Managing passengers with stable respiratory disease planning air travel: British Thoracic Society recommendations

INTRODUCTION Need for new recommendations for managing passengers with respiratory disease planning air travel Since the first British Thoracic Society (BTS) recommendations published in 2002 and web update in 2004, data from several studies have confirmed previous findings suggesting that neither resting sea level oxygen saturations nor forced expiratory volume in 1 s (FEV1) reliably predict hypoxaemia or complications of air travel in passengers with respiratory disease. It is thus now clear that there is no reliable threshold in these variables to determine accurately the safety of air travel or need for in-flight oxygen in an individual patient. Nevertheless, the need for practical recommendations remains. The new guidance covers bronchiectasis, cancer, hyperventilation and dysfunctional breathing, obesity, pulmonary arteriovenous malformations and sinus and middle ear disease, and has expanded sections on infection and comorbidity with cardiac disease. UK airports handled over 235 million passengers in 2008 and around 2 billion passengers flew in 2006, 760 million worldwide. The average age of passengers is likely to rise, making comorbidity more likely. Over 30 years ago around 5% of commercial airline passengers were thought to have a pre-existing medical condition. With new ultralong haul flights, passengers are exposed to cabin altitudes of up to 8000 ft for up to and sometimes more than 20 h. Longer journeys increase the odds of in-flight medical incidents, and physiological disturbances associated with moderate but prolonged hypoxia, prolonged immobility and protracted exposure to reduced barometric pressure are unknown. Longer flights may increase the risk of desaturation, perhaps reflecting a gradual fall in cabin oxygen pressure. There are no established methods for quantifying in-flight medical emergencies. A North American service offering radio link assistance for in-flight medical emergencies logs over 17 000 calls a year; respiratory events accounted for 10e12% of such calls from 2004 to 2008, the third most frequent diagnostic category (Dr Paulo Alves, MedAire Inc, personal communication, 2009). Respiratory symptoms were also the third most frequent cause of medical diversion. Physicians must therefore be aware of the potential effects of the flight environment in those with lung disease. We hope that greater awareness of the challenges posed by air travel will allow physicians to encourage patients to fly safely wherever possible. A UK-wide survey of respiratory physicians in 1997 indicated that many would welcome advice on assessing patients’ fitness to fly. Other information sources include British and European, North American and Canadian 18 guidelines on chronic obstructive pulmonary disease (COPD), a British aviation medicine textbook, Aviation, Space and Environmental Medicine journal supplements and air travel publications. These are, however, not always readily available and not all provide consistent, practical or comprehensive coverage. As in 2002 and 2004, the 2011 recommendations are an expert consensus view based on literature reviews and have as their main aim to give practical advice for respiratory specialists in secondary care. We hope that they will also provide a valuable reference for practice and specialist respiratory nurses, medical and nursing staff in emergency departments and ambulance staff who may be asked for advice at airports. Information for general practitioners and patients is available at http:// www.brit-thoracic.org. uk/. An expanded and comprehensive background literature review has been retained as a resource for educational, reference and research purposes. The advice applies to commercial flights only (including scheduled repatriation with a medical or nurse escort) and excludes emergency aeromedical evacuations. However, if medical practitioners do assist at an in-flight medical emergency, most airlines will indemnify them, the aircraft will have medical equipment and they can often access specialist advice from ground-based support companies.