Pulmonary embolism ventilation/perfusion scan: Difference between revisions
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| [[File:Siren.gif|30px|link=Pulmonary embolism resident survival guide]]|| <br> || <br> | |||
| [[Pulmonary embolism resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] | |||
|} | |||
{{Pulmonary embolism}} | {{Pulmonary embolism}} | ||
'''Editor(s)-In-Chief:''' {{ATI}}, [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]; {{AE}} | '''Editor(s)-In-Chief:''' {{ATI}}, [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]; {{AE}}; {{AE}} {{Rim}} | ||
==Overview== | ==Overview== | ||
A [[ventilation/perfusion scan]] (otherwise known as V/Q scan or lung [[scintigraphy]]) is a study which shows whether an area of the lung is being ventilated with oxygen and perfused with blood. In the setting of a PE, perfusion can be obstructed due to the formation of a clot. The | A [[ventilation/perfusion scan]] (otherwise known as [[V/Q scan]] or lung [[scintigraphy]]) is a study which shows whether an area of the lung is being ventilated with [[oxygen]] and [[perfused]] with blood. In the setting of a pulmonary embolism (PE), [[perfusion]] can be obstructed due to the formation of a clot. The [[ventilation/perfusion scan]] is less commonly used due to the more widespread availability of computed tomography ([[CT]]) technology, however it may be useful in patients who have an allergy to [[iodinated contrast]]. It may also be useful in [[pregnancy|pregnant]] patients in an attempt to minimize radiation exposure. The diagnostic value of the results of the [[V/Q scan]] is improved when combined with the clinical pretest probability of PE. A high probability scan coupled with a high clinical pretest probability of PE is diagnostic for PE, while a normal scan regardless of the clinical pretest probability excludes PE. For the majority of the cases of suspected PE, however, the [[ventilation/perfusion scan]] does not establish the diagnosis nor exclude PE and further tests are required.<ref name="pmid2332918">{{cite journal| author=PIOPED Investigators| title=Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). | journal=JAMA | year= 1990 | volume= 263 | issue= 20 | pages= 2753-9 | pmid=2332918 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2332918 }} </ref> | ||
==Ventilation/Perfusion Scan== | ==[[Ventilation/Perfusion Scan]]== | ||
===Principle=== | ===Principle=== | ||
Technetium (Tc)-99m labeled macro-aggregated albumin particles, when injected, fill small fractions of the pulmonary capillaries. This helps in the assessment of lung perfusion at the tissue level via [[scintigraphy]]. When any branch of the pulmonary artery is occluded, the particles will not reach the capillaries rendering the area "cold" on imaging. | Technetium (Tc)-99m labeled macro-aggregated [[albumin]] particles, when injected, fill small fractions of the pulmonary capillaries. This helps in the assessment of lung perfusion at the tissue level via [[scintigraphy]]. When any branch of the pulmonary artery is occluded, the particles will not reach the capillaries rendering the area "cold" on imaging. | ||
===Indications=== | ===Indications=== | ||
The utilization of | The utilization of ventilation/perfusion scanning has declined since the advent of more widespread availability of CT technology, however it may be useful in particular subgroups of patients, such as: | ||
# Patients who have a known allergy to iodinated contrast. To read more about contrast allergy, click [[Contrast medium#Allergy Reactions|here]]. | # Patients who have a known allergy to iodinated contrast. To read more about contrast allergy, click [[Contrast medium#Allergy Reactions|here]]. | ||
# In pregnant patients to minimize exposure to radiation. | # In pregnant patients to minimize exposure to radiation. | ||
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===Interpretation=== | ===Interpretation=== | ||
A normal or near normal V/Q scan excludes the diagnosis of PE.<ref name="pmid2332918">{{cite journal| author=PIOPED Investigators| title=Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). | journal=JAMA | year= 1990 | volume= 263 | issue= 20 | pages= 2753-9 | pmid=2332918 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2332918 }} </ref><ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870 }} </ref> When the result of the V/Q scan is not normal or near normal, the results of the V/Q scan should be interpreted in combination with the pretest probability of PE. Shown below is a table that summarizes the | A normal or near normal V/Q scan excludes the diagnosis of PE.<ref name="pmid2332918">{{cite journal| author=PIOPED Investigators| title=Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). | journal=JAMA | year= 1990 | volume= 263 | issue= 20 | pages= 2753-9 | pmid=2332918 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2332918 }} </ref><ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870 }} </ref> When the result of the V/Q scan is not normal or near normal, the results of the V/Q scan should be interpreted in combination with the pretest probability of PE. Shown below is a table that summarizes the interpretation of the different results of the V/Q scan.<ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870 }} </ref> | ||
