第8章 肺血栓栓塞

肺血栓栓塞PulmonaryThromboembolism

Definitions定義

RiskFactor危險因素Pathology病理學(xué)

Pathophysiology

病理生理學(xué)ClinicalManifestations臨床表現(xiàn)LaboratoryTesting&SpecialTesting實驗室和特殊檢查Diagnosis&Differentialdiagnosis診斷和鑒別診斷Treatment治療Definitions

定義PulmonaryEmbolism(PE)

肺栓塞PulmonaryThromboembolism(PTE)

肺血栓栓塞PulmonaryInfarction(PI)

肺梗死VenousThromboembolism

靜脈血栓栓塞60%to90%ofPEsoriginatefromDVTAsathrombusbreaksfree,ittravelstotheheartandobstructsbranchesofthepulmonaryarterialtree.Largeclotsmayremainlodgedinthecentralpulmonaryarteryassaddleemboli,whilesmallembolimaytraveltoperipheralsubsegmentalarteries.RiskFactors

危險因素

InheritedAcquiredAgeObesitySmokingOral

contraceptivesPregnancySurgeryTrauma

HistoryofDVTHormonaltherapyImmobilityCentralvenous

CatheterMedicalConditionsVirchow’sTriadLocaltraumatothevesselwall

血管內(nèi)皮損傷Hypercoagulability

高凝狀態(tài)Stasisofbloodflow

血流淤滯Pathology

病理學(xué)Bothlungsinthemajorityofcases,thelowerlobesoftenthanupperlobes,andrightlungoftenthantheleftlung

雙側(cè)多于單側(cè)，右側(cè)多于左側(cè)，下肺多于上肺Rightheartfailure:acutepulmonaryarteryhypertension

右心衰：急性肺動脈高壓Chronicpulmonaryarteryhypertension

慢性肺動脈高壓Pulmonaryinfarction:moreless

肺梗死按栓子大小和部位可以分為

巨大肺栓塞－急性發(fā)作（幾小時到24小時）－肺動脈干阻塞達50%以上或相當(dāng)于兩個或兩個以上的肺葉動脈阻塞－右心功能不全伴低血壓或心源性休克急性次大肺栓塞－不到兩個肺葉動脈受阻－血壓正常，可以出現(xiàn)右心功能不全中等肺栓塞－肺段或亞肺段動脈栓塞－血壓正常，無右心功能不全小肺動脈栓塞－肺亞段及其分支栓塞－血壓正常，無右心功能不全Pathophysiology病理生理學(xué)Hemodynamicalternations

血流動力學(xué)變化Alternationsinnervousandhumoralmediators

神經(jīng)體液介質(zhì)變化Gasexchangealternations

氣體交換變化

栓子堵塞肺動脈毛細血管前動脈壓↑肺循環(huán)阻力↑肺血管床↓肺動脈壓↑右心負荷↑↑右心衰ＢＰ↓血流動力學(xué)變化

肺血管內(nèi)皮損傷內(nèi)皮素血小板活化脫顆粒血管緊張素Ⅱ二磷酸腺甘5–羥色胺組織胺前列腺素

血管收縮神經(jīng)體液介質(zhì)變化

5-羥色胺,血小板激活因子組織胺,交感神神興奮,血栓素Ａ2支氣管痙攣肺血管通透性↑氣道阻力↑肺泡表面活性物質(zhì)↓肺通氣↓肺萎縮,肺不張肺水腫,肺出血

呼吸困難呼吸系統(tǒng)病理生理改變

PTE栓塞部位未栓塞部位有通氣無血流高血流灌注肺泡死腔↑

肺通氣／灌注比例失調(diào)呼吸系統(tǒng)病理生理改變ClinicalManifestations

臨床表現(xiàn)Symptoms

癥狀Signsofrespiratoryandcirculationsystem

呼吸系統(tǒng)和心臟體征Featuresofdeepvenousthrombsis

深靜脈血栓的臨床表現(xiàn)Symptoms癥狀

Dyspnea

呼吸困難Chestpain(pleuritic&angina-like)

