Management of ambulatory patients for travel in a commercial airliner. Working up passengers with medical conditions for fitness to fly in a commercial airliner.

1. Air Travel and Ambulatory PatientsAir Travel and Ambulatory Patients
Dr Wilfred Lim
Aviation Medicine Physician and Anaesthesiologist
wilfredlim@avmed.sg
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2. Outline
 Introductory Comments
 Physiological Stressors of Air Travel
 Pre-flight Assessment and Medical Clearance
 Cardiovascular and Respiratory Diseases
 Deep Vein Thrombosis
 Ear, Nose and Throat Conditions
 Surgical Conditions
 Miscellaneous Conditions
 Case Discussions
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3. Introductory Comments
 2.9 Billion air passengers in 2012
 More patients will seek medical
advice on air travel
 Doctors need to have a basic
understanding of the impact of
stresses related to air travel in order
to properly advise their patients.
 Ambulatory Patient
Does not require in-patient care
and is able to move around
independently or with little
assistance.
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4. Introductory Comments
Module Objective
 Relate stressors of flight to common medical conditions of an
ambulatory air traveller
 Identify potential issues and provide advice to
 Safe-guard patient’s well-being
 Avoid Delays / Diversions
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5. Physiological Stressors of Air Travel
 Ambient pressure
 5000-8000ft
 PaO2 – 55mmHg; SaO2 – 88-90%
 Problems in people with reduced
respiratory/cardiovascular reserves
 Humidity
 10-20%
 Effect on membranes and airways
 Effect on Volume
 Boyle’s Law (P x V = Constant)
 Effect of trapped gases in body cavities
 Confined, isolated environment
 Small spaces – “Cattle Class”
 Circulatory and nursing problems
 Anxiety / Fatigue / Jet-Lag
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6. Pre-flight Assessment & Medical Clearance
 Medical Clearance
 IATA recommends a Medical Information Form (MEDIF)
 MEDIF should be completed by the passenger’s medical attendant and
passed to the airline or travel agent at the time of booking to ensure timely
medical clearance.
 Medical clearance is required when:
 Fitness to travel is in doubt as a result of recent illness, hospitalization,
injury, surgery or instability of an acute or chronic medical condition
 Special services are required, e.g. oxygen, stretcher or authority to carry or
use accompanying medical equipment such as a ventilator or a nebulizer.
 Medical clearance is not required :
 For carriage of an invalid passenger outside these categories, although
special needs, such as a wheelchair, must be reported to the airline at the
time of booking.
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7. 7/25
Pre-flight Assessment & Medical Clearance

8. Considerations in determining a passenger’s fitness to travel
 Will the passenger’s medical condition be adversely affected by air
travel?
 Immobility
 Requirement to be able to adopt the brace position in an emergency and the
confined/constrained environment
 Timing of any regular medication for those undertaking long-haul trans-
meridian travel.
 Travel to/from the airport, processing through security and passport control
 Will the passenger’s medical condition adversely affect the comfort
or safety of the other passengers and the operation of the aircraft?
 Contagious diseases
 Moribund state
 Late stages of pregnancy
 Behavioural problems
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Pre-flight Assessment & Medical Clearance

