The Prone Position During Helicopter Transport of Critically Ill Patients: A Case Series from North Norway

Prone positioning improves oxygenation and survival in patients with severe acute respiratory distress syndrome (ARDS). Transport of intubated patients in the prone position is considered high risk, particularly during air medical transport, where patient access is limited. Evidence on prolonged helicopter transport in the prone position remains limited. We aimed to describe helicopter transport of intubated patients with severe ARDS in the prone position in North Norway.

We conducted an observational, retrospective case series of six consecutive adult patients with severe ARDS who were transported intubated in the prone position by helicopter within mainland North Norway from community hospitals to tertiary referral intensive care units between June 2020 and February 2025. Data were extracted from transport charts and hospital medical records and included transport characteristics, ventilatory parameters, adverse events, and clinical outcomes.

Six intubated patients with severe ARDS were transported by helicopter in the prone position. Five patients were transported in a true prone position and one in a modified semi-prone position because of aircraft constraints. In four transports, the patient was transferred together with the hospital mattress onto the transport stretcher, minimizing repositioning and preserving the established prone position. All patients had severe ARDS with pre-transport PaO₂/FiO₂ (P/F) ratios below 100 mmHg and required vasoactive support. Median transport time was 73 min (range 45-135 min). No catastrophic transport-related events occurred. One patient developed clinically significant hypotension, and one had worsening oxygenation requiring ventilator adjustment. The P/F ratio improved after arrival in five of six patients. Three patients survived to hospital discharge.

In remote regions with long transport distances, prone helicopter transport may be a feasible option for selected intubated patients with severe hypoxemic respiratory failure. Our observations suggest that successful execution depends on careful preparation, appropriate transport resources, experienced air medical teams, and a pragmatic approach aimed at minimizing unnecessary patient handling.