Assessment of adult patients for air travel

INTRODUCTION — Clinicians are frequently asked to make recommendations to patients about travel safety. Air travel exposes people to different factors that could have an impact on their health status. There is also limited availability or absence of medical care in the event of medical emergencies [1]. This topic review will present an overview of issues for clinicians to consider when evaluating the risks posed by commercial air travel.

Multiple topics in UpToDate discuss specific aspects of air travel. Related topics include:

●(See "Jet lag".)

●(See "Approach to patients with heart disease who wish to travel by air or to high altitude".)

●(See "Prevention of venous thromboembolism in adult travelers".)

●(See "Evaluation of patients for supplemental oxygen during air travel".)

●(See "Management of inflight medical events on commercial airlines".)

Other topics about travel-related illnesses or specific destinations include:

●(See "Travel advice for immunocompromised hosts".)

●(See "Immunizations for travel".)

●(See "Travelers' diarrhea: Epidemiology, microbiology, clinical manifestations, and diagnosis".)

●(See "Approach to illness associated with travel to Southeast Asia".)

●(See "Approach to illness associated with travel to Latin America and the Caribbean".)

GENERAL SCREENING AND HEALTH COUNSELING

General considerations — In the United States, the Department of Transportation has issued specific regulations to prevent discrimination against passengers based on disability and requires airline carriers to accommodate patients with disabilities [2]. Similar regulations exist in Europe and many other countries.

As a general rule, patients with unstable medical conditions, including those with an evolving, unpredictable, or rapidly changing medical condition, should not fly on a commercial aircraft [3].

Individuals with a medical condition that could lead to inflight illness, injury, or significant risk to other passengers may be required by the airline to have a medical certificate from their clinician indicating that it is safe for them to fly. The certificate should state that the patient is currently stable, fit for air travel, and, if applicable, not contagious. Although a medical certificate is not needed for most patients, some travelers will be required to present one, for instance those requiring supplemental oxygen. The medical certificate required varies slightly among airlines and often requires that a summary of underlying medical conditions be carried by the passenger; such a summary may be useful in case of an inflight medical decompensation. Patients should contact their airline to inquire about any medical clearance certificates or forms necessary to travel.

Clinicians asked to certify that a patient is safe for airline travel should include consideration of the length of the anticipated flight, any problems in the past with tolerating air travel, and the conditions at the destination (eg, destination altitude, public health risks, and access to medical care). The clinician should assess any worsening of the patient's chronic medical conditions and any relevant medical history. Of particular concern are: cardiovascular disease, thromboembolic disease, anemia, asthma, chronic obstructive pulmonary disease (COPD), epilepsy, stroke, recent surgery or procedure, recent trauma, diabetes, infectious disease, and mental illness.

Depending on their illnesses, patients should keep within reach (ie, not checked with their baggage) the following items [4,5]:

●Detailed list of all medical conditions

●All medications in the original labeled containers and a detailed list of all medications, including doses, and allergies

●Medical alert bracelet for severe diseases and/or allergies

●Copy of a recent electrocardiogram (ECG; for cardiac patients)

Pre-travel immunizations and prophylaxis are discussed separately. (See "Travel advice" and "Immunizations for travel".)

If a clinician is uncertain about a patient's ability to fly on a commercial airline, they may consider referral to an expert in aerospace medicine or review the Aerospace Medical Association (AsMA) medical guidelines for airline travel [3].

Patients with mobility issues should be advised to request additional assistance getting on and off the plane if necessary.

Medications — All patients preparing for air travel should be counseled on keeping unexpired medicines with them in carry-on luggage (preferably in original, labeled medication containers) and adjusting the timing of their medicines (especially if crossing time zones).

Timing of medications — Adjusting medication schedules can be difficult, and strategies vary depending upon the medication, the importance of precise timing of medication usage, distance traveled, and duration of the visit.

●For medications where precise timing is important (eg, administration of insulin relative to time of food intake, or interval between doses of certain Parkinson medications), medication adjustment should be based upon the patient’s planned itinerary. Advice should be given about what to do if a travel delay occurs. Adjusting insulin dosing may also be necessary. (See 'Diabetes' below.)

●For medications where precise time intervals are not clinically critical, general strategies to select among include:

•Maintain normal schedule using the time of the patient's home time zone (this is only practical if the trip will be short; easier to do if the patient carries a clock/watch set to “home” time).

•Begin days before departure to adjust medication schedule daily by one or two hours, until medication is taken according to destination’s local time.

•Immediately upon arrival, change schedule so medication is taken according to destination’s local time (may lead to extended delays between doses; not to be used with insulin or any other medication for which time intervals need to be precise). (See 'Diabetes' below.)

