Chest
Volume 73, Issue 4, April 1978, Pages 460-465
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Pulmonary Embolism in Respiratory Failure

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The occurrence of pulmonary emboli in 617 patients admitted to a respiratory intensive care unit was studied. Pulmonary emboli were found in 18 (27 percent) of 66 autopsies. Half of these pulmonary emboli were not diagnosed before death, despite persistent aggressive attempts to document pulmonary emboli. In this subpopulation of patients with respiratory failure, the usual clinical manifestations of pulmonary emboli (symptoms, signs, chest x-ray film, electrocardiogram, and changes in arterial blood gas levels) frequently are already present, due to the severe underlying pulmonary disease, and any superimposed manifestations of pulmonary emboli are often inapparent In this group under study, the ventilation/perfusion lung scan correlated poorly with pulmonary angiographic results and with examinations at autopsy; the scan generally was inadequate to rule in or rule out pulmonary emboli Again, this was due to the distortion of both ventilation and perfusion by the severe underlying pulmonary disease. Currently, pulmonary angiographic studies remain the only reliable technique to confirm or exclude pulmonary emboli in patients with respiratory failure.

Section snippets

MATERIALS AND METHODS

From January 1972 to November 1975, there were 617 admissions to the Respiratory Intensive Care Unit at University Hospital, Ann Arbor, Mich. The criterion for admission is respiratory failure or insufficiency (eg, arterial oxygen pressure [PaO2] less than 50 mm Hg or arterial carbon dioxide tension [PaCO2] greater than 40 mm Hg), with many patients requiring assisted ventilation at some time in the course of hospitalization. This population of patients is not limited to patients with primary

Group 1

The interpretation of the lung scan and the pulmonary arteriogram in the 12 patients who had both is shown in Table 1. There was an average of two days between procedures, with a range of less than one day to seven days. Pulmonary embolism was demonstrated by arteriograms in only two patients. These two patients had subsequent confirmation of their anteriographic findings on autopsy. The scans did not predict the outcome of the arteriogram. In fact, the lung scan was misleading in one patient

DISCUSSION

The classic presentation of acute pulmonary embolism may be difficult or impossible to recognize in critically ill patients with respiratory failure. The problem is further compounded if the patient requires mechanical ventilation where the history is essentially unobtainable. In his extensive review, Gorham2 states that sudden dyspnea and pain in the chest were major symptoms in acute pulmonary embolism. Israel and Goldstein3 reported chest and abdominal pain, dyspnea, and syncope as frequent

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Supported in part by Pulmonary Academic Award 1K07 168-04 from the Division of Lung Diseases, National Heart and Lung Institute.

Read in part before the 42nd Annual Scientific Assembly, American College of Chest Physicians, Atlanta, Oct 26, 1976.

Manuscript received April 5; revision accepted July 14.

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