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Introduction:

During the COVID-19 and Omicron pandemics, there has been more and more demands for the repatriation and evacuation of patients with acute respiratory failure and altered compensating system, patients with respiratory insufficiency is likely to aggravate their respiratory distress especially with aeronautical constraints and pressurization phenomena. Hence, a briefing of before boarding every patient is essential to make sure both flight Crew and Medical Team are briefed and prepared for any expected incident during the repatriation or the evacuation.

Mission report:

They were asked for the transfer of a 69 years old “Mr. W.M “, Medical history of SARS-COV2 infection with an estimated lung damage of 80% and pulmonary fibrosis; from Freetown, Sierra Leon to Lebanon, Beirut.

Mr. W was hospitalized in the intensive care unit, conscious, calm and cooperative, he benefited from close sessions of NIV “non-invasive ventilation”, with a saturation of 90% under 15 L / min of O2, a respiratory rate of 20c / min, a PaCO2 of 32 mmHg and a PaO2 / FiO2 ratio = 130 mmHg.

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% during the flight.

Airway assessments has become systematic on all our patients, in order to prepare for a difficult intubation in the presence of criteria; our patient was Bearded, had Retrognathism, Short Neck, thyromental Distance < 6.5 and Mallampati score class 2. The boarding of Mr W was in a half sitting position, managing and releasing the space around the stretcher to facilitate the movement and care during the flight.

At an attitude of 11000 m and after 30 minutes of departure, the patient begins to present headaches, visual disturbances, behavioral disorders and SaO2 at 80% under 100% FiO2, ventilated in spontaneous mode with pressure support “NIV PS”.

Hence, Intubation decision immediately made; preparation of difficult intubation equipment’s; rapid sequence induction; the patient is ventilated with bag-valve-mask resuscitators (BVMS). On direct laryngoscopy: Cormack score 4 and failure of two attempts intubation with eschmann’s guide resumption of ventilation with a face mask, and placement of a laryngeal mask number 5 inflated with saline solution.

Under sedation, the patient is put in Pressure-controlled ventilation (PCV) mode to minimize leakage of the laryngeal mask by hyperpressure and so we could lower our oxygen consumption needs during the flight by up to 50% with an oxygen saturation of 95%.

For a flight time of 08 hours, the patient remained respiratory and hemodynamically stable and enroute-flight incident was mentioned on mission report and given to the receiving team in Beirut.

Once arrived at the hospital, after installation in the intensive care unit, the patient is successfully reintubated under a fibroscopy. Patient well evolved and extubated 15 days later.

Discussion:

Upon the arrival of the medical team to Morocco, a meeting was held at Air Ocean Maroc’s headquarter in Rabat the following day to discuss the Experience as part of our continuing education program and several conclusions were drawn that allowed us to establish more detailed procedures to avoid similar incidents during flights with a high probability of intubation difficult “patients with respiratory or smoking insufficiency chronic… »

• To do this, we have added a section dedicated to airways examination in our medical flight log: part of the initial medical assessment
• We established a clear course of action for patients are difficult to intubate and shared with all doctors and nurses in our company.
• We have added in the emergency medical bags a complete kit for difficult intubation and laryngeal masks in all sizes
• And we plan to add the soonest possible a Fibro-laryngoscope as well.

Conclusion:

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, with the mandatory presence of a well-trained medical team accustomed to working in as team….