Medical issues associated with commercial flights

Medical issues associated with commercial fl ights
Almost 2 billion people travel aboard commercial airlines every year. Health-care providers and travellers need to be Lancet 2008; 373: 2067–77
aware of the potential health risks associated with air travel. Environmental and physiological changes that occur
Published Online
during routine commercial fl ights lead to mild hypoxia and gas expansion, which can exacerbate chronic medical
February 19, 2009
conditions or incite acute in-fl ight medical events. The association between venous thromboembolism and long-haul DOI:10.1016/S0140-
fl ights, cosmic-radiation exposure, jet lag, and cabin-air quality are growing health-care issues associated with air Department of Emergency
travel. In-fl ight medical events are increasingly frequent because a growing number of individuals with pre-existing Medicine, Georgetown
medical conditions travel by air. Resources including basic and advanced medical kits, automated external defi brillators, University Hospital and
and telemedical ground support are available onboard to assist fl ight crew and volunteering physicians in the Washington Hospital Center,
management of in-fl ight medical emergencies.

Washington, DC, USA
(D Silverman MD); Department
of Emergency Medicine, Lahey

portion of the oxyhaemoglobin dissociation curve) Clinic Medical Center,
Fitness for air travel is a growing issue because many (fi gure).5,7 However, many passengers with pre-existing Burlington, MA, and Tufts
passengers are unaware of health implications associated
cardiac, pulmonary, and haematological conditions Medical School, Boston, MA,
USA (M Gendreau MD)
with commercial air travel. Almost 2 billion people travel have a reduced baseline PaO , so reduced cabin pressure by air every year,1,2 and physicians are now expected to leads to further reduction of oxygen saturation, which Dr Mark Gendreau, Department identify individuals unfi t for air travel and give them lowers further with increasing fl ight times (fi gure).8,9 of Emergency Medicine, Lahey advice. More than 95% of individuals with health The decreased oxygen saturation can exacerbate medical Clinic Medical Center, 41 Mall problems who have to travel by air would like to receive conditions.2,4,9,10 For example, a recent prospective Road, Burlington, MA 01805, more medical advice from their physician.3 Also, the age observational study showed that 18% of passengers with [email protected]
of travellers is increasing and long-haul aircrafts—such chronic obstructive pulmonary disease have at least as the Airbus A380 and Boeing 777 LR—are now capable mild respiratory distress during a fl ight.11 of extending fl ight times to 18–20 h; therefore, an Several methods are available to assess the need for increasing number of travellers with various underlying in-fl ight oxygen (panel 1).9,10,12,13 Oxygen supplementation medical conditions could face environmental and is recommended for passengers with either a resting physiological changes associated with the fl ight. Here, oxygen saturation of 92% or lower (PaO ≤67 mm Hg) or we review the health issues associated with commercial if the expected in-fl ight PaO is less than 50–55 mm Hg.9 Guidelines from the British Thoracic Society (BTS)9 suggest hypoxic-challenge testing in individuals with Cabin pressure
resting oxygen saturations of 92–95% at sea level who Cabin pressure can aff ect the health and wellbeing of have additional risk factors, such as hypercapnia or passengers in many ways, including hyobaric hypoxia abnormal spirometry. The Aerospace Medical Association aff ecting those with pre-existing respiratory conditions (AsMa) guidelines suggest sea-level blood gas and heart failure, and gas expansion within body cavities determination or pulmonary-function testing with hypoxic-challenge testing as the gold standard, and ights usually cruise at recommend in-fl ight oxygen for individuals with a altitudes of 7010–12 498 m above sea level, the passenger cabin is pressurised to an altitude of 1524–2438 m. Most regulatory governmental agencies require the cabin Search strategy and selection criteria
