肺血栓栓塞症的诊疗和治疗培训课件.ppt

1、肺血栓栓塞症的诊疗肺血栓栓塞症的诊疗和治疗和治疗肺血栓栓塞症相关名词及定义 肺血栓栓塞症诊断与治疗指南（草案）中的有关名词 肺血栓栓塞症(pulmonary thromboembolism,PTE)肺栓塞(pulmonary embolism,PE)肺梗死(pulmonary infarction,PI)深静脉血栓形成(deep venous thrombosis,DVT)静脉血栓栓塞症(venous thromboembolism,VTE)VTE=DVT+PTE 其他相关名词 遗传性易栓症、慢性血栓栓塞性肺动脉高压、经济仓综合征、肺动脉原位血栓形成、特发性肺动脉高压、家族性肺动脉高压、出血性

2、肺不张 其他类型肺栓塞 气体栓塞、脂肪栓塞、羊水栓塞、脂肪栓塞、羊水栓塞、粟粒性肺栓塞（肿瘤、虫卵）、其他（菌栓、药栓）肺血栓栓塞症的诊疗和治疗2脂肪栓塞脂肪栓塞(fat embolism syndrome,FES)定义：长管状骨骨折等严重创伤后脂长管状骨骨折等严重创伤后脂肪滴阻塞肺循环或脑循环等其他微血肪滴阻塞肺循环或脑循环等其他微血管而引起的临床症候群。主要临床表管而引起的临床症候群。主要临床表现为呼吸衰竭、脑功能障碍及淤斑。现为呼吸衰竭、脑功能障碍及淤斑。病理生理：肺血管的机械性梗阻和肺肺血管的机械性梗阻和肺间质的间质的“生物化学性生物化学性”炎症反应。炎症反应。肺血栓栓塞症的诊疗和治疗

3、3Fat embolism in a 58-year-old woman who presented with sudden dyspnea.The patient had undergone intramuscular injection of some fatty materials into the buttock several days earlier.(a)(a)Radiograph shows bilateral ground-glass areas of increased opacity.肺血栓栓塞症的诊疗和治疗4(b)(b)Thin-section(1-mm collima

4、tion)CT scan obtained at the level of the aortic arch shows widespread patchy ground-glass attenuation and consolidation.肺血栓栓塞症的诊疗和治疗5羊水栓塞羊水栓塞(amniotic fluid embolism,AFE)原因：妊娠期羊水中胎儿产物进入母体妊娠期羊水中胎儿产物进入母体循环而引起。循环而引起。途径：分娩时羊水经宫颈内膜血管静脉分娩时羊水经宫颈内膜血管静脉撕裂部位撕裂部位;胎盘早剥和剖宫产时损及胎盘胎盘早剥和剖宫产时损及胎盘附着部位的静脉窦附着部位的静脉窦;子宫损

5、伤或子宫撕列子宫损伤或子宫撕列部位。部位。病理生理：肺血管栓塞肺血管栓塞;变态反应变态反应;凝血凝血机制障碍。机制障碍。肺血栓栓塞症的诊疗和治疗6(a)(a)Radiograph shows bilateral widespread airspace consolidation.Endotracheal intubation was performed.AFE in a 40-year-old woman.The patient experienced sudden respiratory distress shortly after giving birth by caesarean sec

6、tion.肺血栓栓塞症的诊疗和治疗7(b)(b)On a follow-up radiograph obtained 3 days later,the extent of the parenchymal areas of increased opacity has decreased.A chest tube was inserted into the right pleural space to relieve the right pleural effusion.肺血栓栓塞症的诊疗和治疗8DVT-PTE的流行病学 发病率和患病率 西方国家：DVT和PTE的年发病率分别为1.0 和0.5 美

