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  Pulmonary embolism

The word embolism refers to a blockage of an artery by a blood clot, air, clumped tumor cells or fat. Pulmonary embolisms are embolisms that occur in the respiratory system. The most common form of pulmonary embolism is called a thrombo-embolism. A thrombo-embolism is usually a venous (as opposed to arterial) thrombus that has become lose and travels to an arterial blood supply in one of the lungs. If the patient has experience severe trauma (such as car accident or shooting) the materials of the clot can be fat or bone. Deep see divers can have an embolism of air. Mothers can develop an embolism of amniotic fluid during childbirth.

Pulmonary embolism
Pulmonary embolism


Symptoms:

In seventy-three percent of patients with pulmonary embolism, the first sign is shortness of breath (dyspnea). Rapid breathing or tachypnea occurs in seventy percent of patients with pulmonary embolism. Sixty-six percent of patients have a chest pain that is worsened by breathing and thirteen percent cough up blood, also knowm as hemoptysis. In extreme cases, patients may experience cyanosis, tachycardia, hypotension, shock, loss of consciousness or death. A person is at risk of developing a pulmonary embolism if they are diagnosed with a deep venous thrombosis DVT) which can be in the leg or the pelvis. Fifteen percent of all patients with DVTs develop a pulmonary embolism which occurs when the clot dislodges and migrates to the lugs.

There are three categories for DVT and pulmonary embolism risk factors: genetic, acquired and circumstantial. Usually more than one risk factor is responsible for causing DVT and/or pulmonary embolism. Genetic factors are Factor V leiden, prothrombin mutation, protein C deficiency, protein S deficiency, high homocysteine levels due to a MTHFR mutation, plasminogen and fibrinolysis disorders, and an antithrombin III deficiency. Acquired risk factors include antiphospholipid antibodies (such as anticardiolipin antibodies or lupus anticoagulants), renal disease or paroxysmal nocturnal hemoglobinuria. Circumstantial risk factors are immobilization, especially after surgery or injury, obesity, oral contraceptive use, cancer (Trousseau’s syndrome) and pregnancy.

Diagnosis

Diagnosis of pulmonary embolism is made primarily with a procedure known as a pulmonary angiography. A pulmonary angiogram involves a tracer entered into the blood stream and X-rays to detect the passages of circulation. Computed tomography with radiocontrast is a pulmonary angiogram also known as CT PA. This procedure is more accessible to patients and has the advantage of picking up other disorders if a pulmonary embolism is not detected. A ventilation/perfusion scan (V/Q scan) can determine which areas of the lungs are being ventilated but not receiving (perfused) adequate blood. This procedure is a type of scintigraphy and is used less often than the CTPA.

Electrocardiograms are used to detect heart strain or large pulmonary embolisms. This test has limited diagnostic value in terms of detecting a pulmonary embolism as the same readings or measurements can be present with other acute lung diseases. Sinus tachycardia is the most common reading of a patient’s electrocardiogram with pulmonary embolism.

When a massive pulmonary embolism affects a patient, an echocardiogram can detect dysfunction of the right side of the heart. This is a warning signal that the pulmonary artery is greatly obstructed and the heart is unable to unblock it. Sometimes further analysis is needed to exclude other critical secondary causes of pulmonary embolism. These tests include a clotting status, screenings (erythrocyte sedimentation rate, renal function liver enzyme and electrolytes) and a full blood count.

Treatment

Supportive treatments are usually the first prescribed, such as oxygen and pain relief. A massive pulmonary embolism requires an enzymatic breakdown of the clot which is administered with medication.

Anticoagulant therapy is the primary treatment. Medications initially administered are heparin, low molecular weight heparins, enoxaparin or fondaparinux in conjunction with warfarin therapy. Warfarin is usually administered for three to six months. Sometimes it can be a lifelong therapy if the risk is high for recurring DVTs or pulmonary embolisms. If anticoagulant therapy is not an option for a patient or is ineffective an inferior vena cava filter can be implanted in the patient. Surgery for acute pulmonary embolism is usually not performed, though may be help a few patients. A pulmonary thromboendarterectomy is a procedure performed on patients with chronic pulmonary embolisms that have lead to pulmonary hypertension.

Patients who are untreated have a twenty-six percent mortality rate. Prognosis is dependent on the size of the affected area of the lung and other co-morbidities or underlying symptoms and conditions.

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