Pulmonary air embolism.

Pulmonary air embolism is a well-known consequence of surgery, trauma, diving, and aviation. This article reviews the physiological effects, means of detection and methods of prevention and treatment of pulmonary air embolism. The primary physiological effects are elevated pulmonary artery pressures, increased ventilation-perfusion inhomogeneity, and right ventricular failure. The degree of physiological impairment depends on the volume of gas entrained, the rate of entrainment, the type of gas entrained, and the position of the patient when the embolism occurs. Transesophageal echocardiography is the most sensitive method of detection, but it is invasive. Precordial Doppler ultrasound is almost as sensitive and poses no risk to the patient. End-tidal carbon dioxide monitoring is used on all patients and is a moderately sensitive method of detection, which is useful during surgeries that have a low incidence of air embolism. For high-risk procedures, precordial Doppler ultrasound and a multi-orifice right heart catheter should be used to detect and treat pulmonary air embolism. Prevention measures include volume expansion, careful positioning, positive end-expiratory pressure, military anti-shock trousers, and jugular venous compression. Treatment of pulmonary air embolism includes flooding the surgical site with saline, controlling sites of air entry, repositioning the patient with the surgical site below the right atrium, aspiration of air from a central venous catheter, cessation of inhaled nitrous oxide, and resuscitation with oxygen, intravenous fluids, and inotropic agents. Some hypotheses on the effects of air in the pulmonary vasculature and investigational treatment options are discussed.