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Pulmonary embolism: symptoms, treatment, causes

by Josephine Andrews
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In a pulmonary embolism (pulmonary artery embolism), a blood vessel in the lungs is blocked, usually by a blood clot. The lungs are then supplied with less blood. This means that insufficient oxygen gets into the blood. Important signs of a pulmonary embolism are sudden shortness of breath and chest pain. The cycle can collapse. In the worst case, the patient dies. Read everything you need to know about the symptoms, causes and treatment of a pulmonary embolism here.

ICD codes for this disease:

ICD codes are internationally valid codes for medical diagnoses. They can be found, for example, in doctor’s letters or on certificates of incapacity for work.

I26

Pulmonary embolism: a brief overview
  • Symptoms: shortness of breath, chest pain , anxiety and restlessness, coughing (blood) , dizziness or fainting
  • Treatment: Stabilize breathing and circulation, administer oxygen and painkillers/blood-thinning agents (thrombus dissolution), if necessary catheter therapy, rarely surgery
  • Prevention: exercise, stopping smoking, compression stockings, etc.
  • Risk factors: including smoking, birth control pills, heart and lung diseases, old age, long periods of cramped sitting, obesity , operations, being bedridden
  • Examination: blood test , ECG , ultrasound , computed tomography (CT), scintigraphy
  • Prognosis: high risk of death in the first two hours after onset of symptoms; improved prognosis with prompt treatment

Pulmonary embolism: symptoms

The type and severity of pulmonary embolism symptoms depend on the size of the diseased area of ​​the lung. Very small pulmonary embolisms sometimes cause no symptoms. In most cases, however, there is a sudden onset of shortness of breath , which is accompanied by chest pain . A pronounced pulmonary embolism can even lead to a circulatory collapse and, in the worst case, to death.

Classic symptoms of pulmonary embolism

Depending on the size of the blocked blood vessel in the lungs , the following signs of a pulmonary embolism appear:

  • Shortness of breath and/or rapid breathing
  • Cardiac arrhythmia ( palpitations , palpitations )
  • Chest pain (may radiate to abdomen or shoulder)
  • fear and anxiety
  • cough and/or coughing up blood
  • Rattles when breathing
  • sweats
  • Dizziness or fainting

If very large vessels are affected by the embolism or a large area of ​​the lungs is no longer supplied with blood, the circulatory system collapses very quickly in the form of a shock . The blood pressure is very low. The heart still tries to pump enough blood to all organs of the body and therefore beats faster. Hands, arms, feet and legs appear cool because they are the least supplied with blood. Sometimes the lips turn bluish because they are not getting enough oxygen. If they are still conscious, those affected are often very restless and/or very afraid .

If a large area of ​​the lungs is affected, it is also referred to as a fulminant pulmonary embolism.

Heralds of a pulmonary embolism

Before a blood clot blocks a pulmonary artery, small fragments can break loose and travel to smaller pulmonary vessels. These small emboli can already cause symptoms such as chest pain , wheezing , coughing or fainting . If treated quickly, a larger and more dangerous pulmonary embolism can often be prevented.

The complaints mentioned should therefore be taken seriously. This is particularly true in the case of shortness of breath and chest pain if there is venous thrombosis in the leg at the same time . Parts of the blood clot in the deep veins of the leg can be carried away by the blood and washed into the lungs. Then there is a risk of pulmonary embolism. In the case of leg vein thrombosis, the affected leg is often painfully swollen, reddish in color and warmer than the other leg. If the patient was previously not mobile as usual and maybe even bedridden, a red leg is already a thrombosis alarm sign. Since patients are typically (more) inactive after an operation, the risk of a pulmonary embolism is particularly high here. Because without movement, the veins have itharder to keep the blood flowing. Then blood clots form easily.

Inactivity and/or immobilization of a limb slows blood flow. As a result, the risk of a blood clot forming and causing a pulmonary embolism increases!

