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  BTS STATEMENT Managing passengers with respiratory disease planningair travel: British Thoracic Society recommendations British Thoracic Society Standards of Care Committee ............................................................................................................................. Thorax   2002; 57 :289–304 INTRODUCTION Need for recommendations on managingpassengers with lung disease planning air travel  Air travel is now a common mode of travel formillions,with a single UK airline carrying over 33million passengers annually. It is estimated thatover one billion passengers travel by air world- wide each year, and for the majority this is with-out hazard.Despite current uncertainties about the futureof the airline industry, it seems likely that airtravel will continue to offer a convenient form of transport for many. In the longer term passengernumbers may therefore increase further. Giventhe rising age of western populations, the age of air travellers is also likely to increase,with greaterpropensity for medical impairment.Over 25 yearsago it was already estimated that 5% of commer-cial airline passengers were ambulatory patients with some illness including chronic obstructivepulmonary disease (COPD). 1 There are still no established methods forquantifying the risk of in-flight medical prob-lems.However,a North American service offeringexpert assistance by radio link for in-flight medi-cal emergencies logged 8500 calls in 2000, of  which 11% were respiratory in nature. 2 Physiciansshould therefore be aware of the potential effectsof the flight environment in passengers with lungdisease.OnemillionresidentsofDenver,Coloradolive at 5280 ft (1609 m) and coaches crossinghigh Alpine passes reach 10 000 ft (3048 m),indicating that moderate hypoxaemia is not gen-erally hazardous.Nevertheless,greater awarenessof the risks of air travel will enable physicians toencourage patients to fly safely wherever possibleand increase the safety of fellow air passengers.The aircraft crew are subject to regular medicalexamination but passengers are not.For potentialpassengers with lung disease it would clearly be valuable for their physician to have recommenda-tions for assessing the fitness of their patients forflying. A recent national survey of respiratoryphysicians indicated that many would welcomeadvice. 3 Sources of available information includeBritish and European, 4–6 North American, 7 andCanadian 8 COPD guidelines, aviation medicinetextbooks, 9 supplements to the journal  Aviation, Space & Environmental Medicine 10–12 and other publi-cations on air travel. 13 However, these referencesmay not always be readily accessible to physiciansand do not all provide consistent, practical, orcomprehensive coverage. In particular, there isdisparity between European and North Americanguidelines, uncertainty about assessment meth-ods, and failure to consider other respiratorycauses of hypoxaemia such as pulmonary fibrosis.To meet the need for consistent, practical, andcomprehensive advice, the British Thoracic Soci-ety (BTS) Standards of Care Committee set up a Working Party to formulate national recommen-dations for managing patients with lung diseaseplanning air travel. There is currently insufficientevidence to produce formal guidelines. Thefollowing recommendations are derived from lit-erature reviews and aim to provide practicaladvice for respiratory physicians. They apply tocommercial flights only and exclude emergencyaeromedical evacuation situations. Purpose of recommendations ã  To enhance safety for passengers with lung dis-ease travelling by air and reduce the number of in-flight medical incidents due to respiratorydisease. ã  To increase recognition among healthcareprofessionals that patients with respiratorydisease may require clinical assessment andadvice before air travel. ã  To provide an authoritative up to date literaturereview of available evidence. ã  To provide consistent, practical, and compre-hensive advice for healthcare professionalsmanaging such patients. ã  To formulate key research questions to provokefurther investigation. This should produce astrengthened, high quality evidence base from which clearer evidence-based guidelines can bedeveloped. ã  To promote the development of methods formonitoring the size of the problem. Methods of production The Working Party defined the target and purposeof the recommendations. Independent literaturesearches were performed by Working Party mem-bers from which a draft document was producedsummarising current evidence and containingrecommendations regarding (1) the flight envi-ronment, (2) physiological effects of exposure toaltitude, (3) clinical assessment, (4) respiratorydisorders presenting a possible risk for potentialair travellers, and (5) oxygen supplementation.ThedocumentwasreviewedbytheWorkingPartyand redrafted. It was then circulated to the BTSStandardsofCareCommitteeandreviewerslistedin Appendix 1 before being made available to BTSmembers on the members only section of the BTS website.A final