Advertisement

Difficulty Ventilating: A Case Report on Ventilation Considerations of an Intubated Asthmatic Undergoing Air Medical Critical Care Transport

Published:December 15, 2020DOI:https://doi.org/10.1016/j.amj.2020.11.014

      Highlights

      • Transport ventilators have technical limitations on peak inspiratory pressures.
      • The patient's current ventilator settings must be considered before the launch of an aircraft.
      • Extracorporeal membrane oxygenation should be considered in cases of status asthmaticus and cardiovascular collapse.
      • There may be some utility in considering alternative “rescue” modes of ventilation during transport.

      Abstract

      The air medical transport of intubated patients is a high-risk mission that requires preplanning before helicopter launch. This case describes a scenario in which the helicopter emergency medical services (HEMS) team was unable to ventilate a patient because of the mechanical limitations of the transport ventilator. The HEMS mission was ultimately aborted, and the patient had to be transported by a ground crew equipped with a hospital-based ventilator. In addition to the optimal medical management of the patient in status asthmaticus, critical care transport crews must be familiar with the treatment of patients exhibiting extremely high peak airway pressures. Specifically, ventilator manipulations as well as the technical specifications of the transport ventilator may preclude the patient from being transported by the HEMS team. It is imperative that the patient's current ventilator setting be evaluated before the launch of the aircraft to prevent any possible delays in patient care.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Air Medical Journal
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Pendergraft TB
        • Stanford RH
        • Beasley R
        • Stempel DA
        • Roberts C
        • McLaughlin T.
        Rates and characteristics of intensive care unit admissions and intubations among asthma-related hospitalizations.
        Ann Allergy Asthma Immunol. 2004; 93: 29-35
        • Le Conte P
        • Terzi N
        • Mortamet G
        • et al.
        Management of severe asthma exacerbation: guidelines from the Société Française de Médecine d'Urgence, the Société de Réanimation de Langue Française and the French Group for Pediatric Intensive Care and Emergencies.
        Ann Intensive Care. 2019; 9: 115
        • Holley AD
        • Boots RJ.
        Review article: management of acute severe and near-fatal asthma.
        Emerg Med Australas. 2009; 21: 259-268
        • Stanley D
        Tunnicliffe. Management of life-threatening asthma in adults.
        Contin Educ Anaesth Crit Care Pain. 2008; 8: 95-99
        • Papiris S
        • Kotanidou A
        • Malagari K
        • Roussos C.
        Clinical review: severe asthma.
        Crit Care. 2002; 6: 30-44
        • Wener RR
        • Bel EH.
        Severe refractory asthma: an update.
        Eur Respir Rev. 2013; 22: 227-235
      1. Farkas J. Asthma. Available at: https://emcrit.org/ibcc/asthma/. Published October 29, 2019. Accessed August 16, 2020.

