lung and airway disorders
Pulmonary Embolism (PE)
Treatment of Pulmonary Embolism
Supportive therapy Anticoagulation Sometimes placement of an inferior vena cava filter Sometimes thrombolytic ("clot busting") therapy delivered via a vein or through a catheter placed in the pulmonary artery Sometimes removal of the clot via suction through a catheter Pulmonary embolism treatment begins with treating the symptoms. Oxygen is given if blood oxygen levels are low. Analgesics may be needed to relieve pain. If blood pressure is low, intravenous fluids are given, and sometimes medications that increase blood pressure are given. Mechanical Ventilation (a breathing tube) may be needed if Anticoagulant medications are given to prevent existing blood clots from traveling to the lungs and additional clots from forming. Options includeheparin,fondaparinux, direct acting oral anticoagulants, such asapixaban,rivaroxaban,edoxaban, anddabigatran, and occasionallywarfarin. One type ofheparin, called unfractionatedheparinis given intravenously (by vein) and therefore works quickly and can be quickly reversed. However,heparinrequires frequent blood tests to monitor the effect and continued hospitalization. A different kind ofheparincalled low molecular weightheparinand a medication calledfondaparinuxare given subcutaneously (by injection under the skin) once or twice a day. This advantage also allows these medications to be used after the person is discharged from the hospital and the effect of the medication is more predictable to levels do not need to be measured. Whenedoxabanordabigatranis used, doctors must giveheparintherapy (by vein or by injection under the skin) for the first few days of therapy before they can give theedoxabanordabigatran, which sometimes means the person must remain in the hospital. In contrast, whenrivaroxabanorapixabanis used,heparintherapy is sometimes unnecessary if pulmonary emboli are small. When doctors selectwarfarintherapy, bothheparinandwarfarinare given for the first few days of therapy, and thenwarfarinalone is used thereafter. Warfarintherapy requires periodic blood testing to ensure that the blood is thin enough to prevent clots from forming but not so thin as to cause a bleeding tendency (called excessive anticoagulation). Thewarfarindose is frequently adjusted based on the results of the blood tests. Also,warfarininteracts with many different types of food, drugs, and supplements, which can result in blood that is too thin or too thick. If excessive anticoagulation occurs, severe bleeding in a number of body organs can develop. Because many substances can interact withwarfarin, people who take it should be sure to check with their doctor before taking any other drugs or supplements, including those that can be obtained without a prescription (over-the-counter) such asacetaminophenoraspirin, herbal preparations, and dietary supplements. Foods that are high invitamin K(which affects blood clotting), such as broccoli, spinach, kale, and other leafy green vegetables, liver, grapefruit and grapefruit juice, andgreen tea, may need to be either eaten in very consistent amounts or avoided. Direct acting oral anticoagulants, such asapixaban,rivaroxaban,edoxaban, anddabigatran, have several advantages overheparinorwarfarin. Likewarfarin, these medications can be taken by mouth, but dose adjustments and tests to monitor the level of anticoagulation are not needed. Furthermore, these medications do not often interact with food or other medications and are less likely to cause severe types of bleeding when compared withwarfarin.Rivaroxabanshould always be taken with food. How long anticoagulants are given depends on the individual's situation. If pulmonary embolism is caused by a reversible risk factor, such as surgery, treatment is given for 3 months. If the cause is some longer-term problem, such as a clotting disorder, the medication may be given indefinitely. For example, people who have recurrent pulmonary embolism, often because of a hereditary clotting disorder or cancer, usually take anticoagulants indefinitely. Newer research studies have shown that in many people in whomrivaroxabanorapixabanis continued longer than 6 months, reducing the dose decreases risk of bleeding risk and still prevents most recurrent clots. Thrombolytic medications ("clot busting drugs") such asalteplase(tPA) break up and dissolve blood clots. Because these medications can cause dangerous or fatal bleeding, they are usually only used in people who appear to be in danger of dying due to the pulmonary embolism. Except in the most dire situations, these medications are usually not be given to people who have had surgery in the preceding 2 weeks, are pregnant, have had a recent stroke, or have some other increased risk factor for bleeding. Sometimes, if a person appears to be in danger of dying from a massive pulmonary embolism, doctors may try to break up or remove the embolus using a catheter inserted into the pulmonary artery. Surgery may be needed in some cases of severe embolism. Removal of the embolus from the pulmonary artery may be lifesaving. Surgery is also used to remove long-standing pulmonary artery clots that cause persistent shortness of breath and high pressures in the pulmonary artery ( Causes [CTEPH]). Acan be placed via a catheter in the main vein in the abdomen that drains blood from the legs and pelvis to the right side of the heart. Such a filter can be used if emboli recur despite anticoagulant treatment or if anticoagulants cannot be used initially for some reason such as ongoing bleeding. . Because clots generally originate in the legs or pelvis, a filter usually prevents them from being carried into the pulmonary artery. Newer filters are removable (retrievable). Removal helps prevent some complications that can occur when filters are left in place permanently. To prevent pulmonary embolism, doctors usually use medications that limit blood clotting. However, for some people, doctors may recommend that an inferior vena cava (IVC) filter be temporarily or permanently placed in the inferior vena cava. This filter device typically is recommended when medications that limit clotting cannot be used, for example, when a person is also having bleeding. The filter can trap emboli before they reach the heart but allow blood to flow through freely. Emboli that are trapped sometimes dissolve on their own. 