7、国：PTE年新发病例数650，000-700，000 中国：阜外心血管病医院900例连续尸检：11.0（段以上PTE）易患因素 年龄与性别、血栓性静脉炎、静脉曲张、心肺脑血管疾病、创伤、肿瘤、制动、妊娠和口服避孕药、遗传因素、肥胖、吸烟等肺血栓栓塞症的诊疗和治疗9Table Risk Factors for VTESurgeryTrauma(major or lower extremity)Immobility,paresisMalignancyCancer therapy(hormonal,chemotherapy,or radiotherapy)Previous VTEIncreasing

8、 agePregnancy and the postpartum periodEstrogen-containing oral contraception or hormone replacementtherapySelective estrogen receptor modulatorsAcute medical illnessHeart or respiratory failureInflammatory bowel diseaseNephrotic syndromeMyeloproliferative disordersParoxysmal nocturnal hemoglobinuri

9、aObesitySmokingVaricose veinsCentral venous catheterizationInherited or acquired thrombophilia20042004年年9 9月月ACCPACCP第第7 7次抗栓会议共识次抗栓会议共识肺血栓栓塞症的诊疗和治疗10Table Table Absolute Risk of DVT in HospitalizedAbsolute Risk of DVT in HospitalizedPatientsPatients*Patient Group DVT Prevalence,%Medical patients 10

10、20General surgery 1540Major gynecologic surgery 1540Major urologic surgery 1540Neurosurgery 1540Stroke 2050Hip or knee arthroplasty,hip fracture surgery 4060Major trauma 4080Spinal cord injury 6080Critical care patients 1080*Rates based on objective diagnostic testing for DVT in patients not receivi

11、ng thromboprophylaxis.20042004年年9 9月月ACCPACCP第第7 7次抗栓会议共识次抗栓会议共识肺血栓栓塞症的诊疗和治疗11创伤（尸检（尸检PTE，15%）制 动肿瘤(尸检尸检PTE,10%)心肺脑血管病心肺脑血管病（PTE，10%）胫骨骨折（尸检尸检DVT，45%60%）腹部大大手术（尸检DVT，15%30%）胰腺癌（35%）充血性心衰（12%）髋骨骨折（尸检尸检DVT，50%75%）CABG术后（尸检DVT，3%9%）肺癌（20%）急性心肌梗塞（5%35%）脊髓损伤（尸检尸检DVT，50%100%）疝修补术（5%）泌尿道肿瘤（19%）脑卒中（下肢瘫痪）（30

12、%60%）骨盆骨折（尸检尸检PTE，25%）结肠癌（15%）脊柱骨折（尸检尸检PTE，14%）胃癌（16%）乳腺癌（15%）附表部分病种DVT-PTE的患病情况肺血栓栓塞症的诊疗和治疗12国内资料国内资料 488例住院脑卒中患者,下肢DVT总体检出率21.7%.493例骨科住院患者(创伤394人,关节置换92人,脊柱损伤52人),下肢DVT总体检出率为25.5%.肺血栓栓塞症的诊疗和治疗13DVT-PTE的诊断率的诊断率犹如冰山一角，尚犹如冰山一角，尚需各临床和医技功需各临床和医技功能科室的共同努力！能科室的共同努力！无声的杀手无声的杀手VTEVTELowdiagnosticrateofPE肺

13、血栓栓塞症的诊疗和治疗14PTE的临床表现v病史 VTE 易患因素 家族性v症状v体征肺血栓栓塞症的诊疗和治疗15PTE的一般性检查 动脉血气分析：低氧、呼减 ECG：窦速、SIQIIITIII,V3RV5R、V V1 1的的S S波升支顿挫、粗钝和切迹，波升支顿挫、粗钝和切迹，V V1 1V V3 3的的T T波波倒置、倒置、ST段压低等等 胸片 心脏彩超：直接和间接征象 深静脉超声 D-二聚体（D-dimer）肺血栓栓塞症的诊疗和治疗16PTEPTE的的ECGECG改变改变肺血栓栓塞症的诊疗和治疗17PTEPTE的的ECGECG改变改变肺血栓栓塞症的诊疗和治疗18case 1case 1

