1 BTS Clinical Statement on Air Travel for Passengers with Respiratory Disease 2 3 4 Draft for public consultation 5 6 Available for public consultation from Monday 13 January to Monday 10 7 February 2020 8 9 10 11 12 Contact: 13 British Thoracic Society, 14 17 Doughty St, London WC1N 2PL 15 16 [email protected] 17 A response form is available on the BTS website. 18 Please send your responses to Sally Welham by 5pm on Monday 10 February 19 2020 20 21 Consultation draft:10/1/2020 1 22 BTS Clinical Statement on Air Travel for Passengers with Respiratory Disease 23 24 AUTHORS 25 Robina Coker, Alison Armstrong, Colin Church, Steve Holmes, Jonathan Naylor, Katy Pike, Peter 26 Saunders, Kristofer Spurling, Pamela Vaughn on behalf of the British Thoracic Society 27 28 CONTENTS PAGE 29 Introduction 3 30 Scope 4 31 Methodology 5 32 Glossary 6 33 Pre-flight screening 7 34 Infants and children: special considerations 9 35 Hypoxic challenge testing 11 36 Disease/condition-specific advice with clinical practice points 16 37 Chronic airflow obstruction including asthma and COPD 38 Cystic fibrosis 39 Interstitial lung disease 40 Thoracic surgery and other interventional procedures 41 Pleural disease 42 Respiratory infections 43 Obstructive sleep apnoea syndrome 44 Respiratory muscle and chest wall disorders 45 Venous thromboembolism 46 Pulmonary hypertension 47 Lung cancer and mesothelioma 48 Hyperventilation and dysfunctional breathing 49 50 Disclaimer 51 Declarations of interest 52 Appendices 53 1. Practical considerations and useful sources of information 54 2. Logistics of air travel with equipment 55 3. Technical information for respiratory physiologists 56 4. Example of patient information leaflet – not included in consultation draft 57 References 45 58 Consultation draft:10/1/2020 2 59 Introduction 60 BTS recommendations for managing passengers with stable respiratory disease planning air travel 61 were published in Thorax in 2011 (1). This followed original guidance published in 2002 (2) and an 62 online update in 2004 (3). The 2011 recommendations provided an expert consensus view based on 63 literature reviews, aimed at providing practical advice for lung specialists in secondary care. 64 Recognising that our knowledge in this area has grown since 2011 and that updated pragmatic advice 65 regarding respiratory disease and air travel is now required, the Society commissioned a new Clinical 66 Statement in 2018. 67 68 Although air travel appears generally safe for passengers with respiratory disease previously assessed 69 by a lung specialist (4), a decision to undertake air travel cannot always be taken lightly. Diverted 70 flights incur significant expense and inconvenience, and a patient who deteriorates in mid-air can pose 71 huge challenges to airline crew and other passengers. High altitude destinations can also be 72 problematic. 73 74 Regulatory governmental agencies require aircraft cabin pressure to simulate an altitude of 2438 m 75 (8000 ft cabin altitude) and allow only short diversions to a cabin altitude of 3048 m (10 000 ft) for 76 safety reasons (IATA 2018). The choice of 2438 m was based on the oxy-haemoglobin dissociation 77 curve, which shows that up to this level arterial oxygen saturations (SaO2) remain > 90% in the average 78 healthy individual (5). 79 80 In addition to the passenger’s respiratory condition and significant co-morbidities, a decision 81 regarding suitability for air travel should consider flight duration, destination (especially if at altitude 82 or subject to extreme weather conditions), equipment and medications, and whether equipment will 83 operate effectively and safely at altitude. 84 85 There have been developments in three key areas over the last decade. The first is an attempt, with 86 research from several groups, to define more precisely the value and role of the hypoxic challenge 87 test (HCT). This has included examining the accuracy of other, more routinely available lung function 88 parameters, in predicting hypoxaemia during air travel. HCT can be expensive in terms of equipment 89 and consumables, and demands additional resource in terms of staff time. A ‘negative’ HCT (where 90 in-flight oxygen is deemed not to be required) will take 20 minutes excluding preparation; if oxygen 91 titration is needed it will take a minimum of 40 minutes. Spirometry requires 20 minutes, a walk test Consultation draft:10/1/2020 3 92 30 minutes, and ‘full’ lung function testing 45 minutes (6). Furthermore, recent spirometry, walk tests 93 and other parameters may already be available for patients as part of their routine clinical care. 94 95 The second development, following from this, has been increasing recognition that, although early 96 research in this area focused on patients with COPD, other patient groups may behave differently in 97 terms of their response to altitude-related hypoxaemia. Although data remain limited, it does appear 98 that a ‘one size fits all’ approach is no longer supported by the available evidence. 