altitude not to exceed 2438 m.4–6 Most healthy individuals We searched Medline for peer-reviewed publications over the tolerate this cabin pressure; however, a study of adult past 10 years written in English, with the keywords “air volunteers simulating a 20-h fl ight showed that the travel”, together with “hypoxia”, “surgery”, “cosmic frequency of reported complaints associated with acute radiation”, “jet lag”, “venous thromboembolism”, “infectious mountain sickness (fatigue, headache, lightheadedness, diseases”, “pandemic”, and “in-fl ight medical emergencies”. and nausea) increased with increasing altitude and Titles, abstracts, or both, of all articles were reviewed to peaked at 2438 m, with most symptoms becoming assess relevance. We reviewed governmental reports from the apparent after 3–9 h of exposure.7 Cabin pressurisation UK Department of Transport Civil Aviation Authority, UK to 2438 m reduces the atmospheric pressure of the House of Lords, US Federal Aviation Administration, and cabin, resulting in a concomitant decrease of arterial documents published by the British Thoracic Society, oxygen partial pressure (PaO ) from 95 mm Hg to Aerospace Medical Association, WHO, US Institute of 60 mm Hg at the maximum cabin altitude of 2438 m.8 Medicine, and the International Commission on Radiological In healthy passengers, these pressures lead to a Protection. We also searched the above keywords with the 3–4% decrease in systemic oxyhaemoglobin saturation (the corresponding PaO value remains within the fl at Vol 373 June 13, 2009
by the airline is available for individuals with a physician’s statement of need and prescription. Since 2005, portable oxygen concentrators, which concentrate oxygen in ambient air by removing nitrogen content, have become available as an alternative to traditional oxygen cylinders. Passengers should possess a signed doctor’s statement of medical need and notify the airline of their intention to use portable oxygen concentrators before travelling.21 Because of a modifi cation in the US Government Air Carrier Access Act in May, 2008, all US-based air carriers and foreign air carrier fl ights that begin or end in the USA have to accommodate passengers who need Figure: Eff ect of cabin altitude on oxyhaemoglobin saturation
Gas in body cavities is also aff ected by cabin pressure. (A) The aircraft passenger cabin is normally pressurised to an altitude of 1524–2438 m. This reduced pressure According to Boyle’s law, the volume that a gas occupies within the passenger cabin results in lower systemic PaO₂ and decreased oxyhaemoglobin. For most healthy is inversely proportional to the surrounding pressure. passengers, this results in a decrease in the arterial partial pressure oxygen tension from 95 mm Hg (12·7 kPa ) to 65 mm Hg (8·7 kPa) corresponding to an oxyhaemoglobin saturation from 95–100% at sea level (A) to 90 % at a Thus, at the low cabin pressures associated with cruising cabin altitude of 2438 m (B). (B) Passengers with pre-existing lower sea-level oxyhaemoglobin saturations have altitudes, gas in body cavities expands by 30%.6,10,23 For greater declines during a fl ight. In this example, a passenger with mild chronic obstructive pulmonary disease with healthy passengers, this expansion can result in minor a sea-level PaO₂ of 70 mm Hg (A) and a FEV₁ of 1·6 L (50% predicted) will have a corresponding reduction of PaO₂ abdominal cramping and barotrauma to the ears in to about 53 mm Hg or oxyhaemoglobin saturation of approximately 84% at a cabin altitude of 2438 m (B). This passenger should be prescribed oxygen for air travel. PaO₂=arterial oxygen partial pressure. FEV₁=forced expiratory certain circumstances. However, passengers who have undergone recent surgical procedures are at increased risk of problems related to gas expansion, and many sea-level PaO of 70 mm Hg or lower, or with an expected anecdotal reports, including those of bowel perforation24 in-fl ight PaO of 55 mm Hg or lower.10 However, some and wound dehiscence,25 have been published. Guidelines evidence suggests that these guidelines might need recommend delaying air travel for 14 days after major revision because predictive equations often inaccurately surgical procedures.10,23 Individuals with bowel obs-estimate in-fl ight PaO .2,9,12,14–16 Additionally, recent work tructions or diverticulitis are advised to wait 7–10 days has shown that initial sea-level oxygen saturation poorly before air travel.10,23identifi es individuals at risk of desaturation below Passengers who scuba dive also have an increased risk 90% during either hypoxic-challenge testing in the of decompression sickness if they fl y too soon after laboratory17,18 or routine commercial fl ights.15,17 No studies diving. The diver’s alert network recommends a 12-h that assess individuals with heart failure during interval between diving and air travel for divers who commercial air travel exist; however, several small make a dive per day without decompression. Divers studies have shown that people with chronic heart failure participating in several dives per day, or a dive requiring tolerate altitudes up to 2500–3000 m.19,20 BTS or AsMa decompression, should wait 24 h before air travel.10,23guidelines should be followed with patients aff ected by Gas expansion also aff ects medical devices, such as heart failure who have to travel by air.