14、taken on hospital admission shows well-marginated opacities over the right upper and middle lung zones,linear opacities over the right lower zone,and a blunted right costophrenic sulcus.X X 线线 胸胸 片片(一一)肺血栓栓塞症的诊疗和治疗19X X 线线 胸胸 片片(二二)case 2 case 2 taken on hospital admission shows a wedge-shaped,pleur

15、al-based opacity with its apex directed toward the hilum in the left mid-lung zone,a homogenous opacity occupying the left lower zone,and blunting of the left costophrenic sulcus.肺血栓栓塞症的诊疗和治疗20肺血栓栓塞症的诊疗和治疗21肺血栓栓塞症的诊疗和治疗22PTE的确诊检查 肺动脉造影（PAA）CT肺动脉造影（CTPA）V/Q扫描 磁共振肺动脉造影（MRPA）肺血栓栓塞症的诊疗和治疗23肺血栓栓塞症的诊疗和治疗2

16、4CTPA(一一)In case 1 The contrast-enhanced spiral CT scan of the patient taken on hospital admission reveals intraluminal filling defects in both interlober pulmonary arteries,multiloculated pleural effusions,and atelectatic areas in the left lower lobe.肺血栓栓塞症的诊疗和治疗25CTPA(二二)In case 2 taken on hospita

17、l admission reveals an intraluminal filling defect in the right main pulmonary artery,multiloculated effusions,and atelectasis in both the posterior and paramediastinal regions of the right lung.肺血栓栓塞症的诊疗和治疗26CTPA(三三)CTV showslargelow-attenuationthrombifillingtheleftcommoniliacvein(arrow).CTPA shows

18、 multifocal low-shows multifocal low-attenuation emboli(arrows)in attenuation emboli(arrows)in segmental and subsegmental segmental and subsegmental arteries in the right lower lobe.arteries in the right lower lobe.肺血栓栓塞症的诊疗和治疗27肺血栓栓塞症的诊疗和治疗28CT scan in a patient with CTEPH shows a pleurabased wedge

19、-shaped scar in the right upper lobe caused by prior infarction.Lung infarctionLung infarction肺血栓栓塞症的诊疗和治疗29定性诊断：定性诊断：高度可能性高度可能性大于或等于大于或等于2 2个肺段灌注缺损，肺通气显个肺段灌注缺损，肺通气显像和像和X X胸片均未见异常胸片均未见异常;或灌注缺损区大于异常的肺通气或灌注缺损区大于异常的肺通气显像或显像或X X胸片；大于或等于胸片；大于或等于2 2个亚肺段（或一个肺段）的个亚肺段（或一个肺段）的肺灌注缺损，肺通气显像和肺灌注缺损，肺通气显像和X X胸片无明显异

20、常。胸片无明显异常。中度可能性中度可能性低度可能性低度可能性肺血栓栓塞症的诊疗和治疗30多发性肺栓塞多发性肺栓塞肺血栓栓塞症的诊疗和治疗31MRPAAcute pulmonary embolism in a 41-year-old woman.Coronal gadolinium-enhanced three-dimensional pulmonary MR angiogram shows a large embolus(arrows)in the proximal right interlobar artery.肺血栓栓塞症的诊疗和治疗32Chronic pulmonary Chronic

21、pulmonary embolism in a 55-year-old embolism in a 55-year-old man.man.(a)Chest radiograph shows enlargement of the central pulmonary arteries along with cardiomegaly.(b)CTPA obtained at the level of the bronchus intermedius shows eccentric thrombus along the medial margin of the narrowed right inter

22、lobar pulmonary artery(arrows).(c)V/Q scan(right posterior oblique view)shows multisegmental defects,which did not match the findings seen on a ventilation lung scan obtained with Tc-99m Technegas(d)Pulmonary arteriogram shows abrupt cutoff in rounded fashion(pouching defect)of the lower lobar arter

