Search
Flickr PhotoStream
The presence of fragment-D dimers in the blood at 1.5 and 3 hours after beginning therapy indicated the in vivo occurrence of clot lysis. Higher levels of fragment-D dimers were present 3 hours after the onset of therapy in the blood of patients who received rt-PA than in patients who received heparin alone (40±29 |xg/ml vs 4±3 ^g/ml) (mean ±SD) (p<0.01). At 3 hours after the start of treatment among patients who received heparin alone, the plasma fibrinogen was 388 ± 126 mg/dl as compared to 222 ± 182 among patients who received rt-PA and heparin (p = 0.14). Among patients treated with 80 mg of i t-PA, however, the plasma fibrinogen at 3 hours was 7 4 ± 51 mg/dl.
The mean angiographic scores were evaluated for patients who had angiograms both before and 2 hours after treatment. Among patients who received rt-PA, the angiographic scores of the left lung were 12.2 ± 5,6 before treatment and 12.5 ±7.4 (mean±SD) after treatment. The angiographic scores of the right lung among patients treated with rt-PA were I0.0±4,4 before treatment and 8.2±3.8 after treatment. Occasionally the reduction of the thrombus size with rt- PA was appreciable (Fig 1). Among patients who received only heparin, the angiographic scores of the left lung were 12.9±2.2 before treatment and 12.8 ±4.1 after treatment. The angiographic scores tif the right lung among patients treated only with heparin were 15.5 ±6.3 before treatment and 18.0±10.0 after treatment. Changes of the angiographic score with treatment were not significantly different in the comparison of patie nts treated with rt-PA to patients treated with heparin alone.
- In: Main
- Tags: Pulmonary Embolism, Tissue Plasminogen
Tissue Plasminogen Activator for the Treatment of Acute Pulmonary Embolism: VentUation/Berfusion Scans
21 Apr2011
VentUation/Berfusion Scans
Ventilation scans and perfusion scans (V/Q scans), as well as plain chest roentgenograms were obtained before the pulmonary arteriogram, perfusion scans were performed again after double-blind treatment at intervals of 24 hours, 48 hours, and 7 days. All V/Q scans were obtained with wide field-of-view gamma cameras (diameter 38.1 cm) fitted with low-energy all-purpose collimators. Perfusion scans were obtained following the injection of 4 mCi of •Тс macroaggregated albumin. Eight images were made with the patient in the anterior, posterior, anterior oblique, posterior oblique, and lateral positions. Seven hundred and fifty thousand counts were obtained for each image except for the laterals which were made with 500,000 counts for the initial lateral, with the other lateral image obtained over the same amount of time.
Perfusion scans were graded by two readers who evaluated the perfusion defects without knowledge of therapy. Baseline mismatched perfusion defects (defects not associated with radiographic or ventilation abnormalities) were assessed as follows: Each segment of the lung was assumed to constitute 11 percent of the involved lung. The number of mismatched segments in each lung, therefore, was multiplied by 11 percent to determine the percentage of the involved lung that showed a mismatched perfusion defect. In this series, no patient had a new significant consolidation of the lung during the course of the 7 days of follow-up V/Q studies.
- In: Main
- Tags: Pulmonary Embolism, Tissue Plasminogen
A lthough recombinant tissue plasminogen activator would seem to have great potential for the treatment of acute pulmonary embolism, experience with this agent is limited, and no comparisons to placebo have been published. The purpose of the present study, therefore, was preliminarily to evaluate the efficacy of rt-PA, especially in combination with heparin, compared to placebo plus heparin as treatment for patients with acute pulmonary embolism. The thrombolytic effects of rt-PA may be enhanced when administered in combination with heparin because the addition of new fibrin to the thrombus is prevented by heparin during lytic therapy.
Methods
Between Nov 30, 1986, and June 30, 1987 (seven months), 13 patients were studied; nine received rt-PA and four received heparin but no rt-PA. The protocol and consent forms were approved by institutional review boards at the six participating hospitals, the data and coordinating center and the National Heart, Lung and Blood Institute. Among those who received rt-PA, eight of nine received heparin simultaneously. All patients received either rt-PA or placebo in a randomized double-blind fashion; twice as many patients were randomly assigned to the treatment group as to the control group.