Complications of pulmonary embolism

The larger the blood vessel that is blocked, the more severe the consequences. They can even become life-threatening for the patient. The following table lists possible consequences of pulmonary embolism and their main symptoms.

complication of pulmonary embolism symptoms
pneumonia breath-related chest pain
Entry of tissue water between the two lung leaves ( pleural effusion ) Shortness of breath, noises when breathing
pulmonary infarction coughing up blood
Pneumonia caused by a lung infarction (infarction pneumonia) Cough, shortness of breath, fever , chills
Right heart failure and right heart failure Congested (thickened) neck veins, water retention in the legs
High blood pressure in the pulmonary circulation ( pulmonary hypertension ) Declining performance, shortness of breath with light exertion, dizziness

Some of the problems can occur quite quickly after an embolism. Others only develop after days or weeks.

Pulmonary embolism: treatment

If you suspect a pulmonary embolism, you should call the emergency doctor immediately! The patient should move as little as possible. Otherwise, further clots can detach and block a vessel. In the case of cardiac arrest, resuscitation must be started immediately !

The emergency doctor will continue resuscitation if necessary and artificially respirate the patient if necessary. The patient’s breathing and circulation must be stabilized as quickly as possible in order to prevent organ damage (e.g. to the brain ). To do this, the doctor can give the patient oxygen and medication, including blood thinners and painkillers. The necessary examinations are then carried out in the hospital and further measures for pulmonary embolism therapy are initiated. They depend on the severity of the disease. Patients with a severe pulmonary embolism must be monitored and treated in the intensive care unit.

anticoagulants

Drugs that stop the blood clotting (called anticoagulants) are generally given for a pulmonary embolism. These ensure that no new blood clots form and existing clots do not enlarge. Small blood clots are broken down by the body.

Patients are often first given an anticoagulant by injection or infusion , such as heparin, for a few days . After that, patients start taking an anticoagulant in tablet form.

There are now also two anticoagulant active ingredients that can be given as tablets immediately after the diagnosis – i.e. without having to administer anticoagulant injections or infusions beforehand.

Taking an anticoagulant in tablet form (“oral anticoagulation”) must be continued for several months.

In the case of a mild pulmonary embolism, anticoagulants are often sufficient as sole therapy. In addition, if the risk of complications is low, patients can sometimes even be treated on an outpatient basis (at home).

Drugs that dissolve the blood clot

In the case of a more severe pulmonary embolism, anticoagulant therapy is not sufficient. The blood clot in the lungs must be removed in a targeted manner in order to restore blood flow to the lung tissue. This can be achieved with certain drugs called thrombolytics (also called fibrinolytics) such as streptokinase and urokinase. They are administered directly into the patient’s blood and can quickly trigger the blood clot in the lungs. This form of pulmonary embolism therapy is called drug thrombolysis or lysis therapy.

The lysis therapy is very effective for a pulmonary embolism, but can have serious side effects: In some patients, it triggers dangerous bleeding in the body, for example in the brain. Before this form of pulmonary embolism treatment is used, the doctor will therefore weigh up the benefits and risks for the patient in question. Most often, the method is used in people with severe pulmonary embolism and unstable blood flow. These “haemodynamically unstable” patients have a high risk of (fatal) complications. It is therefore particularly important here to quickly eliminate the clot in the lungs.

Remove blood clots with catheter

In some patients, medicinal thrombolysis would be too risky, for example because the risk of bleeding is too high. Then the blood clot in the pulmonary vessel can be removed using a catheter instead. The catheter is carefully inserted through a vein into the affected vessel and advanced to the blood clot. The blood clot can then be broken up into very small parts using tiny instruments. Some catheters also use ultrasound waves to help clear the clot. At the same time, a thrombolytic can be administered via the catheter, which dissolves the clot.

