key: cord-0983061-rwom5jjq
authors: Nieri, Dario; Lenzini, Giulia; Canari Venturi, Barbara; Celi, Alessandro
title: Pulmonary embolism: yet another cause of hypoxaemic respiratory failure in COVID-19
date: 2020-06-01
journal: ERJ Open Res
DOI: 10.1183/23120541.00220-2020
sha: a3577155bae8b56bdcc3cb8762afbab60ef276cf
doc_id: 983061
cord_uid: rwom5jjq

Pulmonary embolism represents an overlooked cause of worsening respiratory failure in COVID-19. A regular bedside evaluation for atypical features like pleuritic chest pain or pleural effusion could help identify suspected cases for appropriate management. https://bit.ly/3bbBPqZ

(COVID-19) patients, the real rate of VTE is currently not known; however, in a study by CUI et al. [6] , 20 (25%) patients out of 81 admitted to an intensive care unit for severe SARS-CoV-2 pneumonia developed VTE and the authors suggest a possible D-dimer cut off level (1.5 μg·mL −1 ) to identify high-risk subjects, even though the retrospective nature of this observation does not allow firm conclusions to be drawn for routine clinical practice. Moreover, these patients often carry an elevated haemorrhagic risk as well [7] , so that prescribing heparin at full anticoagulation dose solely on the basis of D-dimer levels could be potentially dangerous. Raising the clinical suspicion of pulmonary embolism is notoriously challenging; this might be particularly true in a clinical situation, such as COVID-19, in which respiratory failure is a dominant feature, and concerns related to virus containment make it particularly difficult to organise diagnostic tests [8] and even to guarantee appropriate close clinical monitoring. Therefore, it is important to pay particular attention to "atypical" characteristics; pleural effusion, for instance, is a very rare feature in COVID-19 [9] , while it is a relatively frequent and often overlooked feature of pulmonary embolism [10] and should therefore prompt attention to possible complications in COVID-19 patients, especially in those without a clear alternative explanation (such as heart failure). Chest pain is a common symptom in pulmonary embolism patients, once again likely not characteristic of COVID-19.

In conclusion, pulmonary embolism must be kept in mind as a possible complication in COVID-19: a regular bedside clinical evaluation to promptly identify atypical features development (including pleuritic chest pain, novel pleural effusion development as assessed by lung ultrasound, sudden onset of tachycardia or right bundle block on ECG) could help to suspect pulmonary embolism, which should ultimately be confirmed by specific diagnostic tests such as CTPA.

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