ON PNEUMONIA

1. PULMONARY EMBOLISM
PRESENTED BY,
RESMI G S

2. INTRODUCTION
 Problems of the vascular system includes disorders
of the arteries and veins.
 Peripheral arterial disease is a term used to describe
a wide variety of conditions affecting arteries in the
neck, abdomen and extremities.
 Peripheral arterial disease can be subdivided into
occlusive disease, aneurismal disease, and
vasopastic phenomenon.
 In contrast,venous diseases primarily affect the lower
extremities and can be categorised into venous
thrombosis and chronic venous insufficiency.

3. DEFINITION
• Pulmonary embolism is the blockage of
pulmonary arteries by thrombus,fat or air
emboli and tumour tissue.
• It is the most common complication in
hospitalised patients.
• An embolus is a clot or plug that is carried
by the bloodstream from its point of origin
to a smaller blood vessel, where it
obstructs circulation.

4. INCIDENCE
• Actual incidence of mortality and
morbidity from pulmonary embolism is
unknown, it is estimated that nearly
50,000 people die of pulmonary
disease each year in the United states
and another 650,000 have non fatal
pulmonary embolism.

5. ETIOLOGY AND RISK FACTORS
• Virtually all pulmonary embolisms develop
from thrombi(clots),most of which originate in
the deep calf,femoral,popliteal,or iliac veins.
• Other sources of emboli include tumours, fat,
air, bone marrow, amniotic fluid, septic
thrombi, and vegetations on heart valves that
develop with endocarditis.
• Major operations ,especially hip, knee,
abdominal and extensive pelvic procedures
predispose the client to thrombus formation
because of reduced flow of blood through
pelvis.
• Travelling in cramped quarters for a long time
or sitting for long periods is also associated
with stasis and clotting of blood.

6. • The most common sources of embolism
are proximal leg deep venous thrombosis (DVTs) or
pelvic vein thromboses.
• Any risk factor for DVT also increases the risk that the
venous clot will dislodge and migrate to the lung
circulation, which may happen in as many as 15% of all
DVTs.
• The conditions are generally regarded as a continuum
termed venous thromboembolism (VTE).
• The development of thrombosis is classically due to a
group of causes named Virchow's triad (alterations in
blood flow, factors in the vessel wall and factors
affecting the properties of the blood).
• Often, more than one risk factor is present.

7. • Alterations in blood flow: immobilization (after
surgery, injury, pregnancy (also procoagulant), obesity (also
procoagulant), cancer (also procoagulant)
• Factors in the vessel wall: surgery, catheterizations causing direct injury
("endothelial injury")
• Factors affecting the properties of the blood (procoagulant state):
– Estrogen-containing hormonal contraception
– Genetic thrombophilia (factor V Leiden, prothrombin mutation
G20210A, protein C deficiency, protein S
deficiency, antithrombindeficiency, hyperhomocysteinemia and
plasminogen/fibrinolysis disorders)
– Acquired thrombophilia (antiphospholipid syndrome, nephrotic
syndrome, paroxysmal nocturnal hemoglobinuria)
– Cancer (due to secretion of pro-coagulants)

8. CLINICAL FEATURES
• Severity of clinical manifestations of pulmonary
embolism depends on the size of the emboli and the
size and number of blood vessels occluded.Most
common manifestations are,
 Anxiety
 Sudden onset of unexplained dyspnea
 Tachypnea or tachycardia
 Cough
 Pleuritic chest pain
 Hemoptysis
 Crackles

9. Fever
Accentuation of the pulmonic heart sound
Sudden change in mental status as a result of hypoxemia
•In massive emboli,
Shock
Pallor
Severe dyspnea
Crushing chest pain
Pulse is rapid and weak
Bp is low
ECG indicates right ventricular strain

10. •In medium sized emboli,
Pleuritic chest pain
Dyspnea
Slight fever
Productive cough with blood streaked sputum
•In small emboli,
Pulmonary hypertension
ECG and chest X-ray indicates right ventricular hypertrophy

11. PATHOPHYSIOLOGY
• When emboli travel to the lungs, they lodge in the
pulmonary vasculature .
• The size and number of emboli determine the
location.
• Blood flow is obstructed ,leading to decreased
perfusion of the section of the lung supplied by the
vessel.
• The client continues to ventilate the lung portion ,but
because the tissue is not perfused, resulting in
hypoxemia.

