1、肺动脉栓塞的诊治制作XGHRH敬请指正基本概念肺栓塞肺栓塞是以各种栓子阻塞肺动脉系统为其发病原因的一组疾病或临床综合征的总称，包括肺血栓栓塞症，脂肪栓塞综合征，羊水栓塞，空气栓塞等。肺血栓栓塞症肺血栓栓塞症为来自静脉系统或右心的血栓阻塞肺动脉或其分支所致疾病。肺梗死肺梗死为肺动脉发生栓塞后，其支配区的肺组织因血流受阻或中断而发生坏死。肺栓塞的现状发病率高高：仅次于CAD和HBP。易易漏诊及误诊：警惕性不高，漏诊率高。不经治疗死亡率高高：达20%-30%。明确诊疗者死亡率明显下降下降：可降至2-8%。EpidemiologyThere is no accurate data for pulmon
2、ary 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.流行病学0 01 12 23 34 46569656970747074757975798084808485898589年龄（岁）年龄（岁）发生率/1 0 00患 者-年发生率/1 0 00患 者-年DVTDVTPEPEArch.Intern.Med.154:861,1994生存
3、率比较Arch.Intern.Med.154:861,1994随访的年数随访的年数生存的可能性生存的可能性匹配的样本匹配的样本DVTDVTPEPE1.01.0123Risk Factors for Risk Factors for DVT/Pulmonary EmbolismDVT/Pulmonary Embolism（Essential）抗凝血酶缺乏蛋白C缺乏先天性异常纤维蛋白原血症V因子基因突变血栓调节蛋白纤溶酶原缺乏高半胱氨酸血症异常纤溶酶原血症抗心肌碱脂抗体蛋白S缺乏纤溶酶原激活抑制剂过量因子缺乏前凝血酶20210A突变Risk Factors for Risk Factors for
4、 DVT/Pulmonary EmbolismDVT/Pulmonary Embolism（Second）创伤/骨折外科手术卒中制动高龄恶性肿瘤+化疗中心静脉导管肥胖慢性静脉机能不全心力衰竭吸烟长途旅行妊娠/产后期口服避孕药克隆病、狼疮抗凝剂肾病综合征假体表面粘滞性过高血小板异常深静脉血栓形成原因 分类血流滞缓小腿肌肉静脉丛血栓形成髂股静脉血栓形成静脉壁损伤原发性髂肌静脉血栓形成继发性髂股静脉血栓形成高凝状态股青肿肺血栓与深静脉血栓肺栓塞的大体解剖观肺栓塞的显微镜下观肺栓塞的病理生理肺血管阻塞，神经体液因素或肺动脉压力感受器的作用，引起肺血管阻力增加；肺血管阻塞肺泡死腔气体交换肺泡通气低氧血症
5、V/Q单位气体交换面积二氧化碳刺激性受体反射性兴奋（过度换气）支气管收缩，气道阻力增加肺水肿、肺出血、肺泡表面活性物质减少，肺顺应性降低。肺栓塞后右心功能不全的病生肺栓塞冠状动脉灌注右心室氧需右心室壁张力右心室排血量右心室氧供左心室排血量肺动脉压力右心室后负荷解剖阻塞 神经体液作用右心室扩张/功能不全 右心室缺血室间隔移向左心室低血压体循环灌注左心室前负荷肺栓塞后肺血流动力学变化 前毛细血管高压 血管床减少 支气管收缩 小动脉血管收缩 侧支血管的形成支气管-肺动脉吻合形成 肺内动静脉分流 血流改变：血流重分布 Westermark征呼吸动力学改变 过度通气：肺动脉高压 顺应性下降 肺不张 气道
6、阻力增加：局限性低碳酸血症 化学介质 临床分型大面积PE(massive PE)：休克和低血压；动脉收缩压 3 8.5C体温 3 8.5C喘息喘息Homans征Homans征右室抬举右室抬举胸膜磨擦音胸膜磨擦音第三心音第三心音紫绀紫绀D-二聚体分析检验方法病人数PE发生率%敏感性 特异性ELISA1579349843快速 ELISA6352410044传统乳胶试验364469255血乳胶试验140259763Adapted from Bounameaux et al,1997 肺栓塞胸片检查0 01010202030304040505060607070发生率%发生率%正常正常肺不张或实变肺不张
7、或实变胸腔积液胸腔积液胸膜肥厚胸膜肥厚纵隔上抬纵隔上抬肺动脉搏增宽肺动脉搏增宽Westermark征Westermark征心脏增大心脏增大肺水肿肺水肿Peer Review Status:Externally Peer Reviewed by the AMAX-RAY FOR CHESTAtelectasis and parenchymal densities are quite common.The areas of atelectasis are more common in the lower lobe as are the areas of parenchymal densityMos
8、t of these densities are caused by pulmonary hemorrhage and edema and can be confused with infectious infiltrates or malignant massesPleural effusions are common and most often unilateral despite the fact that most clots are bilateral.These effusions are usually visible when the patient seeks medica
9、l 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