99 100 Finally, the equipment used to deliver oxygen has changed significantly over the last decade, with 101 much greater availability of portable oxygen concentrators (POCs). For overseas travel, patients 102 usually need to lease a POC privately, since UK companies do not generally allow their equipment to 103 be taken out of the country. If a POC is to be used in-flight, the equipment must be approved by the 104 airline in advance. There are now a wide variety of such devices, providing varying flow rates and 105 modes of delivery (continuous flow versus pulsed-dose), and not all are suitable for all individual 106 patients. Revised, clear advice on the logistics of air travel for patients requiring oxygen is therefore 107 now essential. 108 109 Attention has therefore been drawn in this Statement to newer data, especially those published 110 since the 2011 BTS recommendations (1). Readers wanting more detailed background information 111 on physiology and the flight environment should consult the 2002 and 2011 BTS documents (1, 2). 112 Scope 113 The Clinical Statement provides practical advice for healthcare professionals in primary and secondary 114 care managing passengers with lung disease planning commercial air travel, including those 115 recovering from an acute event/exacerbation. It provides information for patients and carers, also 116 intended to be helpful to patient support groups, airlines and associated medical services. 117 118 The Statement addresses adults and children with the following conditions or undergoing the 119 following procedures: 120 • Airflow obstruction including asthma and COPD 121 • Bronchopulmonary dysplasia 122 • Cystic fibrosis 123 • Restrictive respiratory disease including ILD, respiratory muscle and chest wall disorders 124 • Thoracic surgery or other interventional procedures 125 • Pleural disease including pneumothorax and pleural effusion Consultation draft:10/1/2020 4 126 • Respiratory infections 127 • Obstructive sleep apnoea syndrome 128 • Venous thromboembolism 129 • Pulmonary hypertension 130 • Lung cancer and mesothelioma 131 • Hyperventilation and dysfunctional breathing 132 133 Pre-flight assessment is described. Appendices provide information for patients; logistics on air travel 134 with equipment (nebulisers, oxygen and ventilators); and technical information for respiratory 135 physiologists. 136 137 Heart disease and HIV are excluded, as are emergency repatriation and travel on military or other non- 138 commercial flights including helicopter travel. The Terrence Higgins Trust and British Heart 139 Foundation provide advice on travel with HIV and heart conditions respectively (see Appendix 1). 140 141 Methodology 142 Dr Robina Coker chaired the Clinical Statement Group (CSG). Membership was drawn from respiratory 143 medicine, paediatrics, nursing, respiratory physiology, physiotherapy and primary care. The CSG 144 identified key areas requiring Clinical Practice Points. The group reviewed previous BTS 145 recommendations on this topic (1) and supplemented the evidence with up to date literature 146 searches. The overall content was developed to reflect the scope approved by the BTS Standards of 147 Care Committee. Following discussions of broad statement content, individual sections were drafted 148 by group members. A final edited draft was reviewed by the BTS SOCC before posting for public 149 consultation and peer review on the BTS website January 2020. The revised document was re- 150 approved by the BTS Standards of Care Committee in TBC before final publication. 151 Consultation draft:10/1/2020 5 152 Glossary 153 CF Cystic Fibrosis 154 COPD Chronic Obstructive Pulmonary Disease 155 CPET Cardiopulmonary Exercise Testing 156 CPAP Continuous Positive Airway Pressure 157 DOAC Direct Oral Anticoagulant 158 DVT Deep Vein Thrombosis 159 HCT Hypoxic Challenge Test 160 ILD Interstitial Lung Disease 161 LMWH Low Molecular Weight Heparin 162 PE Pulmonary Embolism 163 POC Portable Oxygen Concentrator 164 SARS Severe Acute Respiratory Disorder 165 SWT Shuttle Walk Test 166 VTE Venous Thromboembolism Consultation draft:10/1/2020 6 167 Pre-flight screening 168 Why? 169 A medical emergency occurs in 1 of 604 flights and 1 in 30, 000 passengers (7, 8). Respiratory illnesses 170 comprise around 12% of in-flight emergencies; others include syncope (37.4%), cardiac symptoms 171 (7.7%), stroke (2%) and cardiac arrest (0.3%). In a recent study of 1260 healthy volunteers, no 172 significant changes occurred