12. •If an embolus lodges in a large pulmonary vessel, it
increases proximal pulmonary vascular resistance, causes
atelectasis, and eventually reduces cardiac output.
•If the embolus is in a smaller vessel, less dramatic clinical
manifestations follow but perfusion is still altered.
•The arterioles constrict because of platelet degranulation,
accompanied by a release of histamine, serotonin,
catecholamines and prostaglandins.
•These hemical agents result in bronchial and pulmonary
artery constriction.
•This vasoconstriction probably plays a major role in the
hemodynamic instability that follows pulmonary embolism.

13. •Pulmonary embolism can lead to right sided heart failure.
•Once the clot lodges, affected blood vessels in the lung
collapse.
•This collapse increases the pressure in the pulmonary
vasculature.
•The increased pressure increases the work load of the right
side of the heart, leading to failure.
•Massive pulmonary embolism of the pulmonary artery can also
result in cardiopulmonary collapse from lack of perfusion and
resulting hypoxia and acidosis.

15. DIAGNOSTIC STUDIES
 History and physical examination
 Venous studies
 Chest X-ray
 Continous ECG monitoring
 ABGs
 CBC count with WBC differential
 D –dimer level
 Lung scan(ventilation and perfusion)
 Pulmonary angiography
 Spiral CT scan

16. MEDICAL MANAGEMENT
• The objectives of treatment are,
 Prevent further growth or multiplication of thrombi in
the lower extremities
 Prevent embolization from the upper or lower
extremities to the pulmonary vascular system.
 Provide cardiopulmonary support if indicated.

17. CONSERVATIVE THERAPY
• The administration of O2 by mask or cannula may be
adequate for some patients.O2 is given in a
concentration determined by ABG analysis.
• In some situations,endotracheal intubation and
mechanical ventilation may be needed to maintain
adequate oxygenation.
• Respiratory measures such as turning, coughing and
deep breathing are necessary to prevent or treat
atelectasis.

18. •If shock is present, vasopressor agents may be
necessary to support systemic circulation .If
heart failure is present, digitalis and diuretics
are used.
•Pain resulting from pleural irritation or reduced
coronary blood flow is treated with narcotics,
usually morphine.

19. DRUG THERAPY
• Anticoagulant therapy-Properly managed
anticoagulant therapy is effective in the treatment of
many patients with pulmonary embolism.
• Heparin and Warfarin are the anticoagulant drugs of
choice.
• Unless contraindicated, heparin should be started
immediately and is continued while oral
anticoagulants are initiated.
• The dosage of heparin is adjusted according to PTT
and warfarin dose is determined by International
normalized ratio.

20. •Fibrinolytic therapy-The effectiveness of fibrinolytic
therapy in the
management of a massive pulmonary embolism is not
clear,but it may be useful in clients who are
hemodynamically unstable.
•Thrombolytic agents lyse the clots and restore right-
sided heart function.

21. SURGICAL MANAGEMENT
• Surgical interventions that may be used in
the treatment of pulmonary embolism
include,
 Vena caval interruption with the insertion of a
filter and
 Pulmonary embolectomy
• The Greenfield filter, a basket like cone of
wires bent to look like an umbrella ,is the
most commonly used filter.

22. •The filter is inserted by threading it up the veins in the
leg or neck until it reaches the venacava at the level of
renal arteries.
•The filter allows blood flow while trapping emboli,
however venacava filters are less effective than
coagulation and may lead to deep vein thrombosis and
so these are generally are used only when
anticoagulants are contraindicated or ineffective.

23. •Embolectomy is used in clients with significant
hemodynamic instability caused by the
embolus,especially those with unstable circulation and
contraindications to thrombolytic therapy.
•An embolectomy involves surgical removal of emboli
from the pulmonary arteries by either thoracotomy or an
embolectomy catheter.

24. CONCLUSION
• Lower airway disorders include asthma, chronic air
flow limitations and inflammations of the airways.
• Nursing care centers on reversal of any airway
spasm and education of the client about how to live
with the disorder and how to reduce the risk of future
problems.
• Pulmonary embolism is a potentially life threatening
disorder that usually can be managed effectively with
prompt recognition.