A pulmonary embolism is a blood clot that was located in one of your veins, dislodged and traveled to your lung. Once the clot has lodged itself in a blood vessel in your lung, it is blocking the blood supply to part of that organ. This increases the blood pressure in your lungs, which makes your heart pump much harder than usual. If this is not corrected, your heart continues to overwork and enlarges, potentially failing to perform. This is why early diagnosis and treatment is paramount.
How Did I Get a Pulmonary Embolism?
This condition arises from a blood clot in your veins called a Deep Vein Thrombosis (DVT) (please see this section under Venous Conditions) that has dislodged and traveled to your lung. Factors that contribute to a DVT or pulmonary embolism include:
- Family history of blood clots or pulmonary embolism
- Inherited blood clotting disorder
- Surgery or trauma (particularly to the legs), hip, or leg fractures
- Cancer and cancer therapy
- Sitting or standing for long periods of time
- History of heart attack or stroke
- Birth control pills or hormones for menopausal symptoms
How Is a Pulmonary Embolism Diagnosed?
This can be a difficult condition to diagnose because it can mimic many other diseases. A diagnosis is made by a combination of physical examination, reported symptoms, and results of diagnostic testing. Symptoms may include:
- Sudden shortness of breath
- Chest pain that worsens with a deep breath; may extend into the jaw, shoulder, or back
- Rapid breathing
- Anxiety and restlessness
- Dizziness, lightheadedness, or fainting
- Heart palpitations
- Coughing up blood
- Low blood pressure
- Symptoms of a DVT: pain, swelling, redness, or warmth in the effected leg or arm
Tests used to confirm diagnosis include:
- Chest x-ray
- Electrocardiography (ECG)
- D-dimer blood test
- Spiral computed tomography scan (CT)
- Ventilation-perfusion scan (VQ)
- Duplex ultrasound
- Pulmonary angiogram
What Are My Treatment Options for a PE?
Treatment depends upon the extent of disease, signs and symptoms, tolerance to certain medications/therapies, and your age and current health. The goal is to prevent the clot from getting any larger and to prevent further clots from forming.
- Compression Stockings: These elastic stockings should be worn during the day to reduce swelling and prevent blood from pooling in your leg veins.
- Anticoagulant therapy: These medications thin your blood and prevent the current clot from increasing in size, as well as prevent new clots from forming. These medications do not dissolve the clots that you have. You may be on IV heparin for several days or an injection called Lovenox that is given in the abdomen once daily for 5 to 7 days. You will be started on a medication called warfarin (Coumadin), which is an anticoagulant pill. It can take about 3 days for this medication to have effect, so during that time you may be on both warfarin and heparin. You may be on this medication for up to 6 months, during which time routine blood tests are required to ensure your blood is at the appropriate thinness to prevent clots from forming.
- Thrombolytics: During this procedure, a thin flexible tube called a catheter is inserted into a puncture in the skin and guided into the affected blood vessel of the lung. A thrombolytic drug is injected which dissolves the clot over a period of time. There is a much higher risk of bleeding with this therapy as well as stroke, compared to anticoagulants.
- Suction Thrombectomy: During this procedure a thin flexible tube called a catheter is inserted into a puncture in the skin over a blood vessel and guided to the area of the pulmonary blood clot. The catheter shoots a salt water solution into the blocked blood vessel, which can break up the clot. A mechanical device may also be attached to the end of the catheter that uses a rotating head to break up the clot for removal.
- Pulmonary Embolectomy: When clots have been unresponsive to other therapies, they may require surgical removal.
- Inferior Vena Cava (IVC) filter: During this procedure, a thin flexible tube called a catheter is inserted through a vein in your leg, arm, or neck. The vascular surgeon passes a small special metal filter through the catheter and places it in the inferior vena cave, which is a large vein in your abdomen that carries blood back to the lungs. This filter traps clots that break away from leg veins, preventing them from travelling to your lungs. This is generally done if the patient will not be able to be on Coumadin therapy for 6 months.
How Can I Prevent Getting a Pulmonary Embolism?
Pulmonary embolism (PE) is a venous thromboembolism from deep vein thrombosis (DVT) disease. It has a high mortality rate which creates an urgency for prevention in those at risk. The risk factors are the same as those for DVT, which include inherited (genetic) and acquired (fractures, cancer, pregnancy) factors. Thrombus formation is from:
- Venous stasis from immobilization, such as from hospitalization, postoperative convalescence, or a sedentary lifestyle
- Endothelial injury
- Hypercoagulable state
Swelling, pain, and warmth/redness can indicate a DVT. Prevention of initial episodes of PE depends on identifying those at risk for DVT and consideration of prophylactic anticoagulation. A strong family history of PE or DVT puts a patient at risk, and conservative measures should be employed:
- Exercise, mobility, and ambulation
- Avoid prolonged sitting with the legs in a dependent position, as in long airplane trips. Standing up and walking every 1-2 hours
- Cessation of tobacco products
- Keep hydrated.
- Compression stockings
- Passive range of motion exercises via physical therapy
- Avoid medications that enhance coagulation, such as the estrogens in contraceptives or in menopausal hormone replacement
- Consideration of prophylactic anticoagulation
Inferior vena cava (IVC) filter to act as a weir for thrombi to prevent their upward migration to the lungs.
For those with past or current episodes of PE, long-term and indefinite anticoagulation is the mainstay of therapy for prevention of subsequent DVT and recurrence of PE.