23、ies(arrow).(e)Photograph shows organized emboli filling the enlarged central pulmonary arteries.(arrows).肺血栓栓塞症的诊疗和治疗33PTE的治疗 抗凝治疗 溶栓治疗 介入治疗 肺血栓栓塞症的诊疗和治疗34抗凝治疗v药物v监测v特殊情况下的抗凝治疗：妊娠和哺乳、围手术期、恶性肿瘤v抗凝治疗的终止。肺血栓栓塞症的诊疗和治疗35各种LMWH的推荐用法 依诺肝素钠（克塞）：100IU/kg,Q12h 达肝素钠（法安明）：100IU/kg,Q12h 那屈肝素钙（速避凝）：Q12h 50kg,0.4m

24、l;5059kg,0.5ml;6069kg,0.6ml;7079kg,0.7ml;8089kg,0.8ml;90kg,0.9ml.肺血栓栓塞症的诊疗和治疗36Body Weight-Based Dosing of IV Heparin（ACCP 第六次抗栓会议共识）肺血栓栓塞症的诊疗和治疗37Guidelines for Anticoagulation:Unfractioned Heparin（ACCP 第六次抗栓会议共识）肺血栓栓塞症的诊疗和治疗38Duration of Therapy（ACCP 第六次抗栓会议共识）肺血栓栓塞症的诊疗和治疗39长期抗凝华法令 用法、监测、疗程、副作用 常见

25、影响华法令作用的药物和疾病：加强加强作用：作用：乙胺碘呋酮、广谱抗生素、洛伐他汀、流乙胺碘呋酮、广谱抗生素、洛伐他汀、流感疫苗、奥美拉唑、扑热息痛、甲硝唑和甲状腺感疫苗、奥美拉唑、扑热息痛、甲硝唑和甲状腺激素等；甲亢、老年、心衰、肝病、发热、维生激素等；甲亢、老年、心衰、肝病、发热、维生素素K缺乏、恶性肿瘤等。缺乏、恶性肿瘤等。抑制作用：抑制作用：巴比妥类、口服避孕药、利福平和肾巴比妥类、口服避孕药、利福平和肾上腺皮质激素等；甲减、肾病综合征和遗传性华上腺皮质激素等；甲减、肾病综合征和遗传性华法令耐药等。法令耐药等。肺血栓栓塞症的诊疗和治疗40抗凝治疗的紧急终止抗凝治疗的紧急终止 肝素：半衰期

26、1.5小时，硫酸鱼精蛋白1mg可中和不少于100u的肝素，通常只需半量。华法令：半衰期约42小时，维生素K1 15mg口服或静注，24小时内能终止抗凝。紧急情况输新鲜冰冻血浆或补充维生素K依赖性凝血因子。LMWH：半衰期约6小时，每0.6mg鱼精蛋白可中和速避凝0.1ml肺血栓栓塞症的诊疗和治疗41溶栓治疗适应症溶栓方案：尿激酶12小时溶栓方案、重组组织型纤溶酶原激活剂2小时溶栓方案等其他问题：DVT、咯血、二次溶栓、妊娠、症状性PTE护理肺血栓栓塞症的诊疗和治疗42介入治疗 适应症与并发症；方案的选择；腔静脉滤器的应用。肺动脉导管溶栓机械破碎滤器置入肺血栓栓塞症的诊疗和治疗43左肺动脉栓子去

27、除肺血栓栓塞症的诊疗和治疗44下腔静脉滤网肺血栓栓塞症的诊疗和治疗45CTEPH Contrast-enhanced CT scan in a patient with CTEPH shows bronchial artery collaterals.Note that the enlarged main pulmonary artery has a larger diameter than the AO.肺血栓栓塞症的诊疗和治疗46谢谢！谢谢！47Pulmonary Hypertention WANG JinxiangRespiratory Department of Beijing Luh

