References 1. Bedi P, Chalmers JD, Graham C, et al. A Randomized controlled trial of atorvastatin in patients with bronchiectasis infected with pseudomonas aeruginosa: a proof of concept study. Chest. 2017;152(2):368-378. 2. Evans IE, Bedi P, Quinn TM, et al. Bronchiectasis severity is an independent risk factor for vascular disease in a bronchiectasis cohort. Chest. 2017;151(2):383-388. 3. Navaratnam V, Millet E, Hurst JR, et al. Cardiovascular risk factors in people with bronchiectasis: a cross sectional study. Thorax. 2014;69(suppl 2):A11.
Improving CPR PerformanceIn their excellent review on improving CPR performance, we feel that Drs Nassar and Kerber 1 have not emphasized the duration of CPR in certain clinical situations. We have published our experience in patients with pulmonary embolism presenting with cardiopulmonary arrest inhospital, where we successfully discharged four of six patients. 2 We used tenecteplase as a single-dose lytic agent with an emphasis on prolonged intense chest compressions, hypothesizing that this would maintain the circulation while the lytic agent had time to act. Prolonged CPR also modifies the potentially prothrombotic state that cardiopulmonary arrest inherently is. Even if return of spontaneous circulation is established, if the heart rate is low, cardiac output will be inadequate and chest compressions should be continued in patients with cardiopulmonary arrest from pulmonary embolism. 2 As we have emphasized recently, 3 based on our understanding of certain pathologies in congenital heart disease, the right ventricle is ill-equipped to handle sudden increase in pressures unlike the morphological left ventricle, and prolonged CPR may be suited in pulmonary embolism acting as an useful adjunct to thrombolysis.In summary, in addition to the factors that determine the quality of CPR and eventual outcome as elucidated by the authors, in those with pulmonary embolism and cardiopulmonary arrest, the prolongation of CPR beyond the moment of return of spontaneous circulation should also be emphasized, in our opinion.
