Pulmonary embolism
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Pulmonary Embolism. Dr Felix Woodhead Consultant Respiratory Physician. Pulmonary Embolism. Part of VTE Potentially fatal Can complicate hospital admission Preventable Tests poor. Risk factors. Surgery Abdominal Lower limb Obstetric Malignancy Previous VTE. Clinical Probability.

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Pulmonary Embolism

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Pulmonary embolism

Pulmonary Embolism

Dr Felix Woodhead

Consultant Respiratory Physician


Pulmonary embolism1

Pulmonary Embolism

  • Part of VTE

  • Potentially fatal

  • Can complicate hospital admission

  • Preventable

  • Tests poor


Risk factors

Risk factors

  • Surgery

    • Abdominal

    • Lower limb

  • Obstetric

  • Malignancy

  • Previous VTE


Clinical probability

Clinical Probability

  • Wells score

  • Geneva criteria

  • Is a major risk factor present? =1

  • Is there no other explanation? =1

  • Score:

    • 2: High probability

    • 1: Intermediate probability

    • 0: Low probability


D dimer

D-dimer

  • Only useful if NEGATIVE

  • ↑ by many things (including pregnancy and infection)

  • Used only after assessment of clinical probability

    • Not used if high clinical probability


Imaging

Imaging

  • CTPA in most places

  • V/Q

    • only if normal CXR and no cardiopulmonary disease

    • Intermediate scan requires follow-up imaging (CTPA)

  • Doppler USS if DVT (no need for resp imaging)


Screening for thrombophilia cancer

Screening for thrombophilia/cancer

  • Thrombophilic abnormality occurs in 25-50% VTE

  • Usually interacts with environment (esp oestrogens), and risk is multiplicative

  • Does not predict risk of recurrence

  • Screen for cancer with bloods, clinical picture and CXR only


Treatment

Treatment

  • Thrombolysis only in massive PE (circ collapse)

  • Thrombolysis controversial if RV impairment

  • Anticoagulate with LMWH then warfarin for

    • 4-6/52 if associated with temporary risk factor

    • 3/12 if no risk factor (BTS), US recommend 6/12

  • ?unfractionated heparin initial bolus


Pulmonary arterial hypertension

Pulmonary Arterial Hypertension

Dr Felix Woodhead

Consultant Respiratory Physician


Findings

Findings

  • Exertional breathlessness

  • Exertional chest pain and presyncope

  • Normal radiology if idiopathic

  • Normal PFTs if idiopathic

  • ↑ systolic PAP on echo only if TR


Defined by rhc

Defined by RHC

  • mPAP

    • > 25 mmHg at rest (normal 12-16 mmHg)

    • > 30 mmHg on exertion

  • Cardiac Output

  • Cardiac Index (=CO/height2)

  • Pulmonary Vascular Resistance


Causes

Causes

  • Left ventricular impairment (PCWP > 15)

    • LVF

    • Mitral valve disease

  • Increased pulmonary blood flow (L→R shunt) → Eisenmenger’s syndrome

  • Hypoxaemia (cor pulmonale)

  • Chronic Thromboembolic (CTEPH)

  • HIV

  • CTD (SSc etc)

  • Idiopathic (IPAH)


Investigations

Investigations

  • PFTs

  • CTPA

  • Echo (± bubbles)

  • 6 minute walk

  • Right Heart Catheter

  • (traditional) pulmonary angiogram


Treatment1

Treatment

  • Treatment of associated causes

    • LV disease

    • O2 for cor pulmonale

  • Warfarin (for all)

  • Calcium channel blockers – little used now

  • Endothelin receptor blockers – Bosentan, sitaxentan

  • PDE4 antagonists – Sildenafil etc

  • Prostaglandins

    • Nebulised

    • Continuous IV via Hickman line


Sleep medicine

Sleep medicine

Dr Felix Woodhead

Consultant Respiratory Physician


Obstructive sleep apnoea hypopnoea sx

Obstructive sleep apnoea/hypopnoea Sx

  • Periodic reduction of airflow at night

  • Caused by ostruction (cf central apnoea) due to reduced muscle tone in a suceptible airway (obesity)

  • Apnoea : no airflow for 10 s

  • Hypopnoea : ≤ 50% airflow in 10 s

  • AHI (apnoea/hypopnoea index) = no of events/hr

  • AHI

    • 5-14 = mild

    • 15-30 = moderate

    • >30 = severe


Symptoms

Symptoms

  • Sleepiness (daytime hypersomnolence)

    • Epworth Sleepiness Score

  • Witnessed apnoeas

  • Nocturia

  • Hypertension

  • Reduced concentration

  • Reduced libido

  • Tendency to cor pulmonale, esp in COPD


Diagnosis

Diagnosis

  • Overnight oximetry

    • Good screening esp in obese

    • Cannot be used to exclude OSAHS

  • Limited PSG

    • Useful initial test in young, non-obese

  • Full PSG


Treatment2

Treatment

  • Only if symptomatic

  • AHI >15, desat index >10/hr

  • Nasal CPAP

    • fixed

    • Autotitrating device


Domiciliary niv

Domiciliary NIV

  • For ventilatory failure

  • Other treatments

    • Low flow O2 (with care)

    • Treatment of sleep disordered breathing

  • Hallmark of ventilatory failure is ↑pCO2


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