28、e Hospital48肺血栓栓塞症的诊疗和治疗49肺血栓栓塞症的诊疗和治疗50肺血栓栓塞症的诊疗和治疗51Pulmonary HypertentionvClassification vFunctional ClassificationvDiagnostic PrecedurevTherapy肺血栓栓塞症的诊疗和治疗522003,VinicePulmonary arterial hypertension(PAH)Pulmonary hypertension with left heart diseasePulmonary hypertension associated with lung di

29、sease and/or hypoxPulmonary hypertension due to chronic thrombotic and/or embolic diseaseMiscellaneous肺血栓栓塞症的诊疗和治疗54Pulmonary arterial hypertension(PAH)1.1.Idiopathic(IPAH)1.2.Familial(FPAH)1.3.Associated with(APAH):1.3.1.Collagen vascular disease 1.3.2.Congenital systemic-to-pulmonary shunts 1.3.3.

30、Portal hypertension 1.3.4.HIV infection 1.3.5.Drugs and toxins 1.3.6.Other(thyroiddisorders,glycogenstoragedisease,Gaucherdisease,hereditaryhemorrhagictelangiectasia,hemoglobinopathies,myeloproliferativedisorders,splenectomy)1.4 Associated with significant venous or capillary involvement1.4.1 Pulmon

31、ary veno-occlusive disease(PVOD)1.4.2 Pulmonary capillary hemangiomatosis(PCH)肺血栓栓塞症的诊疗和治疗55Pulmonary hypertension with left heart disease2.1.Left-sided atrial or ventricular heart disease 2.2.Left-sided valvular heart disease 肺血栓栓塞症的诊疗和治疗56Pulmonary hypertension associated with lung disease and/or

32、hypoxemia3.1.Chronic obstructive pulmonary disease 3.2.Interstitial lung disease 3.3.Sleep-disordered breathing 3.4.Alveolar hypoventilation disorders 3.5.Chronic exposure to high altitude 3.6.Developmental abnormalities肺血栓栓塞症的诊疗和治疗57Pulmonary hypertension due to chronic thrombotic and/or embolic di

33、sease4.1.Thromboembolic obstruction of proximal pulmonary arteries 4.2.Thromboembolic obstruction of distal pulmonary arteries 4.3.Non-thrombotic pulmonary embolism(tumor,parasites,foreign material)肺血栓栓塞症的诊疗和治疗58MiscellaneousSarcoidosishistiocytosis-XLymphangiomatosiscompression of pulmonary vessels

34、(adenopathy,tumor,fibrosing mediastinitis)肺血栓栓塞症的诊疗和治疗59Functional Classification（WHO,2004,Chest）Class I:Patients with PH without limitation of usual activity Class II:Patients with PH with slight limitation of usual physical activity Class III:Patients with PH with marked limitation of usual physic

35、al activity Class IV:Patients with PH with inability to perform any physical activity without symptoms and who may have signs of right ventricular failure肺血栓栓塞症的诊疗和治疗60A.New York Heart Association functional classification*Class 1:No symptoms with ordinary physical activity.Class 2:Symptoms with ord

36、inary activity.Slight limitation of activity.Class 3:Symptoms with less than ordinary activity.Marked limitation of activity.Class 4:Symptoms with any activity or even at rest.B.World Health Organization functional assessment classificationClass I:Patients with PH but without resulting limitation of

37、 physical activity.Ordinary physical activity does not cause undue dyspnea orfatigue,chest pain,or near syncope.Class II:Patients with PH resulting in slight limitation of physical activity.They are comfortable at rest.Ordinary physical activity causes undue dyspnea or fatigue,chest pain,or near syn

