Pulmonary Emoblism Essay Example
Pulmonary Emoblism Essay Example
Nuclear Medicine and Molecular Imaging
Introduction
Pulmonary Embolism (PE) is a dangerous condition that can lead to the death of the patient, if the patient does not receive the proper treatment. At the same time, there are risk factors which health care professionals and family members should be aware of to reduce the risk of the development of the disease, such as heredity. Heredity increases the risk of the development consistently. If the disease strikes, family members and health care professionals should respond immediately: family members should call the emergency, while health care professionals should provide the patient with the urgent treatment. Pulmonary Emoblism Essay Example.
Preventable disease overview
The patient is diagnosed with Pulmonary Embolism (PE) which is a life-threatening condition caused by obstruction of one or more pulmonary arteries by an embolus that has entered the pulmonary circulation from a distant site (Pulmonary Embolism: Overview). therefore, the disease is very dangerous for the health of patients and requires the immediate intervention of health care professionals. Otherwise, the life of the patient will be under a threat.
The accurate diagnosis of the disease is very important because the accurate diagnosis can help to start the early intervention that can prevent the fast progress of the disease and its negative effects. The diagnostic strategy based on combination of assessment of the pretest probability with perfusion lung scan results to reduce the need for pulmonary angiography (Miniati, et al., 2003). Pulmonary embolism is diagnosed in patients with abnormal scans suggestive of pulmonary embolism and moderately high or high pretest probability (Miniati, et al., 2003). Testing can help to determine accurately whether the patient has PE or not.
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The family history reveals the risk of the vulnerability of the patient to PE. Pulmonary Emoblism Essay Example. The common health problems identified in the family health history include diabetes, heart disease, hypertension, chronic lung disease and other health issues which were less common but still occurred in the family history, like asthma, for example. In case of the target patient is high because the patient has both the history of cardiovascular health problems and asthma which are risk factors that increase the risk of the development of PE.
Evidence-based intervention
At the same time, health care professionals should be aware of risks associated with the treatment of PE and side-effects of the intervention. Pulmonary hypertension and chronic thromboembolic pulmonary hypertension may develop after a pulmonary embolismevent (Tapson, et al., 2016). A ventilation-perfusion scan is recommended as a first-line modality for suspected chronic thromboembolic pulmonary hypertension (Tapson, et al., 2016). Such methods can help to ease the codnition of the patient and to provide the essential aid that will help the patient to cope with PE. The main point of the early intervention is to address symptoms and cope with the destructive impact of PE on the condition of the patient. The aforementioned interventions aim at the stabilization of the condition of the patient after which the further intervention will lead to the steady recovery of the condition of the patient.
Management of PE is initiated based on the acute risk stratification. Anticoagulant and thrombolytic medications are administered concomitantly with cardiorespiratory support and other supportive measures, including oxygen therapy and pain management. Reperfusion therapy with systemic fibrinolytic agents is indicated for patients with high risk or massive PE.Pulmonary Emoblism Essay Example.
The treatment of PE focuses on the support of resuscitation efforts and promotion of cardiorespiratory stability. Cardiorespiratory stability is the key for the survival of the patient and the complete recovery of the patient. The treatment can help the patient to recover only after the stabilization of cardiorespiratory function.
Another important goal of the treatment of PE is initiating long-term pharmacologic therapy and reduction of the risk for complications. The recovery of the patient takes time and health care professionals should have the clear and long-run plan of the treatment, recovery and rehabilitation of the patient.
In addition, the treatment of PE focuses on the provision of emotional and psychological support and education. At this point, the support of family members is essential for the effective treatment and rehabilitation of patients. The patient can recover fast and effectively with the psychological support from the part of family members.
Teaching plan
The teaching plan focuses on the preparation of not only health care professionals but also family members. In this regard, the teaching plan focuses on the development of the awareness of stakeholders about risks associated with PE. Family members should be aware of the risk of the development of PE and risk factors that may trigger the development of the disease.Pulmonary Emoblism Essay Example. In this regard, the target family members should be aware of the risk of the development of PE because of the vulnerability of family members to cardiovascular health issues and respiratory health problems.
Therefore, the teaching plan will focus on the clear identification of symptoms of the disease and first signs that should raise the awareness of people about risks associated with the disease. Furthermore, the teaching plan involves the training how to provide the first aid effectively and how to help the patient, who suffers from PE. Health care professionals should know advanced strategies of the treatment of the disease and rehabilitation of the disease. Family members should also learn how to help the patient after PE and how to facilitate the rehabilitation process.
Evaluation
The short-term goal in the treatment of PE is the stabilization of the condition of the patient because the primary task of health care professionals is to save the patient and eliminate direct threats to the patient’s life. The long-term goal of the treatment of PE is the further minimization of risks associated with the disease and the rehabilitation of the patient after the disease and its treatment.
In addition, the long-term goal is the training and preparation of family members to deal with the high risk of the development of the disease and new cases of PE. Family members should know how to respond to the disease and what to do in case of the immediate deterioration of the condition of the patient.