9. 9/25

10. Cardiovascular & Respiratory Diseases
 Cardiovascular Considerations
 Decreased inspired PO2 at altitude and resultant tachycardia with
increased work of breathing may result in cardiac
decompensation.
 Medical oxygen is required to avoid decompensation.
CARDIOVASCULAR INDICATIONS FOR
MEDICAL OXYGEN DURING COMMERCIAL
AIRLINE FLIGHTS
1.Use of oxygen at baseline altitude
2.CHF NYHA class III–IV or baseline
PaO2 less than 70 mm Hg
3.Angina CCS class III–IV
4.Cyanotic congenital heart disease
5.Primary pulmonary hypertension
6.Other cardiovascular diseases
associated with known baseline
7.hypoxemia
CARDIOVASCULAR INDICATIONS FOR
MEDICAL OXYGEN DURING COMMERCIAL
AIRLINE FLIGHTS
1.Use of oxygen at baseline altitude
2.CHF NYHA class III–IV or baseline
PaO2 less than 70 mm Hg
3.Angina CCS class III–IV
4.Cyanotic congenital heart disease
5.Primary pulmonary hypertension
6.Other cardiovascular diseases
associated with known baseline
7.hypoxemia
CARDIOVASCULAR CONTRAINDICATIONS TO
COMMERCIAL AIRLINE FLIGHT
1.Uncomplicated myocardial infarction within 2–3
weeks
2.Complicated myocardial infarction within 6 weeks
3.Unstable angina
4.Congestive heart failure, severe, decompensated
5.Uncontrolled hypertension
6.CABG within 10–14 days
7.CVA within 2 weeks
8.Uncontrolled ventricular or supraventricular
tachycardia
9.Eisenmenger syndrome
10.Severe symptomatic valvular heart disease
CARDIOVASCULAR CONTRAINDICATIONS TO
COMMERCIAL AIRLINE FLIGHT
1.Uncomplicated myocardial infarction within 2–3
weeks
2.Complicated myocardial infarction within 6 weeks
3.Unstable angina
4.Congestive heart failure, severe, decompensated
5.Uncontrolled hypertension
6.CABG within 10–14 days
7.CVA within 2 weeks
8.Uncontrolled ventricular or supraventricular
tachycardia
9.Eisenmenger syndrome
10.Severe symptomatic valvular heart disease
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11. 11/25
Myocardial Infarction & Air Travel
 ACC / AHA (2012)
 Air travel within the first 2 weeks after an MI only if the patient has no
angina, no dyspnea or hypoxaemia at rest, and no fear of flying
 Must have a companion, must carry GTN and must request airport
transportation assistance
 AsMA (2002)
 No air travel within 2-3 weeks of an uncomplicated MI and within 6 weeks of
a complicated MI
 British Cardiovascular Society (2010)
 Very low risk: ages <65 years, first event, successful reperfusion, left
ventricular ejection fraction (LVEF) >45 percent, no complications and no
planned investigations or interventions. (May fly as early as 3 days)
 Low (or medium) risk: LVEF >40 percent, no symptoms of heart failure, no
evidence of inducible ischemia or arrhythmia and no further investigations or
interventions planned. (May fly from 10 days onwards)
 High risk: LVEF <40 percent with signs and symptoms of heart failure,
those pending further investigations with a view to revascularization or
device therapy. (Should be deferred)

12.  Travel Advice for Cardiovascular Patients
 Assure sufficient quantities of cardiac medications for the entire trip and
keep in carry-on luggage.
 Keep a separate list of medications including dosing intervals and tablet size
in the event that medications are lost.
 Adjust dosing intervals in order to maintain dosing frequency if crossing time
zones
 Carry a copy of the most recent ECG
 Carry a pacemaker card, if a pacemaker patient; ECGs should be done with
and without a magnet
 Contact the airline concerning special needs, e.g., diet, medical oxygen,
wheelchair, etc., and consider special seat requests such as near the front
or close to a restroom.
 Limit unnecessary ambulation, particularly in-flight. Consider curbside
baggage check-in and arranging for a wheelchair or electric cart for in-airport
transportation. Assure adequate time between connections
 Consider in-flight medical oxygen if the patient has Canadian Cardiovascular
Society class III-IV angina or baseline hypoxemia.
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Cardiovascular & Respiratory Diseases

13.  Respiratory diseases considerations
 Type, reversibility, and functional severity
 Evaluation of altitude tolerance and safety for the patient
 Anticipated altitude and duration of the flight
 Evaluation of respiratory reserves
 Arterial Blood Gases
 Ground level PaO2 > 70-72 mm Hg is considered adequate
 PaO2 < 70-72 mmHg may be effectively managed with in-flight medical oxygen
 Elevated arterial PCO2 (hypercapnia) indicates poor pulmonary reserve and
increased risk at altitude, even with oxygen therapy.
 HAST – On 15% O2 and PaO2 < 50 mmHg : medical oxygen must
be considered
 Functional – Able to walk 50 m at normal pace or climb 1 flight of stairs
without becoming severely dyspnoeic / 6 Minute Walking Test (6MWT)
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Cardiovascular & Respiratory Diseases

14. 14/25
Cardiovascular & Respiratory Diseases

15.  Pneumothorax
 Pneumothorax is an absolute contraindication to air travel
 Air travel not recommended until the pneumothorax resolves fully
 British Thoracic Society recommend to wait seven days after x-ray resolution
before flying and to delay flying for two weeks after traumatic pneumothorax
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Cardiovascular & Respiratory Diseases

16.  Travel Advice for Patients with Respiratory Diseases
 Post-pone if suffering of acute exacerbations or infections
 Sufficient quantities of medications for the entire trip, eg. inhalers, oral
steroids and etc.
 Keep a separate list of medications including dosing intervals and tablet size
in the event that medications are lost.
 Contact the airline concerning special needs, e.g., diet, medical oxygen,
wheelchair, etc., and consider special seat requests such as near the front
or close to a restroom.
 Unhurried, early check-in and request for ambulatory aids for intra-airport
transportation.
 If using own oxygen source (eg. O2 concentrators), check with airline
regarding use in flight.
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Cardiovascular & Respiratory Diseases

