Воздушная эмболия: причины, симптомы и лечение.

Vascular blockage by air bubbles

An air embolism, also known as a gas embolism, is a blood vessel blockage caused by one or more bubbles of air or other gas in the circulatory system. Air can be introduced into the circulation during surgical procedures, lung over expansion injury, decompression, and a few other causes. In flora, air embolisms may also occur in the xylem of vascular plants, especially when suffering from water stress. Divers can develop arterial gas embolisms as a consequence of lung over expansion injuries. Breathing gas introduced into the venous system of the lungs due to pulmonary barotrauma will not be trapped in the alveolar capillaries, and will consequently be circulated to the rest of the body through the systemic arteries, with a high risk of embolism. Inert gas bubbles arising from decompression are generally formed in the venous side of the systemic circulation, where inert gas concentrations are highest, these bubbles are generally trapped in the capillaries of the lungs where they will usually be eliminated without causing symptoms. If they are shunted to the systemic circulation through a patent foramen ovale they can travel to and lodge in the brain where they can cause stroke, the coronary capillaries where they can cause myocardial ischaemia or other tissues, where the consequences are usually less critical. The first aid treatment is to administer oxygen at the highest practicable concentration, treat for shock and transport to a hospital where therapeutic recompression and hyperbaric oxygen therapy are the definitive treatment.

Trauma to the lung can also cause an air embolism. This may happen after a patient is placed on a ventilator and air is forced into an injured vein or artery, causing sudden death. Breath holding while ascending from scuba diving may also force lung air into pulmonary arteries or veins in a similar manner, due to the pressure difference.

Air can be injected directly into a vein or artery accidentally during clinical procedures. Misuse of a syringe to meticulously remove air from the vascular tubing of a hemodialysis circuit can allow air into the vascular system. Venous air embolism is a rare complication of diagnostic and therapeutic procedures requiring catheterization of a vein or artery. If a significant embolism occurs, the cardiovascular, pulmonary, or central nervous system may be affected.

Air embolism can occur whenever a blood vessel is open and a pressure gradient exists favoring entry of gas. Because the circulatory pressure in most arteries and veins is greater than atmospheric pressure, an air embolus does not often happen when a blood vessel is injured. In the veins above the heart, such as in the head and neck, the venous pressure may be less than atmospheric and an injury may let air in. This is one reason why surgeons must be particularly careful when operating on the brain, and why the head of the bed is tilted down when inserting or removing a central venous catheter from the jugular or subclavian veins. When air enters the veins, it travels to the right side of the heart, and then to the lungs. This can cause the vessels of the lung to constrict, raising the pressure in the right side of the heart. If the pressure rises high enough in a patient who is one of the 20% to 30% of the population with a patent foramen ovale, the gas bubble can then travel to the left side of the heart, and on to the brain or coronary arteries. Such bubbles are responsible for the most serious of gas embolic symptoms. Venous or pulmonary air embolism occurs when air enters the systemic veins and is transported to the right side of the heart and from there into the pulmonary arteries, where it may lodge, blocking or reducing blood flow. Experiments on animals show that the amount of gas necessary for this to happen is quite variable. Very large and symptomatic amounts of venous air emboli may also occur in rapid decompression in severe diving or decompression accidents, where they may interfere with circulation in the lungs and result in respiratory distress and hypoxia.

If a patent foramen ovale (PFO) is suspected, an examination by echocardiography may be performed to diagnose the defect. In this test, very fine bubbles are introduced into a patient's vein by agitating saline in a syringe to produce the bubbles, then injecting them into an arm vein. A few seconds later, these bubbles may be clearly seen in the ultrasound image, as they travel through the patient's right atrium and ventricle. At this time, bubbles may be observed directly crossing a septal defect, or else a patent foramen ovale may be opened temporarily by asking the patient to perform the Valsalva maneuver while the bubbles are crossing through the right heart – an action which will open the foramen flap and show bubbles passing into the left heart. Such bubbles are too small to cause harm in the test, but such a diagnosis may alert the patient to possible problems which may occur from larger bubbles, formed during activities like underwater diving, where bubbles may grow during decompression. A PFO test may be recommended for divers intending to expose themselves to relatively high decompression stress in deep technical diving.

As a general rule, any diver who has breathed gas under pressure at any depth who surfaces unconscious, loses consciousness soon after surfacing, or displays neurological symptoms within about 10 minutes of surfacing should be assumed to be experiencing arterial gas embolism. Symptoms of arterial gas embolism may be present but masked by environmental effects such as hypothermia, or pain from other obvious causes. Neurological examination is recommended when there is suspicion of lung overexpansion injury. Symptoms of decompression sickness may be very similar to, and confused with, symptoms of arterial gas embolism, however, treatment is basically the same. Discrimination between gas embolism and decompression sickness may be difficult for injured divers, and both may occur simultaneously. Dive history may eliminate decompression sickness in many cases, and the presence of symptoms of other lung overexpansion injury would raise the probability of gas embolism. Administration of high percentage oxygen is recommended for both venous and arterial air embolism. This is intended to counteract ischaemia and accelerate bubble size reduction. Hyperbaric therapy with 100% oxygen is recommended for patients presenting clinical features of arterial air embolism, as it accelerates removal of nitrogen from the bubbles by solution and improves tissue oxygenation. This is recommended particularly for cases of cardiopulmonary or neurological involvement. Early treatment has greatest benefits, but it can be effective as late as 30 hours after the injury. Most fully closed circuit rebreathers can deliver sustained high concentrations of oxygen rich breathing gas and could be used as an alternative to pure open circuit oxygen resuscitators. However pure oxygen from an oxygen cylinder through a Non rebreather mask is the optimal way to deliver oxygen to a decompression illness patient.

In terms of the epidemiology of air embolisms one finds that the intraoperative period to have the highest incidence. For example, VAE (vascular air embolism) in neurological cases ranges up to 80%, and OBGYN surgeries incidence can climb to 97% for VAE. In divers the incidence rate is 7/100,000 per dive.

Direct injection air embolism was one of the methods used by Belgian murderer Ivo Poppe to kill some of his victims (the other method being valium). William Davis, formerly a nurse in Texas, was convicted in October 2021 of murdering four and injuring two patients by injecting air into their arterial lines following heart surgery. During opening arguments for sentencing, prosecutors told the court that they would present evidence of an additional three murders and three attempted murders. Dorothy L. Sayers made use of direct injection air embolism as a murder method in her 1927 Lord Peter Wimsey mystery novel Unnatural Death (published in the US in 1928 as The Dawson Pedigree), although her description was subsequently criticised as implausible on account of the injection site and volume. Air embolism was the method used by an insane nurse to euthanize seven terminally ill patients in the episode "Amazing Grace" of the TV series Shadow Chasers. Near the end of young adult novel Catching Fire, as well as its film adaptation, protagonist Katniss Everdeen grabs a syringe and fills it with air, with the intention of killing Peeta Mellark quickly via air embolism.

Air embolisms generally occur in the xylem of vascular plants because a fall in hydraulic pressure results in cavitation. Falling hydraulic pressure occurs as a result of water stress or physical damage. A number of physiological adaptations serve to prevent cavitation and to recover from it. The cavitation may be prevented from spreading by the narrow pores in the walls between vessel elements. The plant xylem sap may be able to detour around the cavitation through interconnections. Water loss may be reduced by closing off leaf stomata to reduce transpiration, or some plants produce positive xylem pressure from the roots. When xylem pressure increases, the cavitation gases may redissolve.