MEDizzy - A 53-year-old man is admitted with fevers and right

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Disorders of the Respiratory System and Critical Care Illness

A 53-year-old man is admitted with fevers and right pleuritic chest pain for 5 days. He has a history of alcohol dependence. On presentation, his temperature is 39.2°C, heart rate is 112 bpm, blood pressure is 102/62 mmHg, respiratory rate is 24 breaths/min, and SaO2 is 92% on room air. He has absent breath sounds in the right lower chest with dullness to percussion and decreased tactile fremitus. Chest radiograph confirms a right lower lobe consolidation with associated effusion. The fusion is not free-flowing. Initial thoracentesis demonstrates gross pus in the pleural space, and the Gram stain is positive for gram-positive cocci in pairs and chains. A large-bore chest tube is placed. Which of the following treatments should also be recommended in this patient to improve the resolution of the empyema in this individual?

ExplanationEmpyema refers to the presence of a grossly purulent pleural effusion, which is present in this clinical scenario. The management of an empyema requires placement of a chest tube for drainage, and a recent randomized, placebo-controlled clinical trial demonstrated improved outcomes with the use of both alteplase (tissue plasminogen activator) and deoxyribonuclease (DNase) twice daily for 3 days beginning within the first day after chest tube placement. The trial was conducted using a factorial design comparing the combination therapy to placebo and to either therapy alone. The combination of alteplase and DNase showed improved resolution of pleural fluid, shorter duration of hospital stay, and lesser need for surgical intervention when compared to placebo or either therapy alone