BTS Clinical Statement on air travel for passengers with respiratory disease - Thorax (BMJ)
Introduction
BTS recommendations for managing passengers with stable respiratory disease planning air travel were published in Thorax in 2011.1 This followed original guidance published in 20022 and an online update in 2004.3 The 2011 recommendations provided an expert consensus view based on literature reviews, aimed at providing practical advice for lung specialists in secondary care. Recognising that knowledge in this area has grown since 2011, and that updated, pragmatic advice regarding which respiratory patients need specialist assessment is required, the Society has commissioned a new clinical statement.
Although air travel appears generally safe for those with respiratory disease assessed previously by a lung specialist,4 a decision to undertake air travel should not be taken lightly. Diverted flights incur significant expense and inconvenience, and a patient whose condition deteriorates during flight can pose huge challenges to airline crew and other passengers. High altitude destinations may also be problematic.
European and North American regulatory authorities limit maximum cabin altitude to 2438 m (8000 ft) under normal operating conditions.5–7 The choice of 2438 m was based on the oxyhaemoglobin dissociation curve, which shows that up to this level arterial oxygen saturations (SaO2) remain >90% in the average healthy individual.8 Some newer commercial aircraft have a lower normal cabin altitude, for example, the Boeing 787 Dreamliner. However, passengers booking such flights should note that airlines may, for operational reasons, switch at short notice to an aircraft with a higher normal cabin altitude.
Besides the passenger's respiratory condition and significant comorbidities, a decision regarding suitability for air travel should consider flight duration and timings, destination (especially if at altitude or subject to extreme weather conditions), equipment and medications, and whether equipment will operate effectively and safely at altitude.
There have been developments in three key areas over the last decade. The first is an attempt, with research from several groups, to define more precisely the value and role of the hypoxic challenge test (HCT). This has included examining the accuracy of other, more routinely available lung function parameters, in predicting hypoxaemia during air travel. HCT can be expensive in terms of equipment and consumables; and demands additional staff time. A 'negative' HCT (where in-flight oxygen is not considered necessary) takes around 30 min; if oxygen titration is needed it takes around 60 min. In contrast, spirometry requires 20 min, a walk test 30 min, and 'full' lung function testing 45 min.9 Results of such assessments may already be available as part of routine clinical care.
The second development has been increasing recognition that, although early research in this area focused on patients with chronic obstructive pulmonary disease (COPD), other patient groups may respond differently to altitude-related hypoxaemia. Although data remain limited, available evidence no longer appears to support a 'one size fits all' approach.
Finally, the equipment used to deliver oxygen has changed significantly over the last decade, with much greater availability of portable oxygen concentrators (POCs). For overseas travel, patients usually need to lease a POC privately, since UK companies do not generally allow their equipment to be taken out of the country. If a POC is to be used in-flight, the equipment must be approved by the airline before travel. There are now a wide variety of such devices, providing varying flow rates and modes of delivery (continuous flow vs pulse-dose), and not all are suitable for all individual patients.
Attention has, therefore, been drawn in this Statement to newer data, especially those published since the 2011 BTS recommendations.1 Readers wanting more detailed background information on physiology and the flight environment should consult the 2002 and 2011 BTS documents.1 2
Scope
The clinical statement provides practical advice for healthcare professionals in primary and secondary care managing passengers with pre-existing respiratory conditions planning commercial air travel, including those recovering from an acute event/exacerbation. It provides information for patients and carers; and is also intended to be helpful to patient support groups, airlines and associated medical services. Passengers returning home with a new diagnosis should be reviewed in the light of the presenting condition and individual circumstances. The document does not cover emergency aero-medical evacuation, or travel on non-commercial flights. Pregnant passengers with respiratory disease should also consult Royal College of Obstetricians and Gynaecologists guidance (see online supplemental appendix 1).
Supplemental material
The Statement addresses adults and children with the following conditions or undergoing the following procedures:
Airflow obstruction including asthma and COPD.
Bronchopulmonary dysplasia.
Cystic fibrosis (CF).
Non-CF bronchiectasis.
