2022年医学专题-肺栓塞的诊治PPT

肺动脉栓塞(shuānsè)的诊治制作(zhìzuò)XGHRH敬请指正(zhǐzhèng)第一页，共七十页。基本概念肺栓塞是以各种栓子阻塞肺动脉系统为其发病原因的一组疾病或临床综合征的总称，包括肺血栓栓塞症，脂肪栓塞综合征，羊水栓塞，空气栓塞等。肺血栓栓塞症为来自静脉系统或右心的血栓阻塞肺动脉或其分支所致疾病。肺梗死为肺动脉发生栓塞后，其支配区的肺组织因血流受阻或中断(zhōngduàn)而发生坏死。第二页，共七十页。肺栓塞的现状(xiànzhuàng)发病率高：仅次于CAD和HBP。易漏诊及误诊：警惕性不高，漏诊率高。不经治疗死亡率高：达20%-30%。明确诊疗(zhěnliáo)者死亡率明显下降：可降至2-8%。第三页，共七十页。EpidemiologyThereisnoaccuratedataforpulmonaryembolismbecausewehaslimitknowledgeofit.IntheUnitedStates,itisresponsibleforabout2.3newcasesper10,000personsand50,000deathseveryyear.第四页，共七十页。流行病学(liúxínɡbìnɡxué)Arch.Intern.Med.154:861,1994第五页，共七十页。生存率比较(bǐjiào)Arch.Intern.Med.154:861,19941.0123第六页，共七十页。RiskFactorsforDVT/PulmonaryEmbolism

（Essential）抗凝血酶缺乏蛋白C缺乏先天性异常纤维蛋白原血症V因子基因突变血栓调节蛋白纤溶酶原缺乏高半胱氨酸血症异常纤溶酶原血症抗心肌碱脂抗体蛋白S缺乏纤溶酶原激活抑制剂过量Ⅻ因子缺乏前凝血酶20210A突变第七页，共七十页。RiskFactorsforDVT/PulmonaryEmbolism

（Second）创伤/骨折外科手术卒中制动高龄恶性肿瘤+化疗中心静脉导管肥胖慢性静脉机能不全心力衰竭吸烟长途旅行妊娠/产后期口服避孕药克隆病、狼疮抗凝剂肾病综合征假体表面粘滞性过高血小板异常第八页，共七十页。深静脉血栓(xuèshuān)形成原因

分类血流滞缓小腿肌肉静脉丛血栓形成髂—股静脉血栓形成静脉壁损伤原发性髂—肌静脉血栓形成继发性髂—股静脉血栓形成高凝状态股青肿第九页，共七十页。肺血栓(xuèshuān)与深静脉血栓(xuèshuān)第十页，共七十页。肺栓塞的大体(dàtǐ)解剖观第十一页，共七十页。肺栓塞的显微镜下观第十二页，共七十页。肺栓塞的病理(bìnglǐ)生理肺血管阻塞，神经体液因素或肺动脉压力感受器的作用，引起肺血管阻力增加；肺血管阻塞→肺泡死腔↑→气体(qìtǐ)交换↓→肺泡通气↓→低氧血症→V/Q单位↓→气体交换面积↓→二氧化碳↑刺激性受体反射性兴奋（过度换气）支气管收缩，气道阻力增加肺水肿、肺出血、肺泡表面活性物质减少，肺顺应性降低。第十三页，共七十页。肺栓塞后右心功能不全的病生肺栓塞↓冠状动脉(guānzhuàng-dòngmài)灌注↑右心室氧需↑右心室壁张力(zhānglì)↓右心室排血量↓右心室氧供↓左心室排血量↑肺动脉压力(yālì)↑右心室后负荷解剖阻塞神经体液作用右心室扩张/功能不全右心室缺血室间隔移向左心室低血压↓体循环灌注↓左心室前负荷第十四页，共七十页。肺栓塞后肺血流动力学变化(biànhuà)

前毛细血管高压 血管床减少 支气管收缩(shōusuō)

小动脉血管收缩侧支血管的形成 支气管-肺动脉吻合形成 肺内动静脉分流血流改变：血流重分布Westermark征第十五页，共七十页。呼吸(hūxī)动力学改变

过度(guòdù)通气：肺动脉高压 顺应性下降 肺不张气道阻力增加： 局限性低碳酸血症 化学介质第十六页，共七十页。临床(línchuánɡ)分型大面积PE(massivePE)： 休克(xiūkè)和低血压； 动脉收缩压<90mmHg

