肺血栓栓塞症的诊疗和治疗专家讲座

肺血栓栓塞症诊疗和治疗肺血栓栓塞症的诊疗和治疗第1页肺血栓栓塞症相关名词及定义肺血栓栓塞症诊疗与治疗指南（草案）中相关名词

肺血栓栓塞症(pulmonarythromboembolism,PTE)肺栓塞(pulmonaryembolism,PE)肺梗死(pulmonaryinfarction,PI)深静脉血栓形成(deepvenousthrombosis,DVT)

静脉血栓栓塞症(venousthromboembolism,VTE)

VTE=DVT+PTE其它相关名词

遗传性易栓症、慢性血栓栓塞性肺动脉高压、经济仓综合征、肺动脉原位血栓形成、特发性肺动脉高压、家族性肺动脉高压、出血性肺不张其它类型肺栓塞

气体栓塞、脂肪栓塞、羊水栓塞、粟粒性肺栓塞（肿瘤、虫卵）、其它（菌栓、药栓）肺血栓栓塞症的诊疗和治疗第2页脂肪栓塞(fatembolismsyndrome,FES)定义：长管状骨骨折等严重创伤后脂肪滴阻塞肺循环或脑循环等其它微血管而引发临床症候群。主要临床表现为呼吸衰竭、脑功效障碍及淤斑。病理生理：肺血管机械性梗阻和肺间质“生物化学性”炎症反应。肺血栓栓塞症的诊疗和治疗第3页Fatembolismina58-year-oldwomanwhopresentedwithsuddendyspnea.Thepatienthadundergoneintramuscularinjectionofsomefattymaterialsintothebuttockseveraldaysearlier.

(a)Radiographshowsbilateralground-glassareasofincreasedopacity.肺血栓栓塞症的诊疗和治疗第4页(b)Thin-section(1-mmcollimation)CTscanobtainedattheleveloftheaorticarchshowswidespreadpatchyground-glassattenuationandconsolidation.肺血栓栓塞症的诊疗和治疗第5页羊水栓塞(amnioticfluidembolism,AFE)原因：妊娠期羊水中胎儿产物进入母体循环而引发。路径：分娩时羊水经宫颈内膜血管静脉撕裂部位;胎盘早剥和剖宫产时损及胎盘附着部位静脉窦;子宫损伤或子宫撕列部位。病理生理：肺血管栓塞;变态反应;凝血机制障碍。肺血栓栓塞症的诊疗和治疗第6页

(a)Radiographshowsbilateralwidespreadairspaceconsolidation.Endotrachealintubationwasperformed.AFEina40-year-oldwoman.

