This information refers to considerations
regarding fitness to fly as a passenger.
·
'I know of no obvious reason why this person
should not fly' OR
·
'There is nothing in the medical record to
indicate that flying is risky for this patient'.
This ensures that the doctor is not guaranteeing
in any way that this patient can travel without
any problem but rather saying that on the
available evidence, there is nothing to indicate
a greater risk for this person than for others.
However, the doctor is partly dependent on what
the patient chooses to disclose to them about
past health problems. Basic considerations
Basic considerations when assessing a patient's
fitness-to-fly include:
·
The effect of mild hypoxia and decreased air
pressure in the cabin.
·
The effect of immobility.
·
The ability to adopt the brace position in
emergency landing.
·
The timing of regular medication for long-haul/transmeridian
travel.
·
The ability of the patient to cope mentally and
physically with travel to and through airport to
reach the flight and on disembarkation.
·
Will the patient's medical condition adversely
affect the comfort or safety of the other
passengers and the operation of the aircraft?
·
What health insurance cover does the patient
have in case of problems?
Cardiovascular disease Cardiovascular contraindications to commercial airline flight include:
·
Uncomplicated MI within 2–3 weeks
·
Complicated MI within 6 weeks
·
Unstable angina
·
Severe, decompensated congestive cardiac failure
·
Uncontrolled hypertension
·
CABG
within 10–14 days
·
CVA within 2 weeks
·
Uncontrolled tachyarrhythmia/significant
bradycardia
·
Eisenmenger syndrome
·
Severe symptomatic valvular heart disease
Indications for in-flight oxygen in
cardiovascular disease:
·
Need for oxygen at baseline altitude
·
Heart failure NYHA class III–IV or baseline PaO2
< 70 mmHg
·
Angina CCS class III–IV
·
Cyanotic congenital heart disease
·
Primary pulmonary hypertension
·
Other cardiovascular diseases associated with
known baseline hypoxia
It is unusual for patients to be allowed to take
their own oxygen supply and oxygen is usually
arranged by the airline who must be aware in
advance. A fee is usually charged.
DVT
·
The World Health Organisation published the
results of phase I of their WRIGHT (WHO Research
into global hazards of travel) in 2007.
·
These results show that the risk of venous
thromboembolism (VTE) approximately doubles
after a long-haul flight (> 4 hours). The risk
increases with the duration of the travel and
with multiple flights within a short period.
·
The risk also increases significantly in the
presence of other known risk factors for VTE
(obesity, extremes of height, use of oral
contraceptives and the presence of prothrombotic
blood abnormalities).
·
The absolute risk of VTE per flight longer than
4 hours in a cohort of healthy individuals was 1
in 6000.
·
Effective preventive measures will comprise
phase II of the WRIGHT project.
DVT prophylaxis
It is wise for anyone undertaking a long-haul
flight to take sensible precautions such as to:
·
Remain adequately hydrated
·
Exercise the calves
·
Spend periods out of their seat
·
Avoid excess alcohol
·
Avoid tight fitting socks or stockings
·
Perhaps use graduated compression stockings
Advice about any more specific DVT
prophylaxis should be based on relevant risk
stratification and clinical judgement. The table
below outlines advice from the Aerospace Medical
Association. Please also refer to the article
entitled 'Prevention of Deep Vein Thrombosis'
which outlines Department of Health and Clinical
Knowledge Summaries (CKS) guidance. The latter
states that there is no evidence for the use of
aspirin. There is also a link to the British
Committee for Standards in Haematology advice to
passengers below.
Respiratory disease
·
Deciding on fitness to fly for those with
pre-existing respiratory disease can be
difficult.
·
A combination of history, examination, lung
function tests, hypoxic challenge testing and
arterial blood gases may be needed in difficult
cases and in deciding on whether in-flight
oxygen is needed.
·
Those breathless at rest should not fly without
oxygen.
·
A simple fitness-to-fly test is the ability of a
patient to walk 50 metres unaided at normal
pace, or to ascend one flight of stairs, without
becoming severely dyspnoeic. However, there is
no evidence-base to support this test.
·
Anyone with an active exacerbation of
respiratory disease would be wise to wait until
their respiratory condition has improved before
flying.
·
It is often worth seeking the advice of a
respiratory physician in severe or complex
cases, to define criteria and relevant
investigations on which a patient should be
judged as fit to fly, particularly with regard
to the need for oxygen.