- In: Main
- Tags: Pulmonary Embolism, Tissue Plasminogen
Massive Hemoptysis
The initial approaches to airway support during life- threatening hemoptysis reflected practical concerns in the resuscitation of a drowning patient (Table 4). While either the insertion of specialized tubes and blockers or selective endotracheal intubation of the nonbleeding lung are theoretically attractive and consistently recommended in major reviews, the difficulty and/or impracticality of these measures in acute situations often precludes their initial use. Less experienced individuals, in particular, should take note of the cautious approach to airway support that was advocated. Bronchoscopic intubation or nonselective insertion of a large endotracheal tube was preferred by most. During discussions which followed this session, experienced clinicians volunteered potentially useful caveats which have not been emphasized in the literature. A small number had successfully managed patients with life-threatening bleeding without intubation, with the view that these carefully selected, alert individuals could cough more effectively than they could be suctioned. (All specified, however, that such patients were managed in the intensive care unit, with all equipment necessary for immediate intubation available in the event of any clinical deterioration.) In addition, they described their successful use of a polyvinyl chloride double-lumen endotracheal tube which has been used for single lung ventilation in other clinical settings. Publication of such experiences by practitioners would be important to more widely communicate (and prospectively evaluate) these strategies.
- In: Main
- Tags: Clinicians' Perspectives, Hemoptysis
Hemoptysis: Clinicians’ Perspectives DISCUSSION
18 Apr2011
The format of this interactive session provided previously unreported insights about physicians’ perspectives of the diagnosis and management of patients with hemoptysis. Using this computerized system, a survey of clinical opinions could be combined with the educational objectives of the session, resulting in a unique opportunity to compare principles and recommendations described in medical literature with realities encountered in practice.
Hemoptysis in the Outpatient Setting
Responses to questions about case presentations and selection factors for fiberoptic bronchoscopy suggest that criteria which have developed during the past decade for evaluation of patients with unexplained hemoptysis are useful. Analyses of the clinical characteristics of such patients have helped to improve identification of those likely to have diagnostic bronchoscopy. Moreover, combinations of negative clinical findings (eg, patient age <40 years, bleeding duration <1 week, <40 pack-years’ smoking history, <30 ml of blood expectorated daily) have a high negative predictive value. Although 60 percent of the clinicians favored bronchoscopy during the initial 24 hours after presentation with nonmassive hemoptysis, 40 percent deferred it to later in the course. This distribution might reflect agreement with recent observations that patient outcome is similar whether bronchoscopy is performed early in the course of bleeding or on a delayed basis.
- In: Main
- Tags: Clinicians' Perspectives, Hemoptysis
Massive Hemoptysis
Views differed about the most common cause of fatal hemoptysis: lung cancer (29 percent), bronchiectasis (28 percent), tuberculosis (23 percent), mycetoma (11 percent), or lung abscess (9 percent) were each considered. Opinions about the mortality associated with the nonsurgical management of massive hemoptysis also varied greatly. Of the approaches to airway support in patients with life-threatening bleeding (Table 4), only 7 percent advocated initial placement of a Carlens or Robertshaw tube. Either nonselective insertion of a large endotracheal tube (33 percent) or more selective intubation using the fiberoptic bronchoscopy as a stylet (25 percent) was preferred.
- In: Main
- Tags: Clinicians' Perspectives, Hemoptysis
Hemoptysis in the Outpatient Setting
Most (72 percent) respondents held chronic bronchitis to be the major cause of mild hemoptysis; other selections included lung cancer (11 percent), idiopathic causes (“essential” or “cryptogenic”) (7 percent), tuberculosis (5 percent), and bronchiectasis (5 percent). Most (91 percent) advocated fiberoptic bronchoscopy of a 55-year-old, 80 pack-year cigarette smoker with a one-week history of hemoptysis, nondiagnostic sputum, and a nonlocalizing chest roentgenogram. Nearly all (98 percent) would perform bronchoscopy on a similar patient whose duration of bleeding was ten days and bleeding rate exceeded 30 to 60 ml daily. In patients with mild hemoptysis, the best predictor of a specific bronchoscope diagnosis was thought to be abnormal findings on chest x-ray film (54 percent); fewer noted that a bleeding duration > one week (26 percent), anemia and weight loss (12 percent), and patient age >40 years (8 percent) were the best predictors.
- In: Main
- Tags: Clinicians' Perspectives, Hemoptysis