copd air travel guidelines

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Assessing Patients for Air Travel

Advising patients before air travel is a frequently overlooked, but important, role of the physician, particularly primary care providers and pulmonary specialists. Although physiologic changes occur in all individuals during air travel, those with underlying pulmonary disease are at increased risk of serious complications and require a specific approach to risk stratification. We discuss the available tools for assessment of preflight risk and strategies to minimize potential harm. We also present a case discussion to illustrate our approach to assessing patients for air travel and discuss the specific conditions that should prompt a more thorough preflight workup.

Although flight is one of the safest transportation modes, 1 it still poses real risks to travelers, particularly those with pulmonary disease. Respiratory complaints are the second most frequent type of medical emergency encountered during a flight, after syncope or presyncope. 2 Unfortunately, many providers are not sufficiently aware of the risks of air travel to be comfortable counseling patients prior to airplane travel. 3 This review will address which patients need preflight screening, which patients should be advised against air travel, and how to mitigate the risks of flight for those with underlying pulmonary disease.

The Flight Environment

Without cabin pressurization, passengers would be exposed to conditions of severe hypoxia, because the P o 2 at cruising altitude (up to 45,000 feet) 4 is approximately one-sixth the value at sea level. 5 Cabins are pressurized to an equivalent of no higher than 8000 feet, which is equivalent to an inspired fraction of oxygen of 15.1% at sea level. 6 Cabin pressure in private aircraft is more variable, ranging from entirely unpressurized to sea level equivalent; a full discussion of the risks of noncommercial flights is outside the scope of this review.

Although all air travelers are exposed to reduced oxygen-tension levels during flight, those with preexisting lung disease are most susceptible to complications. Patients with limited ability to extract oxygen or those with vulnerability to myocardial hypoxemia may experience respiratory failure, cardiac ischemia, or even death during flight.

In addition to hypobaric hypoxia (reduced atmospheric pressure due to altitude, resulting in lower amounts of available oxygen), passengers are also exposed to cramped conditions with limited ambulation. Humidity levels are quite low (9%-28%), which promotes increased insensible fluid loss and dehydration. These factors predispose passengers to VTE that compounds any hypoxia that may develop secondary to conditions of low oxygen tension.

History and Physical Examination

Patients who are planning air travel, at minimum, should undergo a history examination, a physical examination, and oxygen saturation assessment. 6 Because many patients are unaware of the need for screening; providers are encouraged to ask patients routinely about any upcoming travel. Medical history taking should address comorbidities, history of oxygen use, prior air travel, and any symptoms of chest pain, dyspnea, or cough. Physical examination should focus on the cardiopulmonary examination; any abnormalities that are identified should be investigated prior to planned travel.

Of course, medical evaluation on the day of travel is not generally feasible; patients should be advised to contact their physician if they experience new respiratory symptoms after evaluation. Providers should then reassess the patient’s status and fitness for flight. If patients are experiencing an exacerbation of their underlying pulmonary disease or symptoms suspicious for a newly developing illness, travel should be deferred.

During the examination, the provider’s goals should be to determine whether patients are sufficiently stable to fly and if they need supplemental oxygen during flight. In general, patients with active exacerbations of their underlying pulmonary disease, patients with unstable angina, and patients who would require more oxygen than can be supplied during flight should be instructed to find alternative methods of travel or to defer the trip. Additional information on disease-specific absolute and relative contraindications to flight are specified later.

Resting Pulse Oximetry

Our current practice is to obtain a measurement of arterial oxygenation for every patient, generally with pulse oximetry. Values >95% on room air suggest that inflight hypoxemia is unlikely and that further evaluation is likely not necessary. Patients with saturations <92% on room air at rest should receive supplemental oxygen inflight, because they are at high risk of hypoxemia at altitude. Values between 92% and 95% should prompt further evaluation, particularly in the setting of known risk factors for inflight hypoxemia. Although data for this approach are somewhat limited, they are consistent with other recommended practices. 7 Table 1 provides additional details that compare resting pulse oximetry to other methods of predicting inflight hypoxemia.

Table 1

Methods of Predicting In-Flight Hypoxemia

Arterial Blood Gas

Arterial blood gas analysis on room air can be obtained if pulse oximetry is thought to be unreliable or is unobtainable (despite use of alternative locations of pulse oximetry probe placement [eg, forehead or ear lobe]). Evidence of chronic CO 2 retention should prompt further evaluation and consideration of intervention ideally prior to travel. Less consensus exists on the appropriate Pa o 2 cutoff for further testing; a conservative approach would be to refer any patient with Pa o 2 of <70 mm Hg for additional testing.

High Altitude Simulation Test

If additional certainty is needed regarding possible inflight hypoxemia, the high-altitude simulation test (HAST) offers the best clinically available simulation of conditions at commercial flight cruising altitudes. During the HAST, patients breathe a mixture of gases with an inspired oxygen fraction of 15.1% via a tightly fitting mask or mouth piece for a period of 20 minutes, during which continuous ECG and pulse oximetry readings are obtained, with pre- and postarterial blood gas sampling. 8 If the Pa o 2 remains at >55 mm Hg during the test, patients are considered at low risk of hypoxemia during commercial air travel.

