肺動(dòng)脈栓塞的診治PPT課件.ppt

肺動(dòng)脈栓塞的診治,制作 XGHRH,敬請(qǐng)指正,基本概念,肺栓塞是以各種栓子阻塞肺動(dòng)脈系統(tǒng)為其發(fā)病原因的一組疾病或臨床綜合征的總稱(chēng)，包括肺血栓栓塞癥，脂肪栓塞綜合征，羊水栓塞，空氣栓塞等。 肺血栓栓塞癥為來(lái)自靜脈系統(tǒng)或右心的血栓阻塞肺動(dòng)脈或其分支所致疾病。 肺梗死為肺動(dòng)脈發(fā)生栓塞后，其支配區(qū)的肺組織因血流受阻或中斷而發(fā)生壞死。,肺栓塞的現(xiàn)狀,發(fā)病率高：僅次于CAD和HBP。 易漏診及誤診：警惕性不高，漏診率高。 不經(jīng)治療死亡率高：達(dá)20%-30%。 明確診療者死亡率明顯下降：可降至2-8% 。,Epidemiology,There is no accurate data for pulmonary embolism because we has limit knowledge of it. In the United States, it is responsible for about 2.3 new cases per 10,000 persons and 50,000 deaths every year.,流行病學(xué),Arch.Intern.Med.154:861,1994,生存率比較,Arch.Intern.Med.154:861,1994,1.0,1,2,3,Risk Factors for DVT/Pulmonary Embolism （Essential）,Risk Factors for DVT/Pulmonary Embolism （Second）,深靜脈血栓形成,肺血栓與深靜脈血栓,肺栓塞的大體解剖觀,肺栓塞的顯微鏡下觀,肺栓塞的病理生理,肺血管阻塞，神經(jīng)體液因素或肺動(dòng)脈壓力感受器的作用，引起肺血管阻力增加； 肺血管阻塞肺泡死腔氣體交換肺泡通氣低氧血癥V/Q單位氣體交換面積二氧化碳 刺激性受體反射性興奮（過(guò)度換氣） 支氣管收縮，氣道阻力增加 肺水腫、肺出血、肺泡表面活性物質(zhì)減少，肺順應(yīng)性降低。,肺栓塞后右心功能不全的病生,肺栓塞,冠狀動(dòng)脈灌注,右心室氧需,右心室壁張力,右心室排血量,右心室氧供,左心室排血量,肺動(dòng)脈壓力 右心室后負(fù)荷,解剖阻塞 神經(jīng)體液作用,右心室擴(kuò)張/功能不全 右心室缺血,室間隔移向左心室,低血壓,體循環(huán)灌注,左心室前負(fù)荷,肺栓塞后肺血流動(dòng)力學(xué)變化,前毛細(xì)血管高壓 血管床減少 支氣管收縮 小動(dòng)脈血管收縮 側(cè)支血管的形成 支氣管-肺動(dòng)脈吻合形成 肺內(nèi)動(dòng)靜脈分流 血流改變： 血流重分布,Westermark征,呼吸動(dòng)力學(xué)改變,過(guò)度通氣： 肺動(dòng)脈高壓 順應(yīng)性下降 肺不張 氣道阻力增加 ： 局限性低碳酸血癥 化學(xué)介質(zhì),臨床分型,大面積PE(massive PE)： 休克和低血壓； 動(dòng)脈收縮壓90mmHg 或下降幅度40mmHg，持續(xù)15min以上； 除外其他原因所致血壓下降。 次大面積PE (submassive PE)亞型 超聲心動(dòng)圖示右心室運(yùn)動(dòng)功能減弱 右心功能不全表現(xiàn)。 非大面積PE(non-massive FE)： 不符合以上大面積PE標(biāo)準(zhǔn)的PE。,癥狀,Peer Review Status: Externally Peer Reviewed by the AMA,體征,D-二聚體分析,Adapted from Bounameaux et al, 1997,肺栓塞胸片檢查,Peer Review Status: Externally Peer Reviewed by the AMA,X-RAY FOR CHEST,Atelectasis and parenchymal densities are quite common. The areas of atelectasis are more common in the lower lobe as are the areas of parenchymal density,Most of these densities are caused by pulmonary hemorrhage and edema and can be confused with infectious infiltrates or malignant masses,Pleural effusions are common and most often unilateral despite the fact that most clots are bilateral. These effusions are usually visible when the patient seeks medical attention. They are almost always small, occupying less than 15% of a hemithorax and rarely increase in size after 3 days. Any increase in size after 3 or 4 days should raise the suspicion of a pulmonary infection or re-embolization.,Pleural based opacities with convex medial margins are also known as a Hamptons Hump. This may be an indication of lung infarction. However, that rate of resolution of these densities is the best way to judge if lung tissue has been infarcted. Areas of pulmonary hemorrhage and edema resolve in a few days to one week. The density caused by an area of infarcted lung will decrease slowly over a few weeks to months and may leave a linear scar.,A diaphragm may be elevated, reflecting volume loss in the affected lung.,The central pulmonary arteries may be prominent either from pulmonary hypertension or the presence of clot in those arteries.,Cardiomegally is a non-specific finding but may imply an enlarged right ventricle as seen in the patient who presented with large bilateral pulmonary emboli.,A Westermarks sign implies an area of decreased vascularity and perfusion accompanied by an enlarged central pulmonary artery on the affected side.,肺栓塞的心動(dòng)超聲征象,直接看到血栓 右室擴(kuò)張 右室活動(dòng)減弱 室間隔異?