Acute Bilateral Pulmonary Thromboembolism with Respiratory Failure & Right Heart Failure in a Post-CVA Patient

Chief Complaints

A 55-year-old male patient with a body mass index (BMI) of 19 presented to the Pulmonology Department at PACE Hospitals, Hitech City, Hyderabad, with complaints of shortness of breath, dryness of the throat, and cough with scanty expectoration for the past 15 days. He also reported worsening breathlessness over the preceding few months, with marked deterioration during the last 15 days.

The patient was a known case of cerebrovascular accident (CVA) with right-sided hemiparesis and was on treatment. He had reportedly discontinued his regular medications before the onset of worsening symptoms. He had no known history of hypertension, diabetes mellitus, or tuberculosis. He was a former smoker who had quit smoking five years earlier.

On examination, the patient was conscious, coherent, and oriented but was in severe respiratory distress. He required immediate oxygen support because of significant breathing difficulty. Lower limb swelling was noted on walking, while there was no wheezing, chest tightness, fever, weight loss, or loss of appetite. Considering the severity of his condition, he was admitted to the intensive care unit for close monitoring and further management.

Upon admission to PACE Hospitals, following a detailed clinical assessment, the Pulmonology team evaluated the patient for severe shortness of breath, respiratory distress, dryness of the throat, cough with scanty expectoration, and a history of cerebrovascular accident with right-sided hemiparesis.

CT pulmonary angiography performed before referral revealed bilateral segmental and subsegmental pulmonary thromboembolism. Cardiac evaluation through 2D echocardiography showed dilatation of the right atrium and right ventricle, along with severe pulmonary arterial hypertension and severe tricuspid regurgitation, indicating significant strain on the right side of the heart.

Laboratory investigations showed elevated D-dimer and NT-proBNP levels, supporting the presence of acute pulmonary thromboembolism and cardiac stress. Doppler studies of both lower limbs and the neck veins did not reveal any significant venous thrombosis. The remaining blood investigations were largely within acceptable limits.

Based on the clinical presentation, CT pulmonary angiography, cardiac findings, and laboratory investigations, the patient was diagnosed with acute bilateral pulmonary thromboembolism associated with acute respiratory failure and right heart failure in a patient with a previous cerebrovascular accident.

Based on the confirmed diagnosis, the patient was advised to undergo Acute Pulmonary Thromboembolism Treatment in Hyderabad, India, under the expert care of the Pulmonology Department at PACE Hospitals.

After a detailed consultation with the consultant interventional pulmonologist Dr. Pradeep Kiran Panchadi, and cross consultations with nephrologist Dr. A. Kishore Kumar, the neurophysician, ENT surgeon, and cardiologist, a comprehensive evaluation was performed to determine the most appropriate diagnostic and therapeutic approach.

Considering the patient’s history of cerebrovascular accident with right-sided hemiparesis, progressive breathlessness, severe respiratory distress, and clinical findings suggestive of pulmonary thromboembolism, further evaluation confirmed acute bilateral segmental and subsegmental pulmonary thromboembolism with acute respiratory failure and right heart failure. CT pulmonary angiography showed bilateral pulmonary emboli, while 2D echocardiography revealed right atrial and right ventricular dilatation, severe pulmonary arterial hypertension, and severe tricuspid regurgitation. Doppler studies of both lower limbs and neck veins were normal.

Based on the clinical assessment, imaging findings, and laboratory investigations, it was determined that intensive care management with oxygen support, low molecular weight anticoagulants, diuretics, nebulization, breathing exercises, and physiotherapy was the most appropriate and effective management strategy. This approach was chosen to improve oxygenation, prevent further clot formation, reduce strain on the right side of the heart, manage pedal edema, relieve respiratory distress, and support overall recovery.

The patient and his family members were counselled regarding the diagnosis, clinical findings, treatment plan, importance of anticoagulant compliance, regular coagulation tests, breathing exercises, physiotherapy, follow-up investigations, and continued review with the pulmonologist and cardiologist.

Following the decision, the patient underwent treatment for acute bilateral pulmonary thromboembolism, acute respiratory failure, and right heart failure associated with cerebrovascular accident at PACE Hospitals, Hyderabad, under the expert supervision of the Pulmonology team.

During his hospital stay, the patient received anticoagulant therapy to prevent further clot formation and support the gradual resolution of the pulmonary embolism. Diuretic therapy was given to reduce pedal edema and relieve strain on the right side of the heart.

Nebulisation therapy, oxygen support, breathing exercises, incentive spirometry, physiotherapy for both lower limbs, nutritional support, and other supportive measures were provided to improve respiratory function and overall recovery.

The patient was closely monitored for oxygen saturation, respiratory rate, haemodynamic stability, neurological status, pedal edema, and any signs of bleeding or worsening breathlessness.

After clinical improvement and a reduction in oxygen requirement, the patient was shifted from the intensive care unit to the general ward and later discharged in a stable condition with advice.

At discharge, the patient was advised to continue medications to prevent the formation of new blood clots, reduce excess fluid accumulation and leg swelling, control cholesterol levels, relieve breathing difficulty, manage allergy-related throat irritation, protect the stomach from acidity, and prevent seizures related to the previous cerebrovascular accident. 

Nebulisation was continued as advised to support easier breathing. The patient was also instructed to follow the prescribed dosage and duration carefully, undergo regular blood-clotting tests, and attend scheduled pulmonology and cardiology follow-up visits.

The patient was advised to take all prescribed medications regularly, continue breathing exercises, incentive spirometry, and lower-limb physiotherapy, and avoid prolonged immobility. A protein-rich diet, adequate hydration, and gradual physical activity were also recommended.

The patient was informed to contact the emergency ward at PACE Hospitals in case of sudden or increasing breathlessness, chest pain, reduced oxygen saturation, coughing up blood, fainting, confusion, bluish discoloration of the lips or fingers, increased leg swelling, unusual bleeding, or any other alarming symptoms.

The patient was advised to return for a follow-up consultation with the Pulmonologist in Hyderabad at PACE Hospitals, after 1 month.

This case highlights the successful multidisciplinary management of acute bilateral pulmonary thromboembolism complicated by acute respiratory failure and right heart failure in a patient with a previous cerebrovascular accident. Early diagnosis, prompt intensive care, timely anticoagulation, and coordinated supportive treatment resulted in significant clinical improvement and a stable recovery at discharge.