·
Untreated pneumothorax is an absolute
contraindication to air travel.
·
British Thoracic Society recommendations on
managing passengers with respiratory disease
planning air travel can be viewed using the link
below.
It is unusual for patients to be allowed to take
their own oxygen supply and oxygen is usually
arranged by the airline who must be aware in
advance. A fee is usually charged.
Pregnancy
·
Due to the increasing risk of an in-flight
delivery, most airlines prohibit travel after
the end of the 36th week in uncomplicated
singleton pregnancies. Earlier limits apply for
multiple/complicated pregnancies or with a
history of premature delivery.
·
Most airlines require confirmation of dates from
healthcare providers for pregnancies > 28 weeks;
the standard shared antenatal care documentation
used in the NHS is usually sufficient for this.
·
The risk of DVT is increased in pregnancy but it
is unclear how this risk is affected by flying.
Sensible precautions should be taken as for any
traveller and compression stockings should be
considered. If there are additional risk factors
for thrombosis, specialist advice may need to be
taken.
·
The risk of increased exposure to cosmic
ionising radiation for the fetus is not thought
to be significant, but is unquantifiable and
must be taken at the mother's discretion. The
risk may be increased if flying several times a
week. Infants and children
·
The British Thoracic Society advises waiting 1
week after birth before flying to ensure the
infant is healthy.
·
Infants born prematurely who have had
complications should probably not fly under the
age of 6 months post-expected date of delivery.
·
Infants with a history of neonatal respiratory
illness and children with chronic lung disease
should have pre-flight hypoxic challenge
testing. Anaemia
·
Someone with a haemoglobin < 8.5 g/dl has a risk
of hypoxia and in-flight oxygen should be
considered.
·
The degree of adaptation to the anaemia will
affect the likelihood of problems. Patients with
chronic anaemia will tolerate hypoxia better
than those who have had a recent haemorrhage.
·
Patients with sickle cell disease should have
access to in-flight oxygen. Patients with sickle
cell trait can usually travel without
restriction.
Ear, nose and throat (ENT) problems
·
Active middle ear infections, effusions, or
recent ear surgery are contraindications to
flying unless the patient is deemed fit-to-fly
by an ENT specialist.
·
Acute sinusitis,
large nasal polyps and recent nasal surgery are
relative contraindications.
·
Seek advice from an otolaryngologist if
uncertain.
Post-surgical patients · Patients should not fly for 1-2 weeks after open abdominal surgery.
·
Flying is not advised for 24 hours after a
colonoscopy and polypectomy.
·
Travellers with colostomies may need to use a
larger bag as intestinal distension during the
flight may increase faecal output.
·
British Airways have a list of guidelines
outlining the minimum time before it is
advisable to travel after surgery (see link
below). Different airlines may have different
policies.
Neurological/psychiatric illness
·
Fitness-to-fly is best considered on an
individual basis and with expert advice if there
is uncertainty. The freedoms of the affected
individual to travel must be balanced against
those of other passengers and safety
considerations.
·
Acutely disturbed or psychotic patients should
not travel.
·
Patients with controlled epilepsy can generally
fly safely. However, they should be made aware
of the potential seizure threshold-lowering
effects of fatigue, delayed meals, hypoxia and
disturbed circadian rhythm. Care should be taken
that medication is not omitted inadvertently
when travelling through different time zones.
Contagious infectious disease
·
This is a relative contraindication to travel
depending on the nature of the condition and its
transmissibility at that phase of the illness.
·
Tuberculosis
is a particular concern. A passenger should have
had adequate treatment and be non-infectious
prior to the flight.
Diabetes mellitus
·
There are no restrictions to flying with
well-controlled diabetes.
·
Insulin dependent diabetics are normally
required to have a letter of authorisation from
their doctor to allow carriage of needles in
their hand luggage. Insulin should be carried in
a cool bag or precooled vacuum flask.
·
Insulin should not be stored in the hold as
temperatures may cause it to freeze and
denature. · Special consideration needs to be given to insulin dosing regimens on long-haul flights, depending on the direction of travel and movement across time zones. Advice from a diabetes specialist may be needed. Tables of appropriate regimens are available in the link to the second reference for this article.
·
Sugar tablets and snacks to prevent episodes of
hypoglycaemia should be carried. |
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