或下降幅度≥40mmHg，持续15min以上； 除外其他原因所致血压下降。次大面积PE(submassivePE)亚型 超声心动图示右心室运动功能减弱 右心功能不全表现。非大面积PE(non-massiveFE)： 不符合以上大面积PE标准的PE。第十七页，共七十页。症状(zhèngzhuàng)PeerReviewStatus:ExternallyPeerReviewedbytheAMA第十八页，共七十页。体征第十九页，共七十页。D-二聚体分析(fēnxī)检验方法病人数PE发生率%敏感性特异性ELISA1579349843快速ELISA6352410044传统乳胶试验364469255血乳胶试验140259763AdaptedfromBounameauxetal,1997

第二十页，共七十页。肺栓塞胸片检查(jiǎnchá)PeerReviewStatus:ExternallyPeerReviewedbytheAMA第二十一页，共七十页。X-RAYFORCHESTAtelectasisandparenchymaldensitiesarequitecommon.Theareasofatelectasisaremorecommoninthelowerlobeasaretheareasofparenchymaldensity第二十二页，共七十页。Mostofthesedensitiesarecausedbypulmonaryhemorrhageandedemaandcanbeconfusedwithinfectiousinfiltratesormalignantmasses第二十三页，共七十页。Pleuraleffusionsarecommonandmostoftenunilateraldespitethefactthatmostclotsarebilateral.Theseeffusionsareusuallyvisiblewhenthepatientseeksmedicalattention.

Theyarealmostalwayssmall,occupyinglessthan15%ofahemithoraxandrarelyincreaseinsizeafter3days.Anyincreaseinsizeafter3or4daysshouldraisethesuspicionofapulmonaryinfectionorre-embolization.第二十四页，共七十页。PleuralbasedopacitieswithconvexmedialmarginsarealsoknownasaHampton'sHump.Thismaybeanindicationoflunginfarction.However,thatrateofresolutionofthesedensitiesisthebestwaytojudgeiflungtissuehasbeeninfarcted.Areasofpulmonaryhemorrhageandedemaresolveinafewdaystooneweek.Thedensitycausedbyanareaofinfarctedlungwilldecreaseslowlyoverafewweekstomonthsandmayleavealinearscar.第二十五页，共七十页。Adiaphragmmaybeelevated,reflectingvolumelossintheaffectedlung.第二十六页，共七十页。Thecentralpulmonaryarteriesmaybeprominenteitherfrompulmonaryhypertensionorthepresenceofclotinthosearteries.第二十七页，共七十页。Cardiomegallyisanon-specificfindingbutmayimplyanenlargedrightventricleasseeninthepatientwhopresentedwithlargebilateralpulmonaryemboli.第二十八页，共七十页。AWestermark'ssignimpliesanareaofdecreasedvascularityandperfusionaccompaniedbyanenlargedcentralpulmonaryarteryontheaffectedside.第二十九页，共七十页。肺栓塞的心动(xīndònɡ)超声征象直接看到血栓右室扩张(kuòzhāng)右室活动减弱室间隔异常活动三尖瓣反流速度增快肺动脉扩张无吸气性下腔静脉塌陷减弱Br.Heart.J.1994,72:52第三十页，共七十页。室间隔异常(yìcháng)活动舒张(shūzhāng)期收缩期第三十一页，共七十页。Color-Flow-Doppler-ultrasound

非挤压(jǐyā)性充盈缺损第三十二页，共七十页。心电图表现(biǎoxiàn)不完全性或完全性右束支传导阻滞(zǔzhì)Ⅰ、avL的S波>1.5mmⅢ、avF有Qs波，但Ⅱ无Qs波QRS轴>900或不确定肢导联低电压Ⅲ、avF的T波倒置或V1~V4T波倒置第三十三页，共七十页。图12000年8月27日（急诊(jízhěn)）ECG大致正常2000年8月29日（门诊(ménzhěn)）ECG示IRBBBSⅠQⅢTⅢV1V2T波倒置V3V4T波双向第三十四页，共七十页。Ventilation/PerfusionLungScan

第三十五页，共七十页。PIOPED：肺扫描分类与肺动脉造影(zàoyǐng)结果的比较肺扫描肺栓塞肺动脉造影阴性总数有无不肯定高度可疑1021417124中度可疑105217933364低度可疑391991262312接近正常/正常550274131总计25148024176931JNuclMed1993;34:1119第三十六页，共七十页。肺扫描(sǎomiáo)怀疑PE的患者约25％可因肺灌注正常而否定诊断，而且不用抗凝治疗可能是安全(ānquán)的怀疑PE的患者约25％具有高度的肺扫描结果，他们可能需要行抗凝治疗其余的患者需要进一步的诊断性检查，而这些检查是更广泛的诊断策略第三十七页，共七十页。典型(diǎnxíng)肺栓塞

