Correct!
4. 1 and 3

Recently, the combination of DNase and tissue plasminogen activator has been shown to improve fluid drainage in patients with pleural infection and reduce the frequency of surgical referral and the duration of the hospital stay (3). Treatment with DNase alone or t-PA alone was ineffective. In the largest randomized trial, the use of streptokinase resulted in no reduction in mortality, decortication rates or hospital days compared with placebo in the treatment of empyema (4).

Pearls

1. Tracheostomy misadventures can occur more than 2 weeks after a surgical tracheostomy placement and can be difficult to detect clinically.
2. Urgent diagnostic and therapeutic drainage of empyema is critical.

References

1. Rana S, Pendem S, Pogodzinski MS, Hubmayr RD, Gajic O.Tracheostomy in critically ill patients. Mayo Clin Proc. 2005;80(12):1632-8. [CrossRef] [PubMed]
2. Hess DR. The evidence for noninvasive positive-pressure ventilation in the care of patients in acute respiratory failure: a systematic review of the literature. Respir Care. 2004;49(7):810-29. [PubMed]
3. Rahman NM, Maskell NA, West A, et al. Intrapleural use of tissue plasminogen activator and DNase in pleural infection.N Engl J Med. 2011;365(6):518-26. doi: 10.1056/NEJMoa1012740. [CrossRef] [PubMed]
4. Maskell NA, Davies CW, Nunn AJ et al. U.K. Controlled trial of intrapleural streptokinase for pleural infection. N Engl J Med. 2005;352:865–74. [CrossRef] [PubMed] 

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