Restrictive respiratory disease including interstitial lung disease (ILD), respiratory muscle and chest wall disorders.
Thoracic surgery or other interventional procedures.
Pleural disease including pneumothorax and pleural effusion.
Respiratory infections.
Obstructive sleep apnoea syndrome (OSAS) and obesity hypoventilation syndrome (OHS).
Venous thromboembolism (VTE).
Pulmonary hypertension (PH).
Lung cancer and mesothelioma.
Hyperventilation and dysfunctional breathing (DB).
Preflight assessment is described. Appendix A provides information on logistics for air travel with equipment (nebulisers, oxygen and ventilators); Appendix B provides technical information for respiratory physiologists. Sources of useful information, Information for primary care healthcare practitioners and for patients are provided in online supplemental appendices 1–3.
Supplemental material
Supplemental material
Heart disease and HIV are excluded, as are emergency repatriation and travel on military or other non-commercial flights including helicopter travel. The Terrence Higgins Trust and British Heart Foundation provide advice on travel with HIV and heart conditions respectively (see online supplemental appendix 1).
Methodology
Dr Robina Coker chaired the clinical statement group (CSG). Membership was drawn from respiratory medicine, paediatrics, nursing, respiratory physiology, physiotherapy and primary care. The CSG identified key areas requiring Clinical Practice Points. The group reviewed previous BTS recommendations on this topic1–3 and supplemented the evidence with up-to-date literature searches. The overall content was developed to reflect the scope approved by the BTS Standards of Care Committee (SOCC). Following discussions of broad statement content, individual sections were drafted by group members. A final edited draft was reviewed by the BTS SOCC before posting for public consultation and peer review on the BTS website in January 2020. The document was revised in the light of consultation feedback and approved by the BTS Standards of Care Committee in July 2021 before final publication.
Summary of clinical practice points
Preflight screening
All patients should undergo careful initial evaluation with history and physical examination by a clinician who is competent. The history should include:
Review of symptoms, baseline exercise capacity, recent exacerbation history, treatments and previous experience of air travel.
Consideration of the logistics of the intended journey, to include (if known):
Number and duration of flights, including whether daytime or overnight,
Location of stop-over(s) and destination: these determine air quality, altitude and available medical facilities,
Time away from home
Return journey.
Further assessment by a respiratory specialist is advised for those in whom screening raises concerns, and HCT may be advised.
The following clinical practice points are specific to infants and children
For infants born at term (>37 weeks) it is prudent to delay flying for 1 week after birth to ensure they are healthy.
Infants born prematurely (<37 weeks) with or without a history of respiratory disease who have not reached their expected date of delivery at the time of flying should have in-flight oxygen available. HCT may not be a reliable guide of oxygen requirement in this group. If air travel is essential, they should travel with oxygen at a tolerable low flow, recognising that this may be a minimum of 1 L/min depending on equipment.
Infants under 1 year with a history of chronic respiratory problems should be discussed with a respiratory paediatrician and HCT considered. Those with SpO2 <85% on HCT should have in-flight oxygen available; paediatrician discretion should be used for infants with SpO2 85%–90% recognising that sleep or respiratory infection may further reduce saturations in this group.
In children with chronic lung disease able to perform spirometry whose forced expiratory volume in 1 s (FEV1) is consistently <50% predicted, HCT should be considered. This includes children with CF and primary ciliary dyskinesia (PCD). Children with chronic lung disease who are too young to perform spirometry reliably should have a clinical assessment of disease severity and their likely tolerance of hypoxia. In children with CF the disease is rarely severe enough to compromise lung function significantly at this age.
Infants and children who have required long-term oxygen in the last 6 months should be discussed with a respiratory paediatrician and HCT considered.
Patient selection for HCT
See figures 1 and 2.
Preflight assessment of patients with chronic airflow obstruction.
Preflight assessment of patients with restrictive respiratory disease.
The following patients should not require HCT
Those with stable disease who have previously undergone HCT (no recent hospital admissions, exacerbations, or significant changes to treatment).
Patients with COPD with baseline SpO2 ≥95% and either MRC score 1–2 or desaturation to no less than 84% during 6 min walk test (6MWT) or shuttle walking test (SWT), should be able to travel without in-flight oxygen.
