Method of managing patients in case of pulmonary artery thromboembolism

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to therapy and pulmonology, and can be used for selection of tactics of treating thromboembolism of pulmonary artery. For this purpose computered tomography with bolus enhancement is performed to patient, areas of affection located more distally than thrombotic embolus are examined and number of respiratory movements per minute is taken into account. Presence of occluded vessel or vessels in examined areas is identified. Occlusion of segmental branch of pulmonary artery, located more distally than embolus, is assessed in one point irrespective of degree of vessel occlusion. Occlusion of each of lobar branches in case of affection of right middle lobar, left middle- and upper lobar branches of pulmonary artery is assessed in 2 points. Occlusion of upper lobar branch of pulmonary artery on the right, lower lobar branch of pulmonary artery on the left is assessed in 3 points. Occlusion of right lower lobar branch of pulmonary artery is assessed in 4 points. Occlusion of left main pulmonary artery is assessed in 7 points. Occlusion of right main pulmonary artery is assessed in 9 points. Occlusion of both main pulmonary arteries and/or pulmonary trunk is assessed in 17 points. After that, points are summed up. If the sum of points is from 1 to 6, anticoagulation therapy is performed with heparin. If the sum of points constitutes from 7 to 10 at rate of respiratory movements (RRM) lower than 18, another anticoagulation therapy is performed, at RRM more than 18 - thrombolytic therapy is performed. If the sum of points constitutes from 11 to 17, thrombolytic therapy is performed.

EFFECT: method provides possibility of operative objective assessment of degree of pulmonary bed affection and beginning of required therapy in due time.

5 dwg, 1 tbl, 4 ex

 

The invention relates to medicine and can be used for the diagnosis of thromboembolism.

It is known that the clinical management of patients with pulmonary embolism (PE) depends largely on the volume of lesions of the lung channel. So, if embolism branches of the pulmonary artery is sufficient to use only anticoagulant therapy, with a massive character of pulmonary embolism are more aggressive methods of treatment until surgery (see Saveliev B.C. and other Trombone pulmonary arteries. M.: Medicine, 1979, s-222).

There is a method of optimizing the diagnosis of pulmonary embolism (EN 2334468C1, Vorob'ev and others, 27.09.2008). Surveyed spend echocardiographical examination with measurement of the sizes of the right and left Atria, Express these parameters in terms of a ratio, the value of which predicted the diagnosis of thrombosis of small and medium branches of the pulmonary artery or major branches of the pulmonary artery. However, this method is inherent drawback: when using Ajax impossible to visualize embolic lesion of the lung channel, and thus definitively confirm the diagnosis. The use of this technique is complementary to such basic methods of visualization of the pathological process as pulmonary and computed tomography. When using Ajax possible only indirect determination of the cash is being pulmonary hypertension, which may be associated not only with PE, but other lesions of the lung tissue, for example with bronchoobstructive syndrome. In addition, as only additional methods of examination of the patient, Ajax requires additional time to spare.

A known method for the diagnosis of pulmonary small branches of the pulmonary artery (EN 2303950 C1, Krivonogov, etc., 10.08.2007). After conducting inhalation lung scintigraphy determine alveolar permeability of the right and left lung in the rear-direct projection in static mode, but this method requires a special radiopharmaceutical. When the extreme severity of the patient the diagnosis should be determined as soon as possible, and for a full examination of the patient with LIS requires a large reserve of time, about 60-90 minutes. Besides, the technique of perfusion scintigraphy does not possess sufficient specificity. So if any of inflammatory lung diseases such as pneumonia, there will be a decrease in the accumulation of the radiopharmaceutical in the lung tissue, while expanding the boundaries of cardiac gamma camera records the decrease in perfusion. All of the above factors will contribute to false positive results.

Diagnosis by computed tomography is used only for the detection of pulmonary embolism (Riedel M. Acute pulmonary embolism 1: pathophysology, clinical presentation, and diagnosis. Heart. 2001 Feb; 85(2):229-40.; Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J. 2008 Sep; 29(18):2276-315), but the definition of its volume with this method is empirical and is not supported by any objective digital data.

