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En-Route Care in the Air: Snapshot of Mechanical Ventilation at 37,000 Feet

Barnes, Stephen L. MD, FACS; Branson, Richard MSc, RRT; Gallo, Louis A. MA, CCRN; Beck, George BS, RRT; Johannigman, Jay A. MD, FACS

Journal of Trauma and Acute Care Surgery: February 2008 - Volume 64 - Issue 2 - p S129-S135
doi: 10.1097/TA.0b013e318160a5b4
Presented Papers

Objective: En-route care necessitates the evacuation of seriously wounded service members requiring mechanical ventilation in aircraft where low light, noise, vibration, and barometric pressure changes create a unique clinical environment. Our goal was to evaluate ventilatory requirements, oxygenation, and oxygen use in flight and assess the feasibility of a computer interface in this austere environment.

Methods: A personal computer was integrated with the pulse oximeter and ventilator data port used in aeromedical evacuation from Iraq to Germany. Ventilator settings, inspired oxygen (FiO2), tidal volume (V T), respiratory rate (RR), minute ventilation (V E), monitored values, heart rate (HR), and oxygen saturation (SpO2), were recorded continuously. Oxygen use was determined using the equation ([FiO2 – 21]/79) × (MVE). Additional data were obtained through the United States Air Force (USAF) Transcom Regulation and Command/Control Evacuation System (TRAC2ES) and the United States Army Institute of Surgical Research Joint Theater Trauma Registry databases.

Results: During a 4 month time frame 117 hours of continuous recording was accomplished in 22 patients. Mean age was 27 ± 9.83 and injury severity score military was 31.75 ± 20.63 (range, 9–75). All patients survived transport. Mean values for ventilator settings were FiO2 (24–100%) of 49% ± 13%, positive end-expiratory pressure of 6 ± 2.5 (range, 0–17 cm H2O), RR of 15 ± 2.4 (range, 10–22 breaths/min), and V T of 611 ± 75 (range, 390–700 mL). Delivered V T in mililiter per kilogram was 6.9 ± 1.30 and V E was 9.1 L/min ± 1.4 L/min. Oxygen requirements for desired FiO2 and V E resulted in a mean oxygen usage of 3.24 L/min ± 1.87 L/min (range, 1.6–10.2 L/min). There were 32 changes to FiO2, 18 changes to PEEP, 26 changes to RR, and 20 changes to V T during flight. Five patients under-went no recorded changes in flight. Three desaturation events (<90%) were recorded lasting 35, 115, and 280 seconds. Recorded ventilatory changes averaged less than 1 (0.82) per hour of recorded flight with FiO2 being the most common.

Conclusions: A computer interface is feasible in the austere aeromedical environment. Implications to military operations and civilian homeland defense include understanding casualty oxygen requirements for resource planning in support of aeromedical evacuation. Portable oxygen generation systems may be able to provide adequate oxygen flow for transport, reducing the need for compressed gas. Future studies of oxygen conservation systems including closed loop control of FiO2 are warranted.

From the USAF Center for Sustainment of Trauma and Readiness Skills (CSTARS) (S.L.B., R.B., J.A.J.), University of Cincinnati Division of Trauma/Critical Care, Cincinnati Ohio; CCRN Maj USAF NC (L.A.G.), Headquarters AMC/SBXL Scott AFB, Illinois; Impact Instrumentation, Inc. (G.B.), West Caldwell, New Jersey.

Submitted for publication October 30, 2007.

Accepted for publication October 30, 2007.

This research could not have been accomplished with out the assistance of Impact Instrumentation (D. Lacroy, G. Beck) and Air Force Personnel. Sponsored by NSBRI SMS00003.

Disclaimer: The opinions and assertions contained in this article are solely the authors' private ones and are not to be construed as official or reflecting the views of the United States Air Force or the Department of Defense. This article was prepared by United States Government employees and therefore cannot be copyrighted and may be copied without restriction.

Address for reprints: Stephen L. Barnes, MD, Major, USAF, C-STARS Cincinnati, UC Division of Trauma/Critical Care, 231 Albert Sabin Way, PO Box 670558, Cincinnati, OH 45267-0558; email:

© 2008 Lippincott Williams & Wilkins, Inc.