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A pulmonary embolus or embolism is a relatively common condition in which blood clots elsewhere in the body form and break off into the pulmonary vasculature. The result is that the blood flow cannot get into the lungs and exchange of air and blood cannot happen. This can cause shortness of breath or imminent death, depending on how big the pulmonary emboli are. It is a condition that occurs in several situations, including sitting or lying for long periods of time such as with an airline flight or long car ride, prolonged immobility or post surgery. It is a diagnosis that is often missed as testing for it is not a commonly run test and people die fairly quickly from the disease.
Pulmonary embolism is not a disease in itself but is a complication of a thrombus elsewhere in the body. The most common place where a thrombus or blood clot forms is the deep veins of the legs. They get there because blood flow in the deep veins is sluggish. They then break off, leading to a pulmonary embolus and symptoms occur. Normally, the system is in place to clear the blood clot from the vein but, in the case of a pulmonary embolus, there is an imbalance between the blood clot formation and blood clot resolution that results in the blood clot to grow instead of recede. Conditions of hypercoagulability can be acquired or hereditary such that the blood is encouraged to clot.
The rate of blood clots to the lungs is about one in one thousand people. This means that 250,000 people have the condition each year. It is a disease that is found more often at autopsy than in real life because, in many cases, death is instantaneous and the individual cannot be revived, regardless of the attempt. Others estimate that, because the disease is often misdiagnosed, the actual incidence of pulmonary embolism is between 650,000 and 900,000 per year.
A pulmonary embolus can be broken down into two different categories. There is a condition known as massive pulmonary embolism, causing immediate sudden death, and non-massive or multiple small pulmonary emboli, which has a better chance of survival. In a case of nonfatal pulmonary embolism, there is often multiple small blood clots that damage several areas of the lungs, with some areas of the lungs spared. There is a low blood pressure situation with a systolic blood pressure less than 90 and shortness of breath unassociated with any findings on chest x-ray.
In those with massive pulmonary embolism, the rate of death is between thirty and sixty percent, depending on how large the pulmonary embolus is. Most die within an hour or two of developing the thromboembolism. If the blood pressure is able to be maintained, the rate of death is less than if the blood pressure drops. The success of survival from pulmonary embolism depends on the doctor identifying the disease early enough and initiating treatment before the blood clot does damage to the lungs and the air exchange of the lungs. The death rate of non-massive pulmonary embolism is less than five percent if treated promptly.
Risk factors for pulmonary embolism include prolonged immobility, being post-operative, being African American (have a fifty percent greater risk), and being female. The incidence increases with advancing age. Recent travel increases the incidence of pulmonary embolism, especially with air travel. Having a previous deep vein thrombosis increases one's risk of having a pulmonary embolism. Women on oestrogen have a higher risk of having a deep vein thrombosis and secondary pulmonary embolus. A history of active cancer or metastatic cancer puts one at greater risk for a pulmonary embolism. Certain hereditary thrombophilic diseases increase the risk of blood clots.
Doctors can diagnose a pulmonary embolus by checking the oxygenation of the body, which is often low. There may be swelling of one leg over the other and the pulse is usually rapid. An x-ray is often normal of the lung but a test called a VQ scan can show areas of the lungs where the blood flow is not getting into the lungs. A VQ scan is a scan using radioactive tracer that can show where the blood is not reaching the lungs. There may be pleuritic or sharp chest pain and shortness of breath unassociated with a pneumonia or other lung finding.
The treatment of pulmonary emboli includes giving clot busting drugs to break up the clot. If this is not possible due to recent surgery or other contraindication, heparin is used to thin the blood and allow the blood clot to break up naturally.
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