Those with previous significant intolerance to air travel, such as mid-air emergency oxygen or diversion. These should have in-flight oxygen available at 2 L/min provided there is no history of hypercapnia.
Preterm infants who have not reached their due date at the time of travel, as testing is not a reliable guide of oxygen requirement in these infants. These should have in-flight oxygen available, delivered at 1–2 L/min if they develop tachypnoea, recession, or other signs of respiratory distress.
HCT should be considered for the following patients
Patients with COPD with resting SpO2 ≤95%, MRC score 3 or greater, or desaturation to <84% on 6MWT or SWT, and in whom there are concerns about hypercapnia.
Infants and children with a history of neonatal respiratory problems, or existing severe chronic lung disease including those with FEV1 persistently <50% predicted.
Adults and children with severe asthma, evidenced by persistent symptoms and/or frequent exacerbations despite optimal treatment regardless of resting sea level SpO2.
Patients with ILD in whom SpO2 falls to <95% on exercise, and whose resting sea level arterial oxygen tension (PaO2) is ≤9.42 kPa or whose TLCO is ≤50%.
Those with severe respiratory muscle weakness or chest wall deformity in whom forced vital capacity (FVC) is <1 L.
Those with existing or previous hypercapnia and those at risk of hypercapnia, including those taking medication(s) which can cause respiratory depression.
Patients with a history of type 2 respiratory failure already on LTOT at sea level. However, if there is no evidence of hypercapnia, it seems reasonable to recommend an increase in flow rate by 2 L/min in-flight, provided the equipment can provide it (see Appendix A)
HCT results
PaO2 ≥6.6 kPa (≥50 mm Hg) or SpO2 ≥85%: in-flight oxygen not required.
PaO2 <6.6 kPa (<50 mm Hg) or SpO2 <85%: in-flight oxygen recommended.
Where required, titrate oxygen to maintain PaO2 ≥6.6 kPa or SpO2 ≥85% in adults, SpO2 90% in children aged 1 year or more.
Asthma
The patient's condition should be optimised before travel, with attention paid to inhaler technique and smoking cessation referral as required.
All medications and spacer devices should be carried in hand luggage to mitigate the risk of lost or missing hold baggage.
Emergency medications, including salbutamol inhalers and spacers, must be immediately accessible.
Individuals prescribed epinephrine auto-injectors should have them readily available.
For acute exacerbations on board, the passenger's own bronchodilator inhaler should be given, with a spacer if needed.
The passenger should alert the cabin crew if symptoms do not respond rapidly to use of the inhaler, or if they recur after a short interval.
If the passenger does not have their own inhaler with them, or if it is inaccessible, the airline may carry an inhaler in the emergency medical kit. Spacers are not commonly available.
Those with severe asthma should consult their respiratory specialist beforehand and consider taking an emergency supply of oral corticosteroid in their hand luggage in addition to their usual medication.
Passengers with severe asthma are advised to carry copies of their asthma management plan and/or relevant clinic letters. Information can be held securely as scanned copies on a mobile phone, or on a digital platform such as the National Health Service (NHS) App.
Food allergy affects up to 8.5% of children and adults with asthma and asthma is a risk factor for severe or fatal anaphylaxis. Appropriate precautions for those affected include wiping tray tables and hands, informing the airline beforehand and the cabin crew of allergies, and not eating during flights or bringing known 'safe' foods from home.
Chronic obstructive pulmonary disease
The patient's condition should be optimised before travel, with attention paid to inhaler technique and smoking cessation referral where appropriate.
All medications and spacer devices should be carried in hand luggage to mitigate the risk of missing hold baggage.
Emergency medications, including salbutamol inhalers and spacers, must be immediately accessible.
For acute exacerbations on board, the passenger's own bronchodilator inhaler should be given, with a spacer if appropriate.
Passengers with severe COPD are advised to carry a copy of their COPD management plan and/or relevant clinic letters. This information can be held securely as scanned copies on their mobile phone A history of previous pneumothorax or bullous lung disease necessitates assessment by a respiratory specialist to determine the potential risk of complications from reduced cabin pressure.