Keep medications within reach while on board — Patients should keep all medications within reach on an airplane. Patients should also carry written proof of prescriptions, especially if they need to carry needles or other sharps on board for a medical reason [6].

SPECIFIC PREEXISTING CONDITIONS — Recommendations for specific medical conditions to consider prior to air travel are discussed below. Particular attention should be given to patients with conditions that may worsen with the decreased partial pressure of oxygen during flight, primarily cardiac, pulmonary, and neurovascular conditions. A more detailed description of the cabin environment is found elsewhere. (See "Management of inflight medical events on commercial airlines", section on 'Cabin environment'.)

Cardiovascular — Most patients with well-compensated heart disease can travel without difficulty. Specific recommendations and important precautions for air travel in patients with heart disease are provided separately (see "Approach to patients with heart disease who wish to travel by air or to high altitude"). A variety of practical tips for the cardiopulmonary patient traveling by air are found in the following table (table 1).

Neurologic — Patients who have recently suffered a stroke or other acute neurologic event should be given ample time to recover and demonstrate stability before confronting the stresses of flying. Guidelines from the Aerospace Medical Association (AsMA) advise that patients with stroke should be observed and stable for two to four weeks prior to any air travel [3]. However, this is on the basis of expert opinion rather than explicit evidence. Stable post-stroke patients may travel when considered safe by their neurologist, although we suggest that a minimum two-week period of observation post-stroke, when feasible, is reasonable to assess stability. The guidelines also suggest that patients with frequent or crescendo transient ischemic attacks avoid air travel [3].

Patients with migraines have reported travel in airplanes or trains as triggers of their headaches. The cause is unclear and may relate to the stress of travel, sleep deprivation, high altitude, or other environmental stressors. Patients with migraines, as with other patients, should be advised to maintain their prophylactic medicines and to carry rescue medication with them [7].

Epilepsy is generally not a contraindication to flying; however, patients with frequent seizures (eg, one or more in the prior month) should not fly until their epilepsy is better controlled. Passengers with epilepsy should be counseled about the potential lowered seizure threshold from sleep-related disturbances from air travel (fragmented sleep, circadian rhythm disruption, etc) [3]. (See "Evaluation and management of the first seizure in adults", section on 'Seizure precipitants or triggers'.)

Pulmonary — Patients with clinically significant chronic obstructive pulmonary disease (COPD) or other pulmonary disease can be severely compromised due to the lower partial pressure of oxygen in flight (see "Management of inflight medical events on commercial airlines", section on 'Reduced oxygen'). This can cause hypoxia that may not be tolerated by those with limited pulmonary reserve [8-10]. The clinician must evaluate and determine the degree of respiratory compromise, the ability to tolerate the inflight environment, and whether arrangements should be made for supplemental oxygen (algorithm 1) [11]. A detailed discussion of how to determine the suitability of oxygen dependent patients for air travel, and the how to calculate supplemental oxygen requirements is presented separately. (See "Evaluation of patients for supplemental oxygen during air travel".)

Patients with severe, unstable asthma and those who have been hospitalized for asthma within six weeks should not fly until they are symptom-free on a stable asthma medication regimen [12]. People with asthma who fly should carry on their person a short-acting beta-2 selective adrenergic agonist metered dose inhaler and, for those with severe asthma, a course of oral steroids [3]. (See "Acute exacerbations of asthma in adults: Home and office management" and "Evaluation of patients for supplemental oxygen during air travel", section on 'Access to medications'.)

Patients with cystic fibrosis, bronchiectasis, or comparable lung diseases should be provided with appropriate antibiotics and secretion-clearing medications to be used before and during flight. They should stay well-hydrated and use oxygen in flight, if indicated. (See "Evaluation of patients for supplemental oxygen during air travel", section on 'Patient and disease specific considerations'.)

Traditionally, a pneumothorax is an absolute contraindication to air travel, and how long to wait after resolution varies with the specific clinical situation [12]. Timing of travel in pneumothorax patients is discussed in detail elsewhere. (See "Pneumothorax and air travel".)

Patients with sleep-disordered breathing diagnoses who use continuous positive airway pressure (CPAP) or bilevel PAP (BPAP) who plan to sleep during a flight should be encouraged to bring their home machine onto the flight, and prior to flight should check with the airline about policies and power supply for the machine (battery versus using the airplane’s supply) [13]. (See "Evaluation of patients for supplemental oxygen during air travel", section on 'Traveler resources'.)

Venous thromboembolism — Long-distance travel, either by air or land, confers a small increased risk of venous thromboembolism (VTE). A discussion of factors that increase this risk, as well as interventions to prevent or prophylax against VTE, is presented separately [14]. (See "Prevention of venous thromboembolism in adult travelers".).

