2022年医学专题—肺栓塞的诊治PPT

肺动脉栓塞(shuns)的诊治制作(zhzu)XGHRH敬请指正(zhzhng)第一页，共七十页。基本概念肺栓塞肺栓塞是以各种栓子阻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，包括肺血栓栓塞症，脂肪栓塞综合征，羊水栓塞，空气栓塞等。肺血栓栓塞症肺血栓栓塞症为来自静脉系统或右心的血栓阻塞肺动脉或其分支所致疾病。肺梗死肺梗死为肺动脉发生栓塞后，其支配区的肺组织因血流受阻或中断(zhngdun)而发生坏死。第二页，共七十页。肺栓塞的现状(xinzhung)发病率高高：仅次于CAD和HBP。易易漏诊及误诊：警惕性不高，漏诊率高。不经治疗死亡率高高：达20%-30%。明确诊疗(zhnlio)者死亡率明显下降下降：可降至2-8%。第三页，共七十页。EpidemiologyThereisnoaccuratedataforpulmonaryembolismbecausewehaslimitknowledgeofit.IntheUnitedStates,itisresponsibleforabout2.3newcasesper10,000personsand50,000deathseveryyear.第四页，共七十页。流行病学(lixnbnxu)Arch.Intern.Med.154:861,1994第五页，共七十页。生存率比较(bjio)Arch.Intern.Med.154:861,19941.0123第六页，共七十页。Risk Factors for DVT/Pulmonary Embolism（Essential）抗凝血酶缺乏蛋白C缺乏先天性异常纤维蛋白原血症V因子基因突变血栓调节蛋白纤溶酶原缺乏高半胱氨酸血症异常纤溶酶原血症抗心肌碱脂抗体蛋白S缺乏纤溶酶原激活抑制剂过量因子缺乏前凝血酶20210A突变第七页，共七十页。Risk Factors for DVT/Pulmonary Embolism（Second）创伤/骨折外科手术卒中制动高龄恶性肿瘤+化疗中心静脉导管肥胖慢性静脉机能不全心力衰竭吸烟长途旅行妊娠/产后期口服避孕药克隆病、狼疮抗凝剂肾病综合征假体表面粘滞性过高血小板异常第八页，共七十页。深静脉血栓(xushun)形成原因 分类血流滞缓小腿肌肉静脉丛血栓形成髂股静脉血栓形成静脉壁损伤原发性髂肌静脉血栓形成继发性髂股静脉血栓形成高凝状态股青肿第九页，共七十页。肺血栓(xushun)与深静脉血栓(xushun)第十页，共七十页。肺栓塞的大体(dt)解剖观第十一页，共七十页。肺栓塞的显微镜下观第十二页，共七十页。肺栓塞的病理(bngl)生理肺血管阻塞，神经体液因素或肺动脉压力感受器的作用，引起肺血管阻力增加；肺血管阻塞肺泡死腔气体(qt)交换肺泡通气低氧血症V/Q单位气体交换面积二氧化碳刺激性受体反射性兴奋（过度换气）支气管收缩，气道阻力增加肺水肿、肺出血、肺泡表面活性物质减少，肺顺应性降低。第十三页，共七十页。肺栓塞后右心功能不全的病生肺栓塞冠状动脉(gunzhung-dngmi)灌注右心室氧需右心室壁张力(zhngl)右心室排血量右心室氧供左心室排血量肺动脉压力(yl)右心室后负荷解剖阻塞神经体液作用右心室扩张/功能不全右心室缺血室间隔移向左心室低血压体循环灌注左心室前负荷第十四页，共七十页。肺栓塞后肺血流动力学变化(binhu)前毛细血管高压血管床减少支气管收缩(shusu)小动脉血管收缩侧支血管的形成支气管-肺动脉吻合形成肺内动静脉分流血流改变：血流重分布Westermark征第十五页，共七十页。呼吸(hx)动力学改变过度(gud)通气：肺动脉高压顺应性下降肺不张气道阻力增加：局限性低碳酸血症化学介质第十六页，共七十页。临床(lnchun)分型大面积PE(massivePE)：休克(xik)和低血压；动脉收缩压1.5mm、avF有Qs波，但无Qs波QRS轴900或不确定肢导联低电压、avF的T波倒置或V1V4T波倒置第三十三页，共七十页。图12000年8月27日（急诊(jzhn)）ECG大致正常2000年8月29日（门诊(mnzhn)）ECG示IRBBBSQTV1V2T波倒置V3V4T波双向第三十四页，共七十页。Ventilation/Perfusion Lung Scan第三十五页，共七十页。PIOPED：肺扫描分类与肺动脉造影(zoyng)结果的比较肺扫描肺栓塞肺动脉造影阴性总数有无不肯定高度可疑1021417124中度可疑105217933364低度可疑391991262312接近正常/正常550274131总计25148024176931JNuclMed1993;34:1119第三十六页，共七十页。肺扫描(somio)(somio)怀疑PE的患者约25可因肺灌注正常而否定诊断，而且不用抗凝治疗可能是安全(nqun)的怀疑PE的患者约25具有高度的肺扫描结果，他们可能需要行抗凝治疗其余的患者需要进一步的诊断性检查，而这些检查是更广泛的诊断策略第三十七页，共七十页。典型(dinxng)肺栓塞第三十八页，共七十页。不典型(dinxng)肺栓塞第三十九页，共七十页。ItishighsensitivitybutlowspecificityThedifferentialdiagnosisforaventilationperfusionmismatchincludes:acutepulmonaryemboluspreviouspulmonaryemboluscongenitalvascularabnormalitiesvasculitis,bronchogeniccarcinoma,radiationtherapy,etal.第四十页，共七十页。