Although the HAST does not replicate inflight conditions perfectly (it uses normobaric hypoxia, rather than hypobaric hypoxia), results correlate well with hypobaric chamber testing (the gold standard for predicting hypoxemia at altitude, although clinically impractical). 9 , 10 HAST testing also predicts inflight hypoxemia relatively well in otherwise healthy individuals. 11

Additional Testing Considerations

Pulmonary function testing (PFT) is not specifically indicated as part of the preflight workup. For patients with known pulmonary disease (specifically, COPD, interstitial lung disease, and cystic fibrosis), other authors have suggested that PFTs may be used in an algorithmic approach to determining the need for inflight oxygen. 12 , 13 , 14 Although PFTs clearly provide important information in the management of these chronic diseases, our practice has been to recommend HAST if there is any concern for inflight hypoxemia, rather than relying on extrapolation from PFTs.

Exercise testing (6-minute walk test, 50-meter walk test, or cardiopulmonary exercise testing) is similarly beneficial as part of chronic lung disease evaluation but does not predict consistently the degree of hypoxemia that patients will experience inflight. 15 Although very poor performance on cardiopulmonary exercise testing or 6-minute walk testing likely indicates a risk of inflight hypoxemia, 12 , 16 , 17 HAST is a more reliable method of assessing this risk ( Table 1 ).

A variety of predictive equations have been proposed for anticipating which patients will require supplemental oxygen during air travel. A benefit of these equations is simplicity and ease of use during an office visit. Unfortunately, these equations consistently have poor predictive value, and there is little consensus on which equation to use. 18 , 19 Our practice has been to avoid the use of equations in assessing patients for the need for supplemental oxygen during air travel and to rely on HAST in borderline cases.

Inflight Oxygen

If it is determined that a patient requires supplemental oxygen inflight, options are generally limited to either the patient’s own portable oxygen concentrator or oxygen supplied by the airline. Use of the concentrator has the benefit of being titratable and being able to travel with the person during ambulation. However, depending on the length of the flight, passengers may either need to bring supplemental batteries (with care taken to ensure that these are approved for inflight use) or have the ability to charge the device during flight. Using the airline’s oxygen supply (generally available at a fixed 2 or 4 L/min) avoids the difficulty of supplemental power but does not permit oxygen use after arrival. Use of a patient’s own liquid oxygen cylinder is not permitted generally. Providers should be aware that inflight oxygen use generally requires airline advance notification, a note from a physician, and potentially extra fees. 20 , 21

If patients who are on long-term supplemental oxygen have not completed a HAST, our general practice is to increase their oxygen prescription by 2 L/min during flight. This is a relatively imprecise approach, based primarily on expert consensus. 7 HAST offers a significant advantage in better quantifying inflight oxygen needs. Portable oxygen concentrators can reach a maximum oxygen flow rate of 6 L/min (some devices have a lower maximum of 3 L/min), and airlines generally do not offer >4 L/min of inflight oxygen. If patients require higher flow rates to maintain adequate saturations during flight, we recommend against air travel.

Other Respiratory Equipment

Patients who use metered-dose inhalers should be instructed to bring these in the passenger cabin during flight. Although technically allowed by the Transportation Security Agency in the United States (with liquid medications exempt from the volume restrictions imposed on other fluids), nebulizers are difficult to use in flight and may disturb other passengers with their noise and aerosol distribution.

Patients with sleep apnea should be encouraged to take their CPAP or BIPAP in their carry-on luggage during travel. Whether to recommend inflight use of nocturnal positive pressure ventilation is somewhat controversial. On the one hand, patients with sleep apnea are at higher risk of hypoxemia during flight, compared with those who do not have sleep apnea. 22 Also, CPAP or BiPAP use is permitted by the Transportation Security Agency, 23 and the decreases in machine size over the past decades have made use during air travel feasible. However, carrier policies regarding CPAP or BiPAP use are variable; a recent case series of patient practices showed that 0% of CPAP users used their machine on an overnight flight (despite 50% of them sleeping during the flight). 24 , 25

Ventilator-dependent patients are at significant risk of decompensation during flight 26 and require a medical escort. Advance arrangements with the flight carrier should be made, and consideration should be given (when possible) to the use of other forms of transportation.

Risk of VTE

Air travel can increase the risk of VTE, because passengers remain stationary for long periods with increased fluid loss due to low humidity and reduced access to fluids. Although the overall risk of pulmonary thromboembolism after a flight is low (0.38 incidence per one million international flight passengers, in one report), risk increases with the duration of flight and preexisting risk factors. 27 Compression stockings may reduce the risk of VTE in high-risk patients during flight and may be a reasonable recommendation. 28 Providers occasionally recommend prophylactic dosing with aspirin to prevent VTE; however, to our knowledge this practice is not evidence-based.

Disease Specific Considerations

Risk assessment for air travel in patients with COPD should follow the pattern described earlier, with history examination, physical examination, and initial screening with pulse oximetry. In patients with COPD with resting saturations between 92% and 95%, HAST is a good screening tool for inflight hypoxemia. 29 PFTs may be obtained for other reasons but should not be used to either rule-in or rule-out the need for supplemental oxygen during flight. Regarding algorithm-based assessments, which may include 6-minute walk testing, cardiopulmonary exercise testing, arterial blood gas and/or PFT data, there is some evidence that this approach can be used with success in patients with COPD. 12 , 16 However, if HAST is available, it is a better tool for preflight screening, given that it more directly measures the variable of interest (ie, response to hypoxic conditions).