10、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 de
11、crease 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 fi
12、nding 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.肺栓塞的心动超声征象直接看到血栓右室扩张右室活动减弱室间隔异
13、常活动三尖瓣反流速度增快肺动脉扩张无吸气性下腔静脉塌陷减弱Br.Heart.J.1994,72:52室间隔异常活动舒张期收缩期Color-Flow-Doppler-ultrasoundColor-Flow-Doppler-ultrasound非挤压性充盈缺损心电图表现不完全性或完全性右束支传导阻滞、avL的S波1.5mm、avF有Qs波，但无Qs波QRS轴900或不确定肢导联低电压、avF的T波倒置或V1V4T波倒置图12000年8月27日（急诊）ECG大致正常2000年8月29日（门诊）ECG示IRBBB SQTV1V2T波倒置V3V4T波双向Ventilation/Perfusion Lu
14、ng Ventilation/Perfusion Lung ScanScanTHANK YOUSUCCESS2022-10-1236可编辑PIOPED：肺扫描分类与肺动脉造影结果的比较肺扫描肺栓塞肺动脉造影阴性总数有无不肯定高度可疑1021417124中度可疑105217933364低度可疑391991262312接近正常/正常550274131总计25148024176931J Nucl Med 1993;34:1119怀疑PE的患者约25可因肺灌注正常而否定诊断，而且不用抗凝治疗可能是安全的怀疑PE的患者约25具有高度的肺扫描结果，他们可能需要行抗凝治疗其余的患者需要进一步的诊断性检查，而
15、这些检查是更广泛的诊断策略典型肺栓塞 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 ventilati
16、on/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
17、 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
18、 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 readersConclusionConclusionLung scans are sensitive exams that essentially rule out the diagnosis
19、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 EmbolismCT of Pulmonary EmbolismPulmonary infarcts are more readily identifie
20、d 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
21、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
22、not specific for pulmonary infarction.The differential diagnosis for this abnormality includes infarct,hemorrhage,pneumonia,fibrosis,neoplasia and edemaSince the clinical presentation of pulmonary embolus is usually non-specific,the findings on CT are often the first clinical indication that the pat
23、ient 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 difficu
24、lt 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.肺动脉造影正常肺动脉This selective study was done because of a perfusion defect in the left lower lobe on a ventilation per
25、fusion 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 ConclusionConclusionAngiography is most
26、 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 AssayNormal to Near
27、-NormalLow or Intermediate ProbabilityHigh ProbabilityClinical AssessmentLow ProbabilityIntermediate or High ProbabilityAngiographyPositiveNegative 500mg/L 500mg/LUltrasonogramNo DVTDVTLung ScanInterpretation CriteriaInterpretation CriteriaHigh Probability(80-100%likelihood for PE):High Probability(
