肺栓塞的診治課件

1、肺動脈栓塞的診治制作XGHRH敬請指正肺動脈栓塞的診治制作敬請指正基本概念肺栓塞是以各種栓子阻塞肺動脈系統(tǒng)為其發(fā)病原因的一組疾病或臨床綜合征的總稱，包括肺血栓栓塞癥，脂肪栓塞綜合征，羊水栓塞，空氣栓塞等。肺血栓栓塞癥為來自靜脈系統(tǒng)或右心的血栓阻塞肺動脈或其分支所致疾病。肺梗死為肺動脈發(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?；靖拍罘嗡ㄈ且愿鞣N栓子阻塞肺動脈系統(tǒng)為其發(fā)病原因的一組疾肺栓塞的現(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20%-30%。明確診療者死亡率明顯下降：可降至2-8% 。 肺栓塞的現(xiàn)狀發(fā)病率高：僅次于CAD和H

2、BP。EpidemiologyThere 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.EpidemiologyThere is no accura流行病學Arch.Intern.Med.154:861,1994流行病學Arch.Intern.Med.154:

3、861,19生存率比較Arch.Intern.Med.154:861,19941.0123生存率比較Arch.Intern.Med.154:861,1Risk Factors for DVT/Pulmonary Embolism （Essential）抗凝血酶缺乏蛋白C缺乏先天性異常纖維蛋白原血癥V因子基因突變血栓調節(jié)蛋白纖溶酶原缺乏高半胱氨酸血癥異常纖溶酶原血癥抗心肌堿脂抗體蛋白S缺乏纖溶酶原激活抑制劑過量因子缺乏前凝血酶20210A突變Risk Factors for DVT/PulmonaryRisk Factors for DVT/Pulmonary Embolism （Second）

4、創(chuàng)傷/骨折外科手術卒中制動高齡惡性腫瘤+化療中心靜脈導管肥胖慢性靜脈機能不全心力衰竭吸煙長途旅行妊娠/產(chǎn)后期口服避孕藥克隆病、狼瘡抗凝劑腎病綜合征假體表面粘滯性過高血小板異常Risk Factors for DVT/Pulmonary深靜脈血栓形成原因 分類血流滯緩小腿肌肉靜脈叢血栓形成髂股靜脈血栓形成靜脈壁損傷原發(fā)性髂肌靜脈血栓形成繼發(fā)性髂股靜脈血栓形成高凝狀態(tài)股青腫深靜脈血栓形成原因 分類血流滯緩小腿肌肺血栓與深靜脈血栓肺血栓與深靜脈血栓肺栓塞的大體解剖觀肺栓塞的大體解剖觀肺栓塞的顯微鏡下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)體液因素或肺動脈壓力感受器的作用，引起肺血管阻力增

5、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、肺泡表面活性物質減少，肺順應性降低。肺栓塞的病理生理肺血管阻塞，神經(jīng)體液因素或肺動脈壓力感受器的肺栓塞后右心功能不全的病生肺栓塞冠狀動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脈壓力右心室后負荷解剖阻塞 神經(jīng)體液作用右心室擴張/功能不全 右心室缺血室間隔移向左心室低血壓體循環(huán)灌注左心室前負荷肺栓塞后右心功能不全的病生肺栓塞冠狀動脈灌注右心室氧需肺栓塞后肺血流動力學變化 前毛細血管高壓 血管床減少 支氣管收縮 小動脈血管收縮

6、側支血管的形成支氣管-肺動脈吻合形成 肺內動靜脈分流 血流改變： 血流重分布 Westermark征肺栓塞后肺血流動力學變化Westermark征呼吸動力學改變 過度通氣： 肺動脈高壓 順應性下降 肺不張 氣道阻力增加 ： 局限性低碳酸血癥 化學介質 呼吸動力學改變臨床分型大面積PE(massive PE)：休克和低血壓；動脈收縮壓1.5mm、avF有Qs波，但無Qs波QRS軸900或不確定肢導聯(lián)低電壓、avF的T波倒置或V1V4T波倒置心電圖表現(xiàn)不完全性或完全性右束支傳導阻滯圖12000年8月27日（急診）ECG大致正常2000年8月29日（門診）ECG示IRBBB SQTV1V2T波倒置V

7、3V4T波雙向圖12000年8月27日（急診）ECG大致正常2000年8月Ventilation/Perfusion Lung ScanVentilation/Perfusion Lung ScaTHANK YOUSUCCESS2022/10/436可編輯THANK YOUSUCCESS2022/10/33PIOPED：肺掃描分類與肺動脈造影結果的比較肺掃描肺栓塞肺動脈造影陰性總數(shù)有無不肯定高度可疑1021417124中度可疑105217933364低度可疑391991262312接近正常/正常550274131總計25148024176931J Nucl Med 1993; 34: 1119

8、PIOPED：肺掃描分類與肺動脈造影結果的比較肺掃描肺栓塞肺肺掃描懷疑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果，他們可能需要行抗凝治療其余的患者需要進一步的診斷性檢查，而這些檢查是更廣泛的診斷策略肺掃描懷疑PE的患者約25可因肺灌注正常而否定診斷，而且不典型肺栓塞 典型肺栓塞 不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 include