Patients with COPD are at greater risk of VTE as a direct consequence of the underlying condition, as well as after an exacerbation. They should be advised accordingly, especially if planning longer flights when the risk is further enhanced.
Patients requiring long-term oxygen therapy should also plan for oxygen supplementation at their destination (see online supplemental appendix 1).
Wherever possible, those who have had a recent exacerbation of their condition should not fly until their condition is stable and use of reliever therapy has returned to their usual baseline. If their condition deteriorates while overseas, medical advice should be sought before undertaking the return flight.
Cystic fibrosis
All medications and spacer devices should be carried in hand luggage to mitigate the risk of missing hold baggage.
Patients with CF under the age of 6 are likely to be well enough to fly at the paediatrician's discretion.
In those with CF who are old enough for spirometry and whose FEV1 is <50% predicted, HCT is recommended. If SpO2 falls below the 90% cut-off, as outlined above, in-flight oxygen is advised.
In children with chronic lung disease able to perform spirometry whose FEV1 is consistently <50% predicted, HCT should be considered. This includes children with CF and non-CF bronchiectasis. Children with chronic lung disease who are too young to reliably perform spirometry should have a clinical assessment of assess disease severity and their likely tolerance of hypoxia. For children with CF disease is rarely severe enough to severely compromise lung function at this age.
Non-CF bronchiectasis
Regular airway clearance is essential for those dealing with overproduction of mucus.
Advice from a respiratory physiotherapist on adapting airway clearance techniques should be sought for long-haul flights.
Portable nebulisers and positive expiratory pressure (PEP) devices may be considered, but use of these devices in-flight must be approved by the airline before travel.
Interstitial lung disease
In patients with comorbidity, including PH and/ or cardiovascular disease, attention should also be paid to the impact of air travel on these conditions.
Physicians may wish to consider HCT in those whom SpO2 falls to <95% on exercise, and/or in those in whom either Transfer Factor Carbon Monoxide (TLCO) ≤50% or PaO2 ≤9.42 kPa (if available).
Patients with TLCO <50% of predicted or PaO2 ≤9.42 kPa are likely to need in-flight oxygen. If there are no concerns about hypercapnia it may be reasonable to recommend 2 L/min without recourse to HCT. In those in whom there are concerns about CO2 retention, titration HCT is advised to determine the oxygen flow rate.
Thoracic surgery
The opinion of the surgeon or interventionalist should be obtained before the patient travels by air. Patients, professionals and their carers should be aware that this may result in a delay of 4 weeks for non-essential air travel and 2 weeks for essential air travel.
Careful clinical assessment of the patient is required. This should include consideration of their baseline status including comorbidities, SpO2, postprocedure complications such as infection and/or pain, flight duration and destination.
Other interventional procedures
The opinion of the interventionalist should be obtained before the patient travels by air.
Careful clinical assessment of the patient is required. This should include consideration of baseline status including co-morbidities, SpO2, postprocedure complications such as infection or pain, flight duration and destination.
Patients with no pneumothorax seen on the postprocedure chest X-ray should wait for 1 week before air travel.
Patients with a pneumothorax seen on the post-procedure chest X-ray should wait for one1 week after resolution on chest X-ray before air travel.
Trapped lung
The opinion of the interventionalist should be obtained before the patient travels by air.
Patients should be assessed carefully and advised on a case-by-case basis.
Patients should be clinically stable before air travel.
Bronchoscopic procedures
The opinion of the interventionalist should be obtained before the patient travels by air.
Patients should be clinically stable before they travel.
After interventional bronchoscopy including Transbronchial Needle Aspiration (TBNA), Transbronchial Lung Biopsy (TBB), Endobronchial Ultrasound Bronchoscopy (EBUS) and endobronchial valve insertion, those with no pneumothorax seen on the postprocedure chest X-ray should wait for 1 week before air travel.
After interventional bronchoscopy including TBNA, TBB and EBUS, those with a pneumothorax seen on the post-procedure chest X-ray should wait for 1 week after resolution on chest X-ray before air travel.
