Massive & Sub Massive & Sub ‐ ‐ massive massive Pulmonary Embolism Pulmonary Embolism Current Strategies in investigation & management Current Strategies in investigation & management Phua Ghee Chee Phua Ghee Chee Consultant Consultant Resp & Critical Care Medicine Resp & Critical Care Medicine Singapore General Hospital Singapore General Hospital
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Current Strategies in investigation & managementCurrent Strategies in investigation & management
Phua Ghee CheePhua Ghee CheeConsultantConsultantResp & Critical Care MedicineResp & Critical Care MedicineSingapore General HospitalSingapore General Hospital
Case scenarioA 55‐year‐old man arrives in A&E complaining of acute onset of difficulty breathing and a sore right leg. He has a travel history of a non‐stop New York‐to‐Singapore flight a few days ago.
His BP is 100/60, HR 110, RR 24, SpO2 92%. Physical exam is unremarkable except for right sided chest pain on deep inspiration, and a tender, swollen right calf.
How do we investigate & manage our 55‐year‐old patient?
What is “massive” & “sub‐massive” PE?What are the current diagnostic strategies?What are the current management strategies?
Why is it important to know about PE?
USA: affects 600,000/yr & kills 50,000 to 200,000/yr.(Arcasoy M. Chest 1999)
10 to 20% of all in‐hospital deaths.
? Less in Asians
A local autopsy series found that 74% of fatal PE were unsuspected. (Lau G. Ann Acad Med Singapore 1995)
What are the differential diagnoses? chest pain & dyspnea
Pneumonia, BronchitisAsthma or COPD exacerbationAMIPulmonary edemaAnxietyAortic dissectionPneumothoraxMusculoskeletal pain
What investigations would you order to diagnosis PE?
Chest X‐rayECGArterial Blood GasD‐DimerSpiral CT: PE protocolV/Q scanDuplex ultrasound of lower limbs
S1Q3T3
Should we do a D‐dimer for our patient?
D‐dimer is useful to exclude PE where clinical probability is low
Carrier M et al. VIDAS D‐dimer in combination with clinical pre‐test probability to rule out pulmonary embolism: a systematic review of management outcome studies. Thromb Haemost 2009;101:886‐92.
CT Scan (CT PE Angiogram)
Perrier A et al. Multidetector‐row computed tomography in suspected pulmonary embolism. N EnglJ Med 2005;352:1760‐8.
van Belle et al. Effectiveness of managing suspected pulmonary embolism using an algorithmcombining clinical probability,D‐dimer testing, and computed tomography. JAMA 2006;295:172‐9.
What is the role of the V/Q scan?
A normal V/Q scan essentially rules out PE, with a negative predictive value of 97%.
A high probability V/Q scan has a positive predictive value of 85‐90%.
However, the V/Q scan is diagnostic in only 30‐50% of all patients with suspected PE.
Sostman HD et al. Acute pulmonary embolism: sensitivity and specificity of ventilation‐perfusion scintigraphy in PIOPED II study. Radiology 2008;246:941‐6.
Back to our patient....A 55‐year‐old man arrives in A&E complaining of acute onset of difficulty breathing and a sore right leg. He has a travel history of a non‐stop New York‐to‐Singapore flight a few days ago.
His BP is 100/60, HR 110, RR 24, SpO2 92%. Physical exam is unremarkable except for right sided chest pain on deep inspiration, and a tender, swollen right calf.Are there any other investigations you want to do?
Risk stratification in PESub‐massive & Massive PE
Hemodynamically unstable (Massive PE)Shock or sustained hypotension: Systolic BP<90mmHg, Pressure drop>40mmHg for >15mins
Hemodynamically stable (Sub‐massive PE)Right ventricular dysfunction* on Echo
*independent predictor of 30‐day mortality
Troponins
Right Ventricular Dysfunction in Sub‐massive PE
Investigations for submassive/massive PEChest X‐rayECGArterial Blood GasD‐DimerSpiral CT: PE protocolV/Q scanDuplex ultrasound of lower limbs2‐D EchoTroponins+/‐ Pulmonary angiogram
How would you treat PE?LMWH e.g. ClexaneWarfarinIVC filterthrombolytic therapy e.g. tPA, streptokinaseCatheter embolectomySurgical thrombolectomy
To recapA 55‐year‐old man arrives in A&E complaining of acute onset of difficulty breathing and a sore right leg. He has a travel history of a non‐stop New York‐to‐Singapore flight a few days ago.
His BP is 100/60, HR 110, RR 24, SpO2 92%. Physical exam is unremarkable except for right sided chest pain on deep inspiration, and a tender, swollen right calf.
Investigations & Management of our patient
High clinical probability (Well’s score)Confirm diagnosis with CT ScanEcho to look for RV dysfunction; TroponinsIf present, thrombolytic therapy if no serious bleeding risksIf hemodynamics become unstable –mechanical/surgical interventionsSubsequent anticoagulation.