Jul 10, 2017
Victor F. Tapson, MD, FCCP, FRCP from Cedars-Sinai Medical Group discusses PE Treatment in Part 1 of his 3 Episode Series on Pulmonary Embolism. Dr. Tapson has devoted his medical career to patient care, research, and teaching in pulmonary hypertension (PH) and pulmonary embolism.
You can also hear Dr. Tapson lead a webinar on Team-Based Care in Pulmonary Hypertension Wednesday July 12th at 2pm ET / 11 am PT. Register now: phawareMD.global
Hi, I'm Vic Tapson. I'm in pulmonary critical care. I'm at Cedar Sinai Medical Center in Los Angeles. Today we're going to talk about pulmonary embolism.
So what is deep vein thrombosis and pulmonary embolism?
Well, this disease is one that starts, usually starts in the legs. You get a blood clot, or thrombosis, that forms in the leg vein most commonly. If it's untreated, that clot can propagate - meaning it can move up the leg. Starts in the calf, usually moves up to the knee. When it gets above the knee veins and goes into the thigh it's much more likely to break off and if it breaks off and goes to the lung, that's what we call pulmonary embolism. So the deep vein thrombosis, or DVT, may cause leg pain or swelling, or it may not cause any symptoms at all.
If someone has pulmonary embolism - may have shortness of breath, chest pain, if it's a big one you might get lightheaded, even pass out. So the symptoms can be variable with this disease, but basically what it amounts to is a clot forming in the leg and sometimes breaking off and going to the lung, and it can be fatal.
Deep vein thrombosis and pulmonary embolism are both under-diagnosed. One of the reasons for this is the symptoms can either be minimal for deep vein thrombosis or not even present at all and they can be variable. Patient with DVT may have leg pain and swelling, they can have a silent clot, one that doesn't cause any symptoms at all. If someone has acute pulmonary embolism they sometimes will present with sudden onset of shortness of breath. It may be ongoing for days sometimes; it may even be intermittent. They may get chest pain, which hurts when they take a deep breath, but shortness of breath is the most common symptom.
A larger pulmonary embolus may cause dizziness, lightheadedness, make the patient pass out. Because these symptoms are so non-specific, the patient may get diagnosed with something else. If he's had a little cough, sometimes we say, "Well, we have some bronchitis, or maybe it's some asthma." If they already have some heart failure but that heart failure is stable, and now they have a PE or pulmonary embolism, the symptoms may be mistaken for the heart failure.
It's a tricky disease. We call it "masquerader" sometimes and unfortunately one sad thing about this disease is, if you die from it you're often not even suspected, you're not diagnosed or even suspected until it's too late. We really want physicians to pay close attention to it.
If you're listening to this video you've had a PE before, you've had pulmonary embolism, there's a lot more questions we can answers we can offer here about this disease, but one of the key things is it can be tough to diagnose.
So the kind of specialist someone with pulmonary embolism would see kind of depends on where and when this takes place. Often if someone gets very short of breath they're going to go to the emergency room and that first care is going to be in ED. Once the patient is diagnosed they'll get admitted to either the ICU if it's a significant pulmonary embolism or maybe the hospital floor. Occasionally patients may get sent home, but most often they come in the hospital and they may get seen by a pulmonologist, by a cardiologist, it's kind of a multi-specialty disease. They may get seen by hematologist, sometimes a family practitioner or internist; it really depends on the hospital.
We have a pulmonary embolism response team that we use. So if someone has a concerning pulmonary embolism and there's questions about how to treat it, our team which consists of pulmonologists, cardiologists, radiologists, etc., may convene and make decisions about therapy. Longer term, patients followed in a clinic, again it may be by an internist or family practice doctor, or it might be by someone like myself. We have a pulmonary embolism clinic, so you might be seen by a pulmonologist like myself.
We see patients come in the hospital with chest pain and someone thinks it's a heart attack. We had a patient not long ago fly in from out of town after being diagnosed with what they thought was a heart attack at first and he had a stress test done. It looked like they were okay, they were sent home. His chest pain came back, again went to a heart doctor. They had an EKG, it was normal and was sent home again. Came back this time with pain in the side, and the pain in the side they thought was a kidney stone. It turned out to be pulmonary infarction, a form of pulmonary embolism. After seeing a urologist and being sent home, finally after seven or eight days the patient was diagnosed with a pulmonary embolism in the emergency department. So it masquerades other diseases.
Chest pain can be a heart attack, can be bronchitis, a lung infection, pneumonia, heart failure. Pain in the side, pain in the back, the lungs are in the back too. People get back pain, they pulled a muscle, a lot of things that people think they might have can masquerade as PE or PE can masquerade as other things. It's a tricky diagnosis to make.
We have a number of treatments. The key treatment to get someone on with pulmonary embolism or with deep vein thrombosis for that matter is a blood thinner, anticoagulation. We know that blood thinners save lives in this disease. When a patient comes in the hospital with pulmonary embolism we get them on a blood thinner. Even if it's a highly suspected pulmonary embolism but not proven yet, we may start the blood thinner and then get the diagnostic scan, the CT scan or V/Q scan. Once it's proven, we continue the anticoagulation.
If it's a big pulmonary embolism causing the heart to have problems pumping and causing low blood pressure, we call that massive pulmonary embolism or high-risk pulmonary embolism. We might use something called thrombolytic therapy, or clot busters, to break up the clot. We may use catheter based therapy, putting an IV through a neck vein or a vein in the arm or groin, and run it into the lung, put it into the clot and put low doses of clot busters into the lung. This technique seems to be a little safer because the drug is given at lower dose so the bleeding complications are lower.
Finally, another form of therapy may be surgery if you have a big pulmonary embolism. If you can't get strong medicines for a big PE sometimes an embolectomy can be done. And there's other devices we use - catheter-based therapy without clot busting agents that can be used.
The last thing I should mention though, if you've got pulmonary embolism and it's a high risk PE, meaning you're quite sick from it or at least a big pulmonary embolism we may consider putting an IVC filter in place. Now we probably put too many of these filters in, we probably put in too few of these filters. The bottom line is filters can prevent any more clot from getting to the lung. If someone needs a blood thinner for their big pulmonary embolism, but they can't be put on one because they have a bleeding problem, we put a filter in, and then we put them on the blood thinner as soon as we can.
So there's a number of therapies that have to be thought through, but keep in mind a blood thinner, that's the number one form of therapy, that's the main thing.
I'm Vic Tapson, and I'm aware that I'm rare.
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