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Pulmonary embolism

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Respiratory System

Pulmonary embolism is a condition that occurs when an artery in your lung becomes blocked. In most cases, the blockage is caused by one or more blood clots that travel to your lungs from another part of your body.

Most blood clots originate in your legs, but they can also form in the veins of your arms, the right side of your heart or even at the tip of a catheter placed in a vein. In rare cases, other types of clots - such as globules of fat, air bubbles, tissue from a tumor or a clump of bacteria - also can lodge in your lungs' arteries.

Smaller clots prevent adequate blood flow to the lungs, sometimes causing damage to lung tissue (infarction). Large clots that completely block blood flow can be fatal.

Screening and diagnosis

Pulmonary embolism can be difficult to diagnose, especially in people who have underlying heart or lung disease. For that reason, your doctor will perform one or more tests to help find the cause of your symptoms. These tests may include the following:

  • Chest X-ray. This noninvasive test shows images of your heart and lungs on film. A chest X-ray may appear normal even if you have a pulmonary embolism. Although X-rays can't diagnose pulmonary embolism, they can rule out conditions that mimic the disease.

  • Lung scan. This test, also called a ventilation-perfusion (V/Q) scan, uses small amounts of radioactive tracers (radioisotopes) to study airflow (ventilation) and blood flow (perfusion) in your lungs. The radioisotopes are attached to substances known as radiopharmaceuticals. For the first part of the test, you'll inhale a small amount of radiopharmaceutical while a camera that's able to detect radioactive substances (gamma camera) takes pictures of the movement of air in your lungs. Following this, a small amount of a different radiopharmaceutical is injected into a vein in your arm and pictures are taken of blood flow in your lungs' blood vessels. Comparing the results of the two studies helps provide a more accurate diagnosis of pulmonary embolism than either study alone. Although you may have some concern about exposure to radioactive material, the amount of radioactivity is too small to cause any side effects or complications. The findings of most lung scans are inconclusive. In that case, you'll need another test to confirm a diagnosis of VTE. Furthermore, although a "normal" lung scan can rule out the possibility of pulmonary embolism, it doesn't rule out deep vein thrombosis (DVT) — the most common cause of pulmonary embolism. This test is being slowly replaced by other more sensitive and rapid tests such as the CT scan.

  • Pulmonary angiogram. This test provides a clear picture of the blood flow in your lung's arteries. It's an accurate way to diagnose pulmonary embolism, but because it requires a high degree of skill to administer, it's usually performed when other tests fail to provide a definitive diagnosis. For a pulmonary angiogram, a catheter (a flexible tube that resembles a strand of spaghetti) is inserted into a large vein — usually in your groin — and threaded through your heart into the pulmonary arteries. A special dye is then injected into the catheter and X-rays are taken as the dye travels along the arteries in your lungs. The test generally takes about an hour, but you'll need to rest in bed for a few hours afterward. A risk of this procedure is a temporary change in your heart rhythm. In addition, the dye may cause kidney damage in people with decreased kidney function (renal insufficiency). Although the damage is usually temporary, it occasionally may become permanent. There's also the risk of developing a hematoma — a bruise that occurs when blood collects under the skin at the puncture site in your groin.

  • Fast computed tomography (CT) scan. A CT scan test allows your doctor to see your organs in two-dimensional "slices." Split-second computer processing creates these images as a series of very thin X-ray beams pass through your body. A dye (contrast medium) is commonly used to help visualize the area. Some hospitals now use what's known as a "fast CT" machine. It can scan your arteries in less than 20 seconds as opposed to 20 minutes or more for a standard CT. This speed is important because it allows the dye to be "captured" while still in your arteries. In experienced hands, a fast CT is nearly as sensitive in detecting most cases of pulmonary embolism as a pulmonary angiogram and is much more sensitive than a lung scan. For this reason, many physicians go right to a fast CT if they suspect pulmonary embolism. It doesn't require a catheter into your heart, and it may show other unsuspected conditions not evident on the chest X-ray that might explain your symptoms if you don't have a pulmonary embolism.

In addition to tests that check for a pulmonary embolism, you may also have tests that help detect blood clots in your veins, such as:

  • D-dimer blood test. Having high levels of D-dimer, a clot-dissolving substance, in your blood may indicate an increased likelihood of blood clots, though it can also be elevated for other reasons, such as recent surgery. The results are available in less than an hour. Normal test results are actually much more meaningful than abnormal ones. That's because many conditions can cause elevated fibrogen levels, while a normal result can accurately rule out the possibility of VTE.

  • Ultrasound test. A noninvasive test known as duplex venous ultrasonography (sometimes called duplex scan or compression ultrasonography) uses high-frequency sound waves to check for blood clots in your thigh veins. In this test, your doctor uses a wand-shaped device called a transducer to direct the sound waves to the veins being tested. These waves are then reflected back to the transducer and translated into a moving image by a computer. The test is quick, painless and carries no risk. Unfortunately, it's not very sensitive at detecting clots below the knee. If your doctor suspects that you have deep vein thrombosis below the knee, but you have no symptoms of pulmonary embolism and your D-dimer test is normal, he or she will probably want to repeat the ultrasound of the upper thigh in two to three days, because the source of most pulmonary emboli are from the veins in the upper thigh. If the repeat ultrasound shows a clot in your upper thigh then your doctor will start therapy right away.

  • Extremity (leg) venography. A more complex and invasive procedure called extremity venography can help reveal blockages caused by blood clots at any point in your legs. During the test, a catheter is inserted into a vein in your foot or ankle. Because blood vessels are not normally seen on X-rays, a contrast dye is injected into the vein to make it visible just before X-rays are taken. Although venography generally takes less than an hour, you'll need to keep your leg straight for six hours after the procedure. The test poses some risks, including an allergic reaction to the dye and a chance that the catheter may damage blood vessels or dislodge part of a clot. Although venography can accurately detect DVT, especially when clots are present in the veins below the knee, it has been replaced in large part by duplex ultrasonography.

  • Magnetic resonance imaging (MRI). This test uses no X-rays. Instead, a computer creates tissue "slices" from data generated by a powerful magnetic field and radio waves. Because MRI is more expensive than other tests for VTE, it's usually reserved for people whose kidneys may be harmed by dyes used in X-ray exams and for women who are pregnant.

  • Other blood tests. If you have a family history of blood clots, have had more than one episode of blood clots or have experienced clots for no known reason, your doctor may order a series of blood tests to look for inherited defects in your clotting system. If any defects are found, you may need lifelong therapy with anticoagulants.


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