The practitioner understands that confidentiality is of utmost importance and in order to comply with the Health Professions Council (HPC) (2008) the pseudonym of Mrs Foster will be used for reasons of anonymity and confidentiality.
Mrs Foster is a 61 year old morbidly obese female with exacerbating chronic obstructive pulmonary disease (COPD) and a deteriorating chest infection. On admission to the ICU, she was diagnosed with type 2 respiratory failure and was intubated immediately and an arterial cannula and a catheter inserted. Due to prolonged intubation on the unit, Mrs Foster was transferred from the Intensive Care Unit (ICU) to the theatre department for an operation to remove the endo-tracheal tube which was in situ and replace it with a tracheostomy tube. Mrs Foster was then transferred back to the ICU to continue essential invasive and non invasive monitoring of her critical care.
Mrs Foster was admitted to the ICU for type 2 respiratory failure. The Intensive Care Society (ICS) (1997) state that this is the most appropriate setting for Mrs Foster as she needs advanced respiratory support and has a potentially recoverable condition, and would benefit from more detailed observation and invasive treatment than can be provided safely in an ordinary ward or high dependency area.
Type 2 respiratory failure is where there is severe malfunction in gas exchange between the lungs and the blood causing hypoxaemia and hypercapnia and if not treated correctly can be potentially life threatening (Francis, 2006).The cause of Mrs Foster’s respiratory failure was due to exacerbating COPD, a deteriorating chest infection and being classed as morbidly obese with a Body Mass Index (BMI) of 47 (Association of Anaesthetists of Great Britain and Ireland (AAGBI) 2007a). Mrs Foster had been intubated with an endo-tracheal tube which had been in situ for six days. The Intensive Care National Audit and Research Centre (2008) suggest that anticipated ventilation longer than 7-14 days should indicate a tracheostomy is performed. A tracheostomy is the opening of the trachea through a transverse surgical incision just below the cricoid cartilage and the insertion of a cannula and tracheostomy tube establishing a safer, more permanent, comfortable and less traumatic airway for the patient (Rothrock, 2003).The decision to perform a tracheostomy in the theatre department was that of the critical care anaesthetist in conjunction with the specialist consultant surgeon. The contraindications for performing surgery in theatre were explored and included the COPD and morbid obesity but the potential benefits of the theatre surgery outweighed the convenience of a percutaneous technique at the bedside in the ICU should difficulties arise and an open surgical procedure be needed. This communication showed the appropriate use of a strategy and displayed mutual respect for the skills and contributions of each other’s profession. In the practitioner’s view, the decision making was handled in an appropriate and effective way ensuring safety of the patient, high quality care and that the best possible outcomes for the patient were achieved. This decision was supported by Local Trust Policy (2006a) and the ICS (2008) who agree that prolonged endo-tracheal intubation carries a high risk of damage to the soft tissues of the mouth, pharynx and trachea, it also reduces the patient’s ability to