Management of Pulmonary Embolism and Associated Complications

Oxygen Management

The European Society of Cardiology recommends administration of supplemental oxygen in patients with pulmonary embolism and low oxygen saturation, with a target saturation of 94-98% (or 88-92% if at risk of hypercapnic respiratory failure) 1, 2
For patients with pulmonary embolism requiring oxygen, provide supplemental oxygen to maintain a target saturation of 94-98% using nasal cannula or face mask 2
If the patient has risk factors for hypercapnic respiratory failure, target a lower oxygen saturation of 88-92% 2
Consider high-flow oxygen (high-flow nasal cannula) if conventional oxygen supplementation is insufficient 1
Non-invasive ventilation should be considered before intubation if the patient has increasing respiratory distress despite oxygen therapy 1

Consider bronchodilator therapy with inhaled beta-agonists for symptomatic relief of wheezing 4

The European Society of Cardiology recommends continuation of anticoagulation therapy as the primary treatment for pulmonary embolism 1
Assess for right ventricular dysfunction with imaging (echocardiography) or laboratory biomarkers (troponins, natriuretic peptides) 5
If central venous pressure is low, consider modest fluid challenge (≤500 mL), but avoid aggressive volume expansion which may worsen right ventricular function 1
Risk-stratify the patient using validated tools like PESI or sPESI to guide management decisions 5

Obtain arterial blood gases within 30-60 minutes of initiating oxygen therapy to assess for hypercapnia 6
Monitor for signs of respiratory failure requiring escalation of respiratory support 7

Avoid excessive positive end-expiratory pressure in patients with pulmonary embolism as it may reduce venous return and worsen right ventricular failure 1
If mechanical ventilation becomes necessary, use tidal volumes of approximately 6 mL/kg lean body weight to keep end-inspiratory plateau pressure <30 cmH₂O 1
Be aware that severe hypoxemia refractory to conventional oxygen therapy could indicate right-to-left shunting through a patent foramen ovale 1
Avoid intubation if possible, as induction of anesthesia and positive-pressure ventilation can cause severe hypotension in patients with right ventricular failure 1