What patient transport models have been used in rural areas and jurisdictions? 

Posted on April 11, 2020 by Kristin Walters

Summary

In remote communities with limited access to appropriate medical equipment, supplies, and services, additional complications arise for the effective treatment and transportation of patients.  With the proper clinical team in place, patients can receive emergency resuscitation and stabilization, emergency ambulatory care and out-patient non-urgent services.  Balancing appropriate ventilation of COVID-19 suspected or confirmed cases with AGMP and the safety of first responders remains an issue. Below is a review of the latest evidence with respect to specific ventilation measures and guidelines for patients with COVID-19.

I.   Specific Questions

  • How to safely transport patients with ARDS to appropriate facilities in order to maintain proper oxygen requirements while reducing risk to EMS workers.
  • Problem: high flow O2 administration conflicts with AGMP, therefore what is the precedent for transporting spontaneously breathing patients.

II.   Non-Invasive ventilation (NIV)

  • NIV is absolutely contraindicated when aerosol generating procedures are prohibited according to Alberta EMS protocol (SARS, Covid) (13)
  • Requires expanded PPE precautions (N95 + eye precaution) (1)
  • Possibility of using a CPAP “helmet” is not considered an alternative to NIV/HHFO2
  • Alberta current guidelines recommend against NIV in critically ill patients (acute respiratory failure) with confirmed COVID-19, however this does not extend beyond the ICU (6).
  • Alberta protocol for acute hypercapnic respiratory failure in known COPD patients is to provide two hours of optimized biPAP/NIV (well-sealed interface, reasonable tidal volumes and minute ventilation). If ABG pH <7.25 and or worsening clinical parameters, then discontinue NIV and provide appropriate palliation.

 

III.   Low flow Oxygen

  • For patients with COVID-19, supplementation with a low flow nasal cannula is appropriate (up to 6L/min), however the degree of micro-organism aerosolization is only estimated to be minimal. (3)

IV.   High flow oxygen

  • Early HFNO use and awake prone positioning may have contributed to reduced mortality due to COVID-19 in China, however it may also influence the risk of aerosol spread (3)
  • Compared with standard oxygen therapy, HFNO reduces the need for intubation, and HFNO may be safe in patients with mild-moderate and non-worsening hypercapnia (11)
  • Using high flow oxygenation equipment (face mask, venturi face mask, non-rebreather mask) up to 10-20 L/min are associated with higher levels of dispersion and contamination of the surrounding environment (12).
  • HFNC is preferred to NIV based on limited information to date (12)
  • Evidence suggests that dispersal of liquid from HFNO at 60L/min is minimal and that significantly less aerosolization is caused then by coughing or sneezing, provided that nasal cannulae are well fitted (4)
  • Absolute risk to healthcare workers remains unclear, and will depend on variables (flow rates, ventilator pressures, patient dynamics (coughing), and PPE.

V.   PEEP

  • PEEP titration requirements should be based on tables provided by the WHO based on FiO2 required to maintain SpO2 (9)

VI.   Transport of critically ill patients

  • Prone position ventilation can improve oxygenation in ARDS, and reduce the risk of ventilator induced lung injury (VILI) (9).
  • Further guidelines for prone positioning and a handy clinician checklist have been established by the Nova Scotia Health Authority (10).
  • Prone position ventilation in patients with severe ARDS for 12-16 hrs is recommended (8)
  • Interhospital transport of critically ill patients has been used in the past (2009 flu pandemic, case of hantavirus-induced cardiopulmonary syndrome) where PEEP (16 cmH2O, 100% O2) and prone positioning and the use of vasoactive drugs were utilized to stabilize and transfer patients as a bridge to ECMO therapy (7). Vasoactive drugs utilized were norepinephrine (0.9 mcg/kg/min) and epinephrine (0.7 mcg/kg/min).

