ulmonary

Prepared by : Sultan Alrabeea Alaonud Alsaleh Eddah Alshamaree

mbolism

Outlines:

Definition Sings & symptoms Risk factors Diagnosis Treatment

definition

is an occlusion of a portion of the pulmonary blood vessels by an embolus. An embolus is a clot or other plug (thrombus) that is carried by the blood stream from its point of origin to a smaller blood vessel, where it obstructs circulation.

Mortality Statistics
Pulmonary embolism is one of the most common causes of death in hospitalized people who must remain in bed for a long time. In the United States, more than 600,000 people have a pulmonary embolism each year, and more than 60,000 of them die.

types of emboli
Arise from thrombi in deep venous system of lower extremities

- Right ventricular thrombus.

- Septic embolus (rt sided endocarditis) - Fat - Air - Amniotic fluid - Neoplastic cells

pulmonary embolism

signs &symptoms
- Tachycardia

- Tachypnea - hypoxemia - Accentuated S2 - Fever - Diaphoresis - Signs of DVT - Cardiac murmur - Jugular venous distention - Cyanosis - Hypotension

signs symptoms
- Dyspnea - Chest pain (pleuritic) - Apprehension - Cough - Hemoptysis - Syncope - Palpitations - Wheezing - Leg pain (DVT) - Leg swelling (DVT)

risk factors

- Old age - Pregnancy - Lower-extremity fractures or surgery - Burns - Obesity - Malignancy - Strok - Surgery or trauma - Hypercoagulable state (malignancy, nephrotic syndrom - Smoking - Immobilization - Previous DVT

Diagnosis

D-dimers . CXR .

Ventilation-perfusion scanning .
Spiral CT .

The Workup Algorithm

Patient with clinically suspected pulmonary embolism

PE Unlikely D-Dimer ELISA Normal Abnormal

PE Likely Imaging modality

Writing Group for the Christopher Study Investigators JAMA. 2006; 295:172-179.

D-dimers
D-dimer is a specific degradation product released into the circulation when cross linked fibrin undergoes endogenous fibrinolysis. - Measured by ELISA ( nzyme- inked mmuno orbent ssay) - Non specific elevation of d-dimer may occur in: MI Pneumonia Sepsis

CHEST X-RAY
- Most often normal. - May show collapse, consolidation, small pleural effusion, elevated diaphragm. findings include:

Dilation of vessels proximal to embolism

Pleural based opacities with convex medial margins

Chest X-ray

Westermarks Sign
Hamptons Hump

Lower extremity venous ultrasonography

Definition: This type of ultrasound shows if there is a blockage in a leg vein which may travels through the blood to the lungs. 80% of PE associated with DVT Advantages: 1- Cost 2- Portability 3- May avoid further diagnostic imaging if positive 4- No radiation Limitations: 1- Low sensitivity and risk of false positives 2- Operator dependant 3- Time .

TECHNIQUE
1- High frequency linear array probe (7-10MHz). 2- Patient position supine with elevation of head ,hip is kept in flexion and external rotation. 3-Identify the common femoral vein in the transverse plane ,continue examination distally.

4-pulsed Doppler is performed to evaluate blood flow and compressibility response to augmentation .

Note: if you see clot do not do Augmentation to avoid detaching the clot and causing a PE.

5-Popliteal vein is evaluated behind the knee.

6-Posterior and anterior tibial

vein is examined from below knee in supine Position .

Ultrasound for DVT

Major criterion: - Failure to compress vascular lumen due to an occluding thrombus - Acute thrombus can be anechoic - Slow flowing blood can have internal echoes Minor criterion: -Absence of normal doppler signals and flow is indirect evidence of venous occlusion - Decreased augmentation with distal compression - Distension of vessel

Compressibility: Normal Findings

A V

Compressibility: DVT

A V

Flow

Augmentation

In case of DVT
IVC filter

V/Q Scan

Definition: is a type of medical imaging using scintigraphy

and medical isotopes to evaluate the circulation of air and blood within a patient's lungs . Note: The ventilation study should be performed before the perfusion study.

Advantages:
1- Excellent negative predictive value (97%) 2- Can be used in patients with contraindication to contrast medium 3- Preferred test in pregnant patients 50 mrem vs 800mrem (with spiral CT)

Radiopharmaceutical

LUNG VENTILATION SCAN

Patient Preparation. Radiopharmaceutical: 99mTc DTPA (Diethylenetriaminepentaacetic acid) Adult Dose: 35 - 40 mCi Method of Administration: Via a positive pressure nebulizer. Patient position: Supine or sitting.

Imaging Field.

Acquisition Protocol:

Fit the patient with a fitting mask or a mouth piece and nose clamp.

Slowly introduce the 99mTc-DTPA in 3-4 ml into the nebulizer. Drive the nebulizer with oxygen at a flow rate of 10 L/min Instruct the patient to breathe at a normal rate. When complete, turn off the gas flow to the nebulizer. And acquire the following images: ANT, POST, RAO, LAO, R LAT, L LAT, RPO and LPO for 500K counts in the computer using a 256 x 256 x 16 matrix.