draft was produced incorporatingfeedback after discussion and further review bythe BTS Standards of Care Committee. The  Air Travel Working Party:Dr R K Coker (chair),Dr D A R Boldy,Dr R Buchdahl,Mr D Cramer,Professor D Denison, Wing CommanderD P Gradwell,Professor J M B Hughes,Dr J A Innes,Dr A O C Johnson,Dr K P McKinlay,Dr M R Partridge. . . . . . . . . . . . . . . . . . . . . . . Correspondence to:Dr R Coker, Department of Respiratory Medicine,Hammersmith Hospital,Du Cane Road, LondonW12 0HS, UK;robina.coker@ic.ac.uk .......................289www.thoraxjnl.com group.bmj.comon October 23, 2016 - Published by http://thorax.bmj.com/ Downloaded from   SUMMARY OF KEY POINTS AND RECOMMENDATIONS WITH AHCPR GRADING The flight environment and effects of altitude Modern aircraft are pressurised to cabin altitudes up to 2438 m (8000 ft) although this maximum may be breached in emer-gencies. Cabin altitudes in Concorde are lower at around 1829 m (6000 ft). At 2438 m (8000 ft) the partial pressure of oxy-gen will have dropped to the equivalent of breathing 15.1% oxygen at sea level. In a healthy passenger the arterial oxygentension (Pa O 2 ) at 2438 m (8000 ft) will be influenced by age and minute ventilation, but will fall to 7.0–8.5 kPa(53–64 mm Hg, Sp O 2  85–91%). There is thus concern that altitude exposure may exacerbate hypoxaemia in patients withlung disease, and particular caution seems justified in those who are hypoxaemic at sea level. The physiological compensa-tions for acute hypoxaemia at rest are mild to moderate hyperventilation (lowering of arterial carbon dioxide tension (Pa CO 2 )moderates the hyperventilation) and a moderate tachycardia. Pre-flight assessment for adults The following groups should be assessed: ã severe COPD or asthma; [ B ]ã severe restrictive disease (including chest wall and respiratory muscle disease), especially with hypoxaemia and/or hypercapnia;[ C ]ã patients with cystic fibrosis; [ C ]ã history of air travel intolerance with respiratory symptoms (dyspnoea, chest pain, confusion or syncope); [ C ]ã co-morbidity with other conditions worsened by hypoxaemia (cerebrovascular disease, coronary artery disease, heart failure); [ C ]ã pulmonary tuberculosis; [ C ]ã within 6 weeks of hospital discharge for acute respiratory illness; [ C ]ã recent pneumothorax; [ B ]ã risk of or previous venous thromboembolism; [ B ]ã pre-existing requirement for oxygen or ventilator support. [ C ] The following assessment is recommended: ã history and examination with particular reference to cardiorespiratory disease, dyspnoea, and previous flying experience; [ C ]ã spirometric tests (in non-tuberculous patients only); [ C ]ã measurement of Sp O 2  by pulse oximetry. Readings should be taken from a warm ear or finger after sufficient delay for the oxi-meter to display a stable reading. Blood gas tensions are preferred if hypercapnia is known or suspected. [ C ]In those who are screened who have resting sea level oximetry between 92% and 95% with additional risk factors(table 1, p 293), hypoxic challenge testing is recommended (table 2, p 293). [ C ] Notes (1) The following groups should not fly:ã patients with infectious tuberculosis must not travel by public air transportation until rendered non-infectious. Three smear nega-tive sputum examinations on separate days in a person on effective antituberculous treatment indicates an extremely low poten-tial for transmission, and a negative culture result virtually precludes potential for transmission; [ B ]ã those with a current closed pneumothorax should avoid commercial air travel. [ C ](2) Patients who have undergone major thoracic surgery should ideally delay flying for 6 weeks after an uncomplicated procedure.[ C ] Patients should only fly if essential, and formal medical assessment is required before departure. In practice, some airlines areprepared to accept patients within 2 weeks of major thoracic surgery. The relative risk of these two approaches is not known, butcareful medical assessment is required beforehand, whichever is adopted.(3) Lung cancer per se is not a contraindication to flying. However, associated respiratory diseases should be considered in their ownright. [ C ](4) Additional precautions for all passengers:ã excess alcohol should be avoided before and during the flight, particularly in those with obstructive sleep apnoea and those at riskof venous thromboembolism; [ C ]ã individuals not receiving oxygen should remain mobile during the flight; [ C ]ã exercise without supplemental oxygen may worsen hypoxaemia; it may be prudent for the most compromised to use oxygen whilewalking on the plane and to let a flight attendant know how long they expect to be away from their seat; [ C ]ã the risk of thromboembolic disease should initiate prophylactic measures as detailed in the following summary; [ B ]ã patients should carry preventative and relieving inhalers in their hand luggage; [ C ]ã portable nebulisers may be used at the discretion of the cabin crew, but there is good evidence that spacers are as effective asnebulisers in