17. Deep Vein Thrombosis
 Multi-factorial aetiology
 Rarely observed after flights of less
than 5 hours’ duration and, typically,
the flights are of 12 hours’ duration
or more
 Incidence in travellers:
 >5000km – 1.5/million
 <5000km – 0.01/million
 Risk not confined to air travel
 No scientific basis for giving
recommendations for the prevention
of DVT related specifically to aircraft
travel
Risk factors for the development of DVT in
surgical patients
1. Blood disorders affecting clotting tendency;
2. Impairment of blood clotting mechanism,
such as clotting factor abnormality;
3. Cardiovascular disease;
4. Current or history of malignancy;
5. Recent major surgery;
6. Recent trauma to lower limbs or abdomen;
7. Personal or family history of DVT;
8. Pregnancy;
9. Estrogen hormone therapy
10. Age above 40 yr;
11. Prolonged immobilization;
12. Depletion of body fluids causing increased
blood viscosity.
Risk factors for the development of DVT in
surgical patients
1. Blood disorders affecting clotting tendency;
2. Impairment of blood clotting mechanism,
such as clotting factor abnormality;
3. Cardiovascular disease;
4. Current or history of malignancy;
5. Recent major surgery;
6. Recent trauma to lower limbs or abdomen;
7. Personal or family history of DVT;
8. Pregnancy;
9. Estrogen hormone therapy
10. Age above 40 yr;
11. Prolonged immobilization;
12. Depletion of body fluids causing increased
blood viscosity.
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18. + Change positions regularly
+ Walk whenever possible
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19. SUGGESTED DVT PROPHYLAXIS
Risk Categories Prophylaxis
Low Age over 40; obesity; active inflammation;
recent minor surgery (within last 3 days)
Advice about mobilization and
hydration, and/or support tights/non-
elasticated long socks
Moderate Varicose veins; heart failure
(uncontrolled); recent myocardial
infarction (within 6 weeks); hormone
therapy (including oral contraception);
polycythaemia; pregnancy/postnatal;
lower limb paralysis; recent lower limb
trauma (within 6 weeks)
Passenger advised to consult own
medical practitioner who may
recommend the above + graduated
compression stockings
High Previous VTE; known thrombophilia;
recent major surgery (within 6 weeks);
previous CVA; malignancy; family history
of VTE
As above, but passenger’s medical
practitioner may recommend low
molecular weight heparin
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Deep Vein Thrombosis
Aspirin : No evidence of efficacy for aspirin in prevention of DVT and its use is
associated with GI symptoms.

20. Ear, Nose & Throat
 URTI
 Consequences of flying - painful ears, facial pain, perforation of the tympanic
membrane
 Wait until symptoms resolve and positive Valsalva manoeuvre observed with
auroscope
 Ear
 Middle ear space can trap gas
 Active conditions such as middle ear infections, effusions, recent procedures
(tympanoplasty, mastoidectomy, stapedectomy, endolymphatic shunt,
labyrinthectomy, acoustic neuroma removal, nerve section via middle cranial
fossa, or other otologic surgery) are contra-indications to flight
 Myringotomy is not contraindication to flight
 Equalise regularly : swallowing, chewing, gentle Valsalva, bottle feeding
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21.  Nose and Sinuses
 Acute or chronic sinusitis, large polyps, recent nasal surgery, recurrent
epistaxis and significant upper respiratory tract infections are contraindications
to flying
 Mucolytic agents, oral decongestants, steroids, and temporary use of nasal
decongestant spray such as oxymetazoline may provide temporary sinus
ventilation and drainage
 Throat
 Tracheotomy, laryngectomy, or other laryngeal disorders may need extra
moisturisation and possibly removal of thickened secretions due to lower
humidity inflight.
 Extra oral hydration, moisture generator, and suctioning may be required
 Following tonsillectomy and adenoidectomy, palatoplasty, or nasal or facial
fracture repair, patients can fly once postoperative bleeding risk has passed (2
weeks)
 Facial plastic surgical procedures such as facelift, blepharoplasty, otoplasty,
peels, rhinoplasty, implants, or dermabrasion can fly once drains are removed
and they are cleared by their surgeon (within 1-2 weeks).
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Ear, Nose & Throat