Thepatientexperiencedsuddenrespiratorydistressshortlyaftergivingbirthbycaesareansection.肺血栓栓塞症的诊疗和治疗第7页(b)Onafollow-upradiographobtained3dayslater,theextentoftheparenchymalareasofincreasedopacityhasdecreased.Achesttubewasinsertedintotherightpleuralspacetorelievetherightpleuraleffusion.肺血栓栓塞症的诊疗和治疗第8页DVT-PTE流行病学发病率和患病率西方国家：DVT和PTE年发病率分别为1.0‰和0.5‰美国：PTE年新发病例数650，000-700，000中国：阜外心血管病医院900例连续尸检：11.0﹪（段以上PTE）易患原因年纪与性别、血栓性静脉炎、静脉曲张、心肺脑血管疾病、创伤、肿瘤、制动、妊娠和口服避孕药、遗传原因、肥胖、吸烟等肺血栓栓塞症的诊疗和治疗第9页Table—RiskFactorsforVTESurgeryTrauma(majororlowerextremity)Immobility,paresisMalignancyCancertherapy(hormonal,chemotherapy,orradiotherapy)PreviousVTEIncreasingagePregnancyandthepostpartumperiodEstrogen-containingoralcontraceptionorhormonereplacementtherapySelectiveestrogenreceptormodulatorsAcutemedicalillnessHeartorrespiratoryfailureInflammatoryboweldiseaseNephroticsyndromeMyeloproliferativedisordersParoxysmalnocturnalhemoglobinuriaObesitySmokingVaricoseveinsCentralvenouscatheterizationInheritedoracquiredthrombophilia年9月ACCP第7次抗栓会议共识肺血栓栓塞症的诊疗和治疗第10页Table—AbsoluteRiskofDVTinHospitalizedPatients*PatientGroupDVTPrevalence,%Medicalpatients10–20Generalsurgery15–40Majorgynecologicsurgery15–40Majorurologicsurgery15–40Neurosurgery15–40Stroke20–50Hiporkneearthroplasty,hipfracturesurgery40–60Majortrauma40–80Spinalcordinjury60–80Criticalcarepatients10–80*RatesbasedonobjectivediagnostictestingforDVTinpatientsnotreceivingthromboprophylaxis.年9月ACCP第7次抗栓会议共识肺血栓栓塞症的诊疗和治疗第11页创伤（尸检PTE，15%）制动肿瘤(尸检PTE,10%)心肺脑血管病（PTE，10%）胫骨骨折（尸检DVT，45%～60%）腹部大大手术（尸检DVT，15%～30%）胰腺癌（35%）充血性心衰（12%）髋骨骨折（尸检DVT，50%～75%）CABG术后（尸检DVT，3%～9%）肺癌（20%）急性心肌梗塞（5%～35%）脊髓损伤（尸检DVT，50%～100%）疝修补术（5%）泌尿道肿瘤（19%）脑卒中（下肢瘫痪）（30%～60%）骨盆骨折（尸检PTE，25%）

结肠癌（15%）

脊柱骨折（尸检PTE，14%）

胃癌（16%）

乳腺癌（15%）

附表部分病种DVT-PTE患病情况肺血栓栓塞症的诊疗和治疗第12页国内资料488例住院脑卒中患者,下肢DVT总体检出率21.7%.493例骨科住院患者(创伤394人,关节置换92人,脊柱损伤52人),下肢DVT总体检出率为25.5%.肺血栓栓塞症的诊疗和治疗第13页DVT-PTE诊疗率如同冰山一角，尚需各临床和医技功效科室共同努力！无声杀手——VTELowdiagnosticrateofPE肺血栓栓塞症的诊疗和治疗第14页PTE临床表现病史VTE易患原因家族性症状体征肺血栓栓塞症的诊疗和治疗第15页PTE普通性检验动脉血气分析：低氧、呼减ECG：窦速、

SIQIIITIII,V3R～V5R、V1S波升支顿挫、粗钝和切迹，V1～V3T波倒置、ST段压低等等胸片心脏彩超：直接和间接征象深静脉超声D-二聚体（D-dimer）肺血栓栓塞症的诊疗和治疗第16页PTEECG改变肺血栓栓塞症的诊疗和治疗第17页PTEECG改变肺血栓栓塞症的诊疗和治疗第18页case1takenonhospitaladmissionshowswell-marginatedopacitiesovertherightupperandmiddlelungzones,linearopacitiesovertherightlowerzone,andabluntedrightcostophrenicsulcus.X线胸片(一)肺血栓栓塞症的诊疗和治疗第19页X线胸片(二)case2takenonhospitaladmissionshowsawedge-shaped,pleural-basedopacitywithitsapexdirectedtowardthehilumintheleftmid-lungzone,ahomogenousopacityoccupyingtheleftlowerzone,andbluntingoftheleftcostophrenicsulcus.肺血栓栓塞症的诊疗和治疗第20页肺血栓栓塞症的诊疗和治疗第21页深静脉超声肺血栓栓塞症的诊疗和治疗第22页PTE确实诊检验肺动脉造影（PAA）CT肺动脉造影（CTPA）V/Q扫描磁共振肺动脉造影（MRPA）肺血栓栓塞症的诊疗和治疗第23页肺动脉造影肺血栓栓塞症的诊疗和治疗第24页CTPA(一)Incase1

Thecontrast-enhancedspiralCTscanofthepatienttakenonhospitaladmissionrevealsintraluminalfillingdefectsinbothinterloberpulmonaryarteries,multiloculatedpleuraleffusions,andatelectaticareasintheleftlowerlobe.

