Occlusion of the pulmonary artery and its branches by a blood clot is called pulmonary thromboembolism. The most common source of clots in the pulmonary veins are the deep veins in the legs. It is a serious disease that is common in society, difficult to diagnose, and can result in death.
It is more common in the right lung than the left. Its distribution is more in the lower parts of the lung than in the upper parts.
It is more common in men. However, it is seen equally in men and women after the age of 50. The risk increases with age. Pulmonary embolism also varies seasonally, and it is observed to increase in the winter months. The risk is also high in the families of patients who have had pulmonary embolism. While the risk of death in untreated patients due to pulmonary embolism is 25-30%, it decreases to 3% in those who are treated. Recurrence may occur at a rate of 5-23% in pulmonary embolism. The most dangerous period in terms of recurrence is the 6-12 month period after treatment is terminated.
The main risk factor for pulmonary embolism is previous major surgeries. Surgeries that have been performed in the last 45-90 days increase the risk of embolism by 4-22 times. The surgeries with the highest risk are lower extremity fracture surgeries, hip and knee prosthesis surgeries and abdominal surgeries. The risk of clots in the lungs is also increased in patients hospitalized due to stroke, congestive heart failure, heart attack, COPD, and diabetes. The risk of pulmonary embolism is also increased in cancer patients. The cancers with the highest risk are cancer of the abdominal and thoracic organs and brain tumors. The risk of pulmonary embolism increases in patients receiving chemotherapy, especially in the initial stages of chemotherapy. The risk of pulmonary embolism also increases during pregnancy. The risk increases even more in those over 35 years of age, in the 3rd trimester, in the postpartum period, in those who give birth by cesarean section, and in multiple pregnancies. Birth control pills and postmenopausal hormone replacement therapy are also among the factors that increase the risk of pulmonary embolism. Genetic factors are also among the factors that cause clots to occur in the lungs.
The most common genetic disease that predisposes to pulmonary embolism in our country is Factor 5 Leiden Disease. Those with unexplained, recurrent embolism attacks before the age of 40, and a family history of embolism Genetic tests should be performed in those with a history of embolism, in unusual areas (intra-abdominal veins, upper extremity veins), and in those with a history of recurrent embolism.
It is important to first be clinically suspicious in the diagnosis. Pulmonary embolism should be suspected in patients who present with complaints of sudden onset of shortness of breath and palpitations, whose chest X-ray is normal, and whose condition cannot be explained by any other reason. Since pulmonary embolism often removes the clot in the deep veins of the leg, patients may present with complaints of pain, feeling of heaviness and cramps in the calf. Physical examination may reveal an increase in diameter in the entire leg, edema and redness in one leg. A patient with pulmonary embolism most commonly experiences sudden onset dyspnea, palpitations, presents with a complaint of chest pain. Apart from this, cough, bloody sputum and fever are also symptoms that may be encountered in pulmonary embolism. If the clot is in the main vessels of the lung, the condition becomes even more severe and patients may apply to the emergency room with loss of consciousness, fainting, low blood pressure, cardiac or respiratory arrest. Although there may be findings suggestive of embolism in the chest X-ray during diagnosis, 20-40% may be normal. ECG, arterial blood gas, and some blood tests can help make the diagnosis. Lung tomography with medication provides a definitive diagnosis. In patients with renal failure and pregnant women, lung scintigraphy, which has less radiation risk, can be used in diagnosis instead of tomography. Since embolism usually originates from the leg veins, detection of clot on lower extremity Doppler ultrasonography helps diagnosis in cases of renal failure, pregnancy and contrast allergy. If the embolism is in the main veins entering the lung, this condition is called massive pulmonary embolism. If a patient presents with sudden shortness of breath, bruising (cyanosis) on the lips and nails, signs of right heart failure, and low blood pressure, massive pulmonary embolism should be considered and a tomography should be performed urgently. In the presence of widespread and large clots in both main lung vessels on CT scan, a diagnosis of massive pulmonary embolism should be made and urgent treatment should be initiated. If a tomography cannot be performed due to the poor general condition of the patient, right heart failure can be detected by performing an echocardiography at the bedside. Sometimes, heart failure can be detected. Even the presence of a clot can be shown.
Once the diagnosis of pulmonary embolism is certain and the patient has no risk of bleeding, anticoagulant treatment, also called blood thinners, should be started without delay.
Anticoagulant treatment is standard heparin, low molecular weight heparin, fondaparinux, It includes coumadin and new generation oral anticoagulants. With this treatment, the formation of new clots and the development of existing clots are prevented. Starting treatment quickly reduces the risk of clot recurrence and death. However, caution should be exercised during this treatment due to the risk of bleeding. Rapid anticoagulation is provided by standard heparin administered intravenously, low molecular weight heparin administered subcutaneously, fondaparinux administered subcutaneously, and new oral anticoagulants. Then, treatment is continued with the vitamin K antagonist coumadin or new oral anticoagulants. With this treatment applied for 3-6 months, the risk of recurrence and early death is significantly reduced.
If a diagnosis of massive pulmonary embolism is made, the patient's bleeding risks should be evaluated and direct clot-dissolving drugs, which we call thrombolytics, should be started. After thrombolytic treatment, standard blood thinning treatment is continued. In pulmonary embolism, general supportive treatment is also given according to the patient's condition. Oxygen therapy should be given so that the patient's saturation is 92% or above. If respiratory failure develops despite oxygen therapy, the patient is connected to a ventilator.
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