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Pulmonary Embolism Dr Felix Woodhead Consultant Respiratory Physician
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Pulmonary Embolism Part of VTE Potentially fatal Can complicate hospital admission Preventable Tests poor
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Risk factors Surgery –Abdominal –Lower limb Obstetric Malignancy Previous VTE
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Clinical Probability Wells score Geneva criteria Is a major risk factor present? =1 Is there no other explanation? =1 Score: –2: High probability –1: Intermediate probability –0: Low probability
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D-dimer Only useful if NEGATIVE ↑ by many things (including pregnancy and infection) Used only after assessment of clinical probability –Not used if high clinical probability
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Imaging CTPA in most places V/Q –only if normal CXR and no cardiopulmonary disease –Intermediate scan requires follow-up imaging (CTPA) Doppler USS if DVT (no need for resp imaging)
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Screening for thrombophilia/cancer Thrombophilic abnormality occurs in 25-50% VTE Usually interacts with environment (esp oestrogens), and risk is multiplicative Does not predict risk of recurrence Screen for cancer with bloods, clinical picture and CXR only
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Treatment Thrombolysis only in massive PE (circ collapse) Thrombolysis controversial if RV impairment Anticoagulate with LMWH then warfarin for –4-6/52 if associated with temporary risk factor –3/12 if no risk factor (BTS), US recommend 6/12 ?unfractionated heparin initial bolus
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Pulmonary Arterial Hypertension Dr Felix Woodhead Consultant Respiratory Physician
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Findings Exertional breathlessness Exertional chest pain and presyncope Normal radiology if idiopathic Normal PFTs if idiopathic ↑ systolic PAP on echo only if TR
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Defined by RHC mPAP –> 25 mmHg at rest (normal 12-16 mmHg) –> 30 mmHg on exertion Cardiac Output Cardiac Index (=CO/height 2 ) Pulmonary Vascular Resistance
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Causes Left ventricular impairment (PCWP > 15) –LVF –Mitral valve disease Increased pulmonary blood flow (L→R shunt) → Eisenmenger’s syndrome Hypoxaemia (cor pulmonale) Chronic Thromboembolic (CTEPH) HIV CTD (SSc etc) Idiopathic (IPAH)
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Investigations PFTs CTPA Echo (± bubbles) 6 minute walk Right Heart Catheter (traditional) pulmonary angiogram
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Treatment Treatment of associated causes –LV disease –O2 for cor pulmonale Warfarin (for all) Calcium channel blockers – little used now Endothelin receptor blockers – Bosentan, sitaxentan PDE4 antagonists – Sildenafil etc Prostaglandins –Nebulised –Continuous IV via Hickman line
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Sleep medicine Dr Felix Woodhead Consultant Respiratory Physician
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Obstructive sleep apnoea/hypopnoea Sx Periodic reduction of airflow at night Caused by ostruction (cf central apnoea) due to reduced muscle tone in a suceptible airway (obesity) Apnoea : no airflow for 10 s Hypopnoea : ≤ 50% airflow in 10 s AHI (apnoea/hypopnoea index) = no of events/hr AHI –5-14 = mild –15-30 = moderate –>30 = severe
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Symptoms Sleepiness (daytime hypersomnolence) –Epworth Sleepiness Score Witnessed apnoeas Nocturia Hypertension Reduced concentration Reduced libido Tendency to cor pulmonale, esp in COPD
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Diagnosis Overnight oximetry –Good screening esp in obese –Cannot be used to exclude OSAHS Limited PSG –Useful initial test in young, non-obese Full PSG
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Treatment Only if symptomatic AHI >15, desat index >10/hr Nasal CPAP –fixed –Autotitrating device
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Domiciliary NIV For ventilatory failure Other treatments –Low flow O 2 (with care) –Treatment of sleep disordered breathing Hallmark of ventilatory failure is ↑pCO 2
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