Pulmonary disorders and flying

• asthma - if asthma is severe or there has been a recent hospitalisation then flying may be contraindicated (1)
  
  
• COPD - if the patient is hypoxic breathing air on the ground then, even if inflight oxygen is provided, the patient may not be fit to fly. Most patients already on domicillary oxygen therapy use flow rates of 1 to 2 litres per minute, and so in flight will require 2 to 4 litres per minute, as supplied by major airlines through a face mask. Few airliness routinely supply higher flow rates - this makes air travel difficult for more severe respiratory patients without a medical escort. Specialist opinion may be required
  • NICE suggest that (2):
    • all patients on long term oxygen therapy planning air travel should be assessed in line with the BTS recommendations
    • all patients with an FEV1 < 50% predicted who are planning air travel should be assessed in line with the BTS recommendations
    • all patients known to have bullous disease should be warned that they are at a theoretically increased risk of developing a pneumothorax during air travel
      
      
  • COPD and scuba diving
    • scuba diving is not generally recommended for patients with COPD. Advise people with queries to seek specialist advice (2)
      
      
• cystic fibrosis - significant desaturation can take place during a flight. Specialist opinion should be sought
  

The following table is provided as a guide only to the timeframe that should elapse between a medical event and the intended flight. The timeframes may be changed following considered medical assessment of a specific case (4,5):

Detailed consideration of specific conditions (4,5)

Asthma

• normal aircraft cabin environment does not represent a specific challenge to those suffering from asthma that is stable
• key issue is to ensure that all medication is carried in hand baggage. It may be prudent that patients with asthma, other than the mildest cases, should take a course of oral steroids with them, in order that they could intervene early if there is any deterioration in their condition.

Chronic Obstructive Pulmonary Disease (COPD)

• walking test and/or hypoxic challenge may be appropriate to determine the passenger's requirement for supplemental oxygen in flight. Oxygen can be provided by most airlines with prior notification
• flow rates of 2 or 4 litres per minute are usually available and some airlines may be able to offer a wider range of flow rates using cylinders with pulse dose delivery systems
  • some airlines may permit passengers to carry and use their own oxygen cylinders and passengers who wish to do this should contact the airline for information on their policy
  • passengers may also be able to use approved portable oxygen concentrators and again those wishing to do so should discuss this with the airline

Bronchiectasis and cystic fibrosis

• control of lung infection measures designed to loosen and clear secretions are important aspects of medical care, both on the ground and during travel. Appropriate antibiotic therapy, adequate hydration and medical oxygen may be required for both conditions. Medication to decrease sputum viscosity is helpful e.g. deoxyribonuclease in the low humidity of the aircraft cabin.

Respiratory infection

• patients with active or contagious infection are obviously unsuitable for travel until there is documented control of the infection and they are no longer infectious
• those recovering from acute bacterial infection e.g. pneumonia should be clinically improved with no residual infection and satisfactory exercise tolerance before flying
• patients with respiratory viral infections e.g. influenza, may infect those sitting adjacent to them and they should postpone air travel until the infection has resolved.

Pneumothorax

• presence of a pneumothorax is an absolute contraindication to air travel as trapped air may expand and result in a tension pneumothorax. In general, it should be safe to travel approximately 2 weeks after successful drainage of a pneumothorax with full expansion of the lung. If there is a need to travel earlier, safe travel is possible using a one-way Heimlich valve attached to the chest drain.

For up to date advice then check current guidance (4,5).

Notes:

• breathlessness - if patient suffering from breathlessness then requires a doctor's opinion. In this circumstance may require referral to a respiratory medicine unit for pre-flight assessment, including pulmonary function tests and blood gas analysis. PaO2 may be measured while breathing a mixture simulating cabin environment at altitude: if PaO2 = < 55mmHg (7.315 kPa), oxygen may be required (3)
• arterial oxygen tension (PaO2) is the most relevant predictor of oxygen level requirement during air travel. If a patient has a ground-level PaO2 < 70mmHg (9.31kPa) then s/he is likely to require in-flight oxygen. High arterial PCO2 suggests poor pulmonary reserve with an increased risk, even if using inflight oxygen (2)
• these are only guidelines and each airline has its own regulations and medical standards

Reference:

1. 'Medical guidelines for air travel', Aviation, Space and Environmental Medicine, October 1996, 67, 10, 11
2. NICE (June 2010). Chronic obstructive pulmonary disease
3. Doctor (April 2005). Ready Reckoner - fitness to fly.
4. Civil Aviation Authority. Fitness to Fly (Accessed 26/9/2020)
5. International Air Transport Association. Medical Manual 11th Edition (2018).