Pulmonary embolism (TELA) - Symptoms

The most characteristic subjective manifestation of the disease is sudden pain behind the breastbone of various nature. In 42-87% of patients, acute stabbing pain behind the breastbone is observed. In case of embolism of the main trunk of the pulmonary artery, recurrent chest pains occur, caused by irritation of the nerve apparatuses embedded in the wall of the pulmonary artery. In some cases of massive pulmonary embolism (PE), sharp pain with wide irradiation resembles that in dissecting aortic aneurysm.

In case of embolism of small branches of the pulmonary artery, pain may be absent or be masked by other clinical manifestations. In general, the duration of pain may vary from several minutes to several hours.

Sometimes there are pains of angina pectoris character, accompanied by ECG signs of myocardial ischemia due to the decrease of coronary blood flow due to the decrease of stroke and minute volumes. The increase of arterial pressure in the cavities of the right heart, which disrupts the outflow of blood through the Thebesian and coronary veins, is also of certain importance.

Sharp pains in the right hypochondrium may be observed, combined with intestinal paresis, hiccups, symptoms of peritoneal irritation associated with acute congestive swelling of the liver with right ventricular failure or the development of massive infarctions of the right lung.

As pulmonary infarction develops in the following days, acute pain in the chest is observed, which intensifies with breathing and coughing, and is accompanied by pleural friction noise.

The second most important complaint of patients is shortness of breath. It is a reflection of the syndrome of acute respiratory failure. The sudden onset of shortness of breath is characteristic. It can be of varying severity - from a feeling of lack of air to very pronounced manifestations.

Complaints of coughing appear already at the stage of pulmonary infarction, i.e. 2-3 days after pulmonary embolism; at this time, the cough is accompanied by chest pain and the discharge of bloody sputum (hemoptysis is observed in no more than 25-30% of patients).

It is caused by hemorrhage into the alveoli due to the gradient between the low pressure in the pulmonary arteries distal to the embolus and the normal pressure in the terminal branches of the bronchial arteries. Complaints of dizziness, noise in the head, and tinnitus are caused by transient hypoxia of the brain, and in severe cases, by cerebral edema. Palpitations are a typical complaint of patients with pulmonary embolism. The heart rate can be more than 100 per minute.

The general condition of the patient is severe. Typical is a pale ash-colored skin tone combined with cyanosis of the mucous membranes and nail beds. In severe massive embolism, there is pronounced cast-iron cyanosis of the upper half of the body. Clinically, several syndromes can be distinguished.

1. Acute respiratory failure syndrome - objectively manifests itself as dyspnea, mainly inspiratory, it occurs as "quiet dyspnea" (not accompanied by noisy breathing). Orthopnea is usually absent. Even with pronounced dyspnea, such patients prefer a horizontal position. The number of breaths is over 30-40 per 1 minute, cyanosis is noted in combination with paleness of the skin. When auscultating the lungs, weakened breathing can be determined on the affected side.
2. Moderate bronchospastic syndrome - is detected quite often and is accompanied by dry whistling and buzzing rales, which is a consequence of the bronchopulmonary reflex. Severe bronchospastic syndrome is quite rare.
3. Acute vascular insufficiency syndrome - manifests itself as severe arterial hypotension. This is a characteristic sign of pulmonary embolism (PE). Circulatory shock develops in 20-58% of patients and is usually associated with massive pulmonary occlusion. Arterial hypotension is caused by blockade of pulmonary blood flow due to occlusion of the main branches of the pulmonary artery, leading to a sharp acute overload of the right heart, a sharp decrease in blood flow to the left heart with a drop in cardiac output. The pulmonary vascular reflex also contributes to a drop in arterial pressure. Arterial hypotension is accompanied by severe tachycardia.
4. Acute pulmonary heart syndrome - occurs in the first minutes of the disease and is caused by massive or submassive pulmonary embolism (PE). This syndrome is manifested by the following symptoms:
   • swelling of the jugular veins;
   • pathological pulsation in the epigastric region and in the second intercostal space to the left of the sternum;
   • tachycardia, expansion of the right border of the heart and the zone of absolute cardiac dullness, accentuation and bifurcation of the second tone over the pulmonary artery, systolic murmur over the xiphoid process, pathological right ventricular third tone;
   • increased central venous pressure;
   • Pulmonary edema develops relatively rarely;
   • painful swelling of the liver and a positive Plesh sign (pressure on the painful liver causes swelling of the jugular veins);
   • characteristic ECG changes.
5. Acute coronary insufficiency syndrome is observed in 15-25% of patients and is manifested by severe chest pain, extrasystole, less often - atrial fibrillation or flutter, paroxysmal atrial tachycardia, a decrease in ST downwards from the isoline along the horizontal and ischemic type in leads I, II, V1, simultaneously with a negative T wave.
6. Cerebral syndrome in pulmonary embolism is characterized by general cerebral or transient focal disorders and is caused primarily by cerebral hypoxia, and in severe cases - by cerebral edema, small focal hemorrhages into the substance and membranes of the brain.

Cerebral disorders in PE can manifest themselves in two ways:

• syncopal (like deep fainting) with vomiting, convulsions, bradycardia;
• comatose.

In addition, psychomotor agitation, hemiparesis, polyneuritis, and meningeal symptoms may be observed.

7. Abdominal syndrome is observed in an average of 4% of patients, caused by acute swelling of the liver. The liver is enlarged and painful upon palpation, acute pain in the right hypochondrium, vomiting, belching are often observed, which simulates an acute disease of the upper abdominal cavity.
8. Fever syndrome - an increase in body temperature, usually occurring in the first hours of the disease - is a characteristic symptom of pulmonary embolism (PE). Most patients have subfebrile temperature without chills, a smaller proportion of patients have febrile temperature. The total duration of the febrile period is from 2 to 12 days.
9. Pulmonary-pleural syndrome (i.e. pulmonary infarction and pleuropneumonia or infarction-pneumonia) develops 1-3 days after embolism. The clinical manifestations of the syndrome are as follows:
   • cough and chest pain on the affected side, which intensifies with breathing;
   • hemoptysis;
   • increase in body temperature;
   • lag in breathing of the corresponding half of the chest, decreased lung excursion on the affected side;
   • shortening of percussion sound over the area of pulmonary infarction;
   • in the presence of pulmonary tissue infiltration - increased vocal tremor, the appearance of bronchophony, breathing with a bronchial tint, fine bubbling rales, crepitation;
   • When dry pleurisy appears, pleural friction noise is heard; when exudate appears, pleural friction noise, vocal fremitus and bronchophony disappear, and a distinct dull sound appears on percussion.
10. Immunological syndrome develops in the 2nd-3rd week and is manifested by urticaria-like rashes on the skin, pulmonitis, recurrent pleurisy, eosinophilia, and the appearance of circulating immune complexes in the blood;