Interstitial Lung Disease and Cystic Lung Disease

Patients with diffuse parenchymal lung disease are also at risk of hypoxemia at altitude and should be screened as described earlier. In addition, recent data published by Barratt et al 13 suggest that an algorithm-based approach (based on total lung capacity and P ao 2 ) for referral to HAST may be warranted in patients with interstitial lung disease. In this group, resting pulse oximetry was a less reliable predictor of performance on HAST (27.8% with a resting saturation ≥96% did not meet HAST standards).

Patients with a cystic component to their lung disease should also be advised of the risk of inflight pneumothorax. They should be counseled regarding symptoms of pneumothorax development and the need for urgent medical treatment.

Pulmonary Hypertension

Although fewer data are available on the impact of air travel on patients with pulmonary hypertension, one small case series showed that hypoxemia at altitude is common for these individuals (roughly one-quarter of patients with pulmonary hypertension) and worsened by walking and longer flight duration. 30 Results of HAST in patients with pulmonary hypertension are similar to those of patients with other chronic respiratory disease; one cohort of 36 patients reported that 28% required supplemental oxygen. 31

Neuromuscular Disease and Chest Wall Deformity

Patients with neuromuscular disease or chest wall deformity are at risk of inflight hypoxemia because of their propensity toward hypoventilation. This is another subgroup of patients who may benefit from more frequent referral for HAST. A case series of patients with neuromuscular disease or kyphoscoliosis found that, regardless of baseline oxygen saturation, many (15 of 19 patients) met criteria for supplemental oxygen during flight based on HAST results. 32 As such, we recommend consideration for referral to HAST for any patient with neuromuscular disease or chest wall deformity who also has severe restrictive disease on PFTs (based on American Thoracic Society criteria for grading of restrictive lung disease severity, with FEV 1  <49% predicted). 33

Sleep Disordered Breathing

Little consensus exists on the recommended preflight evaluation of patients with sleep-disordered breathing, in part due to the heterogeneity of these patients. Small case series have suggested that rates of inflight hypoxemia in this group may be significant, even in the presence of resting oxygen saturation >95% (estimates range from 6% to 50%, in series of noninvasive ventilation users). 34 HAST testing therefore should be considered, particularly in patients with severe nocturnal hypoventilation.

Contagious Disease

Viral infection.

Since the advent of the coronavirus disease 2019, individuals increasingly have become aware of the risk of airborne or droplet-based disease transmission during air travel. Any patient with suspected or confirmed contagious infection should be advised to avoid commercial flight until deemed noninfectious by their managing physician. Recent Centers for Disease Control guidelines have recommended considering patients noninfectious 10 days after symptom onset (as long as fever has resolved for 24 hours without the use of antipyretics) in the case of mild-to-moderate disease or up to 20 days in patients with severe illness or immunocompromise. 35

Regarding the potential for transmission of other viral illnesses during air travel, risks are reduced (although not eliminated) by current systems for cabin air exchange and filtration. Although systematic studies are very limited, available data suggest that approximately 20% of passengers report new upper respiratory infection symptoms within 1 week of flight. 36

Patients with pulmonary TB should be counseled to avoid all air travel until they have three negative sputa for acid fast bacilli. This is particularly crucial in cases of drug-resistant TB because the confined space of the commercial aircraft cabin provides ample opportunity for the bacillus to be transmitted from person to person. 7

Pneumothorax

Because of the lower pressure at altitude, patients with pneumothorax are at risk for the expansion of the intrathoracic air pocket, resulting in respiratory distress and/or hypoxemia. Currently, the British Thoracic Society recommends waiting 2 weeks after pneumothorax resolution on chest radiograph to fly (whether the pneumothorax was managed conservatively, with a drain, or with pleurodesis). 7 Although use of a one-way valved pleural drain is possible, concerns about follow up and care at the destination site limit the practicality of this approach. Patients with chronic pneumothorax present a challenge to providers; in a case series of two patients with chronic pneumothorax, Currie et al 37 described extensive testing, which included HAST and hypobaric chamber testing and resulted in an assessment that both patients were fit to fly. One of the two patients then went on to complete multiple transatlantic flights without incident.

Other Considerations

Please see Table 2 for a summary of disease specific recommendations for preflight assessment. Patients with any recent surgery, particularly those that involve the cranial vault or thorax, are at risk of inflight expansion of postsurgical air pockets. Any travel plans should be discussed with the surgeon. Severe decompression sickness (“bends”) generally is considered a contraindication to flight, again, due to the risk of further expansion of trapped gas pockets. Controversy exists regarding milder cases, with some experts recommending avoidance of any air travel and others suggesting that it may be safe in cases in which patients require transportation to more advanced medical care. 38 Patients with severe anemia or hemoglobinopathies are at increased risk of inflight tissue hypoxia and, in the case of sickle cell disease, may be at increased risk of sickling. 39

Table 2

Disease-Specific Considerations in Preflight Screening

HAST = high altitude simulation test.

