The Use of Nitric Oxide as a Rescue Modality for Severe Adult Acute Respiratory Distress Syndrome Patients, Including COVID-19, in Critical Care Rotor Transport: A Retrospective Community Outcome Study

OBJECTIVE: Severe acute respiratory distress syndrome (ARDS) mortality increases in smaller outlying facilities, and patients (especially those diagnosed with coronavirus disease 2019 [COVID-19]) are often “stuck” at these facilities. These patients are on maximal ventilator settings and are often in the prone position. Our purpose was to show that with the use of inhaled nitric oxide (iNO), a “community-based” rotor wing critical care transport (CCT) team can safely, consistently, and effectively transport these extremely precarious patients to the tertiary care that is needed. METHODS: This was a retrospective database review of 50 patients (39 patients with COVID-19) transported between 2017 and 2021 in whom iNO was brought to the bedside and initiated by the rotor wing critical care transport team. The review included patient demographics, vital signs, and ventilator settings from the sending hospital, in-flight, and the receiving hospital. We reviewed the transition from transport to venovenous extracorporeal membrane oxygenation (if applicable), hospital disposition, and length of stay from the receiving hospital side. Concerning the actual transport, we reviewed the mode of transport, the sending facility size, and the distances covered. RESULTS: Upon arrival at the sending facilities, we found severely ill patients with almost half (46%) in the prone position or recently transitioned from a prone position within the last 2 hours. Eighty-six percent were pharmaceutically paralyzed, and 44% were in shock. There was a younger and heavier predominance with an average age of 44 years and an average weight of 103 kg. Thirty-nine patients were diagnosed with COVID-19. The other 11 had a mix of non–COVID-19 ARDS, pulmonary embolism, and pulmonary edema. The patients presented from 27 different community hospitals. Forty-four percent were from small referring hospitals that had less than 200 beds. Twenty-eight patients were transported by a Bell 407 helicopter, 18 with an Airbus H135 helicopter, and 4 by ground ambulance. Forty-one percent of patients were transported within 25 miles, and 4 patients were transferred from > 100 miles away. All 50 patients were safely transported without significant deterioration or significant pulmonary pressure increases. Thirty-seven patients were placed on venovenous extracorporeal membrane oxygenation (34 of those patients cannulated within 2 hours of arrival). The overall mortality rate was 27%, and the COVID-19 mortality rate was 24%. CONCLUSION: iNO retrieval for severe ARDS can be safely and effectively completed within the COVID-19 population and the nonacademic community setting using helicopters prevalent in the global air medical industry (Bell 407 and Airbus H135).