Remove blood clots in open surgery

If pulmonary embolism treatment with catheters is unsuccessful, it may be necessary to remove the blood clot in open surgery. The procedure is called a pulmonary embolectomy . The patient is given general anesthesia and connected to a heart-lung machine. This takes over the tasks of both organs for the duration of the operation.

Since the entire operation is very risky, it is only performed in extreme emergencies.

Pulmonary embolism: causes and risk factors

A pulmonary embolism occurs when a blood supply vessel in the lungs becomes blocked. This constipation can have various reasons.

Pulmonary embolism due to blood clots

In most cases, pulmonary embolism is the result of a blood clot that has formed in a vein in the leg (leg vein thrombosis) and has been carried to the lungs by the bloodstream. The reason why the clot in the leg detaches can have very simple reasons, for example simply getting up in the morning, but also straining during a bowel movement and sudden physical exertion.

The detached clot travels with the venous blood to the right heart and is pumped from there to the lungs. As the pulmonary arteries continue to branch out and become correspondingly narrower, the clot eventually gets stuck and blocks the vessel.

Certain risk factors promote the development of leg vein thrombosis. These include:

  • Smoking
  • Taking birth control pills or hormone replacement therapy
  • pregnancy and childbirth
  • Limited mobility (bedridden, plaster casts)
  • Cancer diseases or treatments
  • Operations (especially on the abdomen, hip or knee joint )
  • overweight
  • longer air travel
  • heart and lung diseases
  • blood clotting disorders
  • old age (from 50 to 60 years)
  • thrombosis in family members
  • Chronic venous insufficiency, varicose veins

Other causes of pulmonary embolism

More rarely, the blockage of a pulmonary artery in pulmonary embolism has reasons other than a blood clot:

Sometimes a fat embolism is behind it. Here, fat is released from the bone marrow , which migrates via the venous vessels into the lungs and blocks a vessel here. This can happen, for example, after orthopedic surgery such as the implantation of a hip prosthesis or after a fracture of the femur.

Amniotic fluid embolism is a very dangerous complication of childbirth for both mother and child . Amniotic fluid can enter the mother’s bloodstream and enter the lungs via the wound caused by the partially detached placenta in the uterus . Various chemical processes and a form of allergic shock cause thrombosis to form in the blood vessels. The arteries of the lungs narrow. The numerous blood clots trigger further embolisms. Ultimately, the heart and circulatory system can collapse.

Pulmonary embolism due to gas (air embolism) occurs when air enters the veins of the body and is transported with the blood to the pulmonary arteries. Very rarely, this can happen through vein access or through medical interventions.

Pulmonary embolism: investigations and diagnosis

Symptoms such as sudden chest pain and shortness of breath can indicate a pulmonary embolism, but they can also have other causes. For clarification, the doctor will first ask the patient a few questions in order to collect the medical history ( anamnesis ). This helps estimate the likelihood of a pulmonary embolism. Possible questions from the doctor are:

  • Are the lower legs swollen or red?
  • Have you had an operation in the last four weeks?
  • Have you been bedridden or restricted in your mobility for a long time?
  • Do you suffer from a tumor disease?
  • Have you received tumor therapy (radiation, chemotherapy , etc.) in the last six weeks?
  • Have you ever suffered from deep vein thrombosis or pulmonary embolism?
  • Are you coughing up blood?
  • Is there a pregnancy?
  • Do you take birth control pills or any other preparation containing female sex hormones?

Following the anamnesis interview, a detailed physical examination follows in order to find further indications of a pulmonary embolism. For example, the doctor listens to the heart and lungs and measures the patient’s blood pressure.

Pulmonary embolism: blood tests

Certain blood values ​​can point the way to a pulmonary embolism diagnosis. Because in the case of a leg vein thrombosis or a pulmonary embolism, the body tries to dissolve the blood clots again. This results in so-called D-dimers . These are breakdown products of the fiber protein fibrin, which is involved in the formation of a blood clot. If no D-dimers are detectable in the patient’s blood, a pulmonary embolism is very unlikely.

