The aims of the study were to look at information on which the decision to ventilate chronic obstructive pulmonary disease (COPD) patients admitted to an intensive care unit (ITU) was based (including whether there was discussion with the patient, relatives and consultant), to identify indicators of poor prognosis, and to assess the outcomes of ventilation and functional capacity after discharge. A retrospective study of 27 months of admissions was carried out. The following variables were studied to see if they influenced prognosis: premorbid history, admission diagnosis, consultant involvement in the decision to transfer to ITU, admission chest radiograph, sputum bacteriology, arterial blood gases, APACHE II scores, duration of ventilation and complications in ITU. In-hospital mortality, post-discharge mortality and length of hospital stay were recorded. Functional capacity after discharge was assessed from the hospital clinic records and from general practitioners. Forty-six percent of case notes had inadequate premorbid information and no documented discussion occurred in 66% of patients/relatives. Poor prognostic indicators were admissions after cardiorespiratory arrest, cases discussed with consultants regarding ITU transfer, previous therapy with long-term oral steroids, and developing renal or cardiac failure in ITU. APACHE II scores were higher in the group that died. There was 49% hospital mortality and 59% 1-year mortality. Fifty-three percent of survivors were dependent upon carers and housebound, and general practitioners felt that 59% of survivors had a higher dependence on carers, a worse exercise tolerance and a poorer quality of life than before admission. The decision to ventilate is often made with inadequate background history, which could be sought from general practitioners, hospital case notes and family. There is significant morbidity and mortality following ventilation. Further prospective studies are required to help select which COPD patients should be ventilated.

Retention of sputum is a major cause of morbidity and mortality following thoracic surgery and regular access to the trachea for suction can only be obtained either by tracheostomy or endotracheal intubation, both of which have significant disadvantages. A simple method of percutaneous tracheal cannulation for suction has therefore been developed in which a 4 mm Portex paediatric endotracheal tube is inserted through a 1 cm incision in the cricothyroid membrane, using a guarded knife and an introducer. The procedure can be performed in the ward or theatre, using local or general anaesthesia. Twenty-four patients have been treated between October 1981 and June 1982. Ages ranged from 19-80 years and the duration of cannulation from 1-45 days. No patient subsequently required any further treatment for sputum retention. Twenty-one patients made an uneventful recovery and 3 died from unrelated causes. Following decannulation healing occurred within 6 days and there were no late sequelae. The method is much simpler and less invasive than existing alternatives and can therefore be used at an early stage and before the consequences of sputum retention become irreversible.

SummaryTracheal rupture as a direct complication of tracheal intubation is rare. We report a case where this occurred during oesophageal surgery. The literature describing eight previous cases is reviewed and recommendations are made to reduce the possibility of such an occurrence.

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Lighting codes in terms of levels of illumination incident on the visual task have served a valuable purpose for over fifty years. When based on sound principles, they are still valid for the lighting on the work. The lighting of the building interior, however, should not have to be constrained by the lighting on any specific visual task, and should be planned in relation to the design of the whole building. Experiment and observation show that the degree of satisfaction given by lighting is regulated by the brightness pattern in the visual field. Good lighting requires selective illumination on the work, together with an environment free from excessive brightness and glare. The relation between the work lighting and the building lighting should properly be developed in terms of apparent brightness, and an outline is given ofthe research programme necessary for this purpose. Meanwhile an interim stage is proposed for a lighting code to be based on existing knowledge of visual comfort in relation to brightness distribution in the visual field.