Pulmonary Embolism

Mean values (±1 SD) of ULSs and of pulmonary gas exchange parameters in the acute phase of pul­monary embolism are reported in the following tabu­lation:

At this time, the mean number of ULSs was 11.3 ±2.6, showing that the fraction of the pulmonary arterial tree obstructed by emboli was 63 percent on the average (18 segments normally visible at perfusion lung scintigraphy =100 percent). Accordingly, all pa­tients presented with marked hypoxemia and hypo- capnia, increased P(A-a)02 (mean value, 59 ±15 mm Hg), presence of P(a-A)CO£ (10 ±4 mm Hg), increased Ve, and Vd/Vt%. In Figure 1, the changes of ULSs and of Pa02st, P(A-a)02, P(a-A)COa, Ve, and Vd/Vt% are reported as a function of time from diagnosis to 180 days later. A significant decrease was found through 180 days after the diagnosis in each step for ULSs and a large part of perfusion recovery was attained within the first month.

The Pa02st increased progressively and significantly during the first month. No significant change was observed thereafter. The P(A-a)02 decreased signifi­cantly during the first month and only slightly but not significantly after six months. The P(a-A)C02 showed a decrease within the first month (it was significant in the first week). The Ve decreased significantly within seven days after the diagnosis, and it did not change later. The Vd/Vt% decreased progressively up to 30 days, with statistical significance within the first week, and it remained unchanged thereafter (Fig 1).

In Table 1, the prevalence of the various radio­graphic abnormalities in pulmonary embolism is re­ported.
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Figure 1. pCarhaamngeteesrs in ansumbfuenrction

FIGURE 1. Changes in number of ULSs and gas exchange parameters as function of time from diagnosis to 180 days later. Dots represent mean values, and vertical lines are SDs. D, At the moment of diagnosis; W, after seven days of therapy; M, after 30 days of therapy; and 6 M, after 180 days of therapy. For explanation, see the text. Statistical significance is p<0.05 by Duncan test. A-aDOa = P(A-a)02; a-ADCO, = P(a-A)C02.

Table 1—Roentgenographic Signs in 33 Patients with Pulmonary Embolism

Roentgenographic Sign

At

Diagnosis

Length of Therapy 1 wk 1 mo 6 mo

Right descending

pulmonary artery

Enlarged

16 (48)

21 (64)

25 (76)

21 (64)

Sausage

12 (36)

5 (15)

Elevation of diaphragm

Monolateral

13 (39)

12 (36)

11 (33)

6 (18)

Bilateral

10 (30)

7 (21)

2(6)

3 (9)

Presence of lines and

densities

Lines

4 (12)

2 (6)

4 (12)

Densities

8 (24)

4 (12)

2 (6)

Both

4 (12)

12 (36)

6 (18)

2 (6)

Westermark sign

6 (18)

2 (6)

Enlargement of the descending pulmonary artery was very frequent at diagnosis; simple enlargement was present in 16 patients (48 percent), whereas the “sausage sign” was present in 12 patients (36 percent). The latter completely disappeared after one month, and the descending pulmonary artery was normal in 12 patients at six months. Monolateral or bilateral elevation of the diaphragm was observed in 23 patients (70 percent) diagnosed and in only nine patients (27 percent) after six months. Lines or densities were present in 16 patients (48 percent) at diagnosis; the association of both lines and densities was more frequent after one week (36 percent; 12 patients) than at diagnosis (12 percent; 4 patients). After six months, only two patients showed residual lung scars. The Westermark sign was present in six patients (18 percent) at diagnosis, and it rapidly disappeared with treatment, being appreciable in only two patients after seven days.
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Table 2—Correlation Coefficients of Linear Regressions between ULSs and Some Parameters of Gas Exchange in 33 Patients with Pulmonary Embolism

Correlation

Diagnosis

Length

of Therapy

1 wk

1 mo

6 mo

r

P

r

P

r

P

r

P

ULSs vs Pa02

-0.41

<0.05

-0.007

NS

-0.34

<0.05

-0.13

NS

ULSs vs P&02st

-0.63

<0.001

-0.25

NS

-0.47

<0.01

-0.32

NS

ULSs vs PaC02

-0.64

<0.001

-0.48

<0.01

-0.40

<0.05

-0.25

NS

ULSs vs Ve

0.71

<0.001

0.49

<0.001

0.43

<0.001

0.08

NS

ULSs vs P(A—a)02

0.73

<0.001

0.34

NS

0.54

<0.001

0.38

NS

ULSs vs P(a — A)C02

0.69

<0.001

0.65

<0.001

0.63

<0.001

0.56

<0.001

ULSs vs Vd/Vt

0.60

<0.001

0.72

<0.001

0.63

<0.001

0.51

<0.001

In Table 2, the results of linear regression analysis between ULSs and pulmonary gas exchange parame­ters at each step are reported. Significant correlation coefficients between ULSs and all functional parame­ters were found at diagnosis and after 7 and 30 days, except for Pa02, Pa02st, and P(A-a)02 one week after diagnosis. After 180 days the significant correlation persisted only for P(a-A)C02 and Vd/Vt percent. In Figure 2, the various parameters of gas exchange at diagnosis are represented vs ULSs in graphic form. High correlation coefficients resulted for P(A-a)02, P(a-A) C02, and Ve (r = 0.73, 0.69, and 0.71, respec­tively). Significant correlations were also present for PaC02 and Pa02st (r=0.64 and 0.63, respectively).