A 32-year-old woman with cystic fibrosis and 2 L/min of oxygen presents for routine pulmonary follow up. Her last admission was 18 months ago, and she is compliant with her airway clearance regimen. She lives in California and is planning to travel to Florida for a family reunion. She has not flown since starting oxygen 2 years ago. Vital signs are notable for oxygen saturation level determined by pulse oximetry of 96% on 2 L/min of oxygen, and examination reveals bilateral rhonchi and scattered wheezes, which clear with cough. How would you advise this patient regarding her upcoming air travel?

We would recommend that she increase her oxygen during flight to 4 L/min. If desired, a HAST could also be ordered to better quantify the amount of oxygen that she requires during flight. We would also advise her to defer travel if she was having symptoms of an exacerbation. She should bring her metered-dose inhalers, nebulizer, vest, and all prescription medication in her carry-on luggage to avoid losing them in transit and to allow the use of her inhalers inflight if needed. There is some increased risk of pneumothorax during flight, and she should be advised to seek medical care on arrival to her destination if she experiences worsening dyspnea or chest pain. Given her significant pulmonary disease, we would also suggest the alternative of overland travel (via train or car) as a way of avoiding the risks of air travel entirely.

Summary, Recommendations, and Resources to Improve Communication

Air travel carries the risk of complications, particularly in patients with a history of lung disease. Patients with risk factors for inflight hypoxemia should undergo history examination, physical examination, and pulse oximetry. Any patient with a resting oxygen saturation level determined by pulse oximetry of <92% should receive inflight supplemental oxygen. Patients with baseline oxygen saturation level determined by pulse oximetry of 92%-95% (and some patients with underlying lung disease and oxygen saturation level determined by pulse oximetry of >95%) should undergo HAST before air travel.

Acknowledgments

Financial/nonfinancial disclosures: None declared.

Role of sponsors: The sponsor had no role in the design of the study, the collection and analysis of the data, or the preparation of the manuscript.

FUNDING/SUPPORT: Research time for author A. Bellingshausen is supported by the T32 Ruth L. Kirschstein Institutional National Research Service Award [Grant HL134632].

NICOLE POWELL-DUNFORD, MD, MPH, JOSEPH R. ADAMS, DO, MPH, AND CHRISTOPHER GRACE, DO, MPH

Am Fam Physician. 2021;104(4):403-410

Related Letter to the Editor: Helping Adults With Dementia Travel by Air

Author disclosure: No relevant financial affiliations.

Air travel is generally safe, but the flight environment poses unique physiologic challenges such as relative hypoxia that may trigger adverse myocardial or pulmonary outcomes. To optimize health outcomes, communication must take place between the traveler, family physician, and airline carrier when there is any doubt about fitness for air travel. Travelers should carry current medications in their original containers and a list of their medical conditions and allergies; they should adjust timing of medications as needed based on time zone changes. The Hypoxia Altitude Simulation Test can be used to determine specific in-flight oxygen requirements for patients who have pulmonary complications or for those for whom safe air travel remains in doubt. Patients with pulmonary conditions who are unable to walk 50 m or for those whose usual oxygen requirements exceed 4 L per minute should be advised not to fly. Trapped gases that expand at high altitude can cause problems for travelers with recent surgery; casting; ear, nose, and throat issues; or dental issues. Insulin requirements may change based on duration and direction of travel. Travelers can minimize risk for deep venous thrombosis by adequately hydrating, avoiding alcohol, walking for 10 to 15 minutes every two hours of travel time, and performing seated isometric exercises. Wearing compression stockings can prevent asymptomatic deep venous thrombosis and superficial venous thrombosis for flights five hours or longer in duration. Physicians and travelers can review relevant pretravel health information, including required and recommended immunizations, health concerns, and other travel resources appropriate for any destination worldwide on the Centers for Disease Control and Prevention travel website.

Air travel has become increasingly popular over time, despite decreases during the COVID-19 pandemic, with 1.1 billion total passengers in 2019 and most Americans having flown at least once in the past three years. 1 Air travel is generally safe, but especially for the aging U.S. population, the flight environment poses unique physiologic challenges, particularly relative hypoxia, which may trigger adverse myocardial or pulmonary outcomes. To optimize health outcomes, communication must take place between the traveler, family physician, and airline carrier when any doubt occurs about fitness for air travel. Travelers should carry current medications in their original containers as well as a list of their medical conditions and allergies and should adjust timing of medications as needed based on time zone changes. Travelers should also consider available medical resources at their travel destinations and layover locations. Family physicians and travelers can review relevant pretravel health information, including required and recommended immunizations, health concerns, and other travel resources appropriate for any destination worldwide at https://wwwnc.cdc.gov/travel/destinations/list .

