Fitness for Air Travel – Guidelines for Doctors Thank-you for submitting a MEDA form for your patient. Key physiological considerations when assessing fitness to fly: Aircraft cabins are pressurized, but not to sea level. The cabin pressure is typically equivalent of up to 8000ft. This results in: 1) Less available oxygen (partial pressure of oxygen drops to the sea-level equivalent of breathing about 15% oxygen instead of 21%) 2) Gas expansion in body cavities (approximately one-third increase in volume) – particularly relevant to middle ear, sinuses, pleural space and after some types of surgery. The following are guidelines only and a case-by-case approach, in consultation with the Air NZ Aviation Medicine Unit (AvMed Unit, ph: +64 9 256 3924), may be warranted in some circumstances. If your patient requires oxygen during flight this must be pre-arranged. Onboard emergency supply oxygen should never be relied upon for passengers who ‘may’ need oxygen. If unsure please discuss with one of our doctors. Medical Conditions and Recommendations on Fitness to Travel Cardiovascular and other Circulatory Disorders Angina If no angina at rest, can walk 50m at moderate pace without SOB or chest pain, and symptoms well controlled with medication, may travel without supplementary oxygen. Otherwise in-flight O 2 (2L/min) recommended. Unstable or severe angina i.e. cannot carry out any activity without discomfort or angina at rest, should only travel if essential, and with supplementary oxygen and wheelchair. In all cases, must bring medication in hand luggage. Myocardial infarction As per British Cardiovascular Society Guidelines, stratify according to risk. High risk = EF<40% with signs and symptoms of heart failure or requiring further investigation/revascularization or device therapy should be discussed with AvMed Unit and travel delayed until stable. Moderate risk = no evidence heart failure or inducible ischaemia or arrhythmia, EF>40% delay travel ≥10d. Low risk = 1 st cardiac event, age<65, successful reperfusion, EF>45%, uncomplicated and no further investigations or interventions planned may fly ≥3d. Patients should not fly within 3d of MI, unless with medical escort, oxygen and AvMed Unit clearance e.g. emergency repatriation. Cardiac failure May travel with controlled and stable chronic heart failure. Adequate control = can walk 50m and up 1 flight stairs without SOB or chest pain, on room air. Borderline cases may require in-flight O 2 and/or medical escort. Patients with SOB/chest pain at rest or unable to carry out any physical activity without discomfort or symptoms should not fly. Advisable to delay travel 6 weeks after an episode of acute heart failure. 1 DVT ≥5d if anti-coagulation stable (INR 2-3). Pulmonary embolism ≥5d if anticoagulation stable, general condition adequate and oxygen saturations normal on room air. Pacemaker or ICD ≥2d if uncomplicated, no pneumothorax. insertion Angiography ≥24h if uncomplicated and original condition stable. Angioplasty with or ≥2d if uncomplicated. without stent Cardiac surgery ≥10d if asymptomatic, uncomplicated recovery and CXR (major) e.g. CABG, valve excludes pneumothorax. Post CABG, Hb≥90. surgery, transpositions, ASD/VSD repairs Cyanotic congenital If has symptoms at rest or with any activity – only essential heart disease flying, with O 2 2L/min. Hypertension Should not fly if severe and uncontrolled. Syncope See neurological section. Respiratory Conditions Pneumonia Should not fly until fully resolved (no SOB, minimal or no cough). COPD, emphysema, Should not fly if unresolved recent exacerbation, cyanosis pulmonary fibrosis, on ground despite supplementary O 2 or PaO2 <55mmHg. pleural effusion, Consider need for in-flight oxygen – 2L/min sufficient for haemothorax most people. If adequate general condition and can walk at least 50m on room air without SOB probably no need for in- flight O 2. Please indicate patient’s current SaO 2 on MEDA form. Asthma Can fly if mild or moderate asthma, currently asymptomatic, travelling with medication in hand luggage. Severe/brittle asthma – discuss with AvMed Unit. Note, most common cause for asthma attack in aviation setting is rushing to board flight and forgetting to have inhaler in carry-on bag. Pneumothorax – Contra-indicated for flight if lung not fully inflated. Travel spontaneous or should be delayed 14 days post resolution. Earlier travel traumatic may be considered in discussion with AvMed Unit. Requires check x-ray post removal of drain to confirm complete resolution of pneumothorax. If Heimlich type drain and medical escort early transportation is acceptable. Chest surgery May fly ≥11d post-op if uncomplicated recovery, no (pulmonary) e.g. pneumothorax. lobectomy, pleurectomy, open lung biopsy Lung cancer Not