Whenaventilation/perfusionscandoesnotfitintoeitherthenormalorhighprobabilitycategory,thenweconsiderthestudytobenon-diagnosticandfurtherinvestigationisrequired.Themajorityofcasesfallintothiscategorywhichischaracterizedbyscanswithsubsegmentaldefectsordefectsofanysizethatmatchabnormalitiesonthechestx-rayortheperfusionscan.第四十一页，共七十页。Alowprobabilitycategoryhasbeensuggestedbyanumberofauthors.However,aswecanseefromthePIOPEDdatathisisnotaparticularlyreliablecategory.Disagreementamongexperiencedreadersiscommonwhenperfusiondefectsaresmallandlimittheutilityofthiscategory.Thisstudywasoriginallyreadasshowingasmallsubsegmentaldefect.Withoutthearrow,thisstudyhassubsequentlybeencallednormalbyanumberofexperiencedreaders第四十二页，共七十页。ConclusionLungscansaresensitiveexamsthatessentiallyruleoutthediagnosisofpulmonaryemboluswhentheyarenormal.Patientswithhighprobabilitylungscanoftenbetreatedwithoutfurtherworkup.Thosepatientswithnon-diagnosticstudiesrequirefurtherdiagnosticinvestigation.第四十三页，共七十页。CT of Pulmonary EmbolismPulmonaryinfarctsaremorereadilyidentifiedonCT.ModernCTscannersnowhavefasteracquisitiontimesandareprovidingadetailedassessmentofthelungparenchymathatisnotavailablefromthechestradiograph.ThetypicalappearanceofapulmonaryinfarctonCTincludesapleuralbaseddensitywithconvexbordersandalinearstrandattheapexofthetriangle第四十四页，共七十页。Theapexofthetriangleisoftentruncatedandnotwedgeshapedwhichcorrespondstothenormalconfigurationofasecondarylobuleinthelungperiphery.Lowattenuationareaswithintheinfarctrepresentsviablelung.Itisimportanttonote,however,thatthisappearanceisnotspecificforpulmonaryinfarction.Thedifferentialdiagnosisforthisabnormalityincludesinfarct,hemorrhage,pneumonia,fibrosis,neoplasiaandedema第四十五页，共七十页。Sincetheclinicalpresentationofpulmonaryembolusisusuallynon-specific,thefindingsonCTareoftenthefirstclinicalindicationthatthepatientmaybesufferingfrompulmonaryembolus.Inadditiontovisualizingtheareaofinfarctionweareoftenabletoseetheclotitself.第四十六页，共七十页。CThasbeenshowtobeespeciallyusefulintheassessmentofpatientswithchronicdyspneaandknownpulmonaryarteryhypertension.ThesepatientsareoftendifficulttodiagnoseasisexemplifiedbythispatientwithknownsclerodemaandpulmonaryarteryhypertensionwhoseCTunexpectedlyshowedalargecalcifiedclotintherightpulmonaryartery.第四十七页，共七十页。肺动脉造影(zoyng)正常(zhngchng)肺动脉第四十八页，共七十页。Thisselectivestudywasdonebecauseofaperfusiondefectintheleftlowerlobeonaventilationperfusionscan.Thefirstangiographicstudywasinconclusive.Therefore,asubselectivestudywasdonethatdemonstratedtheclotwithcertainty.第四十九页，共七十页。Themostreliablesignsofpulmonaryembolusare:AnIntraluminalfillingdefectAnAbruptterminationofab