Pulmonary Conditions

By law, U.S. commercial aircraft cannot exceed a relative cabin altitude of 8,000 feet (2,438 m) because of the potential for significant hypoxia above this altitude. 2 Most passengers exposed to this environment will have a partial pressure of arterial oxygen (Pao 2 ) of 60 to 65 mm Hg (7.98 to 8.64 kPa), corresponding to 89% to 94% peripheral oxygen saturation (Spo 2 ), which may compromise cardiovascular or pulmonary disease in affected travelers. 3 Neither reassuring pulse oximetry nor reassuring forced expiratory volume in one second has been found to predict hypoxemia or in-flight events for patients with pulmonary conditions. 3

The nonstandardized Hypoxia Altitude Simulation Test, administered and interpreted by pulmonologists, can be used to determine specific in-flight oxygen requirements for patients with pulmonary complications or those for whom safe air travel remains in doubt. Typically, the Hypoxia Altitude Simulation Test comprises breathing 15% fraction of inspired oxygen for 20 minutes, with pulse oximeter and blood gas measurements taken before and after testing. 4 – 6 Patients with a Hypoxia Altitude Simulation Test Pao 2 less than 50 mm Hg (6.65 kPa) at any point during the test require supplemental oxygen in flight, whereas those with a Pao 2 greater than 55 mm Hg (7.32 kPa) do not. Pao 2 measurements falling between 50 and 55 mm Hg are considered borderline and may necessitate further testing with activity. 5 Given that the test itself incurs some risk and may not be available to all travelers, family physicians can counsel patients who are unable to walk 50 m (164 ft) or those whose usual oxygen requirements exceed 4 L per minute not to fly. 3 , 4 , 7 , 8

Patients with oxygen requirements less than 4 L per minute can be counseled to double their usual flow rate while flying. 8

Commercial airline carriers usually permit the use of personal Federal Aviation Administration–approved portable oxygen compressors, but carriers require travelers to give from 48 hours to one month's notice before flight when they are requesting the use of compressed oxygen. 9

Table 1 lists indications for which further assessment (e.g., Hypoxia Altitude Simulation Test, ability to walk 50 m) is warranted, including previous respiratory difficulties while flying, severe lung disease, recent or active lung infections, any preexisting oxygen requirements or ventilatory support, or if less than six weeks have passed since hospital discharge for acute respiratory illness. 3 Patients who have undergone an open-chest lung procedure should defer travel for two to three weeks, must not have any recent or residual pneumothorax, and should be assessed for supplemental oxygen needs. 10

Cardiac Conditions

Travelers with underlying cardiac conditions should use airport assistance services such as wheelchairs and baggage trolleys to decrease myocardial oxygen demand. 9 Although most cardiac conditions are safe for flight, some require additional consideration. Travelers with minimally symptomatic, stable heart failure may safely fly, but medication adherence is critical. 9 , 11 Patients with stable angina should be assessed for oxygen needs if they become short of breath after walking 50 m , and they should not fly following any recent medication changes that have not demonstrated clinical stability beyond that medication's half-life. 7 , 11

Patients with unstable angina, new cardiac or pulmonary symptoms, or recent changes in medication without appropriate follow-up should not fly until stable, particularly for medication changes that could impact blood pressure or coronary reserve. 11 Travelers with recent myocardial infarction at low risk should defer air travel for three to 10 days postevent 11 – 15 ( Table 2 11 ) . Low-risk patients who required percutaneous transluminal coronary angioplasty may fly after three days as long as they are asymptomatic. 9 Travelers who have had coronary artery bypass grafting or an uncomplicated open-chest procedure should wait to fly until they are 10 days postprocedure. 7 , 11

Many implantable-cardioverter defibrillators are compatible with standard airport security. 9 The Transportation Security Administration recommends that travelers with pacemakers, defibrillators, or any other implanted metal device request pat-down screening instead of using a walk-through metal detector. 16 For travelers with pacemakers and implantable-cardioverter defibrillators, a two-day flight restriction following uncomplicated placement is appropriate. 11 It is prudent for all cardiac patients to travel with a copy of their most recent electrocardiography results and a preflight graded exercise test, which may aid in assessment and management in case of an event during flight. 9 In patients with hypertension, medication compliance is especially important because aircraft noise and other travel-related stress may provoke blood pressure elevations. 17 Travel in patients with moderately controlled hypertension is not a contraindication, but airline travel for those with uncontrolled hypertension requires shared decision-making and clinical judgment.

Ear, Nose, and Throat Conditions

Trapped gases and sinus air-fluid levels can cause significant pain for the patient with ear, nose, and/or throat conditions. Adult patients with symptomatic rhinosinusitis or allergic rhinitis may benefit from oxymetazoline (Afrin) and/or pseudoephedrine to prevent ear blockage during descent. 18 No evidence suggests that antihistamines or decongestants are beneficial in children with sinusitis, 19 and these medications should not be used to hasten an early clearance for flight in any age group. Flight within 36 hours of otitis media resolution is generally safe. 20 Equalizing pressure on descent can also be accomplished in adults with frequent swallowing, chewing gum or food, or by generating pressure against a closed mouth and glottis. In young children and infants, upright bottle feeding or pacifier use can achieve similar effects. 21

Patients who have undergone jaw fracture repair should defer flying for at least one to two weeks, and jaw wiring should be temporarily replaced with elastic bands in case of emesis. 18 Transdermal scopolamine is effective in preventing air sickness , 22 and alternatives such as first-generation antihistamines may also be useful. Patients who elect to take scopolamine should be counseled on adverse effects of drowsiness, blurry vision, dry mouth, or dizziness. 22 Individuals who are prone to air sickness should refrain from alcohol use during flight and in preflight and should eat smaller, lighter meals. 18 The expansion of trapped gas at altitude may cause severe tooth pain in patients with caries beneath fixed restorations. Travelers with hearing aids should bring extra batteries and all accessories and may need to adjust their volume levels to offset background noise.

