a. Stability for flight is a multi-factorial decision based on the patient, sending facility, CCAT team, and flight characteristics.

b. Patient characteristics

i. PEEP and FIO2

1. PEEP / FiO2 greater than 14 cm H2O/70% should prompt careful consideration of risks and benefits. Such patients have little room to increase FiO2 or mean airway pressure if their condition worsens during flight. However, it is still possible to transport these patients safely.

2. All patients, including those on mechanical ventilation, will experience a decrease in PO2 as the partial pressure of oxygen in the air decreases as you increase in altitude.

a. Patients with marginal gas exchange will require additional support during flight.

b. A cabin altitude restriction will lessen the impact on oxygentation.

ii. Patients on aggressive support that has been stable over time are better candidates for transport than those with increasing support leading up to flight time.

iii. Concurrent hemodynamic compromise, severe metabolic acidosis, or traumatic brain injury will complicate ventilator management and should be considered in assessing stability for flight.

c.. Sending facility characteristics

i.. Type of ventilators available

ii. Availability of rescue therapies (proning, inhaled nitric oxide/prostacyclin, advanced mechanical ventilation techniques, etc.)

iii. Personnel experience and expertise

iv. Current beds available and anticipated casualties

d. Expertise of CCAT team members with advanced mechanical ventilation strategies

e. Flight characteristics

i. Flight duration

ii. Aircraft type

iii. Patient load and complexity

iv. Altitude restriction

f. If in doubt about the patient’s respiratory stability for transport consult the ECMO team

i. Extracorporeal Membrane Oxygenation (ECMO) is available 24/7 by calling commercial 210-916-ECMO (3266). The Brooke Army Medical Center ECMO team is a joint endeavor with the 59th Medical Wing and the US Army Institute for Surgical Research.

ii. ECMO team’s transport capabilities include ECMO for cardiopulmonary support and continuous renal replacement therapy. Early consultation is encouraged to facilitate planning.

iii. ECMO team can provide expert management guidance even if they do not transport the patient.