Pulmonary embolism (PE): symptoms

The most characteristic subjective manifestation of the disease is the sudden pain behind the sternum of a diverse nature. 42-87% of patients experience acute dagger pain behind the sternum. With embolism of the main trunk of the pulmonary artery, recurrent chest pains arise due to irritation of the neural apparatuses embedded in the wall of the pulmonary artery. In some cases of massive pulmonary embolism (PE), a sharp pain with a wide irradiation resembles that of a dissecting aortic aneurysm.

With embolism of small branches of the pulmonary artery, pain may be absent or be veiled by other clinical manifestations. In general, the duration of pain can vary from a few minutes to several hours.

Sometimes there are pains of stenocardic character accompanied by ECG signs of myocardial ischemia due to a decrease in coronary blood flow due to a decrease in stroke and minute volumes. Certain value has also an increase in arterial pressure in the cavities of the right heart, which violates the outflow of blood through the pomosia and coronary veins.

There may be sharp pains in the right upper quadrant, combined with intestinal paresis, hiccups, symptoms of irritation of the peritoneum, associated with acute congestive swelling of the liver with right ventricular failure or the development of massive right heart lung infarctions.

With the development in the next days of a lung infarct, sharp pains in the chest are noted, intensifying with breathing and cough, they are accompanied by a noise of friction of the pleura.

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

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

It is due to hemorrhage in the alveoli due to the gradient between low pressure in the pulmonary arteries distal to the embolus and normal - in the terminal branches of the bronchial arteries. Complaints of dizziness, noise in the head, noise in the ears - due to transient hypoxia of the brain, with severe degree - edema of the brain. Palpitation is a characteristic complaint of patients with PE. The heart rate can be more than 100 per minute.

The general condition of the patient is severe. Typical pale-ashy shade of the skin in combination with cyanosis of the mucous membranes and the nail bed. In severe massive emboli - pronounced cast iron cyanosis of the upper half of the body. Clinically, several syndromes can be distinguished.

1. Syndrome of acute respiratory failure - objectively manifested by dyspnea, mainly inspiratory, it proceeds as a "silent dyspnea" (not accompanied by noisy breathing). Orthopnea, as a rule, is absent. Even with severe dyspnoea, such patients prefer a horizontal position. The number of breaths is more than 30-40 per 1 minute, cyanosis is noted in combination with the pallor of the skin. With auscultation of the lungs, we can determine the weakened breathing on the affected side.
2. Moderate bronchospastic syndrome - is detected quite often and is accompanied by dry wheezing and buzzing rales, which is a consequence of the broncho-pulmonary reflex. Severe bronchospastic syndrome is rare.
3. Syndrome of acute vascular insufficiency - manifested by 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, resulting in sharp acute overload of the right heart, a sharp decrease in blood flow to the left heart with a drop in cardiac output. The drop in arterial pressure is also facilitated by a pulmonary-vascular reflex. Arterial hypotension is accompanied by severe tachycardia.
4. Syndrome of acute pulmonary heart - occurs in the first minutes of the disease and is caused by massive or submasmatic pulmonary embolism (PE). This syndrome is manifested by the following symptoms:
   • swelling of the cervical veins;
   • abnormal pulsation in the epigastric region and in the 2nd intercostal space to the left of the sternum;
   • tachycardia, widening of the right border of the heart and zone of absolute cardiac dullness, accent and bifurcation of II tone over the pulmonary artery, systolic murmur over the xiphoid process, pathological right ventricular III tone;
   • increase of CVP;
   • comparatively rarely develops pulmonary edema;
   • painful swelling of the liver and a positive Plesca symptom (pressing on the painful liver causes swelling of the cervical veins);
   • characteristic ECG changes.
5. The syndrome of acute coronary insufficiency is observed in 15-25% of patients and is manifested by severe chest pains, extrasystole, less often by fibrillation or atrial flutter, paroxysmal atrial tachycardia, lowering of ST down from horizontal and ischemic isolines in leads I, II, V1, simultaneously with negative teeth T.
6. Cerebral syndrome in PE is characterized by cerebral or transient focal disorders and is due primarily to cerebral hypoxia, and in severe cases - cerebral edema, small focal hemorrhage into the substance and the membranes of the brain.

Cerebral disorders in PE can occur in two versions:

• syncopal (according to the type of deep syncope) with vomiting, convulsions, bradycardia;
• comatose.

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

7. Abdominal syndrome is observed on average in 4% of patients, due to acute swelling of the liver. The liver on palpation is enlarged, painful, often acute pains in the right upper quadrant, vomiting, belching, which simulates acute disease of the upper abdominal cavity.
8. Feverish syndrome - an increase in body temperature, usually occurring from the first hours of the disease - a characteristic symptom of pulmonary embolism (PE). Most patients have a subfebrile fever without chills, while a smaller proportion of patients have febrile. The total duration of the febrile period is from 2 to 12 days.
9. Pulmonary-pleural syndrome (ie, lung infarction and pleuropneumonia or infarct-pneumonia) develops 1-3 days after embolism. Clinical manifestations of the syndrome are as follows:
   • cough and chest pain on the side of the lesion, worse with breathing;
   • hemoptysis;
   • increased body temperature;
   • lag when breathing the corresponding half of the chest, reducing the lung excursion on the sore side;
   • shortening of percussion sound over the site of a lung infarction;
   • in the presence of infiltration of pulmonary tissue - increased vocal tremor, the appearance of bronchophoria, respiration with bronchial hue, finely bubbling rales, crepitation;
   • when dry pleurisy occurs, the noise of friction of the pleura is heard, when exudation appears, the pleural friction noise, vocal tremor and bronhophonia disappear, a pronounced blunt sound appears with percussion.
10. Immunological syndrome develops in 2-3 weeks, manifests as urtikaropodobnymi rashes on the skin, pulmonitis, relapsing pleurisy, eosinophilia, the appearance of circulating immune complexes in the blood;