Summary
Thus, PE is a serious, life threatening condition which may lead to the death of the patient, unless the patient receives the immediate and effective treatment. The development of the disease leads to the consistent decline of the health and the immediate intervention can save the life of the patient. Pulmonary Emoblism Essay Example. However, the recovery needs time because patients should regain their physical condition as well as restore their psychological condition after the stressful experience. At the same time, family members should be aware of the risk of PE, especially if the heredity of the patient makes the patient vulnerable to the development of PE. The prevention and first aid methods are important to learn for family members because they can help to identify early signs of the disease and call the emergency in time.
References:
Miniati, M., et al. (2003). A diagnostic strategy for pulmonary embolism based on standardized pretest probability and perfusion lung scanning: A management study. European Journal of Nuclear Medicine and Molecular Imaging, 30(11), 1450-6. doi:http://dx.doi.org.molloy.idm.oclc.org/10.1007/s00259-003-1253-7
Pulmonary Embolism: Overview.
Tapson, V. F., et al. (2016). Monitoring for pulmonary hypertension following pulmonary embolism: The INFORM study. The American Journal of Medicine, 129(9), 978.
Pulmonary embolism (PE) is responsible for approximately 100,000 to 200,000 deaths in the United States each year. With a diverse range of clinical presentations from asymptomatic to death, diagnosing PE can be challenging. Various resources are available, such as clinical scoring systems, laboratory data, and imaging studies which help guide clinicians in their work-up of PE. Prompt recognition and treatment are essential for minimizing the mortality and morbidity associated with PE. Advances in recognition and treatment have also enabled treatment of some patients in the home setting and limited the amount of time spent in the hospital. This article will review the risk factors, pathophysiology, clinical presentation, evaluation, and treatment of PE. Pulmonary Emoblism Essay Example.
INTRODUCTION
Venous thromboembolism (VTE) and PE is the third most common cause of cardiovascular death after myocardial infarction (MI) and cerebrovascular accidents (CVA).[1] Many PEs are likely undiagnosed and calculating the true incidence remains challenging. However, PE remains a significant cause of preventable in-hospital mortality.
RISK FACTORS
Most clinically significant PEs originate as VTEs in the lower extremities or pelvic veins. Less frequently, upper extremity thromboembolic events lead to PE. Various conditions lead to the generation of VTE. Virchow’s triad of hypercoagulability, venous stasis, and vessel wall injury provides a model for understanding many of the risk factors. These factors are usually either inherited or acquired, as shown in Tables Tables11 and and2.2. Overall, major risk factors for thromboembolic events include recent immobilization, MI, CVA, surgery, and recent trauma. Additional major risk factors include prior VTE, advanced age, malignancy, known thrombophilia, and indwelling venous catheter. Moderate risk factors include family history of VTE, use of estrogen or hormone replacement therapy, smoking, pregnancy, and obesity. Pulmonary Emoblism Essay Example.
Table 1
Inherited Risk Factors for VTE[2,3]
Table 2
Acquired Risk Factors for VTE[2–4]
PATHOPHYSIOLOGY
PE occurs when deep venous thrombi detach and embolize to the pulmonary circulation. Pulmonary vascular occlusion occurs and impairs gas exchange and circulation. In the lungs, the lower lobes are more frequently affected than the upper, with bilateral lung involvement being common. Larger emboli wedge in the main pulmonary artery, while smaller emboli occlude the peripheral arteries. Peripheral PE can lead to pulmonary infarction, manifested by intra-alveolar hemorrhage. Pulmonary infarction occurs in about 10% of patients without underlying cardiopulmonary disease. Obstruction of the pulmonary arteries creates dead space ventilation as alveolar ventilation exceeds pulmonary capillary blood flow. Pulmonary Emoblism Essay Example. This contributes to ventilation-perfusion mismatch, with vascular occlusion of the arteries increasing pulmonary vascular resistance. In addition, humoral mediators, such as serotonin and thromboxane, are released from activated platelets and may trigger vasoconstriction in unaffected areas of lung. As the pulmonary artery systolic pressure increases, right ventricular after load increases, leading to right ventricular failure. As the right ventricular failure progresses, impairment in left ventricular filling may develop. Rapid progression to myocardial ischemia may occur secondary to inadequate coronary artery filling, with potential for hypotension, syncope, electromechanical dissociation, or sudden death.
CLINICAL PRESENTATION
Prompt recognition of a PE is crucial because of the high associated mortality and morbidity, which may be prevented with early treatment. Failure to diagnose PE is a serious management error since 30% of untreated patients die, while only 8% succumb with effective therapy.[5] Unfortunately, PE may be asymptomatic or present with sudden death. Characteristic signs and symptoms such as tachycardia, dyspnea, chest pain, hypoxemia, and shock are non-specific and are present in many other conditions, such as acute MI, congestive heart failure, or pneumonia. In the Prospective Investigation of Pulmonary Embolism Diagnosis II (PIOPED II) trial, patients with PE had a range of signs and symptoms. Common signs were tachypnea (54%) and tachycardia (24%). The most common symptoms were dyspnea, usually of onset within seconds, at rest or with exertion (73%), pleuritic pain (44%), calf or thigh pain (44%), calf or thigh swelling (41%), and cough (34%).[6] With only 24% of patients presenting with tachycardia, the majority of patients lacked one of the most common findings.Pulmonary Emoblism Essay Example. Additionally, PIOPED II excluded many types of patients, such as those with chronic elevated creatinine levels or receiving dialysis, critically ill patients, or people with recent MI. Applicability is therefore limited. Therefore, a high index of suspicion and assessment of risk factors are critical for the recognition of pulmonary embolic events.
