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Dear editor, The SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2)-related acute respiratory distress syndrome (ARDS) is associated with an elevated coagulation activation pattern [1] and a high incidence of pulmonary embolism [2]. The diagnosis of pulmonary embolism (PE) may be challenging in these patients because computed tomography pulmonary angiogram (CTPA) requires an intrahospital transport with potential adverse effects and also may increase the risk of acute kidney failure (contrast-induced nephropathy). This is even more the case in up to 10% of SARS-Cov-2 ARDS patients who require venovenous extracorporeal membrane oxygenation (vv-ECMO) as an extracorporeal lung support [1]. In addition to the inherent risks of hospital transport, which are particularly high in these patients [3], extracorporeal circulation is likely to alter the quality of the contrast agent distribution and may reduce the diagnostic performance of the CTPA [4]. Finally, systematic curative antithrombotic therapy is not a safe option as it exposes to a serious risk of bleeding, especially when prolonged vv-ECMO is expected [5]. For all the abovementioned reasons, alternative techniques allowing the diagnosis of PE in these vv-ECMO patients would be of the highest interest. Here, we describe the feasibility, safety, and diagnostic accuracy of endobronchial ultrasound (EBUS) to detect PE in patients with severe SARS-CoV-2 ARDS requiring vv-ECMO. Between April 15 and May 1, 2020, eleven patients were included. The procedure was performed using a 6.7-mm-outer-diameter, real-time, bronchoscope (EB-530US; FUJIFILM Medical Corporation, Tokyo, Japan) with a 7.5-MHz linear ultrasound transducer (SU-1 H; FUJIFILM Medical Corporation, Tokyo, Japan) equipped with color-Doppler. For each patient, EBUS procedure followed the same roadmap [6]. All EBUS images and videos were reviewed by two independent experts in thoracic radiology (S.B. and D.T.) blind from the CTPA interpretation. The study was approved by the research ethics committee of Sorbonne University (CERSU N°2020-48) and information was given to the patients or their relatives. Patients were mostly men (n = 10), 52 [49–55] years old, with a body mass index of 29 [28–31] kg/m (Table 1). The time between intubation, vv-ECMO and EBUS was 21 [11–27] and 13 [7–18] days, respectively. At the time of EBUS procedure, three patients were not receiving antithrombotic therapy, two were receiving effective curative unfractionated heparin, and six were receiving prophylactic unfractionated heparin (dose was 18,000 [14,000–20,000] UI/day). Pulmonary embolism was observed on EBUS in five of the eleven patients

critical care

Endobronchial ultrasound is feasible and safe to diagnose pulmonary embolism in non-transportable SARS-CoV-2 ARDS patients requiring extracorporeal lung support