Internal illnesses. Pulmonary embolism (PE) (lecture notes)

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Internal illnesses. Pulmonary embolism (PE) (lecture notes)

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LECTURE No. 27. Pulmonary embolism (PE)

Blockage of the arterial bed of the lung by a thrombus formed in the venous system, right atrium, ventricle of the heart, or other material that has entered these areas.

Etiology. The etiological factor is a venous thrombus (in 85% of cases, the source is in the system of the inferior vena cava, much less often in the right chambers of the heart and veins of the upper extremities). These can be drops of fat, tumor cells, air, parasites, foreign bodies.

К risk factors include old age, atherosclerosis, the presence of malignant tumors, pregnancy, contraceptives, obesity, varicose veins.

Pathogenesis. R. Virchow's triad is characteristic: slowing down of the blood flow rate, increased blood clotting, damage to the vascular wall.

Pulmonary arterial occlusion blocks blood flow in the pulmonary circulation, causes generalized vasospasm of the pulmonary circulation and bronchospasm. Acute pulmonary arterial hypertension develops, overload of the right heart, arrhythmias, ventilation and perfusion of the lungs worsen, accompanied by right-to-left shunting of insufficiently oxygenated blood, myocardial, brain, and kidney ischemia develops.

Classification. According to the features of clinical manifestations, the disease is divided:

1) downstream: acute, subacute, recurrent;

2) according to the affected area: small (up to 25% of the volume of the switched off channel), submassive (up to 26-50%), massive (up to 51-75%), lethal (more than 75%);

3) according to the severity of manifestations.

Clinic. Major Syndromes are the following: pulmonary-pleural (bronchospasm, shortness of breath, cough, hemoptysis, pleural friction noise, the appearance of pleural effusion), cardiac (the appearance of retrosternal pain, tachycardia, accent II tone and noise (systolic and diastolic) over the pulmonary artery, pericardial friction noise, hypotension, swelling of the jugular veins and cyanosis), abdominal (pain in the right upper quadrant of the abdomen), cerebral (loss of consciousness, convulsions, paresis), renal (anuria).

According to the significance and degree of manifestations, the symptoms are distributed in the following sequence: tachycardia, chest pain, shortness of breath, hemoptysis, fever, moist rales, cyanosis, cough, pleural rub, collapse.

Threatening symptoms of PE: fever in the postoperative period (3-10 days), fever in bed rest, unclear dyspnea, chest pain, migrating pneumonia, the appearance of rapidly passing fibrinous pleurisy and the development of pleural effusion, hemoptysis, worsening of the course of the disease.

Additional diagnostic study. A study of sputum (siderophages), a study of the blood coagulation system (moderate hypercoagulation, an increase in the level of platelet β-thromboglobulin and a decrease in antithrombin III), ECG: tachycardia, deviations of the atrial and ventricular vectors to the right, transient blockade of the right leg of the His bundle (changes are present only in 10 -20% of cases), x-ray examination: expansion of the lung root, diffuse depletion of the lung pattern; possible local oligemia, pulmonary infarction, pleural exudates, basally located atelectasis, high standing of the dome of the diaphragm, expansion of the shadow of the heart. Also, patients are shown perfusion scintigraphy (registration of radiation over the lungs after intravenous administration of a colloidal solution of protein labeled with technetium) - with PE, a decrease in radiation, angiopulmonography (contrast X-ray image of the pulmonary vessels) - with PE, filling defects.

Complications. Complications of the disease are shock, pulmonary infarction, lung abscess, fibrinous or hemorrhagic pleurisy, acute and chronic cor pulmonale.

Differential diagnostics. Should be performed with acute myocardial infarction, pneumonia, dissecting aneurysm of the thoracic aorta.

Flow. The course of the disease is associated with the risk of death.

Treatment. When acute PE at the 10st stage, urgent intravenous administration of 000-15 IU of heparin is carried out, sedatives, analgesics are prescribed, oxygen is given. At the II stage, streptokinase (000 IU intravenously drip), vasoactive drugs, antiacidotic therapy, heparin administration (250-000 IU 5000 times a day under control of blood coagulation) are shown. Cardiac glycosides are not used (due to increased pressure in the pulmonary artery). At the III stage, an embolectomy is performed - in the absence of the effect of the I and II stages of treatment and no later than 10 hours from the onset of the disease.

RџSЂRё recurrent PE long-term use of anticoagulants of indirect action (6-12 months) is indicated, the value of the prothrombin index should be in the range of 40-60%, symptomatic therapy, if surgical treatment is ineffective, the imposition of U-shaped sutures on the inferior vena cava or the installation of a Mobin-Uddin filter in it .

Prevention Prevention of the disease is the timely treatment of the threatened contingent, a decrease in the amount of animal fats and cholesterol in food.

Author: Myshkina A.A.

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