A 49 year-old man was originally admitted four days ago after developing an acute onset of dysarthria and left hemiplegia, and was found to have had a proximal right M1 occlusion. He was treated with thrombectomy. He was intubated for the procedure, but due to the late hour of the day at which this was performed, he was left intubated upon overnight admission to the NCCU. Chest X-ray is obtained to confirm ETT placement, as shown below. Due to the large stroke burden taking about 60% of his MCA territory, he undergoes early decompressive hemicraniectomy on ICU day 2.
Initial vitals are notable for BP 135/78, HR 94, Sp02 97%, T 37.2C. Labs are notable for WBC 8.4, Hb 12.1, Plt 215, Na 140, K 4.5, Cl 112, HCO3 23, BUN 10, Cr 0.78, glucose 156. Ventilator settings are VC/AC, Vt 7mL/kg IBW, PEEP 5, RR 12, FiO2 21%.
There is an alveolar pattern of opacification in the right middle and lower lobes. The former is apparent due to some obscuration of the right cardiac border, while the latter is apparent due to obscuration of the right hemidiaphragmatic border. There's probably some plate atelectasis in the left lower lobe. Cardiac contours appear normal. We can't see the right costophrenic angle, so there could be some fluid there. No apparent pneumothorax. The ETT appears in good position (not measured here, but in the correct range above the carina). In considering the overall lung volumes present bilaterally, but especially the right, we are right to be concerned that this RML/RLL opacification represents consolidation not from atelectasis.
Should we start antibiotics? True, this opacification could represent pneumonia. However, the patient is not hypoxemic, secretion burden hasn't been commented on, and there hasn't been a fever or leukocytosis. At this stage, the patient has a radiographic finding and perhaps could've had a pneumonitis. There isn't any clinical evidence pointing towards a pneumonia.
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