Airway manipulation with tracheotomy

Case presentation An 85-year-old woman has a medical history significant for obesity, hypertension, coronary artery disease, chronic obstructive lung disease with recurrent exacerbations, and peripheral vascular disease. She was originally admitted to hospital with pneumonia, and after a prolonged intensive care unit stay and a failure to wean, she underwent tracheotomy and was transferred to a chronic care facility. After 3 weeks there, she returned to hospital with persistent fevers, increased white blood cell count, and an increasing oxygen requirement despite intravenous antibiotic therapy. A chest computed tomography scan revealed a multiloculated right-sided pleural effusion and significant consolidation of her right lower lobe. The patient is scheduled for right-sided thoracoscopic drainage of empyema. The patient is awake and responds to commands. She is currently mechanically ventilated via a 6.0 cuffed tracheotomy tube. Her ventilator settings are pressure support 10 cm H2O, positive end expiratory pressure (PEEP) of 5 cm H2O, and 50% inspired oxygen. Physical exam reveals a Mallanpatti 3 airway with two finger breadths hyomental distance and limited neck extension secondary to multilevel cervical fusion. She has coarse breath sounds bilateral with decreased air entry noted at the right base.