第三十八页，共七十页。不典型(diǎnxíng)肺栓塞第三十九页，共七十页。ItishighsensitivitybutlowspecificityThedifferentialdiagnosisforaventilationperfusionmismatchincludes: acutepulmonaryembolus previouspulmonaryembolus congenitalvascularabnormalities vasculitis, bronchogeniccarcinoma, radiationtherapy,etal.第四十页，共七十页。 Whenaventilation/perfusionscandoesnotfitintoeitherthenormalorhighprobabilitycategory,thenweconsiderthestudytobenon-diagnosticandfurtherinvestigationisrequired.Themajorityofcasesfallintothiscategorywhichischaracterizedbyscanswithsubsegmentaldefects

ordefectsofanysizethatmatchabnormalitiesonthechestx-ray

ortheperfusionscan.第四十一页，共七十页。Alowprobabilitycategoryhasbeensuggestedbyanumberofauthors.However,aswecanseefromthePIOPEDdatathisisnotaparticularlyreliablecategory.Disagreementamongexperiencedreadersiscommonwhenperfusiondefectsaresmallandlimittheutilityofthiscategory.Thisstudywasoriginallyreadasshowingasmallsubsegmentaldefect.

Withoutthearrow,thisstudyhassubsequentlybeencallednormalbyanumberofexperiencedreaders第四十二页，共七十页。Conclusion Lungscansaresensitiveexamsthatessentiallyruleoutthediagnosisofpulmonaryemboluswhentheyarenormal.Patientswithhighprobabilitylungscanoftenbetreatedwithoutfurtherworkup.Thosepatientswithnon-diagnosticstudiesrequirefurtherdiagnosticinvestigation.第四十三页，共七十页。CTofPulmonaryEmbolism PulmonaryinfarctsaremorereadilyidentifiedonCT.ModernCTscannersnowhavefasteracquisitiontimesandareprovidingadetailedassessmentofthelungparenchymathatisnotavailablefromthechestradiograph.ThetypicalappearanceofapulmonaryinfarctonCTincludesapleuralbaseddensitywithconvexbordersandalinearstrandattheapexofthetriangle

第四十四页，共七十页。Theapexofthetriangleisoftentruncatedandnotwedgeshapedwhichcorrespondstothenormalconfigurationofasecondarylobuleinthelungperiphery.

Lowattenuationareaswithintheinfarctrepresentsviablelung.Itisimportanttonote,however,thatthisappearanceisnotspecificforpulmonaryinfarction.Thedifferentialdiagnosisforthisabnormalityincludesinfarct,hemorrhage,pneumonia,fibrosis,neoplasiaandedema第四十五页，共七十页。

Sincetheclinicalpresentationofpulmonaryembolusisusuallynon-specific,thefindingsonCTareoftenthefirstclinicalindicationthatthepatientmaybesufferingfrompulmonaryembolus.

Inadditiontovisualizingtheareaofinfarctionweareoftenabletoseetheclotitself.第四十六页，共七十页。

CThasbeenshowtobeespeciallyusefulintheassessmentofpatientswithchronicdyspneaandknownpulmonaryarteryhypertension.ThesepatientsareoftendifficulttodiagnoseasisexemplifiedbythispatientwithknownsclerodemaandpulmonaryarteryhypertensionwhoseCTunexpectedlyshowedalargecalcifiedclotintherightpulmonaryartery.第四十七页，共七十页。肺动脉造影(zàoyǐng)正常(zhèngcháng)肺动脉第四十八页，共七十页。Thisselectivestudywasdonebecauseofaperfusiondefectintheleftlowerlobeonaventilationperfusionscan.Thefirstangiographicstudywasinconclusive.Therefore,asubselectivestudywasdonethatdemonstratedtheclotwithcertainty.第四十九页，共七十页。Themostreliablesignsofpulmonaryembolusare:AnIntraluminalfillingdefectAnAbruptterminationofabranchvessel第五十页，共七十页。ConclusionAngiographyismostaccurateinsegmentalandlargersizedarteries.Thereproducibilityofreadingsissubsegmentalandsmallervesselsispoor.Angiographyisasafeprocedurethatismostaccuratewhenimagingembolithatlodgeinsegmentalorlargerarteries.第五十一页，共七十页。TheDiagnosisAlgorithmPlasmaD-DimerAssayNormaltoNear-NormalLoworIntermediateProbabilityHighProbabilityClinicalAssessmentLowProbabilityIntermediateorHighProbabilityAngiographyPositiveNegative<

500mg/L

≥500mg/LUltrasonogramNoDVTDVTLungScan第五十二页，共七十页。InterpretationCriteria

HighProbability(80-100%likelihoodforPE): Greaterthanorequalto2largemismatchedsegmentalperfusiondefectsorthearithmeticequivalentinmoderateorlargeandmoderatedefects.IntermediateProbability(20-80%likelihoodforPE):1.Onemoderateto2largemismatchedperfusiondefectsorthearithmeticequivalentinmoderateorlargeandmoderatedefects.2.Singlematchedventilation-perfusiondefectwithaclearchestradiograph.