pneumatic splints, feeding tubes, urinary catheters, and Several options exist for passengers needing medical cuff ed endotracheal or tracheostomy tubes. Gas-expansion oxygen during air travel. Compressed oxygen supplied concerns in these devices can be eliminated by instillation of water rather than air during air travel.6,26 Panel 1: Assessment of in-fl ight PaO2
Air travel and venous thromboembolism risk
The relation between long-haul fl ights (>8 h) and
Hypoxic-challenge test (hypoxia altitude simulation test):
increased risk of venous thromboembolism has The maximum cabin altitude of 2438 m can be simulated at sea level with a gas mixture generated great interest in both medical publications containing 15% oxygen in nitrogen. Individuals breathe the hypoxic gas mixture for and the media. Overall, studies show an association 20 min while oxygen saturation is monitored. Arterial blood gases are also measured between venous thromboembolism and long-haul air before and at the end of the test. An individual needs in-fl ight oxygen if PaO falls below travel, with risk up to four-fold, depending on study 50 mm Hg or if the oxygen saturation measured via pulse oximetry falls below 85%.
Predictive Dillard equations:
Risk peaks when fl ight duration is more than 8 h;34–36 PaO at altitude can be estimated with several published predictive equations, which use a population-based study showed that risk started to values of ground-level PaO and lung-function measurements to predict in-fl ight PaO : • In-fl ight PaO =0·453×ground-level PaO (mm Hg)+0·386 (FEV % predicted)+2·44 Business-class versus economy-class travel has no • In-fl ight PaO =0·519×ground-level PaO (mmHg)+11·855xFEV (L)–1·760 eff ect on venous thromboembolism incidence.37 A systematic review of publications on air-travel venous FEV₁=forced expiratory eff ort in 1 second. thrombo embolism calculated a pooled odds ratio (OR) Vol 373 June 13, 2009
of 1·59 (95% CI 1·04–2·43) from case–control Defi nition
Quality of
studies27,38–41 and a relative risk of 2·93 (95% CI evidence*
1·5–5·58) from several prospective controlled cohort Flight time less than 8 h or distance less than studies.38,40 These results are consistent with those of the population-based (MEGA) study (OR 1·7, 95% CI 1·0–3·1).32 Another population-based study of 9000 business travellers followed for 4·4 years showed an absolute risk for venous thromboembolism of one Moderate Flight time more than 8 h or distance more than 5000 km, and: obesity, large varicose every 4656 fl ights (incidence rate ratio 3·2, 95% CI 1·8–5·6).33 Risk increased with increasing number of therapy, tobacco use or oral contraceptives, or fl ights during the fi rst 2 weeks after a fl ight and when other traditional risk factors for venous thrombo- Flight time more than 8 h or distance more than 5000 km, and: history of previous venous low-molecular-weight heparin embolism were present. Several factors—such as thromboembolism; hypercoagulable state (eg, injected before departure in immobility, dehydration, hypobaric hypoxia—and factor V Leiden); major surgery 6 weeks before individuals who are not on individual risk factors (obesity, malignancy, recent air travel (including hip or knee arthroplasty); surgery, and history of hypercoagulable states) explain why the risk of venous thromboembolism increases Data are based on references 38, 40, 41, 51–53, and 57. *Grade 1C is a strong recommendation, but existing evidence is of low quality and benefi ts clearly outweigh risk or burden. Grade 2B is a weak recommendation derived from Immobilisation has been linked to 75% of air-travel moderate quality evidence, and benefi ts of therapy are balanced with risk and burden.52 cases of venous thromboembolism, with the long-fl ight Table: Risk of venous thromboembolism prophylaxis in air travellers
thrombosis study (LONFLIT) showing the greatest frequency of venous thromboembolism occurring in survey done by thrombosis and haemostasis professionals non-aisle seating where passengers tend to move less.42–45 showed major diff erences in the use of prophylactic Dehydration can increase risk of venous thrombo- measures for air travel.54 Many clinicians seem to embolism due to haemoconcentration and hyperviscosity, recommend aspirin before air travel for individuals at potentially leading to hypercoagulable states.46 Several moderate risk of venous thromboembolism. However, studies have provided evidence of dehydration or because of scarce evidence showing substantial benefi t, increased lower-limb oedema in healthy people during aspirin is not recommended alone as prophylaxis for any long-simulated fl ights.47,48 Hypobaric-chamber studies air traveller.41,43,52,55 Although randomised trials have shown have not consistently