28、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):Intermediate Probability(20-80%likelihood for PE):1.One moderate to 2 large misma
29、tched 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,enlar
30、ged 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;36:2380-2387Low Probability(0
31、-19%likelihood for Low Probability(0-19%likelihood for PE)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
32、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;36:2380-2387Diagnostic Criteria for Clinically Suspected Pulmonary EmbolismPulmonary embolism absentNegative pulmonary
33、 angiogranNormal or near-normal lung scanD-dimer level50女女/男比例男比例4：11：1临床经过临床经过进行性恶化进行性恶化稳定一段时间后恶化稳定一段时间后恶化肺灌注扫描肺灌注扫描无节段性灌注缺损无节段性灌注缺损节段性或大片灌注缺损节段性或大片灌注缺损肺动脉收缩压肺动脉收缩压60mmHg60mmHg肺动脉造影肺动脉造影“修剪修剪”征征管腔内充盈缺损管腔内充盈缺损肺动脉造影混淆肺动脉造影混淆的问题的问题血栓血栓“修剪修剪”征也提示征也提示PE确诊确诊肺活检肺活检肺血管镜肺血管镜治疗治疗抗凝；大剂量硝苯地平及静抗凝；大剂量硝苯地平及静注前列环素
34、注前列环素抗凝；抗凝；IVC中断；血栓中断；血栓动脉内膜切除术动脉内膜切除术急性PE的治疗一般处理：送入监护病房，加强生命体征的监护防止栓子脱落，绝对卧床情感支持对症治疗：如咳嗽、发热等急性急性PEPE呼吸循环支持治疗一般患者均采用经鼻导管或面罩吸氧治疗低氧血症无创伤性或经气管插管机械通气治疗呼吸衰竭，避免气管切开。尽量减少正压通气对循环的不种影响。急性急性PEPE溶栓治疗的适应证栓塞面积超过2个肺叶血管者合并休克或低血压者合并右心功能不全者排除禁忌证者急性急性PEPE溶栓禁忌证绝对禁忌证活动性内出血近期的自发性颅内出血相对禁忌证大手术、分娩、器官活检或不能压迫的血管穿刺史（10天内）2月内缺
35、血性中风10天内胃肠道出血15天内严重外伤1月内神经外科或眼科手术控制不好的重度高血压近期心肺复苏血小板100000/mm3，PT50%怀孕细菌性心内膜炎糖尿病出血性视网膜病变肺动脉栓塞的溶栓及抗凝治疗12小时溶栓法：v4400u/Kg尿激酶溶于100ml于不少于10分钟静推v2200u/Kg尿激酶溶于250ml用12小时维持v每46小时监测APTT，当其降到正常2倍时，加用低分子肝素钙（0.1ml/10Kg，每天二次，皮下注射)v同用华法令，35天后监测INR，当重复为1.52倍二天时，停用低分子肝素，v维持剂量华法令6周6月，同时监测INR2小时溶栓法：v尿激酶2万u/Kg溶于250ml用
36、2小时静泵，余治疗同上vrt-PA10mg加入10ml液体中10分钟内静推，后rt-PA4090mg加入90ml液体中110分钟内静滴，余治疗同上急性急性PEPE依据体重的肝素（普通）计算图变量变量肝素剂量肝素剂量肝素起始剂量80u/kg推注，然后18u/kg/haPTT35s(90s(3 对照)保持静滴1小时，然后滴速减慢3u/kgAnn.Intern.Med.119:874,1993下腔静脉过滤网适应证抗凝治疗禁忌而肺栓塞已证实活动性出血可能引起贫血（如胃肠道）担心可能是灾难性的出血（如开颅术）现存的抗凝并发症计划强化的癌症化疗尽管治疗充分但抗凝失败在高危病人中预防性使用广泛的进展性静脉血
37、栓和导管或外科肺去栓术并用严重肺高压或肺心病急性急性PEPE肺动脉血栓摘除术大面积PTE，适合手术且无固定肺动脉高压者者。有溶栓禁忌证者。经溶栓和其他积极的内科治疗无效者。急性急性PEPE经静脉导管碎解和抽吸血栓肺动脉主干或主要分支大面积PTE者溶栓和抗凝治疗禁忌经溶栓或积极的内科治疗无效者缺乏手术条件急性急性PEPE慢性栓塞性肺动脉高压的治疗手术治疗：严重肺动脉高压。介入治疗：球囊扩张肺动脉成型术。抗凝治疗：华法令。下腔静脉滤器：反复深静脉血栓脱落者。降低肺动脉压力：血管扩张剂治疗心衰p 经常不断地学习,你就什么都知道。你知道得越多,你就越有力量p Study Constantly,And You Will Know Everything.The More You Know,The More Powerful You Will Be写在最后谢谢你的到来学习并没有结束，希望大家继续努力Learning Is Not Over.I Hope You Will Continue To Work Hard演讲人：XXXXXX 时 间：XX年XX月XX日
