Dr Jason Toniolo

Pulmonary embolism

Pulmonary embolism is where a blood clot from the veins (usually leg veins) dislodges and travels through the heart to the circulatory system of the lungs.

The clog blocks blood from leaving the heart and going to the lungs and prevents the blood from reaching the part of the lung where oxygen is absorbed. A pulmonary embolism occurs when a blood clot from the veins (usually leg veins) dislodges and travels through the heart to the pulmonary artery, blocking blood flow to the lungs. This means that with each breath, you are getting less oxygen in your body than before the clot appeared.

Is it serious? Understanding pulmonary embolism symptoms

It is extremely serious. Symptoms such as chest pain, especially if it worsens with breathing or physical exertion, should be taken seriously and prompt immediate medical attention. Pulmonary embolism is a large cause of death and affects young people and old indiscriminately. Sometimes, small amounts of clot end up in the very small pulmonary arteries, which is less problematic, but when large clots end up in the bigger vessels, the heart can not effectively pump blood out of its chamber, causing heart attacks, as well as not enough oxygen getting into the blood, which can cause the heart to stop pumping.

What are pulmonary embolism’s causes and risk factors, and how do I prevent them?

See the section on deep vein thrombosis to understand leg clots.

To prevent pulmonary embolism, you must do all that you can to prevent deep vein thrombosis.  Prevention measures include:

  1. Stay Active and Move Regularly – One of the most effective ways to prevent DVT is to keep your blood circulating by staying active:
  • Avoid long periods of inactivity: If you’re sitting or lying down for long periods (e.g., during a long flight or car ride), try to get up and move every 1-2 hours.
  • Stretch and flex your legs: If you’re unable to move, stretch your legs, wiggle your toes, and flex your feet every 15-30 minutes to help maintain blood flow.
  • Exercise regularly: Walking, swimming, and cycling promote healthy blood circulation. Aim for at least 30 minutes of moderate exercise most days of the week.
  1. Wear Compression Stockings on flights

Compression stockings apply gentle pressure to your legs, helping veins and muscles circulate blood more effectively. They are especially helpful if you are at risk for DVT recovering from surgery or on a long-haul flight.

  • Who should use them?

Those with a higher risk of DVT, including people who have had recent surgery, those with limited mobility, or those on long flights.

  • How do they work?

The stockings exert pressure that gradually decreases from the ankle upwards, preventing blood from pooling in your legs.

Stay Hydrated

Drinking plenty of fluids helps prevent blood from thickening and clotting. Dehydration can make blood thicker, increasing the likelihood of a clot forming. Aim to drink water throughout the day, especially when travelling in situations where you are less mobile.

Maintain a Healthy Weight

Excess weight increases pressure on the veins in your legs, which can increase the risk of developing DVT. Maintaining a healthy weight through balanced eating and regular exercise can help reduce your risk.

Avoid Smoking

Smoking damages the lining of blood vessels and increases the risk of blood clots. Quitting smoking is one of the best ways to lower your risk of DVT and improve overall vascular health.

Medications that promote blood clots, or prevent blood clots:

For individuals at high risk of DVT, such as those recovering from surgery, blood-thinning medications (anticoagulants) may be prescribed to avoid clot formation.

Patients who are on the oral contraceptive pill are at an increased risk of blood clots, as the hormones tip the balance of the blood slightly towards blood clots. Estrogen-containing birth control pills are also associated with an increased risk of blood clots, particularly in postmenopausal women undergoing hormonal replacement therapy.

Be Aware of Risk Factors

Certain factors increase the risk of DVT, including:

  • Recent surgery or injury
  • Prolonged bed rest or immobility
  • Family history of blood clots
  • Pregnancy
  • Certain medical conditions, such as cancer or clotting disorders
  • The oral contraceptive pill
  • Chronic obstructive pulmonary disease (COPD)
  1.  

Recognize the Symptoms Early

If you catch DVT early, you can prevent complications. Common symptoms include:

  • Swelling in one leg
  • Pain or tenderness in the leg, especially when standing or walking
  • Warmth in the affected area
  • Red or discoloured skin

If you experience any of these symptoms, seek medical attention right away.

treatment options

Management of pulmonary embolus

Medical management

Pulmonary embolism is diagnosed through various methods, including medical history, physical examinations, and specific imaging tests such as computed tomographic pulmonary angiography (CTPA).

All patients with PE should be placed on blood thinners immediately. If the PE had a known cause (e.g. prolonged hospitalisation or long haul flights) it is considered a provoked pulmonary embolus, and the blood thinners will usually be discontinued after 6 months.

If the PE had no known provoking cause, and no cause can be identified for it, then the consideration for lifelong blood thinners must be made as if you come off the blood thinners, it may happen again. Patients having a second, or third pulmonary emboli are more likely to die, as the clot burden within the lungs and the damage it causes to the heart’s right ventricle continues to progress and become overwhelmed.

Surgical management

Pulmonary embolism symptoms such as severe shortness of breath, chest pain, and fainting may necessitate surgical intervention.

Patients who meet certain criteria are offered minimally invasive surgery to treat the blood clot in the lung. To meet these criteria, you need to have a very serious PE that has caused you to collapse or blackout, or you need to have evidence that your heart is struggling to pump on ultrasound of the heart (echocardiography) and blood tests.

Catheter-directed lysis with clot maceration

This procedure involves lying on a table. A small 2mm plastic tube is inserted into the vein of your leg, using an ultrasound to target the vein and some local anaesthetic in the skin.  The catheter is passed up through the veins, the heart and into the lungs of the chest. X-rays and contrast dye are used to see where the catheter is in the body.

Then, the clots in the lungs are targeted, and the catheter pulses out puffs of ‘lytic’ which is medicine to dissolve the clot. This is different from blood thinners;

Blood thinners prevent more clots from forming

Lytic medications actively dissolve clots that have already formed.

The catheter works to break up the clot into smaller fragments and dissolve as much clot as possible. This is a gentle procedure that is well tolerated and does not stress the heart out any further when it is already under duress

Wide-bore catheter suction thrombectomy

Pulmonary embolisms can lead to serious complications, including high mortality rates and potential long-term effects like chronic pulmonary hypertension.

This is a more aggressive surgical intervention for a pulmonary embolus. An 8mm tube is inserted into the vein of the groin under local anaesthetic. The same tools are used to pass this tube up the veins of the body, through the heart and into the lung arteries (x-ray machine, wires, catheters and contrast dye).

When in the lung, a very large syringe is attached to the tube in the lungs and under heavy suction through the 8mm tube, chunks of clots are evacuated out of the lungs and delivered onto the operating table. Quite a large amount of blood is sucked out at the same time. This blood is passed through a filter and re-injected into the body, once it has been cleaned of any blood clots.

This procedure is very aggressive but very effective. It is not done on critically unwell patients as the large tube can increase the stress on the heart at a catastrophically serious time when it needs no additional stress. For patients with a lesser strain on the heart, to the largest amount of clot out and improve the longer-term, it is the preferred surgical intervention for clot removal in the lungs.