肺血栓栓塞症的诊疗和治疗第25页CTPA(二)Incase2

takenonhospitaladmissionrevealsanintraluminalfillingdefectintherightmainpulmonaryartery,multiloculatedeffusions,andatelectasisinboththeposteriorandparamediastinalregionsoftherightlung.

肺血栓栓塞症的诊疗和治疗第26页CTPA(三)CTV

showslargelow-attenuationthrombifillingtheleftcommoniliacvein(arrow).

CTPA

showsmultifocallow-attenuationemboli(arrows)insegmentalandsubsegmentalarteriesintherightlowerlobe.

肺血栓栓塞症的诊疗和治疗第27页肺血栓栓塞症的诊疗和治疗第28页CTscaninapatientwithCTEPHshowsapleurabasedwedge-shapedscarintherightupperlobecausedbypriorinfarction.Lunginfarction肺血栓栓塞症的诊疗和治疗第29页V/Q扫描定性诊疗：高度可能性—大于或等于2个肺段灌注缺损，肺通气显像和X胸片均未见异常;或灌注缺损区大于异常肺通气显像或X胸片；大于或等于2个亚肺段（或一个肺段）肺灌注缺损，肺通气显像和X胸片无显著异常。中度可能性低度可能性肺血栓栓塞症的诊疗和治疗第30页多发性肺栓塞肺血栓栓塞症的诊疗和治疗第31页MRPAAcutepulmonaryembolismina41-year-oldwoman.Coronalgadolinium-enhancedthree-dimensionalpulmonaryMRangiogramshowsalargeembolus(arrows)intheproximalrightinterlobarartery.肺血栓栓塞症的诊疗和治疗第32页Chronicpulmonaryembolismina55-year-oldman.(a)Chestradiographshowsenlargementofthecentralpulmonaryarteriesalongwithcardiomegaly.

(b)CTPAobtainedatthelevelofthebronchusintermediusshowseccentricthrombusalongthemedialmarginofthenarrowedrightinterlobarpulmonaryartery(arrows).

(c)V/Qscan(rightposteriorobliqueview)showsmultisegmentaldefects,whichdidnotmatchthefindingsseenonaventilationlungscanobtainedwithTc-99mTechnegas

(d)Pulmonaryarteriogramshowsabruptcutoffinroundedfashion(pouchingdefect)ofthelowerlobararteries(arrow).

(e)Photographshowsorganizedembolifillingtheenlargedcentralpulmonaryarteries.(arrows).

肺血栓栓塞症的诊疗和治疗第33页PTE治疗抗凝治疗溶栓治疗介入治疗

肺血栓栓塞症的诊疗和治疗第34页抗凝治疗药品监测特殊情况下抗凝治疗：妊娠和哺乳、围手术期、恶性肿瘤抗凝治疗终止。肺血栓栓塞症的诊疗和治疗第35页各种LMWH推荐使用方法依诺肝素钠（克塞）：100IU/kg,Q12h达肝素钠（法安明）：100IU/kg,Q12h那屈肝素钙（速避凝）：Q12h﹤50kg,0.4ml;50～59kg,0.5ml;60～69kg,0.6ml;70～79kg,0.7ml;80～89kg,0.8ml;﹥90kg,0.9ml.肺血栓栓塞症的诊疗和治疗第36页BodyWeight-BasedDosingofIVHeparin