Other important blood values ​​are Troponin and Brain Natriuretic Peptide (BNP) . In the case of a pulmonary embolism, their blood levels are increased.

Oxygen and carbon dioxide in the blood are also important parameters when a pulmonary embolism is suspected. Since gas exchange in the lungs is impaired in the event of a pulmonary embolism, the oxygen content in the blood drops. Breathing accelerates to compensate for this deficiency. As a result, more carbon dioxide is exhaled – its content in the blood also decreases.

Pulmonary embolism: ECG

An electrocardiographic examination can also support a diagnosis of pulmonary embolism. For this purpose, several electrodes are attached to the patient’s chest, wrists and ankles and connected to a measuring device with cables. The heartbeat is recorded by a recorder . Since the heart has to pump against a higher pressure in the event of a pulmonary artery embolism and is supplied with less oxygen, the ECG shows signs of overloading of the heart muscle.

Pulmonary embolism: Ultrasound examination

An ultrasound examination of the heart ( echocardiography ) can show whether the heart function is impaired as a result of a pulmonary embolism. For this purpose, a gel is applied to the chest in the area of ​​the heart. The examiner can use the ultrasound probe to view the heart cavities, valves and blood flow. In addition, the leg veins are often examined with the ultrasound device: Very often, a pulmonary embolism develops as a result of leg vein thrombosis. Any residual clots in the veins can be detected by ultrasound.

Pulmonary embolism: CT and scintigraphy

A pulmonary embolism can usually be visualized very well using computed tomography (CT) . Before the examination, the doctor injects a contrast medium into a vein in the patient’s arm. A CT image of the patient’s chest is then made. The radiologist can then follow the course of the pulmonary vessels and locate thrombi.

In some cases, a scintigraphy of the lungs is also performed. This is a nuclear medicine examination in which the patient has to inhale a radioactively marked substance. The images of the examination show how well the individual lung areas are supplied with blood and ventilated.

Pulmonary embolism: disease course and prognosis

How dangerous a pulmonary embolism is depends on its extent and the patient’s state of health. A pronounced pulmonary embolism is life-threatening. Acute deaths often occur within two hours of the onset of pulmonary embolism symptoms. A patient’s chance of survival can be increased if a doctor is called promptly and the right treatment is initiated.

After recovering from the illness, the probability of suffering another pulmonary embolism is often increased. It is therefore important to reduce the risk of blood clots forming. This includes, for example, that patients conscientiously take the anticoagulant medication as prescribed by the doctor. This drug prevention can last for months or years. Some patients also have to use the anticoagulants for life.

See below for more preventive measures.

Pulmonary embolism: prevention

In general, ensure regular exercise in everyday life . This prevents the formation of blood clots and thus a possible pulmonary embolism.

In the case of prolonged bed rest and illnesses that promote thrombosis formation, the doctor often prescribes anticoagulant medication (e.g. as a heparin injection). They are said to reduce the risk of thrombosis and pulmonary embolism.

Do not smoke! This applies in particular if you have already developed thrombosis.

After an operation , you should – if possible – move again as quickly as possible. If you have to lie in bed, you can accelerate the blood flow in the veins by alternating muscle tension. This reduces the risk of blood clots forming.

You should also stimulate the blood flow in your legs on longer flights . If possible, get up every now and then and walk a few steps. You can also do foot exercises while sitting (for example, circling your feet). Drink enough, but not coffee or alcohol. Do not wear constricting clothing. You should wear compression stockings during the flight, especially if you have a known weakness in your veins. Such stockings can also be useful if you are bedridden for a long time or during pregnancy.

If there is a high risk of thrombosis and pulmonary embolism, a type of sieve ( cava screen ) can be inserted into the inferior vena cava . It traps clots from the veins in the legs so they don’t get into the lungs and cause a pulmonary embolism.

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