Pulmonary embolism diagnostic approach
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editors-in-Chief: Ujjwal Rastogi, MBBS [2]
Overview
Signs and symptoms of pulmonary embolism are nonspecific; therefore, patients presenting with:
- Unexplained dyspnea
- Tachypnea
- Chest pain
- Risk factors for pulmonary embolism
—should undergo diagnostic tests until the diagnosis is confirmed or eliminated or an alternative diagnosis is made.
CT equipped hospitals
In hospitals having experience in performing and interpreting CT Pulmonary angiography, following flowchart approach can be adopted.
| Determine chances of PE | |||||||||||||||||||||||||||||||||
| Low chance | High chance | ||||||||||||||||||||||||||||||||
| D-dimer | |||||||||||||||||||||||||||||||||
| <500 ng/ml | >500 ng/ml | CT Pulmonary angiography | |||||||||||||||||||||||||||||||
| PE excluded | Negative | Positive | |||||||||||||||||||||||||||||||
| PE excluded | PE confirmed | ||||||||||||||||||||||||||||||||
CT Non-equipped hospitals
Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) Study proposed the following, for hospitals who do not have sufficient resources to perform or interpret CT Pulmonary angiography.
Wells criteria are used to assess the clinical probability of PE and its graded as Low, Intermediate or High. later a ventilation-perfusion scan (V/Q) is performed, and based on the result of the scan PE is diagnosed.
The following table summarizes the possible outcome of V/Q scan:
| V/Q Scan | Clinical Probability | Diagnosis |
|---|---|---|
| Normal | any probability | PE excluded |
| Low probability scan | Low | PE excluded |
| High probability scan | High | PE confirmed |
| Variable result/Non diagnostic | Variable | Serial lower extremity USG or Pulmonary angiography |
Low risk outpatient population
In populations with low PE prevalence, the following eight factors constitute the PE Rule-out Criteria (PERC):
- Age less than 50 years
- Heart rate less than 100 bpm
- Oxyhemoglobin saturation ≥95 percent
- No hemoptysis
- No estrogen use
- No prior DVT or PE
- No unilateral leg swelling
- No surgery or trauma requiring hospitalization within the past four weeks.
This approach was tested in a multicenter study involving 8138 outpatients with suspected PE.[1] It was suggested, that when combined with a clinical assessment of low risk for PE, this approach can exclude PE without additional diagnostic testing. However, in clinical settings with a higher prevalence of PE (>20%), the PERC based approach has significantly poor predictive value. [2]
References
- ↑ Kline JA, Courtney DM, Kabrhel C, Moore CL, Smithline HA, Plewa MC, Richman PB, O'Neil BJ, Nordenholz K (2008). "Prospective multicenter evaluation of the pulmonary embolism rule-out criteria". J. Thromb. Haemost. 6 (5): 772–80. doi:10.1111/j.1538-7836.2008.02944.x. PMID 18318689. Retrieved 2011-12-19. Unknown parameter
|month=ignored (help) - ↑ Hugli O, Righini M, Le Gal G, Roy PM, Sanchez O, Verschuren F, Meyer G, Bounameaux H, Aujesky D (2011). "The pulmonary embolism rule-out criteria (PERC) rule does not safely exclude pulmonary embolism". J. Thromb.Haemost. 9 (2): 300–4. doi:10.1111/j.1538-7836.2010.04147.x. PMID 21091866. Retrieved 2011-12-19. Unknown parameter
|month=ignored (help)