IMPRESSION:
In comparison with the earlier study of this date, there again is a
 tracheostomy tube in place with the right subclavian PICC line extending to
 the lower portion of the SVC.  There is substantial enlargement of the cardiac
 silhouette with pulmonary edema and bilateral layering effusions, more
 prominent on the right, with underlying compressive atelectasis at the bases.
 Cervical spine fixation device is again seen.