22.25
Embolia polmonare I: introduzione
L’embolia polmonare (EP) si verifica quando un trombo, un embolo di grasso o aria, liquido amniotico o tessuto tumorale ostruisce una o più arterie po…
Un'embolia polmonare si verifica quando un trombo, un liquido amniotico, un tessuto tumorale, un grasso o un embolo aereo viaggiano attraverso le vene e bloccano una o più arterie polmonari.
Di solito insorge da trombosi venosa profonda spostata o frammentata, stati di ipercoagulabilità, come le trombofilie ereditarie, e stasi venosa nell'obesità.
L'embolia polmonare inizia quando un trombo o un embolo rimosso viaggia attraverso il sistema venoso, passa attraverso l'atrio e il ventricolo destro e nelle arterie polmonari.
Piccoli emboli possono ostruire le arteriole polmonari terminali, causando piccoli infarti polmonari multipli e necrosi ischemica del tessuto polmonare.
Trombi più grandi possono ostruire le arterie polmonari, interrompere il flusso sanguigno e causare una mancata corrispondenza ventilazione-perfusione, portando all'ipossiemia.
Questa ostruzione innesca anche una risposta infiammatoria, provoca vasocostrizione locale e aumenta la permeabilità vascolare. Questi cambiamenti aumentano la pressione nelle arterie polmonari e nel ventricolo destro, causando potenzialmente insufficienza ventricolare destra.
Piccoli emboli possono causare dispnea, dolore toracico, crepitii o respiro sibilante e accentuazione dei suoni cardiaci polmonari.
Gli emboli massicci possono causare arresto cardiorespiratorio.
View the full transcript and gain access to JoVE Core videos
Q1: What causes a pulmonary embolism to develop?
A pulmonary embolism occurs when a thrombus, fat, air, amniotic fluid, or tumor tissue travels through the venous system and blocks pulmonary arteries. It commonly arises from dislodged deep vein thrombosis, hypercoagulable states like inherited thrombophilias, and venous stasis in obesity. Risk factors include prolonged immobility, recent surgery, cancer, oral contraceptives, and pregnancy.
Q2: How does a blood clot travel to the lungs during pulmonary embolism?
When a thrombus dislodges, it travels through the venous system, passing through the right atrium and ventricle before lodging in the pulmonary arteries. Small emboli may block terminal pulmonary arterioles, causing multiple small lung infarctions. Larger thrombi obstruct major pulmonary arteries, disrupting blood flow and causing ventilation-perfusion mismatch.
Q3: What happens to the lungs when a pulmonary embolism blocks blood flow?
Pulmonary artery obstruction increases vascular resistance and elevates pressures in the pulmonary arteries and right ventricle, potentially causing right ventricular failure. The blockage triggers an inflammatory response, causing local vasoconstriction and increased vascular permeability. This creates a ventilation-perfusion mismatch where lung areas receive ventilation but lack perfusion, impairing gas exchange and leading to hypoxemia.
Q4: What are the symptoms of a small pulmonary embolism?
Small emboli may cause vague and transient symptoms including dyspnea, mild to moderate hypoxemia, tachypnea, cough, chest pain, hemoptysis, wheezing or crackles, fever, tachycardia, accentuation of the pulmonic heart sound, and syncope. Symptoms begin gradually or appear suddenly depending on the degree of pulmonary arterial blockage.
Q5: What are the signs of a massive pulmonary embolism?
Massive pulmonary emboli may result in sudden changes in mental status, feelings of impending doom, hypotension, and cardiorespiratory arrest. These severe manifestations reflect the degree of pulmonary arterial blockage and the severity of hemodynamic and respiratory compromise. Prompt recognition and intervention are critical to manage massive PE and mitigate the risk of fatal outcomes.
Q6: What risk factors increase the likelihood of developing pulmonary embolism?
Risk factors for pulmonary embolism include prolonged immobility, recent pelvic or lower extremity surgery, history of venous thromboembolism, cancer, obesity, oral contraceptives or hormone therapy, smoking, prolonged air travel over four hours, heart failure, and pregnancy. Endothelial injury from surgery and trauma also increases PE risk.
Q7: How does obesity contribute to pulmonary embolism development?
Obesity promotes pulmonary embolism through venous stasis, a condition where blood flow slows in the veins, increasing the risk of thrombus formation. Venous stasis combined with hypercoagulable states and endothelial injury creates an environment favoring clot development and dislodgement. This mechanism makes obesity a significant etiological factor in PE pathogenesis.