Diabetes Mellitus

In addition to carrying all medications, travelers with diabetes requiring insulin should request appropriate meals and consider checking blood glucose levels at intervals during longer flights. 23 Bringing snacks or other food can assist those with tenuous diabetes management in the event of layovers or delays. Insulin requirements may change based on the direction of travel and crossing time zones, which may entail lost or gained hours. Even if it is not part of the patient's normal regimen, fast-acting insulin, ideally with a pen device, should be considered for all travelers during flight due to its flexibility and responsiveness. 23 When traveling east, if the day is shortened by two or more hours, it may be necessary to give less insulin on the first day at the destination. When traveling west, if the day is extended by two or more hours, it may be necessary to give more insulin on the first day at the destination. Blood glucose should be checked at least 10 hours after the first-day dose to allow for further adjustments. Travelers can return to their normal insulin regimen on day 2 at their destination. A comprehensive public access resource for medical professionals addressing insulin adjustment for the air traveler is available through the Aerospace Medical Association. 23

Gastrointestinal Conditions

For travelers with recent intra-abdominal procedures, trapped gas expansion could disrupt sutures and cause rebleeding. Travelers should wait until 24 hours have passed and any bloating has resolved following laparoscopic abdominal procedures or colonoscopy. 7 , 10 Travelers should wait one to two weeks after open abdominal surgery. 10 Patients with active gastrointestinal problems, including hematemesis, melena, or obstruction, should not fly. 24

Hematologic Conditions

A baseline anemia may predispose travelers to syncope given the relative hypoxia of the flight environment. Caution should be exercised for travelers with a hemoglobin level below 8.5 g per dL (85 g per L), and some authorities recommend not advising flight for any travelers with levels below 7.5 g per dL (75 g per L). 7 Young, otherwise healthy patients with chronic anemia may be more tolerant of relative hypoxia, especially if their hemoglobin level is greater than 7.5 g per dL. 24 For the traveler with sickle cell anemia, sickling crisis during flight is unlikely 24 ; however, flight should be delayed for 10 days following an acute crisis, and patients with sickle cell anemia who have received a recent transfusion should not fly if hemoglobin levels are less than 7.5 g per dL. 24

Although deep venous thrombosis (DVT) is not caused by the flight environment itself, DVT is a concern for people who sit for extended periods or have risk factors. 25 Incidence of DVT reaches up to 5.4% in high-risk groups flying an average of 12.4 hours. 26 Compression stockings can prevent asymptomatic DVT and superficial venous thrombosis in flights lasting five hours or longer. 27 Table 3 lists recommendations for DVT prophylaxis for travelers who are at low, moderate, and high risk for DVT. 11 The baseline recommendations for each group include staying hydrated, avoiding alcohol to prevent dehydration, walking at least 10 to 15 minutes in each two hours of travel time, and performing isometric exercises while seated. 11 When indicated for high-risk travelers, including those with reduced mobility, low-molecular-weight heparin (e.g., 40 mg of subcutaneous enoxaparin [Lovenox]) on the day of and day after travel is appropriate for anticoagulation. 28

Psychiatric and Intellectual Disability Conditions

Passengers with mental or intellectual disabilities often benefit from a traveling companion because physiologic stresses of flight and the chaotic nature of busy airports may be especially challenging aspects of travel for these groups. 9 Prescription anxiolytics may alleviate travel anxiety, but a test dose is highly encouraged before flight. 9 Service or emotional support animals can be used for a variety of mental health conditions; an article in American Family Physician provides information about considerations for documentation for emotional support animals. 29 See the U.S. Department of Transportation website for current guidelines regarding the use of these animals during air travel. 30

Neurologic Conditions

Passengers predisposed to stress-related headaches and severe migraines should always carry abortive medications. Travelers with uncontrolled vertigo are not good candidates for flight. Patients prone to syncope should remain well-hydrated and be cautioned to avoid alcohol or quickly standing from a seated position. One small study suggests that people who have epilepsy with a history of flight-related seizures and a high baseline seizure frequency are likely to have a seizure after flying. 31 The Aerospace Medical Association recommends that patients with uncontrolled or poorly controlled seizures should not fly. 32 A safe amount of time permitted before flight following a seizure has not been established, but clinical judgment and the presence of a knowledgeable chaperone should factor into any medical recommendation. Although some airline carriers allow patients to fly 72 hours after a stroke, 7 the Aerospace Medical Association recommends waiting one to two weeks. 32

Obstetric Conditions

Background radiation associated with the flight environment does not pose a special hazard for most pregnant air travelers; however, the Federal Aviation Administration recommends informing aircrew or frequent flyers about health risks of radiation exposure. 33 Because a lack of in-flight medical resources may jeopardize safety of the mother and neonate, patients with an uncomplicated singleton pregnancy should generally not fly beyond 36 weeks of estimated gestational age 7 , 24 , 33 , 34 and those with a multiple gestation not beyond 32 weeks . 7 , 34 Body imaging scanners are safe for security screening during pregnancy. 34 , 35 Postpartum travelers are at moderate risk for DVT and should wear compression stockings and perform isometric exercises during flight. 11 Travelers who have undergone an uncomplicated cesarean delivery are generally safe for flight within one to two weeks. 10

