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Have chronic respiratory disease, will travel?
Spotlight
To have a chronic respiratory illness such as chronic obstructive pulmonary disease (COPD), emphysema, or cystic fibrosis might not mean the end of global travel, but it certainly imposes limitations. Careful planning is essential, especially when intending to fly, and the first step is usually a visit to a general physician to determine the patient’s fitness to travel. Lynn K Josephs (University of Southampton, Southampton, UK) and colleagues have delineated the most recent recommendations made by the British Thoracic Society (BTS) for general physicians who are required to assess patients with stable respiratory disease. “The most serious challenges faced by such patients results from the normal inflight cabin pressures being maintained at 0·75 atmospheres. In someone with pre-existing hypoxaemia, the additional drop caused by the lower pressure in an aircraft during flight can bring on severe dyspnea and discomfort,” she explained. Most crucial is the need to determine those who can fly but will need in-flight oxygen supplementation—to determine this usually requires referral for specialist tests. If oxygen is prescribed, many of the world’s airlines can accommodate passengers, either by supplying the oxygen or allowing the patient to take their own oxygen supply on board. “An inflight medical emergency is completely preventable if the patient clearly communicates they plan to travel by air with their health-care team, and that team understands the risk of air travel to the individual”, noted Clayton T Cowl of the Division of Preventive, Occupational & Aerospace Medicine at the Mayo Clinic (Rochester, MN, USA). Cowl, with Jay H Ryu and colleagues reviewed the situation for air travellers with a risk of pneumothorax, pointing out that no detailed adequate guidelines exist. “Unfortunately, there are no specific data to suggest a definite timeperiod to wait prior to embarking on air travel for patients with pneumothorax or who have undergone thoracic surgery”, he said. The current guidelines suggest 1–3 weeks, but because of the variability between individuals, Cowl recommends the longer period. He also cautions that “individuals with medical comorbidities such as pre-existing heart or lung disease are at greater risk for poor outcomes should an acute tension pneumothorax or other problem occur on board an aircraft in flight”. Rules about the provision of inflight oxygen vary widely. In the USA, the Federal Aviation Administration (FAA) approved portable oxygen concentrators in 2009, but an FAA approval of equipment has taken time. Checking the details with individual airlines is recommended before booking to ascertain whether oxygen is allowed or provided, and the number of working days notice required. The European Lung Foundation has compiled a list of 181 European airlines with www.thelancet.com/respiratory Vol 3 August 2015
detailed information about their policies on inflight oxygen supplementation for travellers with medical needs. Patients should be warned that they must be proactive when planning to travel and that their research needs to go a long way beyond what happens in the aircraft. The British Lung Foundation, the Lung Foundation of Australia and the American Lung Association provide detailed information for patients with respiratory disease and their families. Individual patients report that being proactive and determined is essential because travel involves many logistical and bureaucratic challenges. One UK-based traveller told The Lancet Respiratory Medicine that as an occasional user of oxygen when travelling by car, planning a touring holiday to Belgium, France, and Germany by car was complicated by the regulations on taking oxygen cylinders out of the UK. “The NHS will not allow prescribed cylinders to be taken into mainland Europe and my supplier would not allow me to take my privately purchased cylinders either. The only solution was to hire an expensive portable oxygen concentrator, which had to be taken into each hotel in our itinerary to fulfil the insurance requirements,” he explained. Obviously, travel insurance is a necessity for patients with respiratory diseases, yet only a few insurers agree to cover anyone with a pre-existing medical disorder. All the patients we spoke to recommended shopping around for insurance very early in the holiday-planning process. A female traveller aged 65 years with COPD and using three inhalers concluded that, for her, “annual European insurance was the most cost-effective option”. But even the best-planned insurance doesn’t always work out. An Australian couple recently did not manage to get insurance to travel to Alaska after the husband had been prescribed inflight oxygen for a trip in 2014, even though his wife had arranged COPD insurance successfully for that holiday. “No company will even consider covering my husband’s COPD now, so the trip is off. Fortunately we found out just before we booked our flights…” she said. With no plans on the horizon for any of the guidelines on air travel with severe respiratory disorders to be updated, the onus looks set to continue to be on patients and their families to push for increased awareness of their needs. One patient told Lancet Respiratory Medicine that the staff on one of his recent connecting flights almost refused to have him on board at the last minute. “I did reach my destination but only after speaking directly with the Captain and reassuring him”, he warned. “Communication between airlines could certainly be improved and would avoid a great deal of unnecessary stress”, he concluded.
David Nunuk/Science Photo Library
Features Have chronic respiratory disease, will travel?
