ABSTRACT
Background: Radial probe endobronchial ultrasound (R-EBUS) is often utilized in guided bronchoscopy for the diagnosis of peripheral pulmonary lesions. R-EBUS probe positioning has been shown to correlate with diagnostic yield, but overall diagnostic yield with this technology has been inconsistent across the published literature. Currently there is no standardization for R-EBUS image interpretation, which may result in variability in grading concentricity of lesions and subsequently procedure performance. This was a survey-based study evaluating variability among practicing pulmonologists in R-EBUS image interpretation. Methods: R-EBUS images from peripheral bronchoscopy cases were sent to 10 practicing Interventional Pulmonologists at two different time points (baseline and 3 months). Participants were asked to grade the images as concentric, eccentric, or no image. Cohen's Kappa-coefficient was calculated for inter- and intra-observer variability. Results: A total of 100 R-EBUS images were included in the survey. There was 100% participation with complete survey responses from all 10 participants. Overall kappa-statistic for inter-observer variability for Survey 1 and 2 was 0.496 and 0.477 respectively. Overall kappa-statistic for intra-observer variability between the two surveys was 0.803. Conclusions: There is significant variability between pulmonologists when characterizing R-EBUS images. However, there is strong intra-rater agreement from each participant between surveys. A standardized approach and grading system for radial EBUS patterns may improve inter-observer variability in order to optimize our clinical use and research efforts in the field.
ABSTRACT
Background: Right heart thrombus or clot in transit is a rare venous thromboembolism (VTE) with high mortality. COVID-19 infection has been associated with increased risk of such events. We present the case of a 63-year-old man with no traditional VTE risk factors who was diagnosed with a clot in transit three weeks after diagnosis of COVID-19. Clinical Case. A 63-year-old male with no significant past medical history who presented to the emergency department with shortness of breath. He tested positive for COVID-19 three weeks prior. His oxygen saturation was 60% on room air and was put on nonrebreather mask. He was still showing signs of respiratory distress including tachypnea, tachycardia, diaphoresis, and accessory muscle use. The patient was subsequently intubated and mechanically ventilated. Chest computed tomography with contrast showed acute bilateral pulmonary emboli with flattening of the interventricular septum suggestive of right heart strain. Bedside echocardiogram showed severely enlarged right ventricle with reduced systolic function and evidence of right ventricular strain and a mobile echodensity in the right ventricle attached to the tricuspid valve consistent with a clot in transit. The patient was treated with full dose systemic thrombolysis with rapid improvement in his symptoms. He was extubated the following day and a repeat echocardiogram showed resolution of the clot in transit. Conclusion: Clot in transit is rare but can occur in COVID-19 patients even in the absence of traditional thromboembolism risk factors. Management includes systemic anticoagulation, systemic thrombolysis, and surgical embolectomy. Our patient was successfully treated with systemic thrombolysis.