9、s: acute pulmonary embolus previous pulmonary embolus congenital vascular abnormalities vasculitis, bronchogenic carcinoma, radiation therapy,et al.It is high sensitivity but lowWhen a ventilation/perfusion scan does not fit into either the normal or high probability category, then we consider the s

10、tudy 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. When a ventilation/perfusion A low probab

11、ility 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

12、 as showing a small subsegmental defect. Without the arrow, this study has subsequently been called normal by a number of experienced readersA low probability category hasConclusionLung scans are sensitive exams that essentially rule out the diagnosis of pulmonary embolus when they are normal. Patie

13、nts with high probability lungs can often be treated without further workup. Those patients with non-diagnostic studies require further diagnostic investigation. ConclusionLung scans are sensCT of Pulmonary EmbolismPulmonary infarcts are more readily identified on CT. Modern CT scanners now have fas

14、ter 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 CT of Pulmona

15、ry EmbolismPulmoThe 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 s

16、pecific for pulmonary infarction. The differential diagnosis for this abnormality includes infarct, hemorrhage, pneumonia, fibrosis, neoplasia and edemaThe apex of the triangle is ofSince the clinical presentation of pulmonary embolus is usually non-specific, the findings on CT are often the first c

17、linical 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. Since the clinical presentatiCT has been show to be especially useful in the assessment of patients with chronic dyspnea and known

18、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. CT has been show to be especi肺動脈造影正常肺動脈肺動脈造影正常肺動脈

19、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. This selective study was done The most reliable signs

20、 of pulmonary embolus are: An Intraluminal filling defect An Abrupt termination of a branch vessel The most reliable signs of pulConclusionAngiography is most accurate in segmental and larger sized arteries. The reproducibility of readings is subsegmental and smaller vessels is poor. Angiography is

21、a safe procedure that is most accurate when imaging emboli that lodge in segmental or larger arteries. ConclusionAngiography is most The Diagnosis Algorithm Plasma D-Dimer AssayNormal to Near-NormalLow or Intermediate ProbabilityHigh ProbabilityClinical AssessmentLow ProbabilityIntermediate or High

22、ProbabilityAngiographyPositiveNegative 500mg/L 500mg/LUltrasonogramNo DVTDVTLung ScanThe Diagnosis Algorithm PlasmaInterpretation CriteriaHigh Probability (80-100% likelihood for PE ):Greater than or equal to 2 large mismatched segmental perfusion defects or the arithmetic equivalent in moderate or

23、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

24、 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 patie

25、nts with extensive matched V/Q defects and no CXR abnormality was 14% (low probability). J Nucl Med 1995; 36: 2380-2387Interpretation CriteriaHigh PLow Probability (0-19% likelihood for PE ) Perfusion defects matched by ventilation abnormality provided that there are: (a) clear chest radiograph and

26、(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 radiogra

27、ph. J Nucl Med 1995; 36: 2380-2387Low Probability (0-19% likelihDiagnostic Criteria for Clinically Suspected Pulmonary EmbolismPulmonary embolism absentNegative pulmonary angiogranNormal or near-normal lung scanD-dimer level50女/男比例4：11：1臨床經(jīng)過進行性惡化穩(wěn)定一段時間后惡化肺灌注掃描無節(jié)段性灌注缺損節(jié)段性或大片灌注缺損肺動脈收縮壓60mmHg50女/男比例急性P

28、E的治療一般處理：送入監(jiān)護病房，加強生命體征的監(jiān)護防止栓子脫落，絕對臥床情感支持對癥治療：如咳嗽、發(fā)熱等急性PE急性PE的治療一般處理：急性PE呼吸循環(huán)支持治療一般患者均采用經(jīng)鼻導管或面罩吸氧治療低氧血癥無創(chuàng)傷性或經(jīng)氣管插管機械通氣治療呼吸衰竭，避免氣管切開。盡量減少正壓通氣對循環(huán)的不種影響。急性PE呼吸循環(huán)支持治療一般患者均采用經(jīng)鼻導管或面罩吸氧治療低氧血癥溶栓治療的適應證栓塞面積超過2個肺葉血管者合并休克或低血壓者合并右心功能不全者排除禁忌證者急性PE溶栓治療的適應證栓塞面積超過2個肺葉血管者急性PE溶栓禁忌證絕對禁忌證活動性內出血近期的自發(fā)性顱內出血相對禁忌證大手術、分娩、器官活檢或不能

29、壓迫的血管穿刺史（10天內）2月內缺血性中風10天內胃腸道出血15天內嚴重外傷1月內神經(jīng)外科或眼科手術控制不好的重度高血壓近期心肺復蘇血小板100000/mm3，PT50%懷孕細菌性心內膜炎糖尿病出血性視網(wǎng)膜病變溶栓禁忌證絕對禁忌證活動性內出血近期的自發(fā)性顱內出血肺動脈栓塞的溶栓及抗凝治療12小時溶栓法：4400u/Kg尿激酶溶于100ml于不少于10分鐘靜推2200u/Kg尿激酶溶于250ml用12小時維持每46小時監(jiān)測APTT，當其降到正常2倍時，加用低分子肝素鈣（0.1ml/10Kg，每天二次，皮下注射)同用華法令，35天后監(jiān)測INR，當重復為1.52倍二天時，停用低分子肝素，維持劑量華法令6周6月，同時監(jiān)測INR2小時溶栓法：尿激酶2萬u/Kg溶于250ml用2