Pulmonary Embolism

Pulmonary embolism (PE) refers to the obstruction of the pulmonary

artery or one of its branches by a thrombus (or thrombi) that
originate(s) somewhere in the venous system or in the right side of the
heart.

Pathophysiology
Most commonly, PE is due to a dislodged or fragmented DVT.
However, there are other types of emboli that may be implicated: air,
fat, amniotic fluid, and septic (from bacterial invasion of the thrombus)
(Norris, 2019).

A PE is described as an occlusion of the outflow tract of the main

pulmonary artery or of the bifurcation of the pulmonary arteries.
Multiple small emboli can lodge in the terminal pulmonary arterioles,
producing multiple small infarctions of the lungs. A pulmonary
infarction causes ischemic necrosis of part of the lung (Thompson &
Kabrhel, 2020).

When a thrombus completely or partially obstructs a pulmonary artery

or its branches, the alveolar dead space is increased. The area,
although continuing to be ventilated, receives little or no blood flow.
Therefore, gas exchange is impaired or absent in this area. In
addition, various substances are released from the clot and
surrounding area that cause regional blood vessels and bronchioles to
constrict. This results in an increase in pulmonary vascular
resistance—a reaction that compounds the ventilation–perfusion
(V./Q.) imbalance that ensues.

The hemodynamic consequences are increased pulmonary vascular

resistance due to the regional vasoconstriction and reduced size of
the pulmonary vascular bed. In severe instances, this may result in an
increase in pulmonary arterial pressure and, in turn, an increase in
right ventricular work to maintain pulmonary blood flow. When the
work requirements of the right ventricle exceed its capacity, right
ventricular failure occurs, leading to a decrease in cardiac output
followed by a decrease in systemic blood pressure and the
development of shock (Norris, 2019).

Clinical Manifestations
Symptoms of PE depend on the size of the thrombus and the area of
the pulmonary artery occluded by the thrombus; they may be
nonspecific. Dyspnea is the most frequent symptom; the duration and
intensity of the dyspnea depend on the extent of embolization. Chest
pain is common and is usually sudden and pleuritic in origin; however,
it may be substernal and may mimic angina (Thompson & Kabrhel,
2020). Other symptoms include anxiety, fever, tachycardia,
apprehension, cough, diaphoresis, hemoptysis, and syncope. The
most frequent sign is tachypnea (rapid respiratory rate) (De Palo,
2020).

In many instances, PE causes few signs and symptoms, whereas in

other instances, it mimics various other cardiopulmonary disorders
(e.g., pneumonia, heart failure). Obstruction of the pulmonary artery
can result in pronounced dyspnea, sudden substernal pain, rapid and
weak pulse, shock, syncope, and sudden death (Thompson &
Kabrhel, 2020).

Assessment and Diagnostic Findings

Because the symptoms of PE can vary from few to severe, a
diagnostic workup is performed to rule out other diseases. The initial
diagnostic workup may include chest x-ray, ECG, pulse oximetry,
arterial blood gas analysis, D-dimer assay and MDCTA or pulmonary
arteriogram or V./Q. scan. The chest x-ray is usually normal but may
show infiltrates, atelectasis, elevation of the diaphragm on the affected
side, or a pleural effusion. The chest x-ray is most helpful in excluding
other possible causes. In addition to sinus tachycardia, the most
frequent ECG abnormality is nonspecific ST-T wave abnormalities. If
an arterial blood gas analysis is performed, it may show hypoxemia
and hypocapnia (from tachypnea); however, arterial blood gas
measurements may be normal even in the presence of PE (De Palo,
2020).

MDCTA (Multidetector Computed Tomographic Angiography) is the

criterion standard for diagnosing PE. The MDCTA can be performed
quickly and provides the advantage of high-quality visualization of the
lung parenchyma (Weinberger, Cockrill, & Mandel, 2019). If MDCTA is
not available, pulmonary angiography is considered a reasonable
alternative diagnostic method (Ouellette, 2019). The pulmonary
angiogram allows for direct visualization under fluoroscopy of the
arterial obstruction and accurate assessment of the perfusion deficit. A
specially trained team must be available to perform the procedure, in
which a catheter is threaded through the vena cava to the right side of
the heart to inject dye, similar to a cardiac catheterization.

The V./Q. scan continues to be used to diagnose PE, especially in

facilities that do not use pulmonary angiography or do not have
access to MDCTA. The V./Q. scan is minimally invasive and requires
IV administration of a contrast agent. This scan evaluates different
regions of the lung (upper, middle, lower) and allows comparisons of
the percentage of V./Q. in each area. This test has a high sensitivity
but is not as accurate as an MDCTA or pulmonary angiogram (De
Palo, 2020).

