肺栓塞－從病理機轉到診斷治療策略

Pulmonary Embolism: From Pathogenesis to Diagnosis and Treatment

陳郁安(Yu-An Chen) ； 張坤正(Kuan-Cheng Chang)

《內科學誌》 25卷5期 (2014/10) Pp. 307-315

https://doi.org/10.6314/JIMT.2014.25(5).01

摘要

肺栓塞大多是深部靜脈栓塞的併發症，與深部靜脈栓塞同為靜脈血栓症的臨床表現，因此擁有共同的危險因子。在臨床上面對懷疑是肺栓塞的病患時，評估計畫應包括詳細回顧靜脈血栓症的相關病史及確實的理學檢查，而非將肺栓塞和靜脈栓塞視為兩類獨立的病症。肺栓塞的臨床症狀和徵象變化範圍廣，常不具特異性。目前診斷策略主要還是先評估血液動力學狀態，確定穩定後，可再藉由臨床風險評估系統（Wells score和Geneva score）預測肺栓塞的可能性，之後才是進入實驗室檢查和影像學診斷。在美國醫界的研究報告指出，肺栓塞是心肌梗塞和腦中風後導致血管性死亡最常見的原因，同時也是對住院病患而言，居首位能預防死亡發生的疾病。換言之，雖然肺栓塞有其高致命的危險性，但若能及早做出診斷與治療，並落實預防性評估工作，相信此可避免的死亡風險應能降低。

關鍵字

肺栓塞 ； Virchow氏三合症 ； 臨床檢測前機率 ； 血栓溶解治療

並列摘要

Both pulmonary embolism and deep venous thrombosis are clinical manifestations of venous thromboembolism and are associated with the same predisposing factors. When approaching a patient with suspected pulmonary embolism, the evaluation plan should include a complete venous thromboembolism history and physical examination instead of considering pulmonary embolism and deep venous thrombosis as independent diseases. The symptoms and signs of pulmonary embolism range widely and are often non-specific. The current diagnostic strategy of pulmonary embolism is to evaluate hemodynamic status first. In patients with hemodynamic stability, the diagnosis should follow a sequential diagnostic workup consisting of clinical pre-test probability, d-dimer testing, and diagnostic imaging by such techniques as multidetector computed tomography. Pulmonary embolism is one of the most common causes of vascular death after myocardial infarction and stroke; it is also the leading preventable cause of death in hospitalized patients in the United States. Therefore, the rapid diagnosis, effective management, and preventive assessment of pulmonary embolism may lower the risk of lethal complications, despite its high mortality rate.

並列關鍵字

Pulmonary embolism ； Virchow's triad ； Clinical pre-test probability ； Thrombolytic therapy