肺栓塞的诊断与治疗

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1、彭文鸿解放军306医院呼吸内科急性肺栓塞（PE）诊治进展基本概念肺栓塞（pulmonaryembolism,PE):是以各种栓子堵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、脂肪栓塞、羊水栓塞、空气栓塞等。肺血栓栓塞症（pulmonarythromboembolism,PTE):是指来源于静脉系统或右心血栓堵塞肺动脉或其分枝引起肺循环障碍的临床和病理生理综合征。肺动脉血栓形成（pulmonarythrombosis）指肺动脉病变基础上（如肺血管炎、白塞氏病等）原位血栓形成，多

2、见于肺小动脉，并非外周静脉血栓脱落所致，临床不易与肺栓塞相鉴别。基本概念深静脉血栓形成（deepvenousthrombosis,DVT):纤维蛋白、血小板、红细胞等血液成份在深静脉管腔内形成凝血块（血栓）。静脉血栓栓塞症（venousthrombolism,VTE):PTE和DVT是同一疾病过程中两个不同阶段，统称为VTE.从PTE到VTEPTE:pulmonarythromboembolism肺血栓栓塞症DVT:deepvenousthrombosis深静脉血栓形成VTE:venousthrombo

3、embolism静脉血栓栓塞症VTE=PTE+DVT强调VTE观概念的转变与防治策略的选择Theincidenceofphysicalsigns96%havetachypnea(respiratoryrate>16/min)58%developrales53%haveanaccentuatedsecondheartsound44%havetachycardia(heartrate>100/min)43%havefever(temperature>37.8°C)36%havediaphoresis34%h

4、aveanS3orS4gallop32%haveclinicalsignsandsymptomssuggestingthrombophlebitis24%havelowerextremityedema23%haveacardiacmurmur19%havecyanosisOriginalGenevaScoreAge:60–79years(1point)80+years(2points)PreviousDVTorPE(2points)Recentsurgerywithin4weeks(3points)He

5、artrate>100beatsperminute(1point)PaCO2(partialpressureofCO2inarterialblood):<35mmHg(2points)35-39mmHg(1point)PaO2(partialpressureofO2inarterialblood):<49mmHg(4points)49-59mmHg(3points)60-71mmHg(2points)72-82mmHg(1point)RevisedGenevaScoreAge65yearsorover(

6、1point)PreviousDVTorPE(3points)Surgeryorfracturewithin1month(2points)Activemalignantcondition(2points)Unilaterallowerlimbpain(3points)Haemoptysis(2points)Heartrate:75to94beatsperminute(3points)95ormorebeatsperminute(5points)Painondeeppalpationoflowerlimb

7、andunilateraloedema(4points)RevisedGenevaScoreinterpretationThescoreobtainedrelatestoprobabilityofPE:0-3pointsindicateslowprobability(8%)4-10pointsindicatesintermediateprobability(28%)11pointsormoreindicateshighprobability(74%)Theprobabilitiesderivedfrom

8、thescoringsystemscanbeusedtodeterminetheneedfor,andnatureof,furtherinvestigationssuchasD-dimer,ventilation/perfusionscanningandCTpulmonaryangiographytoconfirmorrefutethediagnosisofPE.GenevaScoringforPulmonaryEmbolismSimpli