胸痛Hemoptysis

咯血Cough

咳嗽Apprehension

煩躁不安Syncope

暈厥Abdominalpain腹痛Fever發(fā)熱

Signsofrespiratorysystem

呼吸系統(tǒng)體征Tachypnea>16breaths/min

呼吸急促Cyanosis

紫紺Wheezes/finerales哮鳴音/細濕羅音Signsofcirculationsystem

循環(huán)系統(tǒng)體征Tachycardia(>100beats/min)

心率增快Arrhythmia心律失常AccentuatedS2heartsoundorsplittedS2heartsound

肺動脈瓣第二心音亢進或分裂Galloprhythm右心奔馬律Jugularvenousdistention

頸靜脈怒張Hepatomegaly

肝大Hypotension&shock

低血壓和休克Featuresofdeepvenousthrombsis

深靜脈血栓的臨床表現(xiàn)Legswelling下肢腫脹Legpain下肢疼痛Legerythema下肢紅斑LaboratoryTesting&SpecialTesting

實驗室和特殊檢查

Generaltesting一般檢查Chestradiography胸部X線片EKG心電圖Echocardiography超聲心動圖Ventilation-perfusionscanning通氣/灌注掃描SpiralCT&CTangiographyCT和CT血管成像Pulmonaryarteriography肺動脈造影ExaminationsofDVT深靜脈血栓的檢查Generaltesting一般檢查Ariseincountingofwhitebloodcell,butlessthan15x109/L

白細胞總數(shù)升高，但一般不超過15x109/LAriseinlevelsofESR,LDH,CPK,AST,andFDPfrompherapheblood

血沉、血ESR,LDH,CPK,AST和FDP升高Arterialbloodgasanalysis血氣分析ABG?PaO2下降PaCO2降低pHA-aGradientAlveolararterialoxygengradient148-1.2(PaCO2)-PaO2Gradient>15-20isconsideredabnormalDoneatRoomair肺泡-動脈血氧分壓差增大D-DimerD-二聚體Fibrindegradationproduct

纖維蛋白降解產(chǎn)物Elevatedinmanycircumstances:Malignancy,surgery,inflammation

很多疾病出現(xiàn)D-dimer升高NegativeD-dimercombinedwithlowpre-testprobabliltyhasnegativepredictivevalueof99%D-dimer診斷PTE的陰性預(yù)測值為99%D-Dimercont’dPtswithhigherlikelihoodofPEneedmoreextensivew/uevenifd-dimerisnormal.ApositivetestdoesnothingtoincreasethecertaintyofdiagnosisofPTE

陽性結(jié)果并不能確定診斷心電圖

EKG

IfECGabnormalitiesarepresent,theymaybesuggestiveofPTE,buttheabsenceofECGabnormalitieshasnosignificantpredictivevalue

心電圖正常不能除外PTEOnly20%ofpatientswithprovenPTEhaveanyoftheseclassicECGabnormalities20%的PTE患者心電圖異常ThemostcommonEKGabnormalitiesinthesettingofPEaretachycardiaandnonspecificST-Twaveabnormalities竇性心動過速和非特異性ST-T異常最常見Theclassicfindingsofrightheartstrainandacutecorpulmonalearetall,peakedP-wavesinleadII(P-pulmonale),rightaxisdeviation,rightbundlebranchblock,anS1-Q3-T3patternoratrialfibrillation

肺性P波；ＱＲＳ電軸右偏；右束支阻滯；ＳⅠＱ

ⅢＴⅢEKGwithＳⅠＱⅢＴⅢ

Chestradiography胸部X線片

CXRUsuallyrevealsanonspecificabnormality.14%normal胸部X線片特異性差，僅14%出現(xiàn)正常Classicabnormalitiesinclude:Westermark’sSign-focaloligemiaHampton’sHump-wedgeshapeddensityEnlargedRightDescendingPulmonaryArtery(Palla’ssign典型X線片：Westermark征和Hampton征Westermark’sSignHamptonsHumpPEwhichappearslikeamassPEwitheffusion

andelevateddiaphragm超聲心動圖右心室擴大間隔左移左心室變小，呈Ｄ字形右心室運動減弱肺動脈增寬三尖瓣返流肺動脈高壓Ventilation-perfusionscanning

