Case Study: How to transport a patient with respiratory insufficiency

Briefing of the medical staff before boarding every patient is essential to make sure the flight crew and medical team are fully aware of and prepared for any likely incident during the repatriation or the evacuation.

We were tasked with the transfer of 69-year old Mr W with a medical history of SARSCOV2 infection, an estimated lung damage of 80 per cent and pulmonary fibrosis, from Freetown, Sierra Leone, to Beirut, Lebanon.

Mr W was hospitalised in the intensive care unit, conscious, calm and cooperative, where he benefited from close sessions of non-invasive ventilation (NIV), with a saturation of 90 per cent under 15L/min of O2, a respiratory rate of 20c/min, a PaCO2 of 32mmHg and a PaO2/FiO2 ratio = 130mmHg. After calculating the oxygen requirements, the decision was to transport the patient on NIV with a face mask and a saturation objective to maintain >92 per cent during the flight.

Airway assessments have become mandatory on all our patients in order to prepare for a difficult intubation in the presence of certain criteria. Our patient was bearded, had Retrognathism, short neck, thyromental distance <6.5 and Mallampati score class 2. Mr W was boarded in a half-sitting position, managing and releasing the space around the stretcher to facilitate the crew’s movement and care during the flight.

At an altitude of 11,000m (36,000ft) and within 30 minutes of departure, the patient began to present with headaches, visual disturbances, behavioral disorders and SaO2 at 80 per cent under 100 per cent FiO2, ventilated in spontaneous mode with pressure support NIV PS.

Hence, the decision to intubate was made immediately. Preparation of difficult intubation equipment was done; rapid sequence induction was performed, and the patient was ventilated with bag-valve-mask resuscitators (BVMS). On direct laryngoscopy, the Cormack score was 4 and two attempts at intubation failed with Eschmann’s guide, leading to the resumption of ventilation with a face mask, and placement of a laryngeal mask No 5 five inflated with saline solution.

Under sedation, the patient was put in pressure-controlled ventilation (PCV) mode to minimise leakage of the laryngeal mask by hyperpressure, so we could lower our oxygen consumption needs during the flight by up to 50 per cent, with an oxygen saturation of 95 per cent.

For a flight time of eight hours, the patient remained respiratory and haemodynamically stable. An en-route flight incident was logged in the mission report and given to the receiving team in Beirut.

On arrival at the hospital, the patient was transferred to the intensive care unit, where he was successfully reintubated under a fibroscopy. Mr W made good progress and was extubated 15 days later.

Lessons learned

Upon the arrival of the medical team in Morocco, a meeting was held at Air Ocean Maroc’s headquarters in Rabat the following day to discuss the experience as part of our continuing education program. Several conclusions were drawn, allowing us to establish more detailed procedures to avoid similar incidents during flights presenting a high probability of intubation.

To do this, we have:

• Added a section dedicated to airway examination in our medical flight log as part of the initial medical assessment
• Established a clear course of action for patients who are difficult to intubate and shared this with all doctors and nurses in our company
• Added complete kit for difficult intubation and laryngeal masks in all sizes to the emergency medical bags, and we plan to add a fibrolaryngoscope as well.

The medical repatriation and evacuation of patients with respiratory failure always requires specific preparation, with pre- and post-flight briefings to prepare for any possible incidents, and with the mandatory presence of a well-trained medical team accustomed to working closely together.