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Diagnosing Pulmonary Embolism in Surgical Patients
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Am Fam Physician. 1999 Dec 1;60(9):2668-2670.
Researchers have long sought a noninvasive bedside test for diagnosing acute pulmonary embolism in critically ill surgical patients. Because pulmonary embolism increases the physiologic dead space in the lungs, researchers have tested various ways of using this fact as a diagnostic tool. The tests developed often failed because of the presence of another, coexisting lung disease. A previous study successfully differentiated healthy patients, patients with pulmonary embolism and patients with chronic obstructive pulmonary disease by measuring the late pulmonary dead space fraction (Fdlate) by carbon dioxide (CO2) expirogram. The Fdlate is the calculated difference between arterial CO2 and the concentration of CO2 in an exhalation of 15 percent of total lung capacity.
The CO2 expirogram measures CO2 concentration (in an exhaled breath) versus the volume of a single exhaled breath. The concentration of exhaled CO2 normally reaches the level of the exhaled volume when 15 percent of the patient's total lung capacity has been exhaled. The CO2 concentration of the exhaled breath eventually equals the arterial partial pressure of CO2. In patients with pulmonary embolism, the CO2 concentration of the exhaled breath does not rise to the arterial CO2 level (at the 15 percent exhaled volume level) because of the increase in physiologic dead space. A high Fdlate value is indirect evidence of a pulmonary embolism. Patients with chronic obstructive pulmonary disease exhibit different slopes on the expirogram, but the CO2 concentration level of the exhaled breath still approaches arterial CO2 levels when a patient exhales to the 15 percent level.
In a recent prospective study, Anderson and colleagues evaluated Fdlate levels as a diagnostic tool in a population of post-trauma surgical inpatients. A total of 14 angiograms were performed on 12 patients who exhibited clinical signs of pulmonary embolism. Of the 14 tests, nine were negative for pulmonary embolism. CO2 expirograms were obtained, and all but one of the nine patients had a negative expirogram with an Fdlate value below the predetermined cutoff value. All five patients with angiograms positive for pulmonary embolism had an Fdlate value in the range consistent with pulmonary embolism.
Overall, the CO2 expirogram showed 100 percent sensitivity and 89 percent specificity. These results support previous data and distinguish the CO2 expirogram from other methods of calculating the Fdlate at the bedside. The CO2 expirogram can be determined using the patient's tidal volume, which enables it to be used with ventilated patients and accounts for other lung disease and changes seen on pulmonary function tests. Recent technologic advances make the CO2 expirogram more accessible and make Fdlate calculation promising as a screening test for pulmonary embolism.
Anderson JT, et al. Bedside noninvasive detection of acute pulmonary embolism in critically ill surgical patients. Arch Surg. August 1999;134:869–75.
Copyright © 1999 by the American Academy of Family Physicians.
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