通氣/灌注掃描UsefuliftheresultsarenormalornearnormalAsmanyas40%ofptswithhighclinicalsuspicionforPEandlowprobabilityscanshaveaPEonangiogram

正常灌注掃描可除外PTEVentilation-perfusionscanning

通氣/灌注掃描SpiralCT&CTangiography

CT和CT血管成像PulmonaryAngiogramMostspecifictestavailablefordiagnosisofPECandetectemboliassmallas1-2mmMostusefulwhentheclinicallikelihoodofPEdifferssubstantiallyfromthelungscanresultorwhenthelungscanisintermediateprobability肺動脈造影顯示正常左肺動脈ExaminationsofDVT

深靜脈血栓形成的檢查Contrastvenography:agoldstandard

靜脈造影：金標(biāo)準Duplexultrasonography

超聲多普勒Impedanceplethysmography

靜脈阻抗圖測定放射性核素靜脈造影Diagnosis&Differentialdiagnosis

診斷和鑒別診斷重視發(fā)病誘因血栓性靜脈炎長期臥床下肢和盆腔靜脈血栓不活動（乘機、乘車）慢性心肺疾病手術(shù)、創(chuàng)傷惡性腫瘤、肥胖癥血液病、妊娠、服避孕藥重要的臨床線索胸悶原因不明的勞力性呼吸困難不能解釋的低熱原有疾病的突然變化心力衰竭對洋地黃制劑反應(yīng)差下肢靜脈的檢查雙側(cè)下肢周徑相差＞1CM重視必要的檢查

D-dimer陰性可以除外PTE以心電圖、胸片、動脈血氣、心臟和下肢靜脈超聲提出擬診DiagnosticProcedure

SuspectedPELowClinicalSuspicionIntermediateorHighclinicalsuspicionD-DimerLevelAbnormalCTAngiographyNormal

PEExcludedOtherDiagnosisPENoPEConsiderUSoflowerExtremitiesVein

臨床上懷疑肺栓塞正常灌注顯像肺通氣/灌注顯像高度可能性治療不需治療不能診斷肺動脈造影有肺栓塞低血壓和/低氧血癥雙下肢檢查（DUS、IPGCV、MRI）不存在DVT或不能診斷繼續(xù)做下肢檢查或CV診斷DVT治療無肺栓塞不需要治療臨床情況穩(wěn)定DifferentialDiagnosis

鑒別診斷PTEisknownas“thegreatmasquerader”USA,MIPneumonia,bronchitisCHFAsthmaCostochondritis,RibFx,PneumothoraxPTEcancoexistwithotherillnesses!!Treatment治療Generaltreatment

一般治療Anticoagulation

抗凝治療Thrombolytictherapy

溶栓治療Pulmonaryembolectomy

手術(shù)治療Inferiorvenacavafilters

下腔靜脈濾器植入肺栓塞的藥物治療PaO2＜60~65mmHg

面罩或插管給氧

機械通氣（避免血流動力學(xué)方面的副作用）低潮氣量（7ml／Kg）低液體負荷抗休克治療：多巴胺(dopamine)阿拉明(Aramine)作用：快速溶解血栓,恢復(fù)肺再灌注

阻止慢性肺栓塞的發(fā)展，降低肺高壓指征：大塊PTE(超過2個肺葉血管)

PTE伴休克，原有心肺疾病的次大塊栓塞引

起循環(huán)衰竭時間窗：癥狀發(fā)作2周內(nèi)

2周以上可能有效禁忌證：活動性內(nèi)出血和近期腦出血并發(fā)癥：出血，發(fā)熱，過敏反應(yīng)溶栓治療溶栓方案

1.SK:25萬IU/30min,以10萬IU/h持續(xù)24h

2.UK:4400IU/Kg/10min,以2200IU/Kg/h持續(xù)12h(國內(nèi)UK2萬IU/Kg2h)3.rt－PA:100mg/2h抗凝治療

對于確診的PTE患者如果無禁忌證都應(yīng)抗凝治療