Ophthalmologic Conditions

Passengers with severe visual impairment may benefit from having a traveling companion. Xerophthalmia may be exacerbated in the low humidity of the airplane cabin, and lubricating eye drops are advisable. Cataracts and clinically stable glaucoma are not contraindications to flight; however, any retinal detachment interventions should restrict flight for at least two weeks. 36 Open-globe eye surgery should delay air travel for up to six weeks, and travel recommendations should be made in conjunction with an ophthalmologist. 36

Orthopedic Conditions

Because of expansion of trapped air at altitude, all fixed casts should be bivalved. 7 , 37 Some airlines do not permit air casts of any kind, but if they are used, a small amount of air should be released to prevent any limb compression that occurs as a result of trapped gas expansion. Elastic bandages can be added to a bivalved cast and can be loosened as tolerated. The Transportation Security Administration recommends that passengers with prosthetic limbs should avoid metal detector screening and should be screened with alternative measures. 16 Individuals with significantly decreased mobility should consider wheelchairs and the use of travel companions. Passengers with low back pain and other mobility-limiting conditions can request seating near the front to reduce walking; however, business and first-class seating is an additional cost.

Urologic Conditions

Foley catheters and other inflatable balloons are compatible with flight; however, they should be filled with liquid for air travel, given the previously described expansion of trapped gas at altitude.

Special Considerations for Children

Healthy, term neonates should not fly for at least 48 hours after birth but preferably one to two weeks. 21 Infants younger than one year with a history of chronic respiratory problems since birth should be evaluated by a pulmonologist before air travel. 3

Other Air Travel Considerations

Jet lag occurs as a result of desynchronization between an individual's internal circadian rhythm and the external environment's time zone. 38 , 39 Jet lag is worse for eastward rather than westward travel. 40 Measures for prevention include ensuring enough sleep before travel, timing light exposure using sunglasses, avoiding alcohol, and eating at appropriate times after arriving at the destination. Timed melatonin is highly effective at treating jet lag, 41 and prescription hypnotic-sedative medications may also work in controlling sleep loss. 38

Self-contained underwater breathing apparatus (SCUBA) divers should not fly within 12 hours of a dive because of the concern for decompression sickness or life-threatening arterial gas embolism. 42

The airplane cabin does not inherently pose greater risk for infection than any other close contact, but respiratory viral pathogens are the most commonly transmitted infections. 43 Because of the ongoing COVID-19 pandemic, the Centers for Disease Control and Prevention (CDC) recommends delaying travel until the individual is fully vaccinated because traveling increases the chance of getting and spreading COVID-19. For patients not fully vaccinated who must travel, it is important to follow the CDC's recommendations for unvaccinated people. Check for evolving guidelines on the CDC's website. 44

Patients with breast cancer who have had surgery may fly without risking new or worsening lymphadenopathy. 45

A comprehensive discussion of in-flight emergencies is beyond the scope of this article. See the American Family Physician article on in-flight emergencies for more details. 46

This article updates a previous article on this topic by Bettes and McKenas . 37

Data Sources: A PubMed, Cochrane database, Essential Evidence Plus, ACCESSSS, and ECRI search occurred in April and May 2020 and April and May 2021 using search terms aviation medicine, travel medicine, commercial flight, air travel, and fitness to fly. The Aerospace Medical Association's website resource, Medical Considerations for Airline Travel, was searched in its entirety. The Handbook of Aviation and Space Medicine, Fundamentals of Aerospace Medicine, and Aviation and Space Medicine were reviewed for clinically relevant chapters.

The authors acknowledge Rachel Kinsler, USAARL Research Engineer, for her thoughtful review of this manuscript.

The views, opinions, and/or findings contained in this report are those of the authors and should not be construed as an official Department of the Army position, policy, or decision, unless so designated by other official documentation. Citation of trade names in this report does not constitute an official Department of the Army endorsement or approval of the use of such commercial items.

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Should I stay or should I go? COPD and air travel

Affiliations.

• 1 Dept of Pulmonary and Critical Care, School of Medicine, Dokuz Eylul University, Izmir, Turkey.
• 2 Dept of Pulmonary Diseases, School of Medicine, Ataturk University, Erzurum, Turkey.
• 3 Dept of Clinical, Integrated and Experimental Medicine (DIMES), Respiratory and Critical Care Unit, S. Orsola-Malpighi Hospital, Alma Mater University, Bologna, Italy.
• PMID: 29898904
• PMCID: PMC9489124
• DOI: 10.1183/16000617.0030-2018

Chronic obstructive pulmonary disease (COPD) is a challenging respiratory problem throughout the world. Although survival is prolonged with new therapies and better management, the magnitude of the burden resulting from moderate-to-severe disease is increasing. One of the major aims of the disease management is to try to break the vicious cycle of patients being homebound and to promote an active lifestyle. A fundamental component of active daily life is, of course, travelling. Today, the world is getting smaller with the option of travelling by air. Air travel is usually the most preferred choice as it is easy, time saving, and relatively inexpensive. Although it is a safe choice for many passengers, the environment inside the aeroplane may sometimes have adverse effects on health. Hypobaric hypoxaemia due to cabin altitude may cause health risks in COPD patients who have limited cardiopulmonary reserve. Addressing the potential risks of air travel, promoting proactive strategies including pre-flight assessment, and education of COPD patients about the "fitness to fly" concept are essential. Thus, in this narrative review, we evaluated the current evidence for potential risks of air travel in COPD and tried to give a perspective for how to plan safe air travel for COPD patients.

