A 26-year-old woman with a past history of seizure disorder is admitted to the medical ICU with status epilepticus. Due to continued seizures, she is placed in a barbiturate coma. As pa of suppoive measures, she is intubated, placed on a mechanical ventilator, and given IV fluids through a central line. She remains stable overnight. In the morning, however, the respiratory therapist repos that she has had excessive mucopurulent secretions throughout the night and that her peak and plateau airway pressures have risen 20 cm. She is febrile with a temperature of 100.2degF the next morning. CXR is shown.An impoant step in management of this patient would be

This x-ray shows homogeneous opacity in the right upper lobe with a marked shift of the horizontal fissure. No air bronchograms are seen. This is consistent with right upper lobe atelectasis. There is a small bump near the hilum in the curve of the minor fissure that may represent a proximal mass. The clinical history as well as the homogeneous density seen in the right upper lobe are consistent with right upper lobe atelectasis. Complications of central line placement may include lung contusion or hemothorax, but the x-ray findings usually show an expanding density. The clinical history with seizure disorder, the subsequent intubation, and the excessive secretions suggest that a mucus plug is probably causing right upper lobe atelectasis. In view of this, the next step in immediate management would be to begin aggressive chest physical therapy, or a bronchoscopy could help dislodge the mucus plug and clear the right upper lobe bronchus.