Correct!
1. Begin CPAP/NIV for impending respiratory failure
The thoracic CT scan shows several problems. First, the tracheostomy is too short in this large man and does not reach the trachea. Second, there is consolidation in the right lower lobe but also clearly a right pleural effusion with an air-fluid level.
Continuous positive airway pressure/noninvasive ventilation (CPAP/NIV) is not appropriate in this patient for several reasons (2). First, CPAP/NIV is relatively contraindicated with copious secretions. CPAP/NIV may push the secretions deeper into the airways and limit secretion mobilization. It may also dry secretions making the secretions thicker and more tenacious. Second, the patient has a relatively focal process. CPAP or other positive airway pressure may over-distend the most compliant portions of the lung which are normal. This may shunt blood to the less compliant portions which have poor ventilation worsening ventilation-perfusion mismatch. Lastly, the tracheostomy tube is not in the trachea and beginning CPAP/NIV will likely result in the air in the mediastinum.
The patient was transferred to the ICU and underwent the placement of a new longer Shiley XLTCP (eXtra Long Cuffed Tracheostomy Proximal) under bronchoscopic guidance. He was begun on mechanical ventilation. A thoracostomy tube was inserted and purulent, odiferous fluid was obtained which grew beta-hemolytic Streptococcus. The patient improved with ampicillin/sulbactam and a brief course of mechanical ventilatory support.
The patient was clinically improving but a repeat thoracic CT scan showed residual fluid. Which of the following has been shown to improve pleural fluid drainage in empyema?