EVALUATION
Because of the variable nature of the presentation of PE, the evaluation largely depends on the likelihood of PE and the stability of the patient. There are scoring systems to assist in the determination of likelihood of PE and thromboembolic events. Diagnostic scoring systems such as the Wells criteria and Geneva score are often used [Tables [Tables33 and and44].
Table 3
Modified Wells Criteria
Table 4
Revised Geneva Score
Beyond the Wells and Geneva systems, which clinicians use to help rule in thrombosis, the PE Rule-Out Criteria (PERC) can help rule-out PE in low-risk emergency department patients. PERC criteria are listed in Table 5.
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Table 5
PE Rule-out Criteria[9]
If a patient fulfills all of the PERC criteria and has a low probability of PE by Wells criteria and the gestalt opinion of the evaluating physician, then a PE may be ruled out.[9] In reality, very few patients meet these criteria and the PERC assessment is not reliable for the in-hospital setting. The aforementioned tools: Wells score, Geneva score, and PERC work best in assessing the need for further work-up of stable patients presenting to the emergency room; with inpatients and critically ill patients, such tools are not as reliable. The elements of diagnostic workup will vary depending on whether the patient is hospitalized and whether there is hemodynamic instability.Pulmonary Emoblism Essay Example. In a patient with a suspected PE, diagnosis of proximal DVT in a symptomatic patient, or in an asymptomatic patient who has contraindications to CT angiography, is sufficient to rule in PE.[10] In a stable patient, presenting from an outpatient setting, who has not sustained recent trauma or surgery, a d-dimer test should be performed. If negative, and clinical suspicion is low, then the likelihood of PE is low and further workup is unnecessary. d-Dimer is a degradation product of cross-linked fibrin that is formed immediately after fibrin clots are degraded by plasmin and reflects a global activation of blood coagulation and fibrinolysis. Therefore, d-dimer is not a useful test in post-operative patients because it will be elevated due to coagulation and fibrinolysis. It is also elevated in trauma patients, hospitalized patients, and those with critical illness for similar reasons. Extremity venous ultrasound (US) is a quick, noninvasive modality that can detect DVT. Because it can be performed with a portable machine, venous US may negate the need for potentially dangerous transport of unstable, critically ill patients. Unfortunately, US testing often depends on the availability of technicians to perform the imaging and further evaluation by radiologists and other physicians with such skills. Recently, emergency room physicians and intensivists have been trained in US which results in faster detection of both symptomatic and asymptomatic extremity thromboses. When performed by trained ICU physicians, compression US studies of the extremities yielded a sensitivity of 86% and a specificity of 96% with a diagnostic accuracy of 95%.[11] In this same trial, median time delay between the ordering of formal vascular study (FVS) and the FVS result was 13.8 hours, which leads to significant delays in treatment. In another study, after 10 minutes of training in two point compression ultrasound, emergency medicine physicians were able to detect lower extremity thrombosis with a sensitivity of 100% and a specificity of 99%.[12] Besides the limitations of time delays due to lack of available personnel to perform such imaging, there are certain patient limitations that may limit study accuracy and feasibility; obesity, edema, and dressings often impede good imaging quality.[13] The other consideration in obtaining lower extremity ultrasound for diagnosis of PE is that it is not a reliable modality to check for pelvic venous thrombosis and there are also many instances in which patients have PEs, but no evidence of extremity thrombosis. In one study, the use of ultrasonography alone for suspected PE had a sensitivity of only 29%.[14] Furthermore, false positive results may result in potentially dangerous and unnecessary anticoagulation in patients who do not actually have PEs. Pulmonary Emoblism Essay Example. Helical CT angiography has largely replaced ventilation-perfus ect visualization of PE, and can demonstrate other diagnoses in patients without PE. In patients with a contraindication to intravenous contrast dye, a V/Q scan is used. A normal lung scan effectively excludes the diagnosis of PE, but only 25% of patients with suspected PE have a normal scan. In one of the largest studies evaluating V/Q scanning, the PIOPED II trial, V/Q scans could effectively rule-out PE in patients with a very low probability scan and a very low clinical likelihood of PE.[15] Other additional tests such as EKG or echocardiography may help with the diagnosis. However, EKG findings are often non-specific, as tachycardia is frequent. Evidence of right heart strain on EKG or echocardiography may support the diagnosis as well as provide information about the severity of the PE. One particular finding on echocardiogram, known as the McConnell’s sign, is strongly suggestive of PE. In those patients with suspected PE and right ventricular dysfunction, the finding of normal wall motion of the RV apex but akinesia of the mid-RV free wall has a positive predictive value of 71% for the diagnosis of PE and a negative predictive value of 96%.[16] Pulmonary Emoblism Essay Example.