LUNG PERFUSION SCAN

Patient Preparation. Radiopharmaceutical: 99mTcMAA (Macroaggregated albumin) Adult Dose: 3 mci, For patients who are pregnant or only have one lung, reduce the dose to 1.5 mCi Method of Administration: IV injection Patient position: Supine or sitting, if unable to tolerate supine position. Imaging Field.

Acquisition Protocol:

After injection in the supine position, acquire the following images: ANT, POST, R LAT, L LAT, RAO,LAO ,RPO and LPO for 500K counts in the computer using a 256 x 256 x 16 matrix.

Diagnosis
There are multiple lobar and segmental ventilation / perfusion mismatches with a normal chest X-ray. The lung scan is very positive; the posterior probability of pulmonary embolism is high.

FIGURE: Patient with severe case of chronic obstructive pulmonary disease in left lower. diagnosis in V/Q scintigraphy

CT scan
Why is it more preferable than other exams :

CT can detect abnormalities with much greater precision (High sensitivity and specificity) much faster than other procedure. Few contraindications

P.E with CT

CT chest (spiral for P.E)

p.t preparation : -NPO 4 hours before the procedure. -createnine level normal . -p.t not allergic or asthmatic . -needle gage 18 unticubital in left side .

P.T position :
Center point : Scout :

Supine, feet first ,arm above the head.

Sternal notch. AP and LAT .

Cont
IV contrast : 100 cc xenetix 350 .

Scanning group : Cover chest area . SFOV : Scan type ; Rotation time : large . Helical . 0,4 - 0,5 second

Cont
KV : MA : Pitch : Slice thickness : Scanning time : Algorithm : 100-200 KV 150-200 High speed 1.2 0.6 mm Always short 1-3 second Std and lung

Technique :

After positioning the patient we take localizer to localize the pulmonary trunk.

Then we do the test polus . We give 20 ml of contrast + 20 ml of saline. Start scanning and injection of contrast media. We check the image that the pulmonary trunk filled with contrast .

cont

Number of image 2 = delay time Then we give 45 ml contrast and 25 ml saline and start scanning with known delay time .

We take standerd window and lung window .

ff

Advantages of CT:

Highly detailed images. Speed . Precise Ability to provide cross sectional images of the body.

Disadvantages of CT:

Radiation . Allergic reaction . Cost concern .

New Imaging Approaches

Dual Energy Iodine Distribution Maps Provides functional and anatomic lung imaging Demonstrates perfusion defects beyond obstructive and nonobstructive clots Diagnostic accuracy and inter/intra-observer variability requires further research

Multiple thrombi in main PA with extensive clot burden. Perfusion defects seen on iodine mapping
Pontana F et al. Acad. Radiol. 2008;15(12):1494.

Treatment

Anticoagulant therapy. IVC filter . Thrombolysis. Surgical management.

Anticoagulant therapy
Heparin: - Low risk patient (grade 1 and 2) - Outpatient

Low molecular whight heparin: - patients with an underlying malignancy . - pregnant women.

IVC filter
Indications:

If anticoagulant therapy is contraindicated and/or ineffective .

Thrombolysis

Dissolving of the clot.

Indications: - Massive PE causing hemodynamic instability. - Hypovolemia . - Sepsis .

Surgical management

Acute pulmonary embolism (uncommon). Chronic pulmonary embolism .

REFERENCES

KFMC Wells PS; Anderson DR; Rodger M et al. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer. Thromb Haemost 2000 Mar;83(3):416-20. Wittram C et al. Acute and Chronic Pulmonary Emboli: AngiographyCT Correlation. AJR 2006;186:S421-S429. Writing Group for the Christopher Study Investigators. Effectiveness of Managing Suspected Pulmonary Embolism Using an Algorithm Combining Clinical Probability, D-Dimer Testing, and Computed Tomography. JAMA. 2006;295:172-179. http://en.wikipedia.org/wiki/Pulmonary_embolism http://www.mayoclinic.com/health/pulmonary-embolism/DS00429 http://www.health.harvard.edu/diagnostic-tests/venous-ultrasound-of-thelegs.htm http://en.wikipedia.org/wiki/Ventilation/perfusion_scan Civelek AC, Natarajan, TK, Szabo Z, et al. Nuclear Medicine Division Policy & Procedure Manual, The John Hopkins Hospital Department of Radiology & Radiological Science, Baltimore, USA, 1996.

http://www.google.com/search?hl=en&safe=active&tbm=isch&sa=X&ei=2xte TuicKcztsgaRsNHMDw&ved=0CDsQvwUoAQ&q=radiopharmaceutical+kit&spell =1&biw=1360&bih=566 Agnelli GL Becattini C. Acute Pulmonary Embolism. N. Engl. J. Med. 2010;363:266-74. Anderson DR et al. Computed tomographic pulmonary angiography vs ventilation-perfusion lung scanning in patients with suspected pulmonary embolism: a randomized controlled trial. JAMA. 2007 Dec 19;298(23):274353. Anderson DR; Barnes D. The use of leg venous ultrasonography for the diagnosis of pulmonary embolism. Semin. Nucl. Med. 2008 Sostman HD et al. Radiology. 2008;246:941-6. Weinmann EE; Salzman EW. Deep-vein thrombosis. N. Engl. J. Med. 1994;331:1630. http://www.nationmaster.com/red/pie/mor_pul_emb-mortality-pulmonaryembolism