Pneumothorax
Passengers should not travel by air until 7 days after full resolution on chest X-ray.
Those at higher risk of recurrent pneumothorax should be advised accordingly.
Higher-risk groups, including those with cystic lung disease such as lymphangioleiomyomatosis (LAM) and Birt-Hogg-Dubé (BHD) syndrome, should be advised accordingly.
Patients with trapped lung and a chronic air space thought to present a low risk should be evaluated in secondary care before travel.
Upper respiratory infection including otitis media and sinusitis
In passengers who develop sinus barotrauma after flying, it may be helpful to consider topical and oral decongestants as well as appropriate analgesia. Prolonged use of decongestants is not advised owing to the risk of rebound congestion on withdrawal.
If there is an allergic component, intranasal steroids used for a week prior to travel, and/or oral corticosteroids may be considered.
Symptoms and signs of barotrauma should have resolved before flying again. This usually takes between 1 and 6 weeks.
After an episode of acute otitis media, patients are usually advised not to fly for 2 weeks.
Viral infections
Patients with highly contagious infections including measles, chickenpox, mumps, SARS, Middle East respiratory syndrome (MERS) or COVID-19 should not be allowed to travel until they are considered non-infectious.
Passengers should familiarise themselves with current national and international regulations regarding air travel, which should always be observed.
Tuberculosis
Smear positive patients must not fly until they have provided two smear negative samples on treatment.
Those starting treatment for pulmonary tuberculosis (TB), where not all the information is yet available, should not travel by air for the first 2 weeks.
For those who are smear negative and have a fully sensitive organism, treatment would be expected to render them non-infectious after 2 weeks.
For patients with multidrug resistant/extensive drug resistant (MDR/XDR) TB, travel is prohibited until two negative culture samples have been produced and there is clinical evidence of improvement on treatment.
Extrapulmonary TB does not usually warrant additional precautions before air travel.
Obstructive Sleep Apnoea (OSAS) and Obesity Hypoventilation Syndrome (OHS)
Daytime flights are advised wherever possible.
The patient should be advised to carry their continuous positive airway pressure (CPAP) device as hand luggage, and a hospital letter to advise that the patient uses CPAP.
Careful planning and preparation are required, and use of the patient's own CPAP device is advised.
Alcohol and sedatives should be avoided in the 12 hours before, and during, airline travel.
Patients should use their CPAP device on board if they are travelling overnight, and avoid sleeping during daytime flights.
Consideration should be given to device settings and whether adjustment is required for operation at altitude.
Airline approval for carriage and use of device, including battery specification, must be gained before travel.
Consideration should be given to the whole journey. If driving is required the following day, an overnight stay at destination may be advisable. Patients are advised to refrain from driving if tired and sleepy.
Respiratory muscle and chest wall disorders
HCT is recommended for all adult patients with FVC <1 L, pending further data, and may be considered in others thought to be at particular risk, including children with reduced FVC due to respiratory muscle or chest wall disorders.
If patients are unable to perform spirometry reliably, a walk test may be considered as an alternative.
Patients should be advised to take daytime flights where possible.
Further planning and support are required for those established on non-invasive ventilation (NIV) (see Appendix A). (online supplemental appendix 2
Prevention of VTE during air travel
See table 1.
Summary of risk factors for VTE during air travel
Limit the risk of dehydration with adequate fluid intake.
Avoid alcohol.
Keep mobile, if possible, by walking around or doing seat-based exercises once an hour.
Consider graduated compression stockings (class 1 with 15–30 mm Hg).
Low molecular weight heparin (LMWH) or a Direct Acting Oral Anticoagulant (DOAC) are advised for both outward and return long haul flights (long haul defined as flights of 6–12 hours) in high-risk patients including those with a history of VTE; local policy should be followed regarding liaison with primary care and/or haematology services to teach the patient how to administer the injection and dispose safely of the equipment. There is no formally recommended dose, but enoxaparin at a dose of 40 mg or weight based 1 mg/kg injected once 4–5 hours before the flight has been suggested.
The prophylactic doses of the DOAC may also be used.