shown that the mild hypobaric benefi t of low-molecular-weight heparin as thrombo-hypoxic changes during a fl ight lead to increased prophylaxis for air travellers who are at moderate risk for activation of coagulation in healthy individuals with no venous thromboembolism and do not take routine thrombophilia compared with that in individuals seated anticoagulant drugs,43,56 its routine use in circumstances and not moving at ground level.5,46,49 other than those for air travellers at high risk of venous Thrombophilia or oral contraceptive use substantially thromboembolism remains contro versial.41,52 increase the risk of developing venous thrombo- Overall, use of physical and pharmacological embolism.29,32,50 In the MEGA study,32 factor V Leiden thromboprophylaxis should be based on an individual increased this risk by 14 times (OR 13·6, 95% CI risk assessment. The table summarises evidence-based 2·9–64·2), and thrombophilia or use of oral contraceptives guidelines updated in 2008 by the American College of increased risk 16 times (16·1, 3·6–70·9) and 14 times Chest Physicians conference on antithrombotic and (13·9, 1·7–117·5), respectively.29 Recommendations to reduce the risk of developing venous thromboembolism during air travel are based Cosmic-radiation exposure
more on common sense than on evidence and include: Cosmic radiation comes from outside the solar system
being well hydrated, reducing alcohol and caff eine and from particles released during solar fl ares. Intensity
consumption, changing positions or walking throughout
of radiation depends on the year (due to solar cycles), the cabin, and doing periodic calf-muscle exercises to altitude, latitude, and length of exposure. Because many reduce venous stasis. Use of graduated compression types of cancer might be linked to cosmic radia-stockings with an ankle pressure of 17–30 mm Hg can tion—especially breast cancer, skin cancer, and reduce risk during air travel, as shown by a meta-analysis, melanoma—eff ects of radiation on fl ight crews and in which only two of 1237 individuals who wore frequent air-travellers are of concern.58,59compression stockings had venous thrombosis compared In 1991, the International Commission on Radiological with 46 of 1245 individuals who did not wear them.51 Protection (ICRP) declared cosmic radiation an Compression stockings therefore are recommended for occupational risk for fl ight crews, which led to exposure travellers prone to immobility.51–53 monitoring and guidelines to reduce crew annual Anticoagulant thromboprophylaxis in the context of air exposure to 20 mSv, which is more than double the travel is growing but no formal guidelines exist. One exposure of most crews.60–62 Ground-radiation exposure Vol 373 June 13, 2009
Data for increased cancer risks specifi cally due to Panel 2: Treatments of jet lag
cosmic radiation in crew members are inconclusive.62,65–68 No studies have been done to assess the health Agomelatine73
consequences of cosmic-radiation exposure during air • New dual melatonin-receptor and serotonin 5-HT receptor agonist travel in the general population. However, even the cacious for symptoms of depression and sleep–wakefulness disorders most-frequent air travellers are unlikely to be at risk.69 • Not tested for jet lag , but could be more useful for individuals having westward-travel Recommendations need to be in place for pregnant jet lag, who commonly show symptoms of depression women because the fetus is exposed to the same radiation Benzodiazepines82,84,85
dose as the mother.70 The ICRP recommends a radiation limit of 1 mSv during the whole pregnancy, whereas the cacy in other circadian-rhythm or sleep parameters National Council on Radiation Protection and Measurements recommends a monthly limit of 0·5 mSv. Caff eine82,86
These recommendations limit pregnant crew members and frequent air travellers, because fl ying roughly 15 long-haul round trips, for example, can expose a fetus caff eine showed faster re-entrainment (measured physiologically) to more than 1 mSv.61 To avoid risk to the fetus, the FAA Melatonin73,83,87
recommends pregnant crew members to take short, low-altitude, low-latitude fl ights, and the CAA requests • Usually only needed after arrival but, if travelling across more than 7–8 time zones, that employers of a pregnant crew member schedule her pre-treatment for 2–3 days may be needed fl ights so that she remains under the 1-mSv limit.7,59 • Recommended especially if crossing fi ve or more time zones, travelling eastwardly, or Pregnant women, and air travellers in general, can access the solar-radiation alert system online before • Caution in people with epilepsy or on warfarin (case reports of adverse eff ects) travelling and change fl ight days accordingly.
