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TYPICAL CLINICAL SIGNS AND SYMPTOMS

• SOB, CHEST PAIN, HEMOPTYSIS
• Pleural Rub, Signs Sx. Of DVT
• Typical X-ray
• SpO2 lt 92, HRgt 90 Temp 37.8 - 38.6 C0
• No other Diagnosis for X-ray

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ATYPICAL SIGNS/SYMPTOMS

• Does not have the typical signs/symptoms except
  SOB
• Confusion without B.P.
• New tachyarrhythmias
• New wheezing
• LVF

100
SEVERE SIGNS/SYMPTOMS

• Typical symptoms / signs
• Syncope
• B.P. lt 90, H.R. gt 100
• Resp. failure, intubated, SpO2 lt 92 on gt 40
  FiO2
• New R heart failureS1 Q3 T3, RBBB

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PRE TEST LIKELIHOOD OF PE
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The weather will get better
BONNE JOURNEE
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Symptoms Signsof Pulmonary Embolism in 2110
patients
of patients
Goldhaber SZ et al. Lancet 3531386
1999