肺动脉栓塞的诊治已看）.pptVIP

肺动脉栓塞的诊治 制作 XGHRH 基本概念 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而发生坏死。 肺栓塞的现状 发病率高：仅次于CAD和HBP。 易漏诊及误诊：警惕性不高，漏诊率高。 不经治疗死亡率高：达20%-30%。 明确诊疗者死亡率明显下降：可降至2-8% 。 Epidemiology There is no accurate data for pulmonary embolism because we has limit knowledge of it. In the United States, it is responsible for about 2.3 new cases per 10,000 persons and 50,000 deaths every year. 流行病学 生存率比较 Risk Factors for DVT/Pulmonary Embolism （Essential） Risk Factors for DVT/Pulmonary Embolism （Second） 深静脉血栓形成 肺血栓与深静脉血栓 肺栓塞的大体解剖观 肺栓塞的显微镜下观 肺栓塞的病理生理 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。 肺栓塞后右心功能不全的病生 肺栓塞后肺血流动力学变化 前毛细血管高压 血管床减少 支气管收缩 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 呼吸动力学改变 过度通气： 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 临床分型 大面积PE(massive PE)： 休克和低血压； 动脉收缩压90mmHg 或下降幅度≥40mmHg，持续15min以上； 除外其他原因所致血压下降。 次大面积PE (submassive PE)亚型 超声心动图示右心室运动功能减弱 右心功能不全表现。 非大面积PE(non-massive FE)： 不符合以上大面积PE标准的PE。 症状 体征 D-二聚体分析 肺栓塞胸片检查 X-RAY FOR CHEST Atelectasis and parenchymal densities are quite common. The areas of atelectasis are more common in the lower lobe as are the areas of parenchymal density Most of these densities are caused by pulmonary hemorrhage and edema and can be confused with infectious infiltrates or malignant masses Pleural effusions are common and most often unilateral despite the fact that most clots are bilateral. These effusions are usually visible when the patient seeks medical attention. They are almost always small, occupying less than 15% of a hemithorax and rarely increase in size after 3 days. Any increase in size after 3 or 4 days should raise the suspicion of a pulmonary infection or re-embolization. Pleural based opacities with convex medial margins are also known as a Hampton