To identify the volume of pulmonary embolism is used pulmonary - method unsafe, time consuming and operationability (Healthbar, A.V., Strutynski. Internal diseases. The cardiovascular system. M.: Binom, 2007; Guide to cardiology: a manual 3 so/edited Geastraceae, Nev. - M.: GEOTAR-Media, 2008. - Vol.2). When carrying out angiography calculated index Miller, which allows us to estimate the amount of damage (Savel'ev V.S., Yablokov Mrs x, Kiriyenko A.I. Massive embolism of the pulmonary arteries. - M.: Medicine. - 1990. - 154 C.).

The closest to the technical nature of the patent is the treatment of pulmonary embolism with an estimate of the amount of lesions of the lung channel, including x-ray examination (see Roytberg G., Strutynski A.V. Laboratory and instrumental dagnostika diseases of internal organs, - Moscow: JSC "Publishing BINOM", 1999, s-190 - prototype), but, as noted above, this study requires time to spare.

The method of treatment of thromboembolism of the pulmonary Arte the AI includes x-ray and is characterized by the survey carried out by the method of computer tomography with bolus enhancement. Explore the area of lesion distal to thromboemboli and identify them in the presence of the occluded vessel or vessels. Identified vascular occlusions assign points, with occlusion of the segmental branches of the pulmonary artery, which is located distally of the pitch regardless of the degree of occlusion of the vessel, estimated at 1 point; occlusion of each of the equity of the branches with the defeat of the right srednedushevoj, left of the middle and proximal branches of the pulmonary artery - 2 points; occlusion of the proximal branch pulmonary artery to the right proximal branch pulmonary artery, left - 3 points; occlusion of the right proximal branch pulmonary artery - 4 points; occlusion of the left main pulmonary artery - 7 points; occlusion of the right main pulmonary artery - 9 points; occlusion of both main pulmonary arteries and/or pulmonary trunk - 17 points, then the points are added up.

When the number of points from 1 to 6 conduct of anticoagulant therapy with heparin, when the number of scores from 7 to 10 and the number of respiratory movements (NPV) of less than 18 prescribed anticoagulant therapy, if the NPV is greater than 18 - thrombolytic therapy. When the number of points from 11 to 17 prescribed thrombolytic therapy.

The technical result - the treatment with the objectification of the degree of destruction of pulmonary embolism in terms of OTS is dtvia spare time.

Below is the schema of the destination points. Each sum corresponds to a certain amount of pulmonary embolism, depending on what is being built further tactics. For 1 point adopted 1 segmental branch, ie 3+2+4=9 segmental branches of the right lung. Segmental branch is taken over the points, because resolution computed tomography makes possible to determine the blood circulation only at this level. Smaller branches are not always defined and are hemodynamically insignificant.

The affected area of the lung channelThe number of points
one segmental branch of the pulmonary artery, which is located distally of the pitch, regardless of the degree of occlusion of the vessel1
right srednedushevoe branch2
left srednedushevoe branch2
the left upper lobe branch2
right upper lobe branch3
the left inferior branch3
right inferior ve is V 4
the left main branch7
the right main branch9
pulmonary trunk17

The achievement of the technical result is proved the following clinical examples. In Fig. 1-5 conventionally shown revealed vascular occlusion and position thromboemboli (round label). The figures, for clarity, denoted assigned points.

Example 1. Patient R., 31, was admitted to hospital №1 30.08.12 with a referring diagnosis of pulmonary embolism. At admission the patient's condition is extremely severe, respiratory rate more than 45 min. Given the extreme severity of the patient's condition started - AV. Collect complaints and anamnesis of a patient is impossible due to the extreme weight of the patient. Holding angioplasty for verification of the diagnosis is also impossible due to unstable hemodynamics.

The patient underwent CT with bolus enhancement index was 15 points. There was a lesion of the left main (7 points), the right middle lobar (2 points), proximal (4 points) and 2 segmental branches of the right upper lobe (2 points) (one upper lobe on the right has 3 segmental branches, ie 1+1+1=3, with the defeat of 2-x = 2 BA the Lam) ie 7+2+4+2=15 points (see figure 1), which corresponds to massive pulmonary embolism patient initiated thrombolytic therapy, against which the state with the positive dynamics is stable hemodynamics, breathing self.