FIGURE 2. Graphic representation

FIGURE 2. Graphic representation of data distribution, at diagnosis, of following parameters of pulmonary gas exchange: Pa02; PaO^st; PaC02; A-aD02=P(A- a)Oa; a-ADC02 = P(a-A)C02; VE, and VD/VT% VS number of ULSs. All comparisons were highly significant (p<0.01).

In Figure 3, the mean number of ULSs (±SD) is plotted according to the presence or the absence of roentgenographic abnormalities. A trend toward an increase (not significant) in the mean number of ULSs was observed for patients with abnormalities of the right descending pulmonary artery, for those with diaphragmatic elevation, and for those with the Wes­termark sign. On the contrary, patients without lines or densities on the chest roentgenogram showed a more severe embolization than patients with these signs.
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Figure 3. Mean number

Figure 3. Mean number (+ SD) of ULSs art’ plotted vs presence or absence of various roentgenographic findings, at diagnosis. Those patients w ith presence of roentgenographic abnormalities, such as Wester¬mark sign, diaphragmatic elevation, or enlargement of right descending pulmonary artery, showed non¬significant trend in increase of ULSs. On the contrary, patients with absence of lines and densities showed significant increase of ULSs with reference to patients with presence of lines and densities (p<0.004).

In Table 3, the mean value (± SD) and the level of significance for pulmonary gas exchange parameters and ULSs at diagnosis are reported according to the presence or absence of roentgenographic abnormali­ties.

Table 3—Mean Values ( ± SD) for Gas Exchange Parameters and ULSs at Diagnosis by Roentgenographic Findings

Pa()2st,

Pa(X)2,

P(A — a)()2,

P(a-A)CO„

VE,

VDA’t,

No. of

Data

mm Hg

mm Hg

mm Hg

mm Hg

I ./miii

percent

ULSs

Right descending

pulmonary artery

Normal (n = 5)

62 ± 10

40 ±8

43 ±14

4 ± 4

10 ±4

•35±4

10 ±3

Enlarged (n = 16)

.53 ±16

34 ± 5

55 ±18

8 ± 4

11±3

46± 11

11 ± 2

Sausage (n = 12)

47 ± 11 *

32 ±3*

62 ± 14*

9 ± 4*

13 ±4

47 ±10*

12 ±3

Elevation of diaphragm

Absent (n = 10)

56 ± 14

34 ±6

54 ±15

9±3

12±4

48 ±7

12 ±2

Present (n = 23)

51 ± 14

34 ±6

56 ± 18

7 ±5

11 ± 4

43 ± 1

11±3

Presence of lines and

densities

Absent (n = 17)

49 ±14

32 ±5*

61 ±16

10 ±4*

13 ± 4t

48 ±10

12±2t

Present (n = 16)

56± 14

36 ±6

.50 ±16

6±4

10 ±2

41 ± 10

10 ±3

Westermark sign

Absent (n = 27)

.55 ±13

35 ±6

52 ±15

7 ± 4

11 ± 4

43 ± 10

11±3

Present (n = 6)

41 ±12*

31 ±3

71 ±14*

12 ±3*

13 ± 4

.53 ±
10*

13 ±2

At diagnosis, those patients who presented with the “sausage” sign had a significant decrease in Pa02st and PaC02 and a significant increase in P(A-a)02, P(a-A)C02, and Vd/Vt% compared to those patients with a normal or enlarged right descending pulmonary artery. Similarly, patients with the Westermark sign had a significant decrease in Pa02st and a significant increase in P(A-a)02, P(a-A)C02, and Vd/Vt% cornpared to those patients without the sign. The lowest values of PaOzst and the highest values of P(A-a)02, P(a-A)C02, and Vd/Vt%, respectively, were observed in the six patients with the Westermark sign. With regard to the other roentgenographic signs, no signif­icant association was observed except for ULSs and the presence of densities; these patients showed a lesser number of ULSs than those without this sign at diagnosis; however, this finding disappeared in the following stages.
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Category: Diseases / Tags: Perfusion Lung, Pulmonary Embolism

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