For more on travelling with COPD see Spotlight Lancet Respir Med 2014; 2: 876 For the BTS recommendations see Prim Care Respir J 2013; 22: 234–38 For risk of air travel with pneumothorax see Chest 2014; 145: 688–94 For the current BTS guidelines see Thorax 2011; 66 (suppl 1): i1–30 For the European Lung Foundation airline list see http:// www.europeanlung.org/en/lungdisease-and-information/airtravel/airline-index/ For the British Lung Foundation see https://www.blf.org.uk/ Page/Going-on-holiday-with-alung-condition For the Lung Foundation of Australia see http:// lungfoundation.com.au/patientarea/resources/better-livingwith-copd-a-patient-guide/ For the American Lung Association http://www.lung. org/lung-disease/copd/articles/ traveling-with-copd.html
Kathryn Senior 609
To have a chronic respiratory illness such as chronic obstructive pulmonary disease (COPD), emphysema, or cystic fibrosis might not mean the end of global travel, but it certainly imposes limitations. Careful planning is essential, especially when intending to fly, and the first step is usually a visit to a general physician to determine the patient’s fitness to travel. Lynn K Josephs (University of Southampton, Southampton, UK) and colleagues have delineated the most recent recommendations made by the British Thoracic Society (BTS) for general physicians who are required to assess patients with stable respiratory disease. “The most serious challenges faced by such patients results from the normal inflight cabin pressures being maintained at 0·75 atmospheres. In someone with pre-existing hypoxaemia, the additional drop caused by the lower pressure in an aircraft during flight can bring on severe dyspnea and discomfort,” she explained. Most crucial is the need to determine those who can fly but will need in-flight oxygen supplementation—to determine this usually requires referral for specialist tests. If oxygen is prescribed, many of the world’s airlines can accommodate passengers, either by supplying the oxygen or allowing the patient to take their own oxygen supply on board. “An inflight medical emergency is completely preventable if the patient clearly communicates they plan to travel by air with their health-care team, and that team understands the risk of air travel to the individual”, noted Clayton T Cowl of the Division of Preventive, Occupational & Aerospace Medicine at the Mayo Clinic (Rochester, MN, USA). Cowl, with Jay H Ryu and colleagues reviewed the situation for air travellers with a risk of pneumothorax, pointing out that no detailed adequate guidelines exist. “Unfortunately, there are no specific data to suggest a definite timeperiod to wait prior to embarking on air travel for patients with pneumothorax or who have undergone thoracic surgery”, he said. The current guidelines suggest 1–3 weeks, but because of the variability between individuals, Cowl recommends the longer period. He also cautions that “individuals with medical comorbidities such as pre-existing heart or lung disease are at greater risk for poor outcomes should an acute tension pneumothorax or other problem occur on board an aircraft in flight”. Rules about the provision of inflight oxygen vary widely. In the USA, the Federal Aviation Administration (FAA) approved portable oxygen concentrators in 2009, but an FAA approval of equipment has taken time. Checking the details with individual airlines is recommended before booking to ascertain whether oxygen is allowed or provided, and the number of working days notice required. The European Lung Foundation has compiled a list of 181 European airlines with www.thelancet.com/respiratory Vol 3 August 2015
detailed information about their policies on inflight oxygen supplementation for travellers with medical needs. Patients should be warned that they must be proactive when planning to travel and that their research needs to go a long way beyond what happens in the aircraft. The British Lung Foundation, the Lung Foundation of Australia and the American Lung Association provide detailed information for patients with respiratory disease and their families. Individual patients report that being proactive and determined is essential because travel involves many logistical and bureaucratic challenges. One UK-based traveller told The Lancet Respiratory Medicine that as an occasional user of oxygen when travelling by car, planning a touring holiday to Belgium, France, and Germany by car was complicated by the regulations on taking oxygen cylinders out of the UK. “The NHS will not allow prescribed cylinders to be taken into mainland Europe and my supplier would not allow me to take my privately purchased cylinders either. The only solution was to hire an expensive portable oxygen concentrator, which had to be taken into each hotel in our itinerary to fulfil the insurance requirements,” he explained. Obviously, travel insurance is a necessity for patients with respiratory diseases, yet only a few insurers agree to cover anyone with a pre-existing medical disorder. All the patients we spoke to recommended shopping around for insurance very early in the holiday-planning process. A female traveller aged 65 years with COPD and using three inhalers concluded that, for her, “annual European insurance was the most cost-effective option”. But even the best-planned insurance doesn’t always work out. An Australian couple recently did not manage to get insurance to travel to Alaska after the husband had been prescribed inflight oxygen for a trip in 2014, even though his wife had arranged COPD insurance successfully for that holiday. “No company will even consider covering my husband’s COPD now, so the trip is off. Fortunately we found out just before we booked our flights…” she said. With no plans on the horizon for any of the guidelines on air travel with severe respiratory disorders to be updated, the onus looks set to continue to be on patients and their families to push for increased awareness of their needs. One patient told Lancet Respiratory Medicine that the staff on one of his recent connecting flights almost refused to have him on board at the last minute. “I did reach my destination but only after speaking directly with the Captain and reassuring him”, he warned. “Communication between airlines could certainly be improved and would avoid a great deal of unnecessary stress”, he concluded.
David Nunuk/Science Photo Library
Features Have chronic respiratory disease, will travel?
For more on travelling with COPD see Spotlight Lancet Respir Med 2014; 2: 876 For the BTS recommendations see Prim Care Respir J 2013; 22: 234–38 For risk of air travel with pneumothorax see Chest 2014; 145: 688–94 For the current BTS guidelines see Thorax 2011; 66 (suppl 1): i1–30 For the European Lung Foundation airline list see http:// www.europeanlung.org/en/lungdisease-and-information/airtravel/airline-index/ For the British Lung Foundation see https://www.blf.org.uk/ Page/Going-on-holiday-with-alung-condition For the Lung Foundation of Australia see http:// lungfoundation.com.au/patientarea/resources/better-livingwith-copd-a-patient-guide/ For the American Lung Association http://www.lung. org/lung-disease/copd/articles/ traveling-with-copd.html
Kathryn Senior 609