（ACCP第六次抗栓会议共识）肺血栓栓塞症的诊疗和治疗第37页GuidelinesforAnticoagulation:

UnfractionedHeparin（ACCP第六次抗栓会议共识）肺血栓栓塞症的诊疗和治疗第38页DurationofTherapy（ACCP第六次抗栓会议共识）肺血栓栓塞症的诊疗和治疗第39页长久抗凝——华法令使用方法、监测、疗程、副作用常见影响华法令作用药品和疾病：加强作用：乙胺碘呋酮、广谱抗生素、洛伐他汀、流感疫苗、奥美拉唑、扑热息痛、甲硝唑和甲状腺激素等；甲亢、老年、心衰、肝病、发烧、维生素K缺乏、恶性肿瘤等。抑制作用：巴比妥类、口服避孕药、利福平和肾上腺皮质激素等；甲减、肾病综合征和遗传性华法令耐药等。肺血栓栓塞症的诊疗和治疗第40页抗凝治疗紧急终止肝素：半衰期1.5小时，硫酸鱼精蛋白1mg可中和不少于100u肝素，通常只需半量。华法令：半衰期约42小时，维生素K11～5mg口服或静注，24小时内能终止抗凝。紧急情况输新鲜冰冻血浆或补充维生素K依赖性凝血因子。LMWH：半衰期约6小时，每0.6mg鱼精蛋白可中和速避凝0.1ml肺血栓栓塞症的诊疗和治疗第41页溶栓治疗适应症溶栓方案：尿激酶12小时溶栓方案、重组组织型纤溶酶原激活剂2小时溶栓方案等其它问题：DVT、咯血、二次溶栓、妊娠、症状性PTE护理肺血栓栓塞症的诊疗和治疗第42页介入治疗

适应症与并发症；方案选择；腔静脉滤器应用。肺动脉导管溶栓机械破碎滤器置入肺血栓栓塞症的诊疗和治疗第43页左肺动脉栓子去除肺血栓栓塞症的诊疗和治疗第44页下腔静脉滤网肺血栓栓塞症的诊疗和治疗第45页CTEPH

Contrast-enhancedCTscaninapatientwithCTEPHshowsbronchialarterycollaterals.NotethattheenlargedmainpulmonaryarteryhasalargerdiameterthantheAO.肺血栓栓塞症的诊疗和治疗第46页谢谢！肺血栓栓塞症的诊疗和治疗第47页PulmonaryHypertentionWANGJinxiangRespiratoryDepartmentofBeijingLuheHospital肺血栓栓塞症的诊疗和治疗第48页肺血栓栓塞症的诊疗和治疗第49页肺血栓栓塞症的诊疗和治疗第50页肺血栓栓塞症的诊疗和治疗第51页PulmonaryHypertentionClassificationFunctionalClassificationDiagnosticPrecedureTherapy肺血栓栓塞症的诊疗和治疗第52页Classification肺血栓栓塞症的诊疗和治疗第53页,VinicePulmonaryarterialhypertension(PAH)PulmonaryhypertensionwithleftheartdiseasePulmonaryhypertensionassociatedwithlungdiseaseand/orhypoxPulmonaryhypertensionduetochronicthromboticand/orembolicdiseaseMiscellaneous肺血栓栓塞症的诊疗和治疗第54页Pulmonaryarterialhypertension(PAH)1.1.Idiopathic(IPAH)1.2.Familial(FPAH)1.3.Associatedwith(APAH):1.3.1.Collagenvasculardisease1.3.2.Congenitalsystemic-to-pulmonaryshunts1.3.3.Portalhypertension1.3.4.HIVinfection1.3.5.Drugsandtoxins1.3.6.Other(thyroiddisorders,glycogenstoragedisease,Gaucherdisease,hereditaryhemorrhagictelangiectasia,hemoglobinopathies,myeloproliferativedisorders,splenectomy)1.4Associatedwithsignificantvenousorcapillaryinvolvement1.4.1Pulmonaryveno-occlusivedisease(PVOD)1.4.2Pulmonarycapillaryhemangiomatosis(PCH)肺血栓栓塞症的诊疗和治疗第55页Pulmonaryhypertensionwithleftheartdisease2.1.Left-sidedatrialorventricularheartdisease2.2.Left-sidedvalvularheartdisease