Medical Management
Medical management of the patient with PE revolves around whether
the patient is diagnosed with a hemodynamically unstable PE (also
called a massive PE) or a stable PE. The patient with a
hemodynamically unstable PE, which comprises a life-threatening
emergency, may evidence hypotension, tachycardia, confusion, and
cardiovascular collapse.

Medical Management of Unstable Pulmonary Embolism

The immediate objective is to stabilize the cardiopulmonary system in

the patient with a hemodynamically unstable PE. A sudden increase in
pulmonary resistance increases the work of the right ventricle, which
can cause acute right-sided heart failure with cardiogenic shock.
Emergent measures are initiated to improve respiratory and
cardiovascular status. After emergency measures have been initiated,
the treatment goal is to lyse (dissolve) the existing embolus and
prevent new ones from forming. Thrombolytic therapy with t-PA or
other agents such as reteplase is used in treating unstable PE,
particularly in patients who are severely compromised (e.g., those who
are hypotensive and have significant hypoxemia despite oxygen
supplementation) (Ouellette, 2019). Thrombolytic therapy lyses the
thrombi or emboli quickly and restores hemodynamic functioning of
the pulmonary circulation, thereby reducing pulmonary hypertension
and improving perfusion, oxygenation, and cardiac output. However,
the risk of bleeding is significant. Contraindications to thrombolytic
therapy include having had a stroke within the past 2 months, other
active intracranial processes, active bleeding, surgery within 10 days
of the thrombotic event, recent labor and delivery, trauma, or severe
hypertension. Consequently, thrombolytic agents are advocated only
for PE affecting a significant area of blood flow to the lung and causing
hemodynamic instability (Tapson & Weinberg, 2020).

Before thrombolytic therapy is started, INR, aPTT, hematocrit, and

platelet counts are obtained. Any anticoagulant is stopped prior to
administration of a thrombolytic agent. During therapy, all but essential
invasive procedures are avoided because of potential bleeding. After
the thrombolytic infusion is completed (which varies in duration
according to the agent used), maintenance anticoagulation therapy is
initiated.

A surgical is rarely performed but may be indicated if there are

contraindications to thrombolytic therapy. Embolectomy can be
performed using catheters or surgically. Surgical removal must be
performed by a cardiovascular surgical team with the patient on
cardiopulmonary bypass (Ouellette, 2019).

For patients who have recurrent PE despite therapeutic

anticoagulation, an inferior vena cava (IVC) filter may be inserted
(Tapson, 2019). IVC filters are not recommended for the initial
treatment of patients with PE and should not be used in patients
receiving anticoagulants. The IVC filter provides a screen in the IVC,
allowing blood to flow unobstructed while large emboli from the pelvis
or lower extremities are blocked or fragmented before reaching the
lung.

Medical Management of Stable Pulmonary Embolism

In patients with PE who do not demonstrate any cardiopulmonary

instability (e.g., normotensive, no evidence of hypoxemia) immediate
anticoagulation is indicated to prevent recurrence or extension of the
thrombus and may continue for 10 days (Tapson, 2019). Long-term
anticoagulation is also indicated up to 6 months following the PE and
is critical in preventing recurrence of VTE. This duration may be
extended indefinitely in patients who are at high risk for recurrence
(Weinberger et al., 2019).

In patients with stable PE, the initial anticoagulant selected may

include an LMWH (e.g., enoxaparin), unfractionated heparin, or a
direct oral anticoagulant (DOAC), such as a direct thrombin inhibitor
(e.g., dabigatran), or a factor Xa inhibitor (e.g., fondaparinux,
rivaroxaban, apixaban, edoxaban) (Tapson & Weinberg, 2020)

In select patients with PE who are hemodynamically stable, outpatient

therapy can be started by administering the first dose in the
emergency department or urgent care center and the remaining doses
given at home. Although there are not specific selection criteria for
outpatient treatment, the patient is usually at low risk of death, has no
respiratory or hemodynamic compromise, does not require opioids for
pain control, has no risk factors for bleeding, has no serious comorbid
conditions, and has stable baseline mental status with a good
understanding of the benefits and risks of treatment (Tapson, 2019).
The ideal agent for outpatient administration is not empirically
confirmed, although the DOACs are often prescribed.

Long-term treatment options include warfarin and the DOACs. An

LMWH may also be selected but is usually not prescribed for
long-term therapy since it is given via a subcutaneous injection.
Warfarin dosing requires regular blood draws for INR monitoring and
has a higher bleeding risk, but it has long been the standard of care
prior to the development of DOACs. An antidote (vitamin K) is
available if the INR is high and there is a risk of bleeding. Warfarin
does have interactions with several medications and has dietary
restrictions. DOACs do not require regular blood test monitoring;
however, they are more costly than warfarin. The choice of warfarin
versus a DOAC is dependent upon risk of bleeding, cost, presence of
comorbidities, and provider preference (The Joint Commission [TJC],
2019).