；顒?dòng) 三尖瓣反流速度增快 肺動(dòng)脈擴(kuò)張 無(wú)吸氣性下腔靜脈塌陷減弱,Br.Heart.J.1994,72:52,室間隔異?；顒?dòng),舒張期,收縮期,Color-Flow-Doppler-ultrasound,非擠壓性充盈缺損,心電圖表現(xiàn),不完全性或完全性右束支傳導(dǎo)阻滯 、avL的S波1.5mm 、avF有Qs波，但無(wú)Qs波 QRS軸900或不確定 肢導(dǎo)聯(lián)低電壓 、avF的T波倒置或V1V4T波倒置,圖12000年8月27日（急診）ECG大致正常,2000年8月29日（門(mén)診）ECG示IRBBB SQTV1V2T波倒置V3V4T波雙向,Ventilation/Perfusion Lung Scan,PIOPED：肺掃描分類(lèi)與肺動(dòng)脈造影結(jié)果的比較,J Nucl Med 1993; 34: 1119,肺掃描,懷疑PE的患者約25可因肺灌注正常而否定診斷，而且不用抗凝治療可能是安全的 懷疑PE的患者約25具有高度的肺掃描結(jié)果，他們可能需要行抗凝治療 其余的患者需要進(jìn)一步的診斷性檢查，而這些檢查是更廣泛的診斷策略,典型肺栓塞,不典型肺栓塞,It is high sensitivity but low specificity,The differential diagnosis for a ventilation perfusion mismatch includes: acute pulmonary embolus previous pulmonary embolus congenital vascular abnormalities vasculitis, bronchogenic carcinoma, radiation therapy,et al.,When a ventilation/perfusion scan does not fit into either the normal or high probability category, then we consider the study to be non-diagnostic and further investigation is required. The majority of cases fall into this category which is characterized by scans with subsegmental defects or defects of any size that match abnormalities on the chest x-ray or the perfusion scan.,A low probability category has been suggested by a number of authors. However, as we can see from the PIOPED data this is not a particularly reliable category. Disagreement among experienced readers is common when perfusion defects are small and limit the utility of this category. This study was originally read as showing a small subsegmental defect. Without the arrow, this study has subsequently been called normal by a number of experienced readers,Conclusion,Lung scans are sensitive exams that essentially rule out the diagnosis of pulmonary embolus when they are normal. Patients with high probability lungs can often be treated without further workup. Those patients with non-diagnostic studies require further diagnostic investigation.,CT of Pulmonary Embolism,Pulmonary infarcts are more readily identified on CT. Modern CT scanners now have faster acquisition times and are providing a detailed assessment of the lung parenchyma that is not available from the chest radiograph. The typical appearance of a pulmonary infarct on CT includes a pleural based density with convex borders and a linear strand at the apex of the triangle,The apex of the triangle is often truncated and not wedge shaped which corresponds to the normal configuration of a secondary lobule in the lung periphery. Low attenuation areas within the infarct represents viable lung. It is important to note, however, that this appearance is not specific for pulmonary infarction. The differential diagnosis for this abnormality includes infarct, hemorrhage, pneumonia, fibrosis, neoplasia and edema,Since the clinical presentation of pulmonary embolus is usually non-specific, the findings on CT are often the first clinical indication that the patient may be suffering from pulmonary embolus. In addition to visualizing the area of infarction we are often able to see the clot itself.,CT has been show to be especially useful in the assessment of patients with chronic dyspnea and known pulmonary artery hypertension. These patients are often difficult to diagnose as is exemplified by this patient with known