Copyright ©ERS 2018.

Publication types

• Activities of Daily Living*
• Air Travel*
• Cost of Illness
• Health Status
• Hemodynamics
• Hypoxia / physiopathology
• Lung / physiopathology*
• Oxygen Inhalation Therapy
• Pulmonary Disease, Chronic Obstructive / diagnosis
• Pulmonary Disease, Chronic Obstructive / physiopathology*
• Pulmonary Disease, Chronic Obstructive / therapy
• Pulmonary Gas Exchange
• Risk Assessment
• Risk Factors
• Severity of Illness Index

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INTRODUCTION

The incidence, pathogenesis, and management of in-flight and previous pneumothorax/pneumomediastinum (PTX/PMD) will be reviewed here. Pre-flight medical assessment, the prevention of in-flight hypoxemia in patients with underlying lung disease, and the management of spontaneous PTX are discussed separately. (See "Assessment of adult patients for air travel" and "Evaluation of patients for supplemental oxygen during air travel" and "Treatment of secondary spontaneous pneumothorax in adults" and "Thoracostomy tubes and catheters: Indications and tube selection in adults and children" and "Treatment of primary spontaneous pneumothorax in adults" and "Pneumothorax: Definitive management and prevention of recurrence" .)

A few reports have described the experience of individuals at high risk for pulmonary complications during air travel [ 15-17 ]:

● In a series of 1115 passengers referred to an airline medical advisory service for pre-flight evaluation, 704 had chronic obstructive pulmonary disease (COPD) or another pulmonary disorder [ 15 ]. Over 90 percent were "cleared" for transport. None of those cleared for air travel was known to have experienced a significant in-flight medical problem.

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Should i stay or should i go pulmonary embolism and air travel.

The global increase in air travel, with over 3.97 billion people traveling by air each year, and the ageing population, increase the number of those with an illness who wish to travel (1). Even more, in countries like Greece with hundreds of islands, health professionals are frequently asked to assess a patient’s fitness to fly. Doctors can receive advice and guidance mainly from two sources: the IATA passenger medical clearance guidelines (2) and the Aerospace Medical Association in which the British Thoracic Society’s recommendations for air travel (3) are suggested. Many respiratory conditions can affect a passenger’s fitness to fly with pulmonary embolism being the most debatable (3). A major question that respiratory physicians frequently have to answer, mostly with visitors from overseas who need to be repatriated following diagnosis of pulmonary embolism, is about the right time to “fly with a clot”. The British Thoracic Society guidelines recommend against airline travel during the first four weeks following pulmonary embolism (3). On the other hand, in the IATA medical guidelines published in 2018 it is suggested that patients can fly 5 days after an acute pulmonary embolism episode, if they receive anticoagulation and their PaO2 is normal on room air (2). Although there is little scientific evidence to support the above mentioned recommendations, the huge difference in the suggested period can really confuse healthcare professionals. Moreover, asking patients-tourists to remain in a travel destination one month more than scheduled, launches their cost of stay and many times they are proven unable to follow this recommendation. In our opinion, one size does not fit all. The 4-week period seems too long for a patient with pulmonary embolism severity index I or II, no evidence of right ventricular dysfunction on an imaging test, negative laboratory biomarkers on presentation (low risk patient) and a normal PaO2 on room air (4). On the other hand, the 4-week period and even more the 5-day period may be too short for a patient with pulmonary embolism severity index III-V, evidence of right ventricular dysfunction on an imaging test and positive laboratory biomarkers on presentation (intermediate high risk patient), who has a significantly higher mortality rate during the first thirty days even without traveling (4). Thus, we believe that the risk of flying after being diagnosed with pulmonary embolism is not the same for all patients and in every case we should take into consideration the risk stratification on presentation and the PaO2 level. Further carefully designed studies taking into account risk stratification will give the answer to the tough question “should I stay or should I go” after pulmonary embolism.

References The World Bank. Air transport, passengers carried. https://data.worldbank.org/indicator/IS.AIR.PSGR Date last accessed: December 7, 2018. International Air Transport Association. Medical manual 11th edition. https://www.iata.org/publications/Documents/medical-manual.pdf 2018 Ahmedzai S1, Balfour-Lynn IM, Bewick T, Buchdahl R, Coker RK, Cummin AR, Gradwell DP, Howard L, Innes JA, Johnson AO, Lim E, Lim WS, McKinlay KP, Partridge MR, Popplestone M, Pozniak A, Robson A, Shovlin CL, Shrikrishna D, Simonds A, Tait P, Thomas M; British Thoracic Society Standards of Care Committee. Managing passengers with stable respiratory disease planning air travel: British Thoracic Society recommendations. Thorax. 2011 Sep;66 Suppl 1:i1-30. Konstantinides SV, Torbicki A, Agnelli G, Danchin N, Fitzmaurice D, Galiè N, Gibbs JS, Huisman MV, Humbert M, Kucher N, Lang I, Lankeit M, Lekakis J, Maack C, Mayer E, Meneveau N, Perrier A, Pruszczyk P, Rasmussen LH, Schindler TH, Svitil P, Vonk Noordegraaf A, Zamorano JL, Zompatori M; Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2014 Nov 14;35(43):3033-69, 3069a-3069k.

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