Nursing Management
Monitoring Thrombolytic Therapy
The nurse is responsible for monitoring the patient’s response to
thrombolytic and anticoagulant therapy. During the thrombolytic
infusion, while the patient remains on bed rest, vital signs are
frequently assessed and invasive procedures are avoided. Tests to
determine INR or aPTT are performed 3 to 4 hours after the
thrombolytic infusion is started to confirm that the fibrinolytic systems
have been activated.
Quality and Safety Nursing Alert

Because of the prolonged clotting time, only essential arterial

punctures or venipunctures are performed in patients who have
received thrombolytics, and manual pressure is applied to any
puncture site for at least 30 minutes. Pulse oximetry is used to monitor
changes in oxygenation. The thrombolytic infusion is discontinued
immediately if uncontrolled bleeding occurs.

Managing Pain

Chest pain, if present, is usually pleuritic rather than cardiac in origin.

A semi-Fowler position provides a more comfortable position for
breathing. However, the nurse must continue to turn patients
frequently and reposition them to improve V./Q.. The nurse
administers opioid analgesic agents as prescribed for severe pain.

Managing Oxygen Therapy

Careful attention is given to the proper use of oxygen. The patient

must understand the need for continuous oxygen therapy. The nurse
assesses the patient frequently for signs of hypoxemia and monitors
the pulse oximetry values to evaluate the effectiveness of the oxygen
therapy. Deep breathing and incentive spirometry are indicated for all
patients to minimize or prevent atelectasis and improve ventilation
Nebulizer therapy or percussion and postural drainage may be used
for management of secretions.

Relieving Anxiety

The nurse encourages the patient who is stabilized to talk about any
fears or concerns related to this frightening episode, answers the
patient’s and family’s questions concisely and accurately, explains the
therapy, and describes how to recognize untoward effects early.

Monitoring for Complications

When caring for a patient who has had PE, the nurse must be alert for
the potential complication of cardiogenic shock or right ventricular
failure subsequent to the effect of PE on the cardiovascular system.

Providing Postoperative Nursing Care

If the patient has undergone surgical embolectomy, the nurse

measures the patient’s pulmonary arterial pressure and urinary output.
The nurse also assesses the insertion site of the arterial catheter for
hematoma formation and infection. Maintaining the blood pressure at
a level that supports perfusion of vital organs is crucial. To prevent
peripheral venous stasis and edema of the lower extremities, the
nurse elevates the foot of the bed and encourages isometric
exercises, the use of intermittent pneumatic compression devices, and
walking when the patient is permitted out of bed. Sitting for long
periods is discouraged, because hip flexion compresses the large
veins in the legs.

Promoting Home, Community-Based, and Transitional Care

Educating Patients About Self-Care

Before hospital discharge and at follow-up visits to the clinic, the nurse
educates the patient about preventing recurrence and reporting signs
and symptoms. Patient education instructions, presented in Chart
26-11, are intended to help prevent recurrences and side effects of
treatment.

Chart 26-11 HOME CARE CHECKLIST

At the completion of education, the patient and/or caregiver will be

able to:

Prevention of Recurrent Pulmonary Embolism

● State the impact of pulmonary embolism (PE) on physiologic

functioning, ADLs, IADLs, roles, relationships, and spirituality.
● State changes in lifestyle (e.g., diet, activity) necessary to
restore health.
● Describe the importance of follow-up appointments with
providers.
● Describe strategies to prevent recurrent deep venous thrombosis
and pulmonary emboli:
● Continue to wear anti-embolism stockings (compression
hose) as long as directed.
● Avoid sitting with legs crossed or sitting for prolonged
periods of time.
● When traveling, change position regularly, walk occasionally,
and do active exercises of moving the legs and ankles while
sitting.
● Drink fluids, especially while traveling and in warm weather,
to avoid hemoconcentration due to fluid deficit.
● Describe the signs and symptoms of lower extremity circulatory
compromise and potential deep venous thrombosis: calf or leg
pain, swelling, pedal edema.
● Describe the signs and symptoms of pulmonary compromise
related to recurrent PE (e.g., dyspnea, chest pain, anxiety, fever,
 tachycardia, apprehension, cough, syncope, diaphoresis,
hemoptysis).
● Describe how and when to contact the primary provider if symptoms
of circulatory compromise or pulmonary compromise are identified.
● Identify the need for health promotion, disease prevention, and
screening activities.

medications.

• Name the anticoagulant prescribed and describe relevant patient

education related to taking anticoagulants.

Source:
Brunner and Suddarth’s Textbook of Medical- Surgical Nursing 15th
Edition.