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 Introduction
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
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
www.thelancet.comVol 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)
www.thelancet.comVol 373 June 13, 2009
of 1·59 (95% CI 1·04–2·43) from case–control
Deﬁ nition Recommendations Quality of
studies27,38–41 and a relative risk of 2·93 (95% CI
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
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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
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
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.
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
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
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
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
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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
diseases have been reported aboard commercial airlines, including inﬂ uenza,94,95 measles,96 severe acute respiratory
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
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
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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
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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
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
(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
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
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
www.thelancet.comVol 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
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
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
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International Clinical Psychopharmacology 2002, 17:115–119Quetiapine augmentation in patients withtreatment resistant obsessive^compulsivedisorder: a single-blind, placebo-controlled studyM. Atmaca, M. Kuloglu, E. Tez can and O. GeciciFirat University, Medical Faculty Hospital, Department of Psychiatry, Elazig, TurkeyCorrespondence to Murad Atmaca, Firat (Euphrates) Universitesi, Firat T|p M