There are no studies evaluating risk with airplane travel in patients being treated for acute deep venous thrombosis (DVT) or pulmonary embolism (PE). Patients should consider deferring air travel if they have ongoing symptoms. In addition, some experts recommend delaying travel for two to four weeks after a diagnosis of DVT or PE, although other experts feel that there is no contraindication to air travel once a patient is therapeutically anticoagulated [15]; again, there are no data informing this recommendation.

Pregnancy — Commercial airline travel is generally safe for women with uncomplicated pregnancies. In general, airlines do not impose flight restrictions before 28 weeks gestation; some international airline carriers have restrictions after 28 weeks. United States airlines generally do not prohibit flight at any gestational age for domestic travel but might require a medical certificate if flying near term or for international travel. Pregnant passengers should check with the airline carrier for specific details regarding flying restrictions. Additional information about air travel by pregnant women, including those with complicated pregnancies or underlying disease, is discussed separately. (See "Prenatal care: Patient education, health promotion, and safety of commonly used drugs", section on 'Airline travel'.)

Issues related to Zika virus in pregnant women are discussed separately. (See "Zika virus infection: Evaluation and management of pregnant patients", section on 'Guidance for pregnant patients'.)

Infections

Infections that prohibit travel — The United States prohibits commercial air travel by people who have certain communicable diseases or are reasonably believed to have been exposed to a communicable disease that would be a threat to others (eg, Ebola) [16,17]. Patients are placed on the United States Do Not Board list (DNB) by health care providers who report the patient to state or local public health departments, and by local, state, federal, or international public health agencies. Additional details about federal travel restrictions are available from the Centers for Disease Control and Prevention.

Tuberculosis — Active pulmonary tuberculosis is a contraindication to air travel until there is objective evidence of effective treatment (ie, two consecutive sputum cultures negative for tuberculosis after at least six weeks of incubation) and the patient is clinically stable [18].

COVID-19 — Travel by an individual infected with SARS-CoV-2 potentially exposes others to COVID-19 infection [19,20]. International travelers should consult appropriate airlines and governmental agencies for travel guidance. Prevention of COVID-19 is reviewed elsewhere. (See "COVID-19: Epidemiology, virology, and prevention" and "COVID-19: Infection prevention for persons with SARS-CoV-2 infection".)

Upper respiratory infection and ear barotrauma — An upper respiratory infection (URI), or cold, may cause blockage of the Eustachian tube, making it difficult to equilibrate air pressure in the middle ear during descent. This can lead to a number of problems including pain, vertigo, and tympanic membrane rupture. (See "Acute otitis media in adults", section on 'Otitis media with effusion' and "Ear barotrauma", section on 'Prevention of ear barotrauma'.)

Patients with URIs who cannot avoid flying may benefit from an oral decongestant before the flight and a nasal spray containing a vasoconstrictor used 30 minutes before descent. On very long flights, the oral decongestant may have to be repeated. One randomized controlled trial found that oral pseudoephedrine (120 mg taken at least 30 minutes before departure) reduced barotrauma in adults during flight; no trial has demonstrated the efficacy of nasal decongestants [21,22]. Patients should avoid alcoholic beverages and drink plenty of fluids to ensure hydration and to keep secretions thin and easier to clear. Patients unable to clear their ears prior to flight should not fly due to the risk of developing barotitis or barosinusitis.

Nasal and sinus disease — Commercial air travel is contraindicated for patients with severe sinusitis, large obstructing polyps, recent nasal or facial surgery, or severe recurrent epistaxis. Such conditions can obstruct sinus ostia, preventing pressure equilibration and predisposing to extension of disease into the orbits or central nervous system [3]. For patients with allergic rhinitis, oral antihistamines and nasal steroids may be helpful. (See "Pharmacotherapy of allergic rhinitis".)

Gastrointestinal — Expansion of gas within the colon, with change in atmospheric pressure, can cause isolated abdominal pain. Some authors note that this can be exacerbated by fermenting or gas-producing food, eg, carbonated beverages [1]. Patients with gastrointestinal disease should be made aware of this effect and may choose to avoid carbonated beverages while in flight.

Surgery and procedures — More patients now travel far from home for surgery and fly home soon after their procedure. Patients with significant comorbidities, pulmonary surgery, or postoperative anemia are at greater risk during flight and should be carefully assessed [3,4]. General anesthesia is not usually a concern, but postspinal headache has been reported seven days after a spinal anesthetic, possibly because changes in cabin pressure induced a dural leak [23].

Some surgeries introduce air into body cavities, and this air may expand during air flight and cause barotrauma. Thus, patients should postpone air travel until