VII.   Transport of patients in prone position

  • Transport (ambulance, helicopter) of mechanically ventilated patients with respiratory failure in the prone position has been shown to be safe, with minimal complications (2)

VIII.   EMS PPE Guidelines

  • Current guidelines do not support the use of powered air-purifying respirator (PAPR) (5)

Questions? Comments? Does this need to be updated? Do you have valuable points to add ? Please email ask.reakt@ubc.ca.

References

Alberta Health Services. AGMP for Respiratory Illness Guidelines. March 13, 2020. [Online] https://www.albertahealthservices.ca/assets/healthinfo/ipc/hi-ipc-respiratory-additional-precautions-assessment.pdf

Accessed: April 9, 2020

  1. DellaVolpe JD, Lovett J, Martin-Gill C, Guyette FX. Transport of Mechanically Ventilated Patients in the Prone Position. Prehosp Emerg Care. 2016 Sep-Oct;20(5):643-7. April 13, 2016.  [Online] https://www.ncbi.nlm.nih.gov/pubmed/27075163/

Accessed: April 9, 2020

  1. Lyons, C., Callaghan, M. The Use of High Flow Nasal Oxygen in COVID-19. Wiley Online Library. April 4, 2020. [Online] https://onlinelibrary.wiley.com/doi/10.1111/anae.15073

Accessed: April 9, 2020

  1. Brewster, D.J., et al., Consensus statement: Safe Airway Society Principles of Airway Management And Tracheal Intubation Specific to the COVID-19 Adult Patient Group. Medical Journal of Australia. March 16, 2020. https://www.mja.com.au/journal/2020/consensus-statement-safe-airway-society-principles-airway-management-and-tracheal

Accessed: April 9, 2020

  1. BC centre for disease control, BC ministry of Health. March 6, 2020. [Online]

http://www.bccdc.ca/Health-Info-Site/Documents/Respiratory-protection-COVID19.pdf

Accessed: April 9, 2020

  1. Alberta Health Services.  Non Invasive Ventilation (NIV) in Adult Acute Care during COVID-19 Pandemic. April 2, 2020. [Online]  https://fecc97bb-b90e-4ff0-bcc0-d46492e2fab0.filesusr.com/ugd/366013_81af24fca9274dbd9309cf6a8fe5c1fc.pdf

Accessed: April 9, 2020

  1. Cornejo, R., et al., Prone Position Ventilation Used During a Transfer as a Bridge to ECMO Therapy in Hantavirus-Induced Severe Cardiopulmonary Syndrome. Hindawi Case Reports in Critical Care [Online] http://downloads.hindawi.com/journals/cricc/2013/415851.pdf

Accessed: April 9, 2020

  1. Government of Canada Management of Patients with Moderate to Severe Covid-19. April 2, 2020. [Online] https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/clinical-management-covid-19.html#9

Accessed: April 9, 2020

  1. WHO. Clinical Management of Severe Acute Respiratory Infection (SARI) when COVID-19 Disease is Suspected. March 13, 2020. [Online]  https://www.who.int/docs/default-source/coronaviruse/clinical-management-of-novel-cov.pdf

Accessed: April 9, 2020

  1. Rochwerg, B., et al., Official ERS/ATS Clinical Practice Guidelines: Non-Invasive Ventilation for Acute Respiratory Failure. European Respiratory Journal. [online] https://www.ncbi.nlm.nih.gov/pubmed/28860265

Accessed: April 9, 2020

  1. Lt Col Renee, I., et al. US DoD COVID-19 Practice Management Guide: Clinical Management of COVID-19. March 23, 2020. [Online] https://health.mil/Reference-Center/Technical-Documents/2020/03/24/DoD-COVID-19-Practice-Management-Guide

Accessed: April 9, 2020

Disclaimer

The above is intended to serve as a rapidly-created, accessible source of information curated by medical students and healthcare professionals. It is for educational purposes only and is not a complete reference resource. It is not professional medical advice, and is not a substitute for the discretion, judgment, and duties of healthcare professionals. You are solely responsible for evaluating the information above.