All patients with a recent (<6 weeks) history of VTE, especially any who presented with significant right ventricular strain and decompensation should be reassessed before air travel.
Air travel after VTE
Pulmonary hypertension
Those in New York Heart Association (NYHA) WHO functional class 3 or 4 are usually advised to have in-flight oxygen. If there is no evidence of hypercapnia it seems reasonable to suggest 2 L/min by nasal cannulae. If there are concerns about hypercapnia, HCT should be considered if available.
Those eligible for LTOT (sea level PaO2 <8 kPa at rest on air) should have in flight oxygen at double the flow rate recommended at sea level, provided there is no evidence of hypercapnia.
Lung cancer and mesothelioma
Hyperventilation and DB
Patients with DB, inducible laryngeal obstruction (ILO) and/or vocal cord dysfunction (VCD) should be referred to a respiratory physiotherapy specialist for advice on symptom management before travel.
Those with anxiety disorders should be reviewed before travel; compliance with medication assessed; and use of short acting anxiolytics encouraged.
Other life-threatening conditions presenting with dyspnoea should be excluded on board as far as possible.
Supplemental oxygen should be given on board if the cause of breathlessness is unclear
Rebreathing via a paper bag is not recommended.
HCT outcomes
Preflight respiratory screening
Why?
Medical incidents have been reported in around 1 in 600 flights,10 or 1 in 30 000 passengers.11 12 Estimates vary and reliable data are difficult to obtain, but respiratory events account for around 12% of in-flight incidents. In a recent study of 1260 healthy volunteers, no significant changes occurred in pulse oximetry (SpO 2 ) during a simulated 8-hour flight at cabin altitudes up to 2438 m (8000 ft).13 However, if cabin altitude exceeds 3048 m (10 000 ft), hypoxaemia becomes more prominent and SaO 2 falls to∼89% in healthy individuals.14 Other potential hazards for passengers with respiratory conditions include low relative humidity, and altitude-related expansion of gases within enclosed pulmonary parenchymal spaces. It follows from Boyle's Law that a cabin altitude of 2438 m (8000 ft) will result in a 38% expansion of humidified gas.
Who?
There is no good-quality evidence to determine who should have a formal respiratory review before air travel. Experts generally advise preassessment or screening for the following adults, children and infants:
Those with a respiratory condition with the potential to deteriorate acutely resulting in incapacitation and/or the need for medical intervention. This includes (but is not exclusive to):
Severe (FEV1 <50% predicted15 or poorly controlled obstructive airway disease (evidenced by symptoms, oxygen requirements, severe and/or frequent exacerbations).
Symptomatic restrictive lung or chest wall conditions, or known respiratory muscle weakness causing breathlessness and exercise limitation.
PH.
Comorbid conditions which may be worsened by hypoxaemia (cerebrovascular or cardiac disease).
Recent (<6 weeks) hospital treatment for a respiratory condition.
Requirement for CPAP or ventilator support such as NIV.
Active cancer with lung involvement.
Patients requiring domiciliary oxygen.
Recent (<6 weeks) pneumothorax and those at higher risk of pneumothorax (cystic lung disease or recurrent pneumothorax), and patients with trapped lung and a chronic air space.
Recent (<6 weeks) pulmonary embolus or deep venous thrombosis, or increased risk of VTE.
Anyone who has experienced significant symptoms during previous air travel, or whose condition is of concern to their physician.
The following are generally considered contraindications to air travel:
Untreated respiratory failure.
Untreated pneumothorax.
Active infection representing a risk to others for example, TB, SARS, MERS, COVID-19.
Bronchogenic cysts. Cerebral air embolism, in some cases fatal, has been reported in aircraft passengers after rupture of a bronchogenic cyst.16
Patients with severe hypoxaemia requiring >4 L/min in-flight oxygen were previously advised against air travel, because 4 L/min was the maximum fixed flow rate routinely available on commercial aircraft. With the availability of flight approved POCs delivering a range of continuous and intermittent flow rates, this cut-off no longer applies. In-flight oxygen delivery is more varied, and maximum flow rate is determined by the equipment available. Pulse-dose delivery systems can however complicate determination of the flow delivered and may not be well tolerated. The effects of mouth-breathing, speech, snoring and/or sleeping should be considered. High-flow nasal oxygen (HFNO) cannot be delivered on board commercial aircraft.
