Division of Pulmonary, Critical Care and Sleep Medicine. University of California, San Diego, San Diego, CA.
Division of Pulmonary, Critical Care and Sleep Medicine. University of California, San Diego, San Diego, CA.
Chest. 2023 Apr;163(4):933-941. doi: 10.1016/j.chest.2022.06.036. Epub 2022 Jul 2.
Long-term dyspnea and exercise intolerance are common clinical problems after acute pulmonary embolism. Unfortunately, no single test can distinguish among the range of potential pathologic outcomes after pulmonary embolism. We illustrate a stepwise approach to post-pulmonary embolism evaluation that uses a hierarchic series of clinically validated diagnostic tests. The algorithm is represented by the acronym SEARCH, which stands for Symptom screening, Exercise testing, Arterial perfusion, Resting echocardiography, Confirmatory chest imaging, and Hemodynamics measured by right heart catheterization. We illustrate the algorithm with a patient whom we saw in our pulmonary embolism follow-up clinic. Patients are asked at least 6 months after pulmonary embolism whether they have returned to their baseline level of respiratory comfort and exercise tolerance. Patients with dyspnea and exercise intolerance undergo noninvasive cardiopulmonary exercise testing to identify elevated ventilatory dead space ratios, decreased stroke volume augmentation with exercise, and other physiologic abnormalities during exertion. Ventilation-perfusion scanning is performed on those patients with exercise-related physiologic findings to confirm the presence of residual pulmonary arterial obstruction or to suggest alternative diagnoses. Resting echocardiography may provide evidence of pulmonary hypertension; confirmatory imaging with pulmonary angiography or CT angiography may disclose findings characteristic of chronic pulmonary artery obstruction. Finally, right heart catheterization is performed to confirm chronic thromboembolic pulmonary hypertension; if resting pulmonary hemodynamics are normal, then invasive cardiopulmonary exercise testing may disclose exercise-induced defects.
急性肺栓塞后，长期呼吸困难和运动耐量下降是常见的临床问题。不幸的是，没有单一的检查可以区分肺栓塞后一系列潜在的病理结果。我们展示了一种逐步评估肺栓塞后情况的方法，该方法使用一系列临床验证的诊断测试。该算法由缩写 SEARCH 表示，代表症状筛查、运动试验、动脉灌注、静息超声心动图、确认性胸部成像和右心导管测量血流动力学。我们通过在我们的肺栓塞随访诊所看到的一位患者来说明该算法。患者在肺栓塞后至少 6 个月时被问及他们的呼吸舒适度和运动耐量是否恢复到基线水平。有呼吸困难和运动耐量下降的患者进行非侵入性心肺运动测试，以确定通气死腔比升高、运动时每搏量增加减少和其他运动期间的生理异常。对有运动相关生理发现的患者进行通气灌注扫描，以确认是否存在残余肺动脉阻塞或提示其他诊断。静息超声心动图可能提供肺动脉高压的证据；肺血管造影或 CT 血管造影的确认性成像可能显示慢性肺动脉阻塞的特征性发现。最后，进行右心导管检查以确认慢性血栓栓塞性肺动脉高压；如果静息肺血流动力学正常，则侵入性心肺运动测试可能会发现运动诱导的缺陷。