3.Difficulttocategorizeasloworhigh,ornotdescribedasloworhigh.4.Nonsegmentalperfusiondefects(e.g.,cardiomegaly,enlargedaorta,enlargedhila,elevateddiaphragm).5.MultiplematchedV/Qabnormalities,evenwhenrelativelyextensive,arelowprobabilityforPE.TheprevalenceofPEinpatientswithextensivematchedV/QdefectsandnoCXRabnormalitywas14%(lowprobability).

JNuclMed1995;36:2380-2387第五十三页，共七十页。LowProbability(0-19%likelihoodforPE)

Perfusiondefectsmatchedbyventilationabnormalityprovidedthatthereare:(a)clearchestradiographand(b)someareasofnormalperfusioninthelungs.ExtensivematchedV/Qabnormalitiesareappropriateforlowprobability,providedthattheCXRisclear.Anyperfusiondefectwithasubstantiallylargerchestradiographicabnormality.Anynumberofsmallperfusiondefectswithanormalchestradiograph.

JNuclMed1995;36:2380-2387第五十四页，共七十页。DiagnosticCriteriaforClinicallySuspectedPulmonaryEmbolismPulmonaryembolismabsent Negativepulmonaryangiogran Normalornear-normallungscan D-dimerlevel<500mg/LPulmonaryembolismpresent Positivepulmonaryangiogram High-orintermediate-probabilitylungscan andultrasonogramevidenceofdeep-vein thrombosisThorax51:23,1996第五十五页，共七十页。鉴别(jiànbié)诊断呼吸困难、咳嗽、咯血、呼吸频率增快等呼吸系统表现为主的患者多被诊断为其它的胸肺疾病如肺炎(fèiyán)、胸膜炎、肺不张等以胸痛、心悸、心脏杂音、肺动脉高压等循环系统表现为主的患者易衩诊断为其它的心脏疾病如冠心病、风心病等以晕厥、惊恐等表现为主的患者有时被诊断为其它心脏或神经及精神系统疾病如心律失常、脑血管意外、癫痫等第五十六页，共七十页。原发性肺动脉高压(gāoyā)与肺栓塞复发相似点：症状：疲乏，活动时呼吸困难最常见，胸痛、昏厥、咯血、紫绀也较常见临床经过：进行性呼吸困难，右心衰竭血流动力学：右心室压力升高(shēnɡɡāo)、肺毛细血管嵌压正常治疗：包含抗凝治疗第五十七页，共七十页。区别(qūbié)点原发性肺动脉高压PE复发年龄20~40>50女/男比例4：11：1临床经过进行性恶化稳定一段时间后恶化肺灌注扫描无节段性灌注缺损节段性或大片灌注缺损肺动脉收缩压>60mmHg<60mmHg肺动脉造影“修剪”征管腔内充盈缺损肺动脉造影混淆的问题血栓“修剪”征也提示PE确诊肺活检肺血管镜治疗抗凝；大剂量硝苯地平及静注前列环素抗凝；IVC中断；血栓动脉内膜切除术第五十八页，共七十页。急性(jíxìng)PE的治疗一般处理： 送入监护病房，加强生命体征的监护 防止栓子脱落，绝对卧床 情感(qínggǎn)支持对症治疗：如咳嗽、发热等急性(jíxìng)PE第五十九页，共七十页。呼吸循环支持(zhīchí)治疗一般患者均采用经鼻导管(dǎoguǎn)或面罩吸氧治疗低氧血症无创伤性或经气管插管机械通气治疗呼吸衰竭，避免气管切开。尽量减少正压通气对循环的不种影响。急性(jíxìng)PE第六十页，共七十页。溶栓治疗(zhìliáo)的适应证栓塞(shuānsè)面积超过2个肺叶血管者合并休克或低血压者合并右心功能不全者排除禁忌证者急性(jíxìng)PE第六十一页，共七十页。溶栓禁忌证绝对禁忌证

活动性内出血

近期的自发性颅内出血相对禁忌证

大手术、分娩、器官活检或不能压迫的血管穿刺史（10天内）

2月内缺血性中风

10天内胃肠道出血

15天内严重外伤

1月内神经外科或眼科手术

控制(kòngzhì)不好的重度高血压

近期心肺复苏

血小板<100000/mm3，PT<50%

怀孕

细菌性心内膜炎

糖尿病出血性视网膜病变第六十二页，共七十页。肺动脉栓塞(shuānsè)的溶栓及抗凝治疗12小时溶栓法：4400u/Kg尿激酶溶于100ml于不少于10分钟静推2200u/Kg尿激酶溶于250ml用12小时维持每4~6小时监测APTT，当其降到正常2倍时，加用低分子肝素钙（0.1ml/10Kg，每天二次，皮下注射)同用华法令，3~5天后监测INR，当重复为