Interfacility Transport of Mechanically Ventilated Patients with Suspected COVID-19 in the Prone Position

Abstract

Objective

Prone positioning during mechanical ventilation in patients with severe respiratory failure is an important intervention with both physiologic and empiric rationale for its use. This study describes a consecutive cohort of patients with severe hypoxemic respiratory failure due to COVID-19 who were transported in the prone position in order to determine the incidence of serious adverse events (SAEs) during transport.

Methods

This retrospective study used prospectively collected data from a provincial air and land critical care transport system where specially trained critical care paramedic crews transported intubated and mechanically ventilated patients with COVID-19 in the prone position. SAEs were determined a priori, and included markers of new hemodynamic or respiratory instability, new resuscitative measures, and equipment or vehicle malfunction. Two authors independently reviewed each patient care record to identify SAEs during transport, and the ability of the crews to successfully manage such events.

Results

From April 2020 to June 2021, 127 intubated and mechanically ventilated patients were transported in the prone position. Of these, 117 were transported by land vehicle, 7 by rotor-wing, and 3 by fixed wing aircraft. 67 (52.8%) were vasopressor-dependent, 5 (3.9%) were receiving inhaled vasodilators, 9 (7.1%) were hypoxic (SpO₂ < 88%), and 3 (2.4%) were hypotensive (SBP < 90 or MAP < 65 mm Hg) when the transport crew made patient contact at the sending hospital. Of the 122 (96.1%) patients in which a pre-transport PaO₂/FiO₂ ratio was available, the mean (median; range) was 86.7 (81; 47–144), with 27 patients greater having a ratio greater than 100. The mean (median; range) transport time was 49 (45; 14–176) minutes. There were 19 SAEs in 18 (14.2%) patients during transport, the most common of which was new hypoxia requiring ventilator adjustments (15 of 18 patients). All SAEs were successfully managed by the transport crews. No patient experienced tracheal tube obstruction, unintentional extubation, cardiac arrest, or died during transport.

Conclusion

Patients with severe hypoxemic respiratory failure due to COVID-19 can be safely transported in the prone position by specially trained critical care paramedic crews.

Acknowledgments

The authors would like to thank the paramedics who provided care to the critically ill and injured, maintained an exceptional level of service, and exhibited professionalism and dedication despite the challenges posed by the SARS-CoV2 pandemic.

Authors’ Contributions

RDM, AP, and MP conceived the study and acquired the data. AP, MP, PA, and DP developed the patient care protocols and carried out the training. AP, PA, and DP performed the medical records review. All authors participated in interpretation of the results. RDM drafted the initial manuscript. All authors contributed substantially to its revisions and approved the final manuscript. RDM takes responsibility for the manuscript as a whole.

Disclosure Statement

The authors report no conflicts of interest.