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|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |Further tests are needed | |style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |Further tests are needed | ||
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===Supportive Trial Data=== | ===Supportive Trial Data=== | ||
* Data regarding the use of the | * Data regarding the use of the V/Q scan for the evaluation of patients with suspected PE is provided by the findings of the [[Pulmonary embolism landmark trials#Trials assessing the diagnosis|PIOPED]] study. The rates of confirmed PE by [[angiography]] for each of the categories of the V/Q scan are:<ref name="pmid2332918">{{cite journal| author=PIOPED Investigators| title=Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). | journal=JAMA | year= 1990 | volume= 263 | issue= 20 | pages= 2753-9 | pmid=2332918 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2332918 }} </ref> | ||
** High probability scan: 88% | ** High probability scan: 88% | ||
** Intermediate probability scan: 33% | ** Intermediate probability scan: 33% | ||
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** Normal or near normal probability scan: 9% | ** Normal or near normal probability scan: 9% | ||
* Shown below is the sensitivity and specificity of ventilation/perfusion scan | * Shown below is the sensitivity and specificity of V/Q scan for the detection of PE:<ref name="pmid2332918">{{cite journal| author=PIOPED Investigators| title=Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). | journal=JAMA | year= 1990 | volume= 263 | issue= 20 | pages= 2753-9 | pmid=2332918 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2332918 }} </ref> | ||
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* For a [[prevalence]] of PE of 33% (confirmed by [[angiography]]), the [[positive predictive value]] (PPV) and [[negative predictive value]] (NPV) of the ventilation/perfusion scan for PE are as follows:<ref name="pmid2332918">{{cite journal| author=PIOPED Investigators| title=Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). | journal=JAMA | year= 1990 | volume= 263 | issue= 20 | pages= 2753-9 | pmid=2332918 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2332918 }} </ref> | |||
** [[PPV]] for high probability scan: 88% | |||
** [[NPV]] for intermediate probability scan: 84%-88% | |||
** [[NPV]] for a normal or near normal scan: 91%-96% | |||
* PIOPED demonstrated that the value of the V/Q scan is improved when combined with the clinical pretest probability of PE. For example, among patients with suspected PE and high probability V/Q scan, the rates of confirmed PE by [[angiography]] were 56%, 88%, and 96% in cases of low, intermediate, and high clinical pre-test probability of PE respectively.<ref name="pmid2332918">{{cite journal| author=PIOPED Investigators| title=Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). | journal=JAMA | year= 1990 | volume= 263 | issue= 20 | pages= 2753-9 | pmid=2332918 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2332918 }} </ref> | |||
===Comparison with CT Pulmonary Angiography (CTPA)=== | |||
====Benefits of V/Q Scan over CTPA==== | |||
* Less radiation exposure | |||
* Diagnostic test of choice in an institution lacking a CT facility, or with inexperienced staff | |||
====Benefits of CTPA over V/Q Scan==== | |||
* Cost effectiveness | |||
* CT may also identify right heart dysfunction, or provide an alternative diagnosis. | |||
* | |||
* CT may also identify right heart dysfunction, or provide an alternative | |||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
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[[Category:Hematology]] | [[Category:Hematology]] | ||
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[[Category:Emergency medicine]] | [[Category:Emergency medicine]] | ||
[[Category:Intensive care medicine]] | [[Category:Intensive care medicine]] | ||
Latest revision as of 23:53, 29 July 2020
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Pulmonary embolism ventilation/perfusion scan On the Web |