38、cope.Class III:Patients with PH resulting in marked limitation of physical activity.They are comfortable at rest.Less than ordinary activity causes undue dyspnea or fatigue,chest pain,or near syncope.Class IV:Patients with PH with inability to carry out any physical activity without symptoms.These p

39、atients manifest signs of right-heart failure.Dyspnea and/or fatigue may even be present at rest.Discomfort is increased by any physical activity（Contrast of NYHA and WHO）肺血栓栓塞症的诊疗和治疗61Hemodynamic classification Mild:mPAP 2635mmHg Moderate:mPAP 3645mmHg severe:mPAP 46mmHg肺血栓栓塞症的诊疗和治疗62 Essential Eva

40、luation Contingent EvaluationHistory and physical examination；Transesophageal echoChest x-ray；Echo with bubble studyElectrocardiogram；CT chest high resolutionPulmonary function testing；Pulmonary angiogramVentilation-perfusion scan；Arterial blood gasTransthoracic echo；Cardiac MRIBlood tests:HIV,TFTs,

41、LFTs,ANA；Blood tests:Uric acid,BNPSix-minute walk test；PolysomnographyOvernight oximetry；Cardiopulmonary exerciseRight heart catheterization；Open lung biopsySuspect PH肺血栓栓塞症的诊疗和治疗63ECG characteristics of PAHECG characteristics of PAH肺血栓栓塞症的诊疗和治疗64Chest x-ray of PAH肺血栓栓塞症的诊疗和治疗65Therapy of PAH肺血栓栓塞症的

42、诊疗和治疗66Pulmonary Angiography in PAHThe amount of blood clot that you can see there;the vessels tapering,the abrupt cutoffs of the blood vessels.The pictures been taken out at the time of a pulmonary thrombo-endarterectomy.This is chronic fibrotic organized material;it is not fresh clot.肺血栓栓塞症的诊疗和治疗6

43、7王金祥,胥振扬,李晓辉,等.21例肺血栓栓塞症临床分析.中国呼吸与危重监护杂志.2003,2(5):367-371.【被引情况】【被引情况】共共 8 8 篇篇 胡瑞霞 宋伯良：肺栓塞26例临床分析 下载全文来自中华实用中西医杂志中华实用中西医杂志 2005 年 第 15 期 于雷 徐海燕 肖庆龙：胸部手术后急性肺栓塞的诊疗 下载全文 来自中国急救医学中国急救医学 2004 年 第 06 期 李利红 王辰 陈世伦 庞宝森 王峰 伍燕兵 牛淑杰：不同溶栓方案治疗肺栓塞时凝血纤溶变化的实验研究 下载全文 来自中国呼吸与危重监护杂志中国呼吸与危重监护杂志 2005 年 第 03 期 张卓然 时国朝：

44、11例肾病综合征并发肺栓塞临床病理分析 下载全文 来自中国呼吸与危重监中国呼吸与危重监护杂志护杂志 2005 年 第 01 期 李文兵 高德伟 俞森洋 刘长庭：肺血栓栓塞与肺梗死形成的临床和病理特征及其相关因素分析 下载全文 来自中国呼吸与危重监护杂志中国呼吸与危重监护杂志 2004 年 第 02 期 王蓉美 张小瑜 李小波 冯玉麟：影像诊断在肺栓塞中的应用进展 下载全文 来自中国呼吸与中国呼吸与危重监护杂志危重监护杂志 2004 年 第 01 期 彭燕：肺血栓栓塞症22例误诊分析 下载全文 来自中中国呼吸与危重监护杂志国呼吸与危重监护杂志 2004 年 第 01 期 谢美云 穆耀强 金兰花：35例肺栓塞的诊治体会 下载全文 来自中国呼吸与危重监护杂志中国呼吸与危重监护杂志 2004 年 第 01 期 王金祥,石逸杰,胥振扬,等.家族性肺动脉高压家二例.中国呼吸与危重监护杂志.2006,5(6):463.肺血栓栓塞症的诊疗和治疗68