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Communications to the Editor |

ICU Transport : Interhospital Transport of Critically Ill Patient With Dedicated Intensive Care Ventilator FREE TO VIEW

E. J. van Lieshout, MD; M. V. Vroom, MD, PhD
Author and Funding Information

Affiliations: Academic Medical Center, Amsterdam, the Netherlands,  University of Pennsylvania Medical Center, Philadelphia, PA

Correspondence to: E. J. van Lieshout, MD, Department of Intensive Care, Academic Medical Center, Amsterdam, the Netherlands 1100 DD; e-mail: vanlieshout@amc.nl



Chest. 2005;127(2):688-689. doi:10.1378/chest.127.2.688
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Published online

To the Editor:

The use of inhaled prostacyclin to enable the safe interhospital helicopter transport of a patient with ARDS complicated by life-threatening hypoxemia was described by Reily et al1 (April 2004). Their efforts to optimize the patient for transport to provide optimal care should be acknowledged. However, their choice for an unconventional ARDS therapy like inhaled prostacycline, not initially administered during treatment in their department, could be debated. Instead of a pharmacologic therapy with potential side effects despite their clinical experience, a dedicated intensive care (IC) ventilator mounted with an IC transport trolley (a mobile ICU) could have been used to facilitate this high-risk air medical transport. Mechanical ventilation was possible in the ICU before departure but not with the transport ventilator, which points to an (transport) equipment limitation rather than adverse effects of transport itself.

The inability of transport ventilators compared to ICU ventilators to adequately ventilate ARDS patients has been recognized and is probably due to pneumatic characteristics.2Gas compression in the ventilatory circuit, technical limits of the Venturi flow delivery system with pressurization gas source with cylinders, or insufficient delivery of positive end-expiratory pressure could cause the failure to adequately ventilate an ARDS patient with transport ventilators. Therefore, IC transfers should be executed with mobile ICUs equipped with IC ventilators for the continuation of critical care on the move.34

Reily, DJ, Tollok, E, Mallitz, K, et al (2004) Successful aeromedical transport using inhaled prostacyclin for a patient with life-threatening hypoxemia.Chest125,1579-1581. [CrossRef] [PubMed]
 
Breton, L, Minaret, G, Aboab, J, et al Fractional inspired oxygen on transport ventilators: an important determinant of volume delivery during assist control ventilation with high resistive load [letter]. Intensive Care Med. 2002;;28 ,.:1181. [CrossRef] [PubMed]
 
Gebremichael, M, Borg, U, Habashi, NM, et al Interhospital transport of the extremely ill patient: the mobile intensive care unit.Crit Care Med2000;28,79-85. [CrossRef] [PubMed]
 
Bellingan, G, Olivier, T, Batson, S, et al Comparison of a specialist retrieval team with current United Kingdom practice for the transport of critically ill patients.Intensive Care Med2000;26,740-744. [CrossRef] [PubMed]
 
To the Editor:

Thank you for the opportunity to respond to the letter you received from Drs. Lieshout and Vroom about our report published in CHEST (July 2004). We appreciate the critique of Drs. Lieshout and Vroom, who suggest that the use of a mobile ICU equipped with a more sophisticated ICU ventilator might be preferable to our use of inhaled prostacyclin to enable the interhospital helicopter transport of a very hypoxemic patient. We feel that our use of prostacyclin is a superior approach in our health system for multiple reasons.

Several years ago our health system invested in a helicopter transport system, rather than a mobile intensive care ground transport ambulance, to support our level I trauma program, which is also utilized to transport appropriate critically ill nontrauma patients. Air transport provides a much more rapid rescue system, and has the advantage of not only minimizing out-of-hospital time, but also allows us to extend our tertiary care services to a much larger geographic community of patients. In the example of the patient described in our report, the estimated travel time from Princeton, NJ, to Philadelphia, PA, was cut by 1.5 to 2 h.

Since the frequency that our flight crews encounter a critically ill hypoxemic patient that cannot be supported safely with our transport ventilator is approximately 1% of all transfers (approximately two patients per year), there is no justification for our health system to also invest in the additional equipment and staffing to support a mobile intensive care ground transport unit (at an additional estimated cost of $300,000 to $400,000 dollars per year). The benefit that this additional resource would provide us, as Drs. Lieshout and Vroom point out, is that it would enable our transport team to prescribe for the patient the same level of ventilatory support that they were receiving while at the ICU of the transferring hospital; however, as mentioned, we estimate that this would be necessary for only approximately two patients per year. In contrast, at a fractional cost of approximately $300/yr, for prostacyclin and disposable equipment (no additional staffing required), we can potentially improve oxygenation during transport for these few patients, even above the levels achieved at the referring hospital, despite the use of a less sophisticated ventilator. We realize, based on data from ICU patients treated with prostacyclin, that the magnitude of response in oxygenation seen in our patient will not be realized in all patients; however, given the simplicity of a prostacyclin trial, the rapidity of the response and the opportunity cost, we believe it is the most appropriate intervention to employ in this circumstance.

For hospitals that only use a mobile intensive care ground transport unit to transfer critically ill patients our demonstration of inhaled prostacyclin use during transport remains relevant, since acute arterial desaturation may still occur during ground travel even though support is being provided with an ICU ventilator. In summary, inhaled prostacyclin provides a quick, simple, inexpensive, and very safe way to treat life-threatening hypoxemic events in the small minority of patients where this may occur during transport outside the ICU, analogous to its use as a salvage treatment for this problem within the ICU.


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References

Reily, DJ, Tollok, E, Mallitz, K, et al (2004) Successful aeromedical transport using inhaled prostacyclin for a patient with life-threatening hypoxemia.Chest125,1579-1581. [CrossRef] [PubMed]
 
Breton, L, Minaret, G, Aboab, J, et al Fractional inspired oxygen on transport ventilators: an important determinant of volume delivery during assist control ventilation with high resistive load [letter]. Intensive Care Med. 2002;;28 ,.:1181. [CrossRef] [PubMed]
 
Gebremichael, M, Borg, U, Habashi, NM, et al Interhospital transport of the extremely ill patient: the mobile intensive care unit.Crit Care Med2000;28,79-85. [CrossRef] [PubMed]
 
Bellingan, G, Olivier, T, Batson, S, et al Comparison of a specialist retrieval team with current United Kingdom practice for the transport of critically ill patients.Intensive Care Med2000;26,740-744. [CrossRef] [PubMed]
 
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