Statement on Air Travel for Passengers with Respiratory Disease Presentation

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Statement on Air Travel for Passengers with Respiratory Disease Presentation

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BTS Clinical Statement Robina Kate Coker,1 Alison Armstrong,2 Alistair Colin Church,3 Steve Holmes,4 Jonathan Naylor,5 Katharine Pike,6 Peter Saunders,7 Kristofer John Spurling,8 Pamela Vaughn9 INTRODUCTION ► Additional supplemental material is published online only. To view, please visit the journal online (http://d​ x.​doi.​org/1​ 0.​1136/​thoraxjnl-​2021-​218110). 1 Respiratory Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK 2 The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK 3 Scottish Pulmonary Vascular Unit, Golden Jubilee Hospital, Clydebank, UK 4 The Park Medical Practice, Shepton Mallet, UK 5 Queen Elizabeth Hospital, Birmingham, UK 6 Department of Paediatric Respiratory Medicine, Bristol Royal Hospital for Children, Bristol, UK 7 Churchill Hospital, Oxford, UK 8 Respiratory Physiology Department, North Middlesex University Hospital, London, UK 9 Glasgow Royal Infirmary, Glasgow, UK Correspondence to Dr Robina Kate Coker, Respiratory Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, London, UK;​robina.​coker@​imperial.​ac.u​ k Published Online First 28 February 2022 © Author(s) (or their employer(s)) 2022. Re-­use permitted under CC BY-­NC. No commercial re-­use. See rights and permissions. Published by BMJ. To cite: Coker RK, Armstrong A, Church AC, et al. Thorax 2022;77:329–350. 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). Coker RK, et al. Thorax 2022;77:329–350. doi:10.1136/thoraxjnl-2021-218110    329 Thorax: first published as 10.1136/thoraxjnl-2021-218110 on 28 February 2022. Downloaded from http://thorax.bmj.com/ on August 18, 2022 by guest. Protected by copyright. BTS Clinical Statement on air travel for passengers with respiratory disease BTS Clinical Statement 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 330 – 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 (

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Main Posting 45 (45%) – 50 (50%)

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Written clearly and concisely with no grammatical or spelling errors and fully adheres to current APA manual writing rules and style.

40 (40%) – 44 (44%)

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Supported by at least three credible sources.

 

Written clearly and concisely with one or no grammatical or spelling errors and fully adheres to current APA manual writing rules and style.

35 (35%) – 39 (39%)

Responds to some of the discussion question(s).

 

One or two criteria are not addressed or are superficially addressed.

 

Is somewhat lacking reflection and critical analysis and synthesis.

 

Somewhat represents knowledge gained from the course readings for the module.

 

Post is cited with two credible sources.

 

Written somewhat concisely; may contain more than two spelling or grammatical errors.

 

Contains some APA formatting errors.

0 (0%) – 34 (34%)

Does not respond to the discussion question(s) adequately.

 

Lacks depth or superficially addresses criteria.

 

Lacks reflection and critical analysis and synthesis.

 

Does not represent knowledge gained from the course readings for the module.

 

Contains only one or no credible sources.

 

Not written clearly or concisely.

 

Contains more than two spelling or grammatical errors.

 

Does not adhere to current APA manual writing rules and style.

Main Post: Timeliness 10 (10%) – 10 (10%)

Posts main post by day 3.

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First Response 17 (17%) – 18 (18%)

Response exhibits synthesis, critical thinking, and application to practice settings.

 

Responds fully to questions posed by faculty.

 

Provides clear, concise opinions and ideas that are supported by at least two scholarly sources.

 

Demonstrates synthesis and understanding of learning objectives.

 

Communication is professional and respectful to colleagues.

 

Responses to faculty questions are fully answered, if posed.

 

Response is effectively written in standard, edited English.

15 (15%) – 16 (16%)

Response exhibits critical thinking and application to practice settings.

 

Communication is professional and respectful to colleagues.

 

Responses to faculty questions are answered, if posed.

 

Provides clear, concise opinions and ideas that are supported by two or more credible sources.

 

Response is effectively written in standard, edited English.

13 (13%) – 14 (14%)

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Response may not be on topic and lacks depth.

 

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Second Response 16 (16%) – 17 (17%)

Response exhibits synthesis, critical thinking, and application to practice settings.

 

Responds fully to questions posed by faculty.

 

Provides clear, concise opinions and ideas that are supported by at least two scholarly sources.

 

Demonstrates synthesis and understanding of learning objectives.

 

Communication is professional and respectful to colleagues.

 

Responses to faculty questions are fully answered, if posed.

 

Response is effectively written in standard, edited English.

14 (14%) – 15 (15%)

Response exhibits critical thinking and application to practice settings.

 

Communication is professional and respectful to colleagues.

 

Responses to faculty questions are answered, if posed.

 

Provides clear, concise opinions and ideas that are supported by two or more credible sources.

 

Response is effectively written in standard, edited English.

12 (12%) – 13 (13%)

Response is on topic and may have some depth.

 

Responses posted in the discussion may lack effective professional communication.

 

Responses to faculty questions are somewhat answered, if posed.

 

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Response may not be on topic and lacks depth.

 

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Participation 5 (5%) – 5 (5%)

Meets requirements for participation by posting on three different days.

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Total Points: 100