Pulmonary embolism (PE) is responsible for most mortality as it's diverse range of clinical presentation and sometimes asymptomatic presentation creates room for challenges in the diagnoses. It is medical emergence and prompt diagnosis and treatment are vital in reducing mortality and associated morbidity.
- The main cause of PE is thrombosis dislodge and circulating in the blood stream to occlude the pulmonary artery. Blood clot can occur due to serious limb injury, surgery, prolonged bed rest and static lower limb posture for more than 6 hours.
- Cancer or cancer treatments such as chemotherapy and radiotherapy could lead to possible thrombosis formation
- Other factors are overweight and hypercholesterolemia as it could lead to fat embolism; pregnancy as there an increase rick of PE to in the first few weeks postpartum; smoking; some hormone replacement therapy (HRT).
- Hyper-coagulation of blood
- PE can also arise from the right side of the heart
- Non-thrombotic materials such as amniotic fluid, fat, air, bone and organ fragments.
Mechanism of Injury / Pathological Process
The initial cardiorepiratory state and size and number of emboli affects the severity of the of the change in pulmonary blood flow and respiration. a small blockage of the pulmonary artery may not be symptomatic but a large emboli can lead to several events which are deleterious the the individual. Thrombosis formation occur due to stasis in the deep veins especially the vein at the calf. Blood stasis leads to thrombosis been formed and it's dislodge makes it to circulate freely in the blood as an embolus and can occlude blood vessels; most especially the pulmonary artery. The occlusion can also be as a result of other emboli like air bolus , fat e.t.c. Pulmonary embolism causes wasted ventilation as it increases the alveoli dead space thus resulting in ventilation perfusion mismatch and an increase in pulmonary artery pressures and right ventricular work. Consequently, there is eventual right heart failure, accompanied by the left side of the heart due to decrease in blood volume and coronary perfusion to the left ventricle. Cardiac muscle dysfunction ensues; thus, the heart ceases to pump blood.
Prevalence/Incidence of PE
After myocardial infarction (MI) and cerebrovascular accidents (CVA), PE follows as the third leading cause of cardiovascular death. Some persons with PE are asymptomatic with incidence of 2.6% and upto 71.4% in patient with distal DVT. The European guidelines for the diagnosis and management of PE report annual incidence rates of venous thrombosis and PE of approximately 0.5 to 1.0 per 1000 inhabitants. A national incidence of 0.6/1000/year was reported by a study done by swedish in 2005
- Dyspnea and/or Tachypnea
- Crackle lung sound on chest auscultation
- Prounced second heart sound
- Pleuritic chest pain
- Profuse sweating
- Cough with hemoptysis
- Tachycardia with rapid feeble pulse, arrhythmia
- Hypotension, lightheadedness, dizziness (occasionally induced
- by exercise only)
PE is difficult to diagnose clinically as only few cases show the triad of chest pain, dyspnoea and haemoptysis  and some are even unsymptomatic with incidence of 2.6% and up to 71.4% in patient with distal DVT.
A test such as D-dimer and Doppler Ultrasound.to for thrombosis as more than 70% of patients with PE also has DVT with sensitivity of 86% and a specificity of 96% with a diagnostic accuracy of 95%.
Ventilation/perfusion (V/Q) scan and 50% accurate
Computed tomographic angiography (CTA) which is a spiral CT with intravenous contrast medium is the best diagnostic tool as it is 90% conclusive.
MRI is another option used if there is fear of harm from other procedures especially in pregnant women.
A PE Rule-out Criteria could be used in out patient emergency as a clinical decision rule.
- Duke Anticoagulation Satisfaction Scale (DASS) 
- Perception of Anticoagulation Treatment Questionnaire (PACT-Q).
Management / Interventions
A fast acting fibrinolytic agent such as heparin should be administered. Heparin prevents blood clot progression.
A sedative to decrease the patient’s anxiety and pain;
Oxygen to reduces the pulmonary artery pressure and improve PAO2.
The role of physiotherapy comes in when embolism has been controlled and no further clot is been formed. The main aim of physiotherapy is to restore a clear lung field and oxygen uptake to optimal level.This could be achieved by appropriate chest Physiotherapy and then progressed to endurance exercises such as bicycle ergometry, threadmill , hydrotherapy e.t.c. see...
- Acute heart failure
- Chronic obstructive pulmonary disease exacerbation
- Atrial fibrillation
- Acute myocardial infarction
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