treating asthma; [  A  ]ã patients should check with their local or hospital pharmacists whether any medicine may be adversely affected by the extreme tem-perature in the hold baggage compartment; [ C ] 290 British Thoracic Society Standards of Care Committeewww.thoraxjnl.com group.bmj.comon October 23, 2016 - Published by http://thorax.bmj.com/ Downloaded from   SUMMARY OF KEY POINTS AND RECOMMENDATIONS WITH AHCPR GRADING (continued) ã dry cell battery powered continuous positive airway pressure (CPAP) machines may be required by patients with obstructive sleepapnoea on long haul flights, but they must be switched off before landing; [ C ]ã ventilator dependent patients should inform the airline of their requirements at the time of reservation, and a doctor’s letter isrequired outlining the medical diagnosis, necessary equipment, recent blood gas results, and ventilator settings. A medical attend-ant is likely to be needed. Arrangements must be made for proceeding through air terminals before and after the flight. [ C ](5) Logistics of air travel with oxygen: supplementary in-flight oxygen is usually prescribed at a rate of 2 l/min and should be givenby nasal cannulae. In-flight oxygen need not be switched on until the plane is at cruising altitude, and may be switched off at thestart of descent. For patients on oxygen at sea level, the rate should only be increased while at cruising altitude. [ B ](6) In complex circumstances patients can be referred for testing in a hypobaric chamber. Centres are listed in Appendix 3.Even with in-flight oxygen, travel cannot be guaranteed to be safe. Air travel is almost always possible with appropriate medi-cal support, but the logistics and economic costs may outweigh the benefits in individual cases. Pre-flight assessment for children ã It is prudent to wait for 1 week after birth before allowing infants to fly to ensure the infant is healthy. [ C ]ã If the infant has had any neonatal respiratory problems, the proposed journey should be discussed with a paediatrician and ahypoxic challenge test considered. [ B ]ã For oxygen dependent children including ex-premature infants with chronic lung disease (bronchopulmonary dysplasia) where fly-ing is imperative, oxygen requirements should be titrated in a body box [ B ] as follows:The infant, receiving oxygen via nasal cannulae, is placed in the body box in the company of a parent or carer, and Sp O 2 monitored. The air in the body box is then diluted to 15% oxygen with nitrogen. Any fall in Sp O 2  can be restored to the srcinalvalue by titration of the flow of oxygen through the nasal cannulae. This flow of oxygen should then be supplied during the flight. Disease specific recommendations Asthma ã Assessment is recommended as described above.ã Preventative and relieving inhalers should be carried in the hand luggage.ã Portable nebulisers may be used at the discretion of cabin crew. They may be connected to the aircraft electrical supply on somebut not all airlines. Some airlines can provide nebulisers for in-flight use and patients should check with the carrier when booking.Spacers are as effective as nebulisers. COPD ã Assessment is recommended as described above.ã Passengers should travel on a non-smoking flight.ã Preventative and relieving inhalers should be carried in the hand luggage.ã Portable nebulisers may be used at the discretion of cabin crew. They may be connected to the aircraft electrical supply on somebut not all airlines. Some airlines can provide nebulisers for in-flight use and patients should check with the carrier when booking.Spacers are as effective as nebulisers.ã Patients prescribed in-flight oxygen should receive oxygen while visiting high altitude destinations (see Appendix 4).ã Many airports can provide wheelchairs for transport to and from the aircraft. Cystic fibrosis ã Assessment by the cystic fibrosis physician is recommended as described above.ã Medications should be divided between hand and hold baggage to allow for delays and stopovers.ã Portable nebulisers may be used at the discretion of cabin crew and can be connected to the aircraft electrical supply on some butnot all airlines. Some airlines can provide nebulisers for in-flight use and patients should check with the carrier when booking.Spacers are as effective as nebulisers.ã Passengers should undertake physiotherapy during stopovers.ã In-flight nebulised antibiotics and DNase should not be necessary.ã Passengers should check with their pharmacist whether any medicine may be adversely affected by extreme temperatures in thehold baggage compartment.ã Many airports can provide wheelchairs for transport to and from the aircraft. Infections ã Assessment is recommended as described above.ã Aircraft boarding should be denied to those known to have infectious tuberculosis.ã Patients with infectious tuberculosis must not travel by public air transportation until rendered non-infectious. WHO guidelines statethat three smear negative sputum examinations on separate days in a person on effective antituberculous treatment indicate anextremely low potential for transmission, and a negative sputum culture result virtually precludes potential for transmission. 