        • Rezaie S.
        REBEL Cast Episode 11: The Crashing Asthmatic.
        REBEL EM blog. June 1, 2015; (Available at:) (Accessed Augest 16, 2020)
        • Nowak RM
        • Tokarski GF.
        • et al.
        Asthma.
        in: Marx JA Hockberger RS Walls RM Rosen's Emergency Medicine: Concepts and Clinical Practice. 8th ed. Mosby, Inc, St Louis, MO2014: 941-958
      2. Core EM: life-threatening asthma.
        2015 (Published October 21,Accessed August 16, 2020)
        • Smith D
        • Riel J
        • Tilles I
        • et al.
        Intravenous epinephrine in life-threatening asthma.
        Ann Emerg Med. 2003; 41: 706-711
        • Goyal S
        • Agrawal A.
        Ketamine in status asthmaticus: a review.
        Indian J Crit Care Med. 2013; 17: 154-161
        • Maselli DJ
        • Peters JI.
        Medication regimens for managing acute asthma.
        Respir Care. 2018; 63: 783-796
        • Levy Z
        • Slesinger TL.
        Does intravenous magnesium reduce the need for hospital admission among adult patients with acute asthma exacerbations.
        Ann Emerg Med. 2015; 65: 702-703
        • Goodacre S
        • Cohen J
        • Bradburn M
        • et al.
        Intravenous or nebulized magnesium sulphate versus standard therapy for severe acute asthma (3Mg trial): a double-blind, randomised controlled trial.
        Lancet Respir Med. 2013; 1: 293-300
        • Soroksky A
        • Stav D
        • Shpirer I.
        A pilot prospective, randomized, placebo-controlled trial of bilevel positive airway pressure in acute asthmatic attack.
        Chest. 2003; 123: 1018-1025
        • Ram FSF
        • Wellington S
        • Rowe B
        • Wedzicha JA.
        Non-invasive positive pressure ventilation for treatment of respiratory failure due to severe acute exacerbations of asthma.
        Cochrane Database Syst Rev. 2005; 3CD004360
        • Hashemian SM
        • Fallahian F.
        The use of heliox in critical care.
        Int J Crit Illn Inj Sci. 2014; 4: 138-142
        • Rehder KJ.
        Adjunct therapies for refractory status asthmaticus in children.
        Respir Care. 2017; 62: 849-865
        • Laher AE
        • Buchanan SK.
        Mechanically ventilating the severe asthmatic.
        J Intensive Care Med. 2018; 33: 491-501
        • Kornhall D
        • Hellikson F
        • Näslund R
        • Lind F
        • Broms J
        • Gellerfors M.
        A protocol for helicopter in-cabin intubation.
        Air Med J. 2018; 37: 306-311
        • Chesters A
        • Keefe N
        • Mauger J
        • Lockey D.
        Prehospital anaesthesia performed in a rural and suburban air ambulance service staffed by a physician and paramedic: a 16-month review of practice.
        Emerg Med J. 2014; 31: 65-68
        • Lockey D
        • Crewdson K
        • Weaver A
        • Davies G.
        Observational study of the success rates of intubation and failed intubation airway rescue techniques in 7256 attempted intubations of trauma patients by pre-hospital physicians.
        Br J Anaesth. 2014; 113: 220-225
        • Rehn M
        • Hyldmo PK
        • Magnusson V
        • et al.
        Scandinavian SSAI clinical practice guideline on pre-hospital airway management.
        Acta Anaesthesiol Scand. 2016; 60: 852-864
        • Hossfeld B
        • Bein B
        • Boettiger BW
        • et al.
        Recommended practice for out-of-hospital emergency anaesthesia in adults: statement from the Out-of-Hospital Emergency Anaesthesia Working Group of the Emergency Medicine Research Group of the German Society of Anaesthesiology and Intensive Care.
        Eur J Anaesthesiol. 2016; 33: 881-897
      3. Hamilton T1 Transport Ventilator technical specification. Available at: https://www.hamilton-medical.com/en_US/Landingpages/HAMILTON-T1.html. Accessed August 16, 2020.

        • Stather DR
        • Stewart TE.
        Clinical review: mechanical ventilation in severe asthma.
        Crit Care. 2005; 9: 581-587
        • Golchin A
        • Hachey K
        • Khan A.
        Is there a role of applied PEEP (PEEPe) in controlled mechanically ventilated severe asthma exacerbations?.
        in: Paper presented at: American Thoracic Society International Conference, San Diego, CA2018 (May 22. Available at:) (Accessed Augest 17, 2020.)
        • Kondili E
        • Alexopoulou C
        • Prinianakis G
        • et al.
        Pattern of lung emptying and expiratory resistance in mechanically ventilated patients with chronic obstructive pulmonary disease.
        Intensive Care Med. 2004; 30: 1311-1318
        • Zhou Y
        • Jin X
        • Lv Y
        • et al.
        Early application of airway pressure release ventilation may reduce the duration of mechanical ventilation in acute respiratory distress syndrome.
        Intensive Care Med. 2017; 43: 1648-1659
        • Jain SV
        • Kollisch-Singule M
        • Sadowitz B
        • et al.
        The 30-year evolution of airway pressure release ventilation (APRV).
        Intensive Care Med Exp. 2016; 4: 11
        • Arshad Z
        • Prakash R
        • Aggarwal S
        • Yadav S.
        Ventilating patient with refractory hypercarbia: use of APRV mode.
        J Clin Diagn Res. 2016; 10 (UD01-UD2)