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Pneumonia and flying (fitness to fly) (air travel)

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

  • 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):

Diagnosis

Assessment required by a doctor with aviation medicine experience

Accept as fit to fly if:

Comments

Pneumothorax (air in the cavity around the lung due to a puncture wound or spontaneous)

6 days or less after full inflation. If general condition is adequate, early transportation with 'Heimlich type' drain and a doctor or nurse escort is acceptable

7 days after full inflation 14 days after inflation for traumatic pneumothorax

Chest surgery

10 days or less

>=11 days with uncomplicated recovery

e.g. lobectomy, pleurectomy, open lung biopsy

Pneumonia

With symptoms

Fully resolved or, if X-ray signs persist, must be symptom free

Consider supplementary oxygen especially in case of recent episode, elderly passenger and longer flights

Tuberculosis

Untreated or non-responsive to treatment

After at least two weeks of appropriate treatment and with evidence of response to treatment

COPD, emphysema, pulmonary fibrosis, pleural effusion (fluid in the lung cavity) and hemothorax (Blood in the cavity around the lung) etc.

Supplementary oxygen needed at ground level.

PO2 < 50mmHg

Unresolved recent exacerbation

Exercise tolerance (walk)> 50 metres without dyspnea and general condition is adequate.

Full recovery if recent exacerbation. No current infection

Asthma

Currently asymptomatic and no infection

Remind to carry usual prn medication in carryon luggage.

Bronchiectasis

Hypoxaemic at ground level

No current infection

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).

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