Managing a difficult airway

Managing a difficult airway during long-range international fixed-wing aeromedical transport presents a specific set of challenges. With two medical crewmembers – usually an intensive care unit (ICU) physician and a critical care nurse – airway interventions must be executed with precision, adaptability, and a deep understanding of the constraints and capabilities of the airborne ICU environment.

Case scenario

A 58-year-old male with septic shock and progressive respiratory failure required intercontinental evacuation. His history of head-and-neck surgery and limited mouth opening identified him as an anticipated difficult airway. Two hours into the flight, while crossing a remote oceanic region with no diversion options for several hours, the patient developed worsening hypoxaemia and agitation despite maximal non-invasive respiratory support. The crew initiated in-flight intubation.

Operational considerations

Although the aircraft cabin remains a confined workspace, Unicair’s long-range fleet is designed specifically for critical care delivery. The stretcher platform, lighting, and equipment layout allow the twoperson crew to function as a coordinated, efficient unit. Equipment preparation and checklists, escalation to backup plans, communication strategies, and task allocation are well rehearsed in simulation training, enabling complex procedures to be performed safely in flight.

All Unicair aircraft do carry an ICUlevel airway management suite. Available tools include standard and video laryngoscopes, bougies, laryngeal masks, video stylet, and single-use bronchoscopes (latter on request). In addition, a complete surgical airway kit, including a tracheostomy set, is available, ensuring that the full spectrum of airway interventions can be performed without reliance on diversion or external support. Oxygen, suction, and power systems are optimised for long-duration missions, providing a stable platform for advanced airway care even over remote regions and oceans.

Airway strategy

A tiered approach was prepared:

• Primary plan: video laryngoscopy for optimal visualisation, bougie-assisted intubation if necessary

• Secondary plan: video stylet, with a pre-mounted 6.5 ID endotracheal tube (ProVu, Flexicare Inc, Irvine, California, US)

• Rescue options: laryngeal mask airway (LMA) placement (with escalation to LMA-assisted intubation if appropriate, see below), fibreoptic intubation, and surgical airway capability.

The video stylet is a novel piece of equipment that does offer several advantages in the aeromedical environment:

• Real-time visualisation out of the tip of the endotracheal tube with minimal airway manipulation

• 95-degree range of movement of the manoeuvrable tip of the pre-mounted endotracheal tube

• Removable, malleable rod.

A particularly iniguing capability is its use in LMA-assisted intubation. When a size 4 LMA is placed as a rescue airway, the video stylet with a 6.5 ID pre-mounted endotracheal tube can be advanced through the LMA and actively steered past the vocal cords under direct video guidance. This controlled, stepwise transition from supraglottic to definitive airway is especially advantageous in the confined aeromedical setting.

Outcome and discussion

In this case, initial video laryngoscopy yielded a partial view. A bougie was successfully passed, and the tube was railroaded into position. The availability of the video stylet, bronchoscope, and surgical airway kit provided essential backup pathways, reducing cognitive load and enhancing procedural safety.

Conclusion

Difficult airway management during long-range aeromedical transport requires a flexible, device-savvy strategy tailored to the constraints of flight. Unicair’s ICU-level equipment, including video-assisted devices and surgical airway capability, enables safe and effective airway management even when hours from diversion and far from definitive care.