• Paediatric use not studied and therefore not recommended Ramelteon73
Jet lag is a temporary circadian-rhythm disorder associated • New melatonin-receptor agonist with no abuse potential with long-haul fl ights, characterised by daytime fatigue, • Indication for treatment of primary insomnia in individuals of 55 years of age or older sleep–wake disturbances, decreased appetite, constipation, • Untested for circadian-rhythm disturbances and reduced psychomotor coordination and cognitive Phototherapy72,80,81
skills.71–73 Jet lag is due to desynchronisation between the • Involves intentional exposure or avoidance to bright light to hasten re-entrainment body’s internal clock mechanism, residing within the suprachiasmatic nucleus of the hypothalamus,74–76 and the new light–dark cycle caused by abrupt time-zone changes.72,73,77–79 The degree and severity of jet lag is Pre-fl ight sleep hygiene72,81,88
infl uenced by both fl ight direction and number of time • Westbound: go to sleep 1 h later than usual and be awake 1 h later than usual 3 days zones crossed.72,80 Westward travel lengthens the traveller’s day, thereby causing a phase delay in the circadian • Eastbound: go to sleep 1 h earlier than usual and be awake 1 h earlier than usual 3 days rhythm, whereas eastward travel shortens the day and causes a phase advance.72,73,80 Travellers have greater diffi culty falling asleep after an eastward travel than after should be restricted to 1 mSv per year in the population, a westward travel because of the internal clock’s natural but air-travel-related cosmic-radiation exposure does not tendency to resist shortening the 24-h day cycle.79,81–83 have a specifi c limit.63 The UK Civil Aviation Authority Re-entrainment (synchronisation) typically takes one day (CAA) and the European Joint Aviation Authority (JAA) for every time zone crossed westward or 1·5 days for every require aircraft capable of fl ying at altitudes greater than time zone crossed eastward.72,73,80,8115 km, to actively monitor radiation levels, so that they Panel 2 lists various therapies available to keep jet lag can lower fl ying altitude as needed. However, this to a minimum. Exogenous melatonin is the gold regulation is currently not relevant to commercial standard treatment for jet-lag symptoms.73,83,89,90 When aviation because no commercial aircraft fl y at such taken in the evening, melatonin phase advances the altitudes.7 circadian clock, whereas early morning administration For the solar-radiation alert
A solar-radiation alert system monitors high-particle phase delays the circadian rhythm.73,90 Various treatment system see http://www.sec.
intensity from solar radiation, and the US Federal regimens have been recommended, but a Cochrane Aviation Administration (FAA) issues a solar-radiation meta-analysis of ten trials concluded that taking advisory to air carriers via the national oceanic and 0·5–5 mg of melatonin at the desired destination atmospheric administration (NOAA) weather wire service bedtime is eff ective for reducing or preventing jet lag.83 when solar fl ares might cause increased radiations at Use of bright-light exposure to adjust circadian rhythm has shown confl icting results and its benefi t depends on Vol 373 June 13, 2009
combination with other therapies, such as bedtime Whether reducing the number of fl ights during a large- adjustment or melatonin.91–93 Simulation studies showed a scale epidemic or pandemic would slow the spread of an benefi t of gradually advancing the sleep cycle by going to infectious-disease outbreak remains unclear.109,110 An sleep 1 h earlier than usual every day for 3 days before observational study, however, showed that the peak date of travelling eastward, combined with morning bright-light the US infl uenza season was delayed 13 days after the exposure, in an attempt to phase advance the circadian terrorist attacks of Sept 11, 2001, consistent with a greatly rhythm.87,92 For westward travel, one small randomised con- reduced number of fl ights during that time.111 This, trolled study of 20 individuals combined bedtime together with other modelling studies, suggest that fl ight adjustment with timed bright-light versus dim-light limita tions might slow the spread of pandemic infl uenza exposure after westward travel, and showed larger phase by several weeks, thereby providing time for mass vacci-delays in the bright-light group than in the dim-light group nation of the population and contingency plan setup.111 (2·59 h vs 1·5 h, p <0·02), but no signifi cant diff erence in sleep effi ciency or self-reported symptoms of jet lag.93 In-fl ight medical events
Calculation of the exact incidence of in-fl ight medical
Infectious diseases and air travel
events for commercial air travel has always been diffi Air travellers spend long periods in enclosed spaces, which facilitates the spread of infectious diseases. Panel 3: Typical contents of an enhanced emergency
Since 1946, several outbreaks of serious infectious medical kit
diseases have been reported aboard commercial airlines, including infl uenza,94,95 measles,96 severe acute respiratory Diagnostic/general
syndrome (SARS),97,98 tuberculosis,99,100 food poisoning,101,102 viral enteritis,103 and small pox.104 Although less-serious outbreaks—such as the common cold or some viral syndromes—have not been reported, they can occur. Lack of reporting is likely to be the result of incubating periods of many infections being longer than the fl ight. One prospective questionnaire study of air travellers going from San Francisco to Denver during the winter • Instructions on use of medications*† months showed an upper-respiratory tract infection Medications