肺血栓栓塞症的诊疗和治疗第56页Pulmonaryhypertensionassociatedwithlungdiseaseand/orhypoxemia3.1.Chronicobstructivepulmonarydisease3.2.Interstitiallungdisease3.3.Sleep-disorderedbreathing3.4.Alveolarhypoventilationdisorders

3.5.Chronicexposuretohighaltitude3.6.Developmentalabnormalities肺血栓栓塞症的诊疗和治疗第57页Pulmonaryhypertensionduetochronicthromboticand/orembolicdisease4.1.Thromboembolicobstructionofproximalpulmonaryarteries4.2.Thromboembolicobstructionofdistalpulmonaryarteries4.3.Non-thromboticpulmonaryembolism(tumor,parasites,foreignmaterial)肺血栓栓塞症的诊疗和治疗第58页MiscellaneousSarcoidosishistiocytosis-XLymphangiomatosiscompressionofpulmonaryvessels(adenopathy,tumor,fibrosingmediastinitis)

肺血栓栓塞症的诊疗和治疗第59页FunctionalClassification

（WHO,,Chest）ClassI:PatientswithPHwithoutlimitationofusualactivityClassII:PatientswithPHwithslightlimitationofusualphysicalactivityClassIII:PatientswithPHwithmarkedlimitationofusualphysicalactivityClassIV:PatientswithPHwithinabilitytoperformanyphysicalactivitywithoutsymptomsandwhomayhavesignsofrightventricularfailure肺血栓栓塞症的诊疗和治疗第60页A.NewYorkHeartAssociationfunctionalclassification*Class1:Nosymptomswithordinaryphysicalactivity.Class2:Symptomswithordinaryactivity.Slightlimitationofactivity.Class3:Symptomswithlessthanordinaryactivity.Markedlimitationofactivity.Class4:Symptomswithanyactivityorevenatrest.B.WorldHealthOrganizationfunctionalassessmentclassificationClassI:PatientswithPHbutwithoutresultinglimitationofphysicalactivity.Ordinaryphysicalactivitydoesnotcauseunduedyspneaorfatigue,chestpain,ornearsyncope.ClassII:PatientswithPHresultinginslightlimitationofphysicalactivity.Theyarecomfortableatrest.Ordinaryphysicalactivitycausesunduedyspneaorfatigue,chestpain,ornearsyncope.ClassIII:PatientswithPHresultinginmarkedlimitationofphysicalactivity.Theyarecomfortableatrest.Lessthanordinaryactivitycausesunduedyspneaorfatigue,chestpain,ornearsyncope.ClassIV:PatientswithPHwithinabilitytocarryoutanyphysicalactivitywithoutsymptoms.Thesepatientsmanifestsignsofright-heartfailure.Dyspneaand/orfatiguemayevenbepresentatrest.DiscomfortisincreasedbyanyphysicalactivityClassification

（ContrastofNYHAandWHO）肺血栓栓塞症的诊疗和治疗第61页HemodynamicclassificationMild:mPAP26～35mmHgModerate:mPAP36～45mmHgsevere:mPAP﹥46mmHg肺血栓栓塞症的诊疗和治疗第62页

EssentialEvaluation

ContingentEvaluationHistoryandphysicalexamination；TransesophagealechoChestx-ray；EchowithbubblestudyElectrocardiogram；CT

chest±highresolutionPulmonaryfunctiontesting；PulmonaryangiogramVentilation-perfusionscan；ArterialbloodgasTransthoracicecho；CardiacMRIBlo