5.2 Preparing and Packaging the Patient for Flight
Key Takeaways
- Secure the ETT by centimeters at the lip, a continuous ETCO2 waveform, and a backup airway you can reach from your seat.
- Establish two large-bore IVs or IO plus a second access; add a Foley when indicated and decompress the stomach before altitude if there is ileus or obstruction.
- Never clamp a bubbling chest tube for flight without a plan; add collection capacity because Boyle's law increases residual pleural gas and output.
- Spinal restriction must fit the aircraft door; a padded, warmed vacuum mattress beats a naked long board for most flight legs.
- Know your program's ETT-cuff rule and monitor pressure—Boyle expands air-filled cuffs. Strap for real weight, pad pressure points, cover for cold, and keep lines inside the litter.
Packaging keeps the assessment you just finished from coming apart in the air. Domain 1.E of the August 2026 Certified Flight Registered Nurse (CFRN) outline pairs preparing the patient for transport with physical assessment because a sloppy package becomes a lost airway, a line on a skid, or an expanding pneumothorax you cannot reach. Finish the package on the ground, while the door still opens.
Airway, access, bladder, and stomach
Secure what vibration will try to steal
For an endotracheal tube (ETT), write the centimeters at the lip or teeth, confirm a continuous end-tidal carbon dioxide (ETCO2) waveform, and stage a backup airway you can reach from the seat you will occupy. Tape plus a commercial tube holder beats a single loose twill tie. Recheck depth after every stretcher-to-litter transfer.
Obtain two large-bore intravenous (IV) catheters or a working intraosseous (IO) device plus one other reliable access. Large-bore means you can give blood, not a leftover 22-gauge. Label every line. Pressure-bag or pump anything you cannot watch continuously.
Place a Foley catheter when you need hourly urine, a long fixed-wing leg, pelvic trauma, or a patient who cannot void under straps. Decompress the stomach with a working nasogastric or orogastric (NG/OG) tube before altitude if there is ileus, bowel obstruction, or a lot of bag-mask air. Bowel gas obeys Boyle's law. A tense abdomen and a vomiting, helmeted, packaged patient is a preventable crisis.
Chest tubes, flutter valves, and extra volume
A bubbling chest tube is venting expanding pleural gas. Do not clamp it for flight unless you have a specific, time-limited reason and a plan to unclamp immediately if the patient deteriorates. Know the hardware:
| Device | What it does | Flight use |
|---|---|---|
| Underwater-seal or three-chamber drainage system | Collects fluid and lets air exit through a seal | Acceptable if it stays upright, below the chest, and has spare volume |
| Heimlich / flutter valve | One-way valve; air leaves and does not re-enter | Useful when a hanging chamber will not stay upright; add a bag if output is wet |
| Clamped tube | Traps pleural gas | Unsafe default for a bubbling tube as cabin altitude rises |
Give the collection system extra capacity. Residual pneumothorax and chest-tube output both increase as ambient pressure falls. A chamber that is already two-thirds full at the sending dock can overflow on climb. Keep connections taped and visible so a disconnect is obvious.
Spine, mattress, door, and who else flies
Fit the aircraft, not the hallway
Spinal motion restriction has to fit the aircraft door. A long board that cleared the ambulance bumper may not turn into a rotor-wing cabin or a small fixed-wing door. Measure patient-plus-device length against the actual aircraft. A vacuum mattress usually wins for flight: it conforms and still restricts motion if you evacuate it correctly, but only if you pad and warm it. A vacuum shell against cold cabin air is a hypothermia machine. Pad occiput, sacrum, heels, and every splint edge. On long fixed-wing legs, recheck those pressure points in cruise, not only at landing.
Bariatric patients need extra straps at chest, hips, and legs, plus a litter rated for the actual weight. Isolation patients need contained suction, covered drains, and a wipe-down plan. Family and belongings fly only if the program, the weight-and-balance sheet, and security allow it. A suitcase in the footwell is a missile; a family rider is extra weight and a second patient if they panic.
Weight, lines, heat, pads, and the cuff debate
Call the weight—patient, equipment, incubator, balloon pump, extra blood, and crew—before you commit the aircraft. The pilot owns the final number. You own not surprising the pilot after the engines are running.
Secure IV pumps and ventilator circuits against vibration so a short tug cannot extubate. Route lines inside the litter envelope, never dangling toward a rotor, skid, or door jamb. A snagged chest tube during a hot load is a scene injury you created. Place defibrillator pads before takeoff on high-risk patients—recent arrest, unstable arrhythmia, or deep shock—because you will not place them well after the straps are tight.
Thermal management is packaging, not a comfort extra. Cabins are cold; rotor wash on the ramp is colder. Cover the head while leaving the airway visible, use a heat-reflective wrap or forced-air device if the program carries one, and warm fluids when you can. Neonates, burns, and exposed trauma patients lose heat fastest.
Monitor the cuff; do not pick a brand fight
ETT cuff management is a Boyle problem. An air-filled cuff expands as cabin altitude rises and can cause ischemia of the tracheal mucosa; it then underfills on descent and leaks. Know your program and monitor cuff pressure. Some programs fill the cuff with sterile saline; others keep air and use a manometer after climb and descent. Either is defensible if you measure. Leaving an air cuff untouched from the sending ICU to an 8,000-foot cabin is not.
- Confirm ETT depth, waveform, and a reachable backup airway.
- Establish two large-bore IVs or IO plus a second access; add a Foley and a gastric tube when indicated.
- Leave bubbling chest tubes unclamped; add collection volume; never fly a mystery clamp.
- Fit spinal restriction to the door; prefer a padded, warmed vacuum mattress over a naked board.
- Strap for the real weight, pad pressure points, cover for cold, and keep every line inside the litter.
An intubated patient will fly unpressurized to a cabin altitude near 8,000 feet. The ETT cuff was inflated with air at the sending ICU and no manometer is attached. What is the most appropriate action?
A bubbling right chest tube drains into a three-chamber system that is already more than half full. The team is loading an unpressurized helicopter. What is the safest packaging plan?
A patient with small-bowel obstruction is being packaged for a pressurized fixed-wing flight with a planned cabin near 8,000 feet. Which action best reduces a Boyle-related abdominal crisis on climb?