PULMONARY

VASCULAR

PE pulmonary emboli

In patients with recognized massive PE, the

incidence of physical signs has been reported
as follows:

96% have tachypnea (respiratory rate >16/min)

58% develop rales
53% have an accentuated second heart sound
44% have tachycardia (heart rate >100/min)
43% have fever (temperature >37.8 C)
36% have diaphoresis
34% have an S3 or S4 gallop
32% have clinical signs and symptoms suggesting
thrombophlebitis
24% have lower extremity edema
23% have a cardiac murmur
19% have cyanosis

venous thrombi (i.e., blood clots) detach from their sites of

origin on blood vessel walls, travel through the blood to the
lungs, obstruct blood vessels, and reduce blood flow.
Most pulmonary thromboemboli (95%) arise in the deep veins
of the lower extremities.
Approximately 650,000 patients develop PTE annually,
resulting in a quarter-million hospitalizations.
Pulmonary thromboembolism occurs in 6080% of patients
with DVT, even
though more than half the patients are asymptomatic.
Sixty percent of patients who die in the hospital have
experienced PTE.
Because patients with PTE present with non-specific clinical
manifestations, the diagnosis is missed in approximately
400,000 individuals in the United States each year.
Virtually every primary healthcare provider encounters
patients who are at risk for PTE.

Pulmonary
thromboembolism
Embolism: It is a
detached solid,
liquid or a gaseous
mass carried
through the blood to
a distant site from
its point of origin.
TYPES:
Blood clot.
Rare causes: fat, air,
amniotic fluid.

Most common cause for P.E is DVT

(deep venous thrombosis) of lower
extremities.
-Femoral vein.
-Pelvic veins
Risk factors: For pulmonary
thromboembolism are same as for
DVT.

Because of impaired venous return and locally

increased venous pressure, a lower extremity
with a deep vein thrombosis is often dusky red
and edematous, as seen in this image.

RISK FACTORS

Physiological factors contributing to

venous thrombosis
A-Venous stasis
B-Endothelial cell injury
C- Hypercoagulable states

RISK FACTORS

Prologed bed rest: trauma, surgery

(orthopedic, (femur , hip) gynecological
cancer).
Congestive cardiac failure/Atrial fibrillation.
Myocardial Infarction/mural thrombous.
Spinal cord injury.
Cancer patients.
Pregnancy, child birth, oral contraceptives
(smoking >35y), HRT (hormone replacement
therapy)

Pathophysiology
The effect of pulmonary embolism is:
A- Mechanical obstruction of
pulmonary circulation.
B- Vasoconstriction.(rule of pulmonary
circulation is hypoxia leads to
vasoconstriction)
C-Bronchoconstriction (AS A Reflex in
the affected areas of lungs)

CONTD
-Wasted ventilation
Impaired gas exchange.
Hypoxemia
Chronic thromboembolic phenomena
leads to Pulmonary hypertension and
eventually right sided heart failure.
Large embolism causes: Acute right
sided heart failure if lodges in
pulmonary trunk.

This image illustrates a large pulmonary thromboembolus from an

autopsy performed on an elderly woman who died suddenly while
hospitalized for evaluation of an abdominal mass. The main
pulmonary artery has been opened anteriorly to reveal a massive
thromboembolus that straddles the bifurcation of the main
pulmonary artery and completely occludes the right and left
pulmonary arteries. Postmortem examination of the abdomen
revealed a mucin-producing adenocarcinoma (cancer) of the sigmoid

This is a closer view of the pulmonary thromboembolus illustrated in

the previous image, demonstrating complete occlusion of both the
right and left pulmonary arteries by the saddle embolus. Delicate
fibrin-platelet lamellae, or lines of Zahn, are visible on the external

Clinical manifestations
Depends on the size of embolus and
location of the obstruction.
MODERATE SIZED EMBOLUS:
Most common symptoms:
Chest pain(Pleuritic type).
Dyspnea and apprehension.
Increased Respiratory Rate.
Mild fever.
Cough productive of sputum.

Massive embolus:
Chest pain, shock.
Weak pulse and low BP.
Distended neck veins.
Cyanosis.

DIAGNOSIS

CTPA
Clinical suspicion.
Blood gases.(low PO2 and Normal PCO 2