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PULMONARY

EMBOLISM
Clinical Manifestations, Pathophysiology,
Lung changes, Complications.
PATHOPHYSIOLOGY
Effects of PE on gas exchange (hypoxemia)
Arteriovenous communications in lungs and heart new
vessels bypassing capillaries in the lungs; (in patients with
coexisting patent foramen ovale) right to left shunt in the heart.
V/Q disturbances release of histamine causing bronchospasm,
release of serotonin causing vasospasm. In addition, reduced
surfactant production leading to atelactasis.
Fall in cardiac output
Respiratory alkalosis occlusion or pulmonary artery lead to
increase in dead space and impairs elimination of CO2. increase in
CO2 reflex increase in ventilation (hyperventilate)
In some patient when PE is massive, present with hypercapnia.
Effects of PE on pulmonary circulation
Emboli + vasospasm pulmonary circulation obstruction
increase RV afterload + tachycardia increase wall stress and RV
dilatation Increase O2 consumption risk of ischemia.
Increase in pressure and volume of RV displacement of
interventricular septum affect distensibility and diastolic filling of
LV reduced cardiac output.
In pts with co-existing PFO, increased RA pressure may lead to
paradoxical embolism to systemic circulation.


**Mean pulmonary pressure > 40mmHg acute RV failure
Small PE will only affect hemodynamics if pt have pre-existing cardiac
or pulmonary disease that increases pulmonary vascular resistance.


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MORPHOLOGICAL CHANGES
Large emboli sudden hypoxia/acute right ventricular failure
(acute cor pulmonale) no changes seen.

Small emboli hemorrhagic, raised areas, red-blue
appearance (48hrs) red cells lyse, infarct pales red-brown
due to hemosiderin deposition fibrous tissue replaces as
grey-white peripheral zones until cover whole infarct.

**Infarction only occurs in 10% of patients, because lung
parenchyma oxygenated by bronchial arteries and directly by air
in alveoli too!
Patients with compromised cardiovascular status, or
thromboemboli in more peripheral region infarct results.
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CLINICAL PRESENTATION
Acute massive PE Acute
mild/moderate PE
Chronic PE
Signs Faintness or
collapse, crushing
central chest pain,
severe dyspnea
Pleuritic chest pain,
restricted breathing,
hemoptysis
Exertional dyspnea,
late symptoms of
pulmonary
hypertension or
Right heart Failure.
Symptoms Major circulatory
collapse:
tachycardia,
hypotension, raised
JVP, reduced urine
output. Severe
cyanosis.
Tachycardia, pleural
rub, crackles, low
grade fever, blood-
stained effusion.
May be minimal in
early disease.
Later: right
ventricular heave.
Terminal: signs of
right heart failure.
COMPLICATIONS
Atrial or ventricular arrhythmias
Cor pulmonale
Severe hypoxemia
Right-to-left intracardiac shunt
Paradoxical embolism
Lung infarction
Pleural effusion