frequency of 3–20% depending on the reporting methods.105 PCR assays to study atypical bacteria and respiratory viruses in 155 air travellers showed that not many travellers had the same viral profi le and no association existed between any pathogen and a particular airport, suggesting that travellers acquired their viruses before rather than during the fl ight.106 Most commercial aircrafts re-circulate up to 50% of the • Major analgesic drugs (eg, morphine)† One study showed no signifi cant diff erence in self-reported infection rates in aircrafts that use these fi lters compared with those in aircrafts that use a Risk of onboard transmission of infection is mainly restricted to individuals with either close personal contact or seated within two rows of an index passenger.1,107 However, on Air China fl ight 112, 22 passengers and crew member developed probable onboard severe acute respiratory syndrome-associated coronavirus (SARS-CoV) infection.97 The 2002–03 SARS epidemic indicated that commercial air travel has an eff ect on infectious-disease spread. WHO estimates that 6·5 passengers per million who travelled aboard commercial fl ights originating from regions of active iv=intravenous. po=orally. The list was complied from references 6, 112, and 115. It does not include all contents but only what is mandated by each regulatory agency. Contents, transmission during the outbreak were symptomatic such as adhesive bandages, gauzes, and elastic bandages, are stocked in basic fi rst-aid with probable SARS.108 Overall, 40 fl ights carried kits, which are also carried on aircraft. Both the CAA and the JAA do not require aircraft to 37 probable SARS-CoV source cases during the outbreak, carry an automated external defi brillator, although most air carriers have one. *Kit specifi cation FAA. †Kit specifi cation JAA.
resulting in 29 probable onboard secondary cases.108 Vol 373 June 13, 2009
mainly because air carriers are not obliged to report Panel 4: Response to in-fl ight medical events
in-fl ight medical events, and no national or international database exists. Scarce data suggest an incidence of 1 in • Be prepared to show medical credential (eg, licence) or answer questions about degree 10 000–40 000 passengers (about 50–100 in-fl ight medical events per day) aboard US-registered airlines.112 British Airways health services reported 31 200 medical incidents • Obtain consent from the aff ected passenger. Assume implied consent when passenger aboard their aircrafts during 2007, with 3000 being • Do not fear litigation. Although physicians have been deposed, no litigation has ever Many in-fl ight medical events arise aboard commercial been brought forward against a responding physician airlines and most are minor.6,114 Cardiac, neurological, • Request and establish communication with the airline’s ground medical support for and respiratory complaints are the most serious in-fl ight advice and consultation regardless of how minor or serious the in-fl ight medical medical events, with cardiac and neurological complaints accounting for most diversions.114 Passengers older than • Request the enhanced emergency medical kit (many airlines will initially only off er the 70 years have the highest rates of in-fl ight medical basic fi rst-aid kit) but do not open it unless needed. Each kit has a placard listing the events,114 but the mean age of passengers with an in-fl ight medical event is 44 years for men and 49 years for • Recommend diversion of the aircraft if you believe it is needed. Recommendation to divert the aircraft should be considered if a passenger has chest pain, shortness According to British, Canadian, and US laws, medical of breath, severe abdominal pain that does not improve with initial treatment professionals are not required to volunteer assistance interventions, cardiac arrest, acute coronary syndrome, severe dyspnoea, during an in-fl ight medical event, unless they have a stroke, refractory seizure, severe agitation, or if a passenger is persistently pre-existing clinical relationship with the passenger. In contrast, physicians in Australia and many Asian, cially pronounce a passenger dead, even if you assess that resuscitation is European, and middle east countries are required to futile and cease treatment, especially on international fl ights provide assistance.6 For international fl ights, the country where the aircraft is registered has jurisdiction, except when the aircraft is on the ground or in sovereign Panel 5: Guidelines for initial management of in-fl ight medical events
airspace.6,112 Medical assistance during an in-fl ight medical Acute abdominal pain
event is protected under Good Samaritan laws, and no physician has ever been held liable for his or her actions while providing medical care. The 1998 US Aviation • Request cabin altitude reduction to increase cabin pressure, which will increase Medical Assistance Act limits liability for volunteering physicians under the assumption that they act in good • Administer paracetamol or ibuprofen to relieve discomfort. Some medical kits contain faith, receive no monetary compensation, and provide morphine, which can be used in cases of extreme pain reasonable care. This law pertains to events that occur • A parenteral or oral antiemetic drug if available in the medical kit might help in cases within US airspace and aircraft registered within the USA.6 Gifts, such as seat upgrades and liquors, are not Acute agitation or misconduct