When control CT scan after 2 days the index was 4 points. There was a lesion of the left upper lobe and right srednedushevoj, ie 2+2=4 points (see figure 2).

Thus, the above example proves the achievement of the technical result - the index made it possible to quickly assess the degree of pulmonary lesions bed and promptly initiate appropriate therapy.

The result achieved by reducing the degree of destruction of the lung channel and reducing the risk of formation of chronic postembryonal pulmonary hypertension.

Example 2. Patient B., 52 years old, was admitted to hospital №1 19.07.12 with a referring diagnosis of pulmonary embolism. On admission, the patient's condition is severe, respiratory rate more than 17 per minute.

The patient underwent CT with bolus enhancement index was 8 points. There was a lesion of the right average equity (2 points), proximal (4 points) and upper lobe artery to the left, ie 4+2+2=8 points (see figure 3), which corresponds to submassive of pulmonary embolism. Patient initiated on anticoagulation therapy. Considering the NPV is less than 18 and CT index 8, from thrombolytic therapy decided to abstain.

As a result of a diagnosis of cure achieved a favorable outcome without the use of thrombolytic therapy.

Example 3. Patient F., 61, was admitted to hospital №1 03.09.12 with a referring diagnosis of pulmonary embolism. On admission, the patient's condition is severe, the frequency of respiratory movements (NPV) greater than 24 per minute.

The patient underwent CT with bolus enhancement index was 10 points. There was a lesion of the left main (7 points), right upper lobe (3 points), resulting in a total of 10 points (see figure 4), which corresponds to submassive PE - patient initiated thrombolytic therapy, taking into account the NPV over 18 and CT - index of 10.

As a result, reduce the degree of destruction of the lung channel and reducing the risk of formation of chronic postembryonal pulmonary hypertension.

Example 4. Patient S., 74 years old, was admitted to hospital №1 06.09.12 with a referring diagnosis of pulmonary embolism. On admission, the patient's condition is severe, the frequency of respiratory movements (NPV) greater than 24 per minute.

The patient underwent CT with bolus enhancement index was 4 points. There was a lesion of the right proximal artery (4 points) (see figure 5), which corresponds to TE branches LA patient was started on anticoagulant therapy. From thrombolytic therapy decided to abstain.

The result is a favorable outcome without the use of thrombolytic therapy decreased dyspnea on the background of therapy.

Thus, the above paragraph is emery substantiate the possibility for rapid assessment of the extent of damage to the lung channel and timely need therapy.

The method of treatment of pulmonary embolism, including x-rays, characterized in that the survey carried out by the method of computer tomography with bolus enhancement, investigate the area of a lesion distal to thromboemboli and identify the presence of occluded vessel or vessels in them, identified vascular occlusions assign points, with occlusion of the segmental branches of the pulmonary artery, which is located distally of the pitch regardless of the degree of occlusion of the vessel, estimated at 1 point; occlusion of each of the equity of the branches with the defeat of the right srednedushevoj, left of the middle and proximal branches of the pulmonary artery - 2 points; occlusion of the proximal branch pulmonary artery to the right proximal branch pulmonary artery left - 3 points; occlusion of the right proximal branch pulmonary artery - 4 points; occlusion of the left main pulmonary artery - 7 points; occlusion of the right main pulmonary artery - 9 points; occlusion of both main pulmonary arteries and/or pulmonary trunk - 17 points, then the points are added up and if the number of points from 1 to 6 conduct of anticoagulant therapy with the introduction of heparin, when the number of scores from 7 to 10 and the number of respiratory movements (NPV) of less than 18 conduct of anticoagulant therapy, if the NPV is greater than 18 - thrombolytic therapy, and when the number of points from 11 to 17 spend thrombolite is a mini-therapy.



 

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31 cl, 3 tbl, 11 ex, 10 dwg

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1 dwg, 1 tbl, 1 ex

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40 cl, 69 ex, 30 dwg, 32 tbl

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25 cl, 6 ex, 3 tbl

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