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Editor(s)-In-Chief: The APEX Trial Investigators, C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: ; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]
Overview
A ventilation/perfusion scan (otherwise known as V/Q scan or lung scintigraphy) is a study which shows whether an area of the lung is being ventilated with oxygen and perfused with blood. In the setting of a pulmonary embolism (PE), perfusion can be obstructed due to the formation of a clot. The ventilation/perfusion scan is less commonly used due to the more widespread availability of computed tomography (CT) technology, however it may be useful in patients who have an allergy to iodinated contrast. It may also be useful in pregnant patients in an attempt to minimize radiation exposure. The diagnostic value of the results of the V/Q scan is improved when combined with the clinical pretest probability of PE. A high probability scan coupled with a high clinical pretest probability of PE is diagnostic for PE, while a normal scan regardless of the clinical pretest probability excludes PE. For the majority of the cases of suspected PE, however, the ventilation/perfusion scan does not establish the diagnosis nor exclude PE and further tests are required.[1]
Ventilation/Perfusion Scan
Principle
Technetium (Tc)-99m labeled macro-aggregated albumin particles, when injected, fill small fractions of the pulmonary capillaries. This helps in the assessment of lung perfusion at the tissue level via scintigraphy. When any branch of the pulmonary artery is occluded, the particles will not reach the capillaries rendering the area "cold" on imaging.
Indications
The utilization of ventilation/perfusion scanning has declined since the advent of more widespread availability of CT technology, however it may be useful in particular subgroups of patients, such as:
- Patients who have a known allergy to iodinated contrast. To read more about contrast allergy, click here.
- In pregnant patients to minimize exposure to radiation.
- For patients who are in a hospital lacking CT technology.
Interpretation
A normal or near normal V/Q scan excludes the diagnosis of PE.[1][2] When the result of the V/Q scan is not normal or near normal, the results of the V/Q scan should be interpreted in combination with the pretest probability of PE. Shown below is a table that summarizes the interpretation of the different results of the V/Q scan.[2]
| V/Q Scan | Clinical Probability | Interpretation |
| Normal | Any probability | PE excluded |
| Low probability scan | Low | PE excluded |
| High probability scan | High | PE confirmed |
| Any other combination of V/Q scan and clinical probability | Further tests are needed | |
Supportive Trial Data
- Data regarding the use of the V/Q scan for the evaluation of patients with suspected PE is provided by the findings of the PIOPED study. The rates of confirmed PE by angiography for each of the categories of the V/Q scan are:[1]
- High probability scan: 88%
- Intermediate probability scan: 33%
- Low probability scan: 16%
- Normal or near normal probability scan: 9%
- Shown below is the sensitivity and specificity of V/Q scan for the detection of PE:[1]
| Category of ventilation/perfusion scan | Sensitivity | Specificity |
| High probability scan | 41% | 97% |
| High or intermediate probability scan | 82% | 52% |
| High, intermediate, or low probability scan | 98% | 10% |
- For a prevalence of PE of 33% (confirmed by angiography), the positive predictive value (PPV) and negative predictive value (NPV) of the ventilation/perfusion scan for PE are as follows:[1]
- PIOPED demonstrated that the value of the V/Q scan is improved when combined with the clinical pretest probability of PE. For example, among patients with suspected PE and high probability V/Q scan, the rates of confirmed PE by angiography were 56%, 88%, and 96% in cases of low, intermediate, and high clinical pre-test probability of PE respectively.[1]
Comparison with CT Pulmonary Angiography (CTPA)
Benefits of V/Q Scan over CTPA
- Less radiation exposure
- Diagnostic test of choice in an institution lacking a CT facility, or with inexperienced staff
Benefits of CTPA over V/Q Scan
- Cost effectiveness
- CT may also identify right heart dysfunction, or provide an alternative diagnosis.
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 PIOPED Investigators (1990). "Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED)". JAMA. 263 (20): 2753–9. PMID 2332918.
- ↑ 2.0 2.1 Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P; et al. (2008). "Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)". Eur Heart J. 29 (18): 2276–315. doi:10.1093/eurheartj/ehn310. PMID 18757870.