considered compensation. Furthermore, many airlines • Attempt to de-escalate the situation. Look for medical causes, such as hypoxia or indemnify volunteering physicians, and the captain should provide written confi rmation on request.112 • Off er or administer benzodiazepine, if available and indicated (be aware for possible Commercial aircraft have medical kits (1–4 fi rst-aid kits oversedative eff ect, if passenger is already taking other substances) and at least one enhanced emergency medical kit), as • If physical restraint is needed, it should be undertaken by 4–5 individuals. The required by aviation regulatory agencies.6,112 Emergency restrained individual should be placed in the left lateral recumbent position medical kits vary from carrier to carrier and can be • Appropriately monitor patient if chemical or physical restraints are used. Be aware of extensively complex (panel 3). Most commercial fl ights high risk of complications (hypoxia, metabolic acidosis, and sudden death) because of also carry an automated external defi brillator, and some fi ghting against restraints coupled with recent extreme exertion by the agitated models have a screen showing a basic rhythm strip. Most commercial air carriers use on-ground telemedical assistance to medically assess at the gate passengers who Acute allergic reaction and anaphylaxis
seem unfi t for travel, and to provide medical advice and • Administer diphenhydramine 12·5 mg po, im, or iv (paediatric); 25–50 mg po, im, or iv(adult) for both simple allergic reactions and anaphylaxis companies and academic medical institutions provide • Administer epinephrine 0·01 mL/kg/dose 1 in 1000 solution im or sc every 5–20 min 24-h ground-to-air medical support and have ground- as needed up to three doses (paediatric), or 0·3–0·5 mL 1 in 1000 solution im or sc based physicians, who also advise the fl ight deck on the every 5–20 min as needed up to three doses (adults) in the presence of severe best diversion location and arrange emergency personnel generalised urticaria, angio-oedema, stridor, or bronchospasm • Establish iv access and administer fl uids in presence of anaphylaxis if possible Clinicians who off er medical assistance during a fl ight should know that their role is to assist the fl ight crew and Vol 373 June 13, 2009
not to take complete control of the situation. The captain of the aircraft has the ultimate authority (panel 4). In case of violent or unruly passengers, volunteering physicians Chest pain
might need to assist in chemical or physical restraint. If • If diagnosis is uncertain, an antacid could help to confi rm dyspepsia chemical restraint is used, physicians should consider • For persistent pain or if myocardial infarction is suspected, administer oxygen, aspirin that passengers could have ingested alcohol or other 325 mg po, and nitroglycerin 0·4 mg sublingual every 5 min up to three doses or substances that might cause oversedation or other morphine sulfate 3 mg iv or im, as indicated eff ects.116 Panel 5 lists general guidelines for the initial • Request cabin altitude reduction to increase cabin pressure management of common in-fl ight medical events.
• Some airlines carry automated external defi brillators with a cardiac rhythm display to Medical fi tness for air travel
Airlines have the right to refuse passengers who are unfi t
Asthma or chronic obstructive pulmonary disease
y for medical reasons.6,119 Many conditions • Administer oxygen and inhaled bronchodilator (two puff s every 15 min) as indicated contraindicate air travel and passengers who cannot • Request cabin altitude reduction to increase cabin pressure tolerate hypoxia or pressure changes should not fl y Cardiac arrest
(panel 6). Passengers should be able to walk a distance of defi brillator on patient. Some defi brillators incorporate a 50 m and climb one fl ight of stairs without angina or rhythm display that can help making decisions severe dyspnoea.6 If a passenger needs oxygen, he or she • Follow basic life support or advanced cardiac life support resuscitation algorithms requires physician documentation stating fi tness to travel • If resuscitation is stopped because of no return of spontaneous circulation, the at 2438 m. Passengers bringing needles and syringes into individual should not be pronounced dead offi cially on international fl ights due to the cabin should possess documentation of need and carry the medication that requires that equipment with pharmacy-labelled identifi cation.124 Some passengers Hypoglycemia
might also need a qualifi ed medical escort, such as • If conscious, administer oral glucose gel passengers whose fi tness to travel is in doubt due to • If not conscious, establish iv access and administer D50 dextrose (1 amp) for adult or possible exacerbation or instability of chronic disease or 2 mL/kg of D25 dextrose (D50 diluted 1:1 with normal saline solution) for paediatric passengers who have organ failure requiring Seizure
transplantation.119 Many air carriers have limited transport • Keep passenger away from nearby objects of passengers on stretchers or those unable to sit upright • Do not place anything in passenger’s mouth in a seat.125 Numerous air ambulance services and clinics • Administer benzodiazepine if available (diazepam 0·1–0·3 mg/kg iv or im for off er physician-assisted or nurse-assisted escorts for paediatrics, and 5 mg iv or im for adults) commercial air fl ights, and physicians or passengers can call airlines for assistance.