In-flight oxygen may be contraindicated in adults and children with a history of type 2 respiratory failure.17 18 Hypoxic challenge with arterial carbon dioxide tension (PaCO2) measurement was advised for this group in 199617 but there has been little research since. This document, therefore, follows the 2015 BTS Guideline for Home Oxygen Use in Adults19 when making recommendations for managing patients with previously documented hypercapnia.
Clinical practice points
All patients should undergo careful initial evaluation with history and physical examination by a clinician who is competent. The history should include:
Review of symptoms, baseline exercise capacity, recent exacerbation history, treatments and previous experience of air travel.
Consideration of the logistics of the intended journey, to include (if known):
Number and duration of flights, including whether daytime or overnight.
Location of stop-over(s) and destination: these determine air quality, altitude and available medical facilities.
Time away from home.
Return journey.
Further assessment by a Respiratory Specialist is advised for those in whom screening raises concerns, and hypoxic challenge testing may be advised.
Infants and children
In general, similar considerations apply to both adults and children if they have severe chronic airway disease, or require chronic supplementary oxygen, or non-invasive or tracheostomy ventilation. Both children and adults with these conditions require a preflight assessment. Similarly, unless otherwise stated, recommendations for individuals with previous thoracic surgery, pneumothorax or empyema apply to both adults and children. There are, however, some specific considerations for infants and younger children since several factors place infants at greater risk of developing hypoxia. These factors include left shift of the oxygen dissociation curve (due to the presence of foetal haemoglobin), smaller airway diameter, relatively fewer alveoli, compliant rib cage and increased tendency to pulmonary vasoconstriction and bronchoconstriction and thus ventilation–perfusion mismatch under hypoxic conditions. Moreover, preterm infants and infants under 2 months of age may develop apnoea/hypoventilation in response to hypoxia or infection.20 21 Beyond 3 months of age there is no evidence that ex-preterm infants, without bronchopulmonary dysplasia, are at significantly greater risk of desaturation during a HCT than term infants.22
In addition to very young and ex-preterm infants, the children most at risk of hypoxia are those with anaemia, congenital heart disease with an actual or potential right to left shunt,23 neuromuscular disorders or chronic or acute lung disease. Low humidity during air travel can also present a problem for children with respiratory conditions such as CF. Those most at risk of complications associated with reduced air pressure are children with upper respiratory tract infections, or trapped intrathoracic air, including those with recent pneumothorax or cystic lung disease.24
For infants born at term (>37 weeks) it is prudent to delay flying for 1 week after birth to ensure they are healthy.25 In view of their greater risk of apnoea and hypoxia, infants born prematurely (<37 weeks) with or without a history of respiratory disease who have not reached their expected date of delivery at the time of flying should have in-flight oxygen available. HCT may not be a reliable guide of oxygen requirement in this group.26 If air travel is essential, they should travel with oxygen at a tolerable low flow, recognising that this may be a minimum of 1 L/min depending on equipment.
The following Clinical Practice Points are specific to infants and children.
Clinical practice points
For infants born at term (>37 weeks) it is prudent to delay flying for 1 week after birth to ensure they are healthy.
Infants born prematurely (<37 weeks) with or without a history of respiratory disease who have not reached their expected date of delivery at the time of flying should have in-flight oxygen available. HCT may not be a reliable guide of oxygen requirement in this group. If air travel is essential, they should travel with oxygen at a tolerable low flow rate, recognising that this may be a minimum of 1 L/min depending on equipment.
Infants under 1 year with a history of chronic respiratory problems should be discussed with a respiratory paediatrician and HCT considered. Those with SpO2 <85% on HCT should have in-flight oxygen available; paediatrician discretion should be used for infants with SpO2 85%–90% recognising that sleep or respiratory infection may further reduce saturations in this group.
In children with chronic lung disease able to perform spirometry whose FEV1 is consistently...
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