sclerodema and pulmonary artery hypertension whose CT unexpectedly showed a large calcified clot in the right pulmonary artery.,肺動(dòng)脈造影,正常肺動(dòng)脈,This selective study was done because of a perfusion defect in the left lower lobe on a ventilation perfusion scan. The first angiographic study was inconclusive. Therefore, a subselective study was done that demonstrated the clot with certainty.,The most reliable signs of pulmonary embolus are: An Intraluminal filling defect An Abrupt termination of a branch vessel,Conclusion,Angiography is most accurate in segmental and larger sized arteries. The reproducibility of readings is subsegmental and smaller vessels is poor. Angiography is a safe procedure that is most accurate when imaging emboli that lodge in segmental or larger arteries.,The Diagnosis Algorithm,Plasma D-Dimer Assay,Normal to Near-Normal,Low or Intermediate Probability,High Probability,Clinical Assessment,Low Probability,Intermediate or High Probability,Angiography,Positive,Negative, 500mg/L,500mg/L,Ultrasonogram,No DVT,DVT,Lung Scan,Interpretation Criteria,High Probability (80-100% likelihood for PE ): Greater than or equal to 2 large mismatched segmental perfusion defects or the arithmetic equivalent in moderate or large and moderate defects. Intermediate Probability (20-80% likelihood for PE ): 1. One moderate to 2 large mismatched perfusion defects or the arithmetic equivalent in moderate or large and moderate defects. 2. Single matched ventilation-perfusion defect with a clear chest radiograph . 3. Difficult to categorize as low or high, or not described as low or high. 4. Nonsegmental perfusion defects (e.g., cardiomegaly, enlarged aorta, enlarged hila, elevated diaphragm). 5. Multiple matched V/Q abnormalities, even when relatively extensive, are low probability for PE . The prevalence of PE in patients with extensive matched V/Q defects and no CXR abnormality was 14% (low probability).,J Nucl Med 1995; 36: 2380-2387,Low Probability (0-19% likelihood for PE ),Perfusion defects matched by ventilation abnormality provided that there are: (a) clear chest radiograph and (b) some areas of normal perfusion in the lungs. Extensive matched V/Q abnormalities are appropriate for low probability, provided that the CXR is clear. Any perfusion defect with a substantially larger chest radiographic abnormality. Any number of small perfusion defects with a normal chest radiograph.,J Nucl Med 1995; 36: 2380-2387,Diagnostic Criteria for Clinically Suspected Pulmonary Embolism,Pulmonary embolism absent Negative pulmonary angiogran Normal or near-normal lung scan D-dimer level500 mg/L Pulmonary embolism present Positive pulmonary angiogram High-or intermediate-probability lung scan and ultrasonogram evidence of deep-vein thrombosis,Thorax 51:23, 1996,鑒別診斷,呼吸困難、咳嗽、咯血、呼吸頻率增快等呼吸系統(tǒng)表現(xiàn)為主的患者多被診斷為其它的胸肺疾病如肺炎、胸膜炎、肺不張等 以胸痛、心悸、心臟雜音、肺動(dòng)脈高壓等循環(huán)系統(tǒng)表現(xiàn)為主的患者易衩診斷為其它的心臟疾病如冠心病、風(fēng)心病等 以暈厥、驚恐等表現(xiàn)為主的患者有時(shí)被診斷為其它心臟或神經(jīng)及精神系統(tǒng)疾病如心律失常、腦血管意外、癲癇等,原發(fā)性肺動(dòng)脈高壓與肺栓塞復(fù)發(fā),相似點(diǎn)： 癥狀：疲乏，活動(dòng)時(shí)呼吸困難最常見(jiàn)，胸痛、昏厥、咯血、紫紺也較常見(jiàn) 臨床經(jīng)過(guò)：進(jìn)行性呼吸困難，右心衰竭 血流動(dòng)力學(xué)：右心室壓力升高、肺毛細(xì)血管嵌壓正常 治療：包含抗凝治療,區(qū)別點(diǎn),急性PE的治療,一般處理： 送入監(jiān)護(hù)病房，加強(qiáng)生命體征的監(jiān)護(hù) 防止栓子脫落，絕對(duì)臥床 情感支持 對(duì)癥治療：如咳嗽、發(fā)熱等,急性PE,呼吸循環(huán)支持治療,一般患者均采用經(jīng)鼻導(dǎo)管或面罩吸氧治