Unresponsive passenger
• Place
Controversies and future directions
Passenger health and wellbeing during commercial air • Administer oxygen, D50 dextrose (1 amp) iv for adult or D25 dextrose (2 mL/kg) for travel continues to evolve. Cabin air quality remains an paediatric, naloxone 0·1–2 mg iv or im (if available) issue, and it has been linked to passenger and fl ight • Follow basic life support or advanced cardiac life support resuscitation algorithms crew complaints of dry eyes, stuff y nose, and skin Vasovagal syncope
irritation, as well as headaches, lightheadedness, and • Lay patient supine and elevate legs if possible confusion.126 Peer-reviewed studies on the eff ect of vaporised organic compounds, such as tricresyl phosphate, that have led to reported cases of crew and im=intramuscular. iv=intravenously. po=orally. sc=subcutaneously. The list is based on references 6 and 116–118.
passenger incapacitation are needed. These compounds are the result of vaporised jet oils that can mix with air governmental regulatory agencies remains unclear. At entering the aircraft cabin. Several research groups, present, no regulations by the CAA, FAA, or JAA exist such as the cabin air-quality reference group and the requiring use, certifi Australian civil aviation safety authority, are addressing high-effi ciency particulate air. New aircrafts, such as the knowledge gaps on health eff ects of cabin air, including Airbus A380 and Boeing 787, are being designed to the role of vaporised organic compounds.
operate at cabin altitude of 1829 m compared with the The American society of heating, refrigerating, and air current altitude of 2438 m, in addition to having conditioning engineers—an industry leader in improved cabin air quality and passenger seating. These developing indoor air-quality standards—set, for the fi rst changes will improve passenger wellbeing and comfort.
time, new air-quality standards in commercial aircrafts. How individuals with compromised cardiac and The new standards also address chemical, physical, and pulmonary function can endure long air travel needs to biological contaminants that aff ect cabin air quality. How be assessed, and current screening guidelines should these standards will be adopted by aviation and undergo re-assessment. Furthermore, absence of a Vol 373 June 13, 2009
other stakeholders, have established guidelines for Panel 6: Contraindications to commercial air travel
aviation-industry operations during pandemic infl uenza outbreaks to keep commercial air-travel spread to a Cardiac and pulmonary disorders
minimum. These include communication of the risk to • Myocardial infarction 7–10 days before air travel the population, establishment of national passenger exit screening from outbreak regions, and increasing • Coronary artery bypass graft 10–14 days before air tarvel airline preparedness (in-fl ight illness and aircraft In-fl ight medical events are projected to increase and AsMa encourages the creation of a database, but many air • Baseline sea-level PaO <67–70 mm Hg without carriers are reluctant to participate. Commercial space travel is projected to start within the next decade and • Obstructive/restrictive lung-disease exacerbation aerospace medical societies have set up subcommittees to address the unique medical conditions associated with • Pneumothorax 3 weeks before air travel (7–14 days with In the modern travel era, clear understanding of the Neurological disorders
medical consequences of commercial fl ights has become increasingly important. Individuals need to be aware of • Uncontrolled seizures or 24–h after grand-mal seizure the possible medical complications of air travel, and physicians should identify people at potential risk from Surgical interventions
air travel and advise them of any necessary treatments to • Any gastrointestinal, thoracic, ear, nose, and throat, and neurological surgical procedure 10–14 days before air travel • Uncomplicated appendectomy or laparoscopic surgery Confl ict of interest statement
We declare that we have no confl ict of interest.
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