22. Surgical Conditions
 General Considerations
 Safety of air travel following a surgical procedure is becoming an important
issue with the increasing frequency of ambulatory surgery and medical
tourism.
 Optimal timing of a post-operative flight, patient stability, special medical
needs, such as pain management and precaution awareness are important
considerations
 Anaesthesia
 Modern anaesthetic drugs and techniques are not contraindication to flying
 Effects generally dissipated when fit for discharge from ambulatory unit
 Dural leak causing severe headache from a spinal anaesthetic with small
gauge needles is very rare
 Post-surgical Stress
 State of increased oxygen consumption
 O2 delivery may be decreased or fixed in patients who are elderly, volume
depleted, anaemic, or who have cardiopulmonary disease
 Consider delaying air travel for several days or provide medical O2 during
the flight.
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23.  Post-surgical Anaemia
 Not uncommon to see younger patients with haemoglobins down to 7.0 g/dL
and elderly patients with haemoglobins down to 8.0 g/dL
 Extra consideration for elderly patient with underlying cardiovascular disease
 Consider in-flight oxygen therapy below these levels
 Abdominal Surgery
 Relative ileus for several days, risk for tearing of suture lines, bleeding, and
perforation if fly pre-maturely
 Air travel should be discouraged for 1-2 weeks after the procedure
 Colonoscopy – inadvisable for 24h because of retained gas
 Laparoscopic procedures – can fly the next day if no bloating symptoms
 Colostomies – May increase output, use large bag
 Neurosurgery
 Gas trapped within the skull will cause increased intracranial pressure when
it expands at altitude
 Advisable to wait at least 1 week post-op
 CSF leak – should not fly
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Surgical Conditions

24. Miscellaneous
 Pregnancy
 Generally permitted up to the end of the 36th week for uncomplicated single
pregnancy, 32 weeks for uncomplicated multiple pregnancies (SQ)
 For uncomplicated single pregnancies between 29 weeks and 36 weeks of
pregnancy, passengers are required to provide a medical certificate stating
the following: (1) fitness to travel, (2) number of weeks of pregnancy and (3)
estimated date of delivery.
 Normal pregnancy is also associated with an increased risk of DVT
 Pregnant patients at high risk of developing DVT may require heparin.
 Anaemia
 Special consideration should be given to haemoglobin below 8.5 g/dL
 Individual variability depending upon how well compensated
 If there is any question about suitability to fly, medical oxygen should be
administered.
 Sickle Cell Anaemia - can be life-threatening, such patients should be
advised not to travel by air without medical oxygen.
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25. Decompression Illness (DCI)
 Caused by excess nitrogen coming out of
solution in the form of micro-bubbles in
different tissues
 Facilitated by exposure to low barometric
pressure (flying) too soon after exposure
to high barometric pressure (diving)
Divers Alert Network (DAN) Revised
Flying-after-Diving Guidelines
1.For a single no-decompression dive, a
minimum pre-flight surface interval of 12
hours is suggested.
2.For multiple dives per day or multiple days
of diving, a minimum pre-flight surface
interval of 18 hours is suggested.
3.For dives requiring decompression stops,
there is little evidence on which to base a
recommendation and a pre-flight surface
interval substantially longer than 18 hours
appears prudent.
Divers Alert Network (DAN) Revised
Flying-after-Diving Guidelines
1.For a single no-decompression dive, a
minimum pre-flight surface interval of 12
hours is suggested.
2.For multiple dives per day or multiple days
of diving, a minimum pre-flight surface
interval of 18 hours is suggested.
3.For dives requiring decompression stops,
there is little evidence on which to base a
recommendation and a pre-flight surface
interval substantially longer than 18 hours
appears prudent.
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Miscellaneous

26. Fractures
 May require the purchase of an
extra seat or seats, or
alternatively to fly business or
first class.
 Passengers with full-length
above-knee casts are required
by some airlines to travel by
stretcher
 Casts applied within 24-48 h
should be bi-valved to avoid
harmful swelling, particularly on
long flights
 Pneumatic splint – some air
should be released to allow for
gas expansion at altitude
 Consider risk of DVT
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Miscellaneous

27. References
 Ernsting Aviation Medicine, 4th
Edition (2006). Ch 54 – Commercial
passenger fitness to fly.
 Aerospace Medical Association. Medical guidelines for airline travel, 2nd
edition. Aviation, Space, and Environmental Medicine 2003; 74:II:A1-
19
 British Medical Association. The impact of flying on passenger health :
A guideline for healthcare professionals. London : BMA, 2004.
 Centers for Disease Control and Prevention. 2012 Yellow Book. Ch 6 –
Conveyance & Transportation Issues
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28. M5.5L9 Case Studies
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