14 Thismay be over-cautious. While this remains the policy for HIV positive patients, HIV negative patients who have completed 2 weeksof effective antituberculous treatment are, in practice, generally considered non-infectious. 15 Managing passengers with respiratory disease planning air travel 291www.thoraxjnl.com group.bmj.comon October 23, 2016 - Published by http://thorax.bmj.com/ Downloaded from   SUMMARY OF KEY POINTS AND RECOMMENDATIONS WITH AHCPR GRADING (continued) Fibrosing alveolitis ã Assessment is recommended as described above. Neuromuscular disease and kyphoscoliosis ã Assessment is recommended as described above. Ventilator dependent patients For all patients: ã The airline must be consulted before reservation.ã A doctor’s letter is required outlining the medical diagnosis, necessary equipment, recent blood gas results, and ventilator settings.It should state that the ventilator must travel in the cabin as extra hand luggage.ã Long haul flights are best avoided.ã A dual 110/240 volt function is recommended so that the ventilator is compatible with the voltage at the intended destination.ã A dry cell battery pack is essential for back-up and for proceeding through air terminals before and after the flight. For patients on permanent (24 hour) ventilation: ã Ventilator dependent patients need a medical escort.ã An electrical supply can be provided on the flight if arranged in advance.ã Wet acid batteries are prohibited.ã The medical escort must be competent to change the tube, operate suction, and ambubag the patient for emergency ventilation if electrical power fails.ã A spare tracheostomy tube and battery powered suction must be taken.ã Owing to reduced barometric pressure at altitude, patients with a tracheostomy should have the air in the cuff of their tube replacedwith an equal volume of saline before boarding. Obstructive sleep apnoea (OSA) ã Assessment is recommended as described above.ã The airline must be consulted before reservation.ã A doctor’s letter is required outlining the medical diagnosis and necessary equipment. It should state that the CPAP machine shouldtravel in the cabin as extra hand luggage.ã Long haul flights are best avoided.ã A dual 110/240 volt function is recommended so that the CPAP machine is compatible with the voltage at the intended destina-tion.ã Dry cell battery powered CPAP can be used during the flight but must be switched off before landing.ã Patients should avoid alcohol immediately before and during the flight.ã Patients with mild snoring and hypersomnolence are unlikely to require CPAP during the flight.ã Patients with significant desaturation intending to sleep during the flight should consider using their CPAP machine.ã Patients with significant desaturation should use CPAP during sleep while visiting high altitude destinations (see Appendix 4). Previous pneumothorax ã Patients with a current closed pneumothorax should not travel on commercial flights.ã Patients may be able to fly 6 weeks after a definitive surgical intervention and resolution of the pneumothorax. Careful medicalassessment is required beforehand.ã Patients who have not had surgery must have had a chest radiograph confirming resolution, and at least 6 weeks must haveelapsed following resolution before travel.ã Although recurrence is unlikely during the flight, the consequences at altitude may be significant given the absence of promptmedical care. This is particularly true for those with additional co-existing lung disease. Passengers may wish to consider alterna-tive forms of transport within 1 year of the initial event. Venous thromboembolic disease (VTE) ã All passengers should avoid excess alcohol and caffeine containing drinks, and preferably remain mobile or exercise their legsduring the flight.ã Passengers at slightly increased risk of VTE include those aged over 40, those who are obese or who have extensive varicose veins,polycythaemia, and those who have undergone minor surgery in the previous 72 hours. In addition to the above precautions theyshould avoid alcohol and caffeine containing drinks, take only short periods of sleep unless they can attain their normal sleepingposition, and avoid sleeping pills. Physicians may wish to recommend support tights or non-elasticated long socks.ã Passengers at moderately increased risk of VTE include those with a family history of VTE, recent myocardial infarction, pregnancyor oestrogen therapy (including hormone replacement therapy and some types of oral contraception), postnatal patients within 2weeks of delivery, and those with lower limb paralysis, recent lower limb trauma or recent surgery. In addition to the above pre-cautions, physicians may wish to recommend pre-flight aspirin and graduating compression stockings. 292 British Thoracic Society Standards of Care Committeewww.thoraxjnl.com group.bmj.comon October 23, 2016 - Published by http://thorax.bmj.com/ Downloaded from 
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