fit to fly if clinical stability in question. Correct severe or symptomatic anaemia + significant electrolyte disturbances. If advanced or complicated, must be discussed with AvMed unit. Major haemoptysis Contraindicated for air travel until clinically stable. Please indicate Hb on MEDA form. DVT/Pulmonary See section on ‘Cardiovascular and other Circulatory embolism Disorders’ 2 Endocrine Diabetes Should not travel if unstable, including hypoglycemic attack requiring assistance of other in the last 24h. Brittle diabetes – see GP or endocrinologist before travel. Passenger must carry medication(s) onboard and administer own medications or have someone with them who can administer. Aim to avoid hypoglycaemia in flight. Note insulin should not be stored in aircraft hold as too cold. Insulin cannot be stored in aircraft fridge – consider purchase of small cooling storage wallet. Useful patient information websites re diabetes and air travel: www.diabetes.org.nz ; www.diabetes.org.uk Pregnancy Singleton, May fly without medical clearance up to the start of 38 th uncomplicated week for domestic flights or short international flights (i.e. pregnancy up to 5h duration). For flights >5h duration, travel acceptable up to the start of the 36 th week. Should carry a letter from GP/midwife confirming dates and that pregnancy is uncomplicated/fit for travel. Multiple, Travel up to 32 weeks permitted. uncomplicated Complicated On an individual basis. For fetal problems in which baby will pregnancies, or history need tertiary care travel up to term may be acceptable if of premature labour escorted by midwife with delivery pack and no signs active labour prior to flight. Miscarriage May not travel with active bleeding. Travel once stable, no bleeding or pain for >24h. Neonates Newborns and infants May travel ≥ 48h after birth if born at term and otherwise well/no complications. Discuss with AvMed Unit if premature (<37/40), those with respiratory or cardiovascular conditions and incubator and ventilator cases. Orthopaedic and Trauma Encircling plaster cast, Travel after ≥48h unless cast bivalved (split twice along lower limb (flight entire length). Comply also with the anaemia rules for # duration >2h) femur/ pelvis (i.e. Hb >95). Doctor completing MEDA should consider anticoagulation for flights >8h if major fracture and no contra-indication. Encircling plaster cast, Travel ≥ 24h since cast applied or earlier if cast bivalved. lower limb (flight duration < 2h) Upper limb fractures Travel ≥ 24h if no neurovascular compromise, no requirement to split cast. Joint replacement After 7-10d if uncomplicated, pain well controlled, mobility surgery (e.g. hip, knee) considered. Doctor completing MEDA should consider anticoagulation for flights >8h if no contra-indication. 3 Burns If medically stable and well in other respects, may travel with appropriate wound dressings. If unstable e.g. in shock/ widespread infection or hospital to hospital transfer, must be discussed with AvMed Unit. Ventilators Seriously ill cases will require detailed discussion. Advice must be sought from the airline as to the compatibility of any ventilator with aircraft power and oxygen supplies. Head injuries See ‘neurological’ section. Wired jaw See ‘ENT and Dental’ section. Psychological/ Mental health illness Acute psychiatric Not fit for travel if active symptoms. Providing stable for 7d disorders including may travel with a doctor and/or psychiatric nurse escort. psychosis (e.g. mania, Consider stress of air travel and length of journey – in some schizophrenia, drug cases 2 escorts/security escort may be required for safety induced) reasons. Hospital to hospital transfer of unstable patients requires AvMed unit clearance. Chronic complex Not fit to travel if significant risk of deterioration in flight. If psychiatric disorders in hospital, should be stable for 7d and travel with a doctor (e.g. bipolar affective and/or psychiatric nurse escort. If earlier hospital to disorder, hospital transfer being proposed, discuss with AvMed Unit. schizophrenia) If stable, calm and co-operative, living in community and taking care of own needs including medication use, may be able to travel alone or with a family/friend escort. Fear of flying Give advice on non-pharmacological techniques such as breathing exercises. Consider educating about typical symptoms of hyperventilation. If prescribing anxiolytic ensure ground trial before flight. Advise against consuming alcohol, especially if taking an anxiolytic. Submit MEDA if symptoms significant as helpful for cabin crew to be aware. Neurological Conditions CVA/TIA ≤2d should not fly. Minor CVAs including TIAs fit for travel ≥ 3d if stable and improving. Major CVA can travel after 10d if stable. Travel may be considered after