The Diagnosis of Clinically Suspected Pulmonary Embolism: Practical Approaches

Abstract

Pulmonary embolism is a common complication of venous thrombosis that usually originates in the deep veins of the legs. It is now well recognized that the clinical diagnosis of pulmonary embolism is highly nonspecific. 1 Urokinase Pulmonary Embolism TrialA national co-operative study. Circulation. 1973; 47: 1-108 Google Scholar , 2 Hull R Hirsh J Carter C et al. Pulmonary angiography, ventilation lung scanning, and venography for clinically suspected pulmonary embolism with abnormal perfusion lung scan. Ann Intern Med. 1983; 98: 891-899 Crossref PubMed Scopus (563) Google Scholar , 3 McNeil BJ Ventilation-perfusion studies and the diagnosis of pulmonary embolism: concise communication. J Nucl Med. 1980; 21: 319-323 PubMed Google Scholar , 4 Biello DR Mattar AC McKnight RC et al. Ventilation perfusion studies in suspected pulmonary embolism. Am J Radiol. 1979; 133: 1033-1037 Google Scholar , 5 Bell WR Simon TL Demets DL The clinical features of submassive and massive pulmonary emboli. Am J Med. 1977; 62: 355-360 Abstract Full Text PDF PubMed Scopus (212) Google Scholar , 6 Bell WR Simon TL A comparative analysis of pulmonary perfusion scans with pulmonary angiograms: from a national cooperative study. Am Heart J. 1976; 92: 700-706 Abstract Full Text PDF PubMed Scopus (82) Google Scholar , 7 Szucs MM Brooks HL Grossman W et al. Diagnostic sensitivity of laboratory findings in acute pulmonary embolism. Ann Intern Med. 1971; 74: 161-166 Crossref PubMed Scopus (129) Google Scholar Clinical diagnosis is nonspecific because none of the symptoms or signs of pulmonary embolism is unique, and all may be caused by a variety of other cardiorespiratory disorders. The common symptoms and signs of pulmonary embolism and the associated differential diagnoses are listed in Table 1. The nonspecificity of the clinical diagnosis of pulmonary embolism was strikingly demonstrated in the Urokinase/Streptokinase Pulmonary Embolism Study (UPET) in which more than 60% of over 2,500 patients entered with clinically suspected pulmonary embolism had this diagnosis excluded by the finding of a negative perfusion lung scan. 1 Urokinase Pulmonary Embolism TrialA national co-operative study. Circulation. 1973; 47: 1-108 Google Scholar , 5 Bell WR Simon TL Demets DL The clinical features of submassive and massive pulmonary emboli. Am J Med. 1977; 62: 355-360 Abstract Full Text PDF PubMed Scopus (212) Google Scholar , 6 Bell WR Simon TL A comparative analysis of pulmonary perfusion scans with pulmonary angiograms: from a national cooperative study. Am Heart J. 1976; 92: 700-706 Abstract Full Text PDF PubMed Scopus (82) Google Scholar The results of the UPET study are consistent with the findings of other studies, 2 Hull R Hirsh J Carter C et al. Pulmonary angiography, ventilation lung scanning, and venography for clinically suspected pulmonary embolism with abnormal perfusion lung scan. Ann Intern Med. 1983; 98: 891-899 Crossref PubMed Scopus (563) Google Scholar , 3 McNeil BJ Ventilation-perfusion studies and the diagnosis of pulmonary embolism: concise communication. J Nucl Med. 1980; 21: 319-323 PubMed Google Scholar , 4 Biello DR Mattar AC McKnight RC et al. Ventilation perfusion studies in suspected pulmonary embolism. Am J Radiol. 1979; 133: 1033-1037 Google Scholar , 7 Szucs MM Brooks HL Grossman W et al. Diagnostic sensitivity of laboratory findings in acute pulmonary embolism. Ann Intern Med. 1971; 74: 161-166 Crossref PubMed Scopus (129) Google Scholar all of which indicate that more than half of all patients with clinically suspected pulmonary embolism do not have this diagnosis confirmed by objective testing. Thus, objective testing is mandatory either to confirm or to exclude a diagnosis of pulmonary embolism. Table 1Differential Diagnosis of the Clinical Features of Pulmonary Embolism Dyspnea Atelectasis Pneumothorax Acute pulmonary edema Acute bronchitis Acute bronchiolitis Acute bronchial obstruction Hemoptysis Pneumonia Bronchial neoplasm Bronchiectasis Acute bronchitis Mitral stenosis Tuberculosis Acute right heart failure Myocardial infarction Myocarditis Cardiac tamponade Acute respiratory infection complicating chronic lung disease Pleuritic chest pain Pneumonia Pneumothorax Pericarditis Pulmonary neoplasm Bronchiectasis Subdiaphragmatic inflammation Myositis Muscle strain Rib fracture Cardiovascuiar collapse Myocardial infarction Acute massive hemorrhage Gram-negative septicemia Cardiac tamponade Spontaneous pneumothorax Open table in a new tab