124例肺血栓栓塞症的临床分析

目的 对本院1998～2006年189例肺血栓栓塞症(pulmonary thromboembolism,PTE)患者中资料完整的124例进行临床回顾性分析.方法 发诊断标准符合中华医学会呼吸病学会制定的诊断标准,对所有124例PTE患者的病史、临床表现、心电图、X线胸片、血气、下肢深静脉超声、彩色多普勒心脏超声、螺旋CT肺血管造影(CTPA)、肺通气/灌注扫描(V/Q显像)等临床资料进行分析.结果 PTE-DVT年发病数逐年增加.大面积PTE 83例(66.9%),次大面积PTE 20例(16.1%),非大面积PTE 21例(16.9%).DVT 70例,术后40例,长期卧床65例,恶性肿瘤6例,结缔组织病3例,睡眠呼吸暂停低通气综合症1例.所有患者均有不同程度的呼吸困难,心悸90例,胸痛30例,咯血19例.咳嗽40例,晕厥16例,突然心跳、呼吸停止机械通气5例.呼吸频率>20次/min 86例,心率>100次/min 112例,发绀65例,肺部闻及干湿哕音22例.PaO<,2><60 mm Hg 72例,PaCO<,2><35 mm Hg 92例,PaCO<,2> >35 mm Hg 32例;心电图窦速112例,S<,Ⅰ> Q<,Ⅲ>T<,Ⅲ>型改变者25例,CRBBB型改变26例,非特异性S-T改变42例,窦性心动过缓5例;胸部X线检查有阴影者20例,行CTPA检查105例,V/Q显像18例,肺动脉造影1例;心脏超声显示右心室扩张合并肺动脉高压共91例,20例仅有肺动脉高压,无右心室扩大,8例心脏超声完全正常.首诊24 h内确诊72例,其余52例确诊时间为2～60 d,误诊率为30%(37例),其中误诊为冠心病、急性左心衰、肺炎者最多.溶栓抗凝治疗83例,单纯抗凝治疗41例,死亡8例(6.5%).结论 经 PTE的发病呈逐年增高的趋势;特别要注意恶化肿瘤和结缔组织病是重要的易感因素;PTE最常见的症状是呼吸困难.因此,提高临床医生的诊断意识,以减少漏诊和误诊.

Clinical analysis of 124 pulmonary thromboembolism

Objective To retrospectively analyse the clinical characteristics of 124 pulmonarythromboembolism(PTE) patients adimitted in the hospital from 1998 to 2006. Methods A total of 178 PTEpatients were diagnosed in the hospital, of which 124 cases had complete medical documents. All the casesmet the criteria set by the respiratory division of Chinese Medical Society. The clinical characteristics, resultsof auxiliary examinations such as ECG, chest x-ray, blood gas analysis, ultrasound of lower limb deep veins,echocardiograph,CTPA and V/Q scan were recorded and analysed. Results PTE patients increased year byyear. Massive, submassive and non-massive area eases were 83 (66.9%), 20(16.1%), 21 (16.9%). Amongthe patients, the main risk factors were DVT (70 cases), surgery(40 cases), immobility( 65 cases), tumor(6cases), connective tissue disease ( 3 cases), OSAS ( 1 case). The main symptoms were dyspnea ( 100%),palpitation( 90 cases), chest pain ( 30 cases), haemoptysis ( 19 cases), cough ( 40 cases), syncope ( 16 cases),cardiac-respiratory arrest(5 cases) by turns. The main findings of physical examinations were rapid breathrate(>20 times/min) (86 cases),rapid heart beating( >100 beats/min)(112 cases),cyanosis(65 cases),dryand wet rales(22 cases). The main meaningful findings of lab tests were: PaO<,2> < 60 mm Hg (72 cases),PaCO<,2> < 35 mm Hg(92 cases),PaCO<,2> > 35 mm Hg(32 cases);ECG:sinus tachycardia:112 cases,S<,Ⅰ> Q<,Ⅲ>T<,Ⅲ>(25 cases),CRBBB 26 cases,non-specific S-T changes 42 cases,sinus bradyeardia(<60 beats/min)5 cases;chest x-ray: Wedge shape(20 cases),positive result of CTPA( 105 cases), high probobility of V/Q scan (18cases); echocardiograph: right ventricular dilatation, pulmonary hypertension 91 cases, 20 cases, only 8patients had a normal echocardiograph examination. Only 72 patients got confirmed diagnosis in the first 24hours of admission, other 52 patients were diagnosed in 2-60 days, 30% (37 cases), and the misdiagnosis wasmost were as coronary heart disease, acute heart failure or pneumonia, etc. 83 patients received boththrombolysis and anticoagulation therapies,41 patients received anticoagulation therapy alone,the death was8 patients(6.5%). Conclusions Morbidity of PTE tends to increase yearly, partly due to the progress madein the diagnosis means and improvement of the pyhsians' awareness of this disease. PTE should be suspectedwhen a patient has symptoms such as dyspnea, syncope, ete, especially combined with some risk factors suchas cancer or connective tissue disease. PTE trilogy of chest pain,haemoptysis and dyspnea is not common asit is supposed to be. Improvement of awareness of PTE helps the most for the physicans avoid themisdiagnosis.