pulmonary disorders
Pulmonary Embolism (PE)
General Treatment of Pulmonary Embolism
Supportive therapy Anticoagulation Inferior vena cava filter placement (rarely, in selected patients) Rapid clot burden reduction via thrombolysis or embolectomy (in selected patients) Rapid assessmentfor the need for supportive therapy should be undertaken. In patients with hypoxemia, oxygen should be given. In patients with hypotension due to massive PE, IV fluids should be administered as boluses, paying close attention to effect and volume status. Caution is warranted because overloading the right ventricle can result in deterioration. Vasopressors may also be given if IV fluids fail to sufficiently increase blood pressure.Norepinephrineis the most commonly used first-line agent. Inotropic agents such asdobutamineandmilrinoneshould also be considered depending on right ventricular function. In general, Patients at low risk should receive anticoagulation alone Patients at high risk require anticoagulation plus additional measures such as systemic thrombolysis or surgical or catheter-directed therapy For patients at intermediate risk (high or low), treatment considerations are more complicated. Patients who are at intermediate-low risk are most commonly treated with anticoagulation alone. However, patients in intermediate-risk categories require repeat assessment of the entire clinical picture for any clinical deterioration, including Deterioration of vital signs Severity of RV dysfunction by echocardiography Amount of oxygen and need for vasopressor agents Clot burden and location Anticoagulation None Hospitalizationfor at least 24 to 48 hours is done for most patients with PE. Patients with abnormal vital signs or high risk or intermediate risk PE require longer periods of hospitalization. ICU (intensive care unit) admissionis required for patients with high risk PE. ICU admission should also be considered if patients have Extensive clot burden RV compromise Significant hypoxemia Low or borderline blood pressure Clinical deterioration Outpatient managementmay be used for select patients who are at low risk and have incidentally discovered PE or for those with very small clot burdens and minimal symptoms provided their vital signs are stable, education is undertaken, and a reasonable plan for outpatient treatment and follow-up is in place. Given the evolving therapeutic options and the lack of randomized controlled trials, choosing appropriate treatment for individual patients can be challenging. Many hospitals use a multidisciplinary group of clinicians (pulmonary embolus response team) to rapidly evaluate patients, determine the level of pulmonary embolism risk, and make the complex treatment decisions needed. These teams may be comprised of clinicians in pulmonary/critical care medicine, interventional cardiology, interventional radiology, cardiothoracic surgery, hematology, emergency medicine, and other specialties. Recent single-center studies published have shown lower rates of bleeding, shorter time to therapeutic anticoagulation, decreased 30-day mortality, and decreased use of IVC filters in patients whose care is managed by a PERT. The use of PERT in the management of acute PE is now recommended by the European Society of Cardiology ( General treatment references , 1.Chaudhury P, Gadre SK, Schneider E, et al. Impact of Multidisciplinary Pulmonary Embolism Response Team Availability on Management and Outcomes.Am J Cardiol2019;124(9):1465-1469. doi:10.1016/j.amjcard.2019.07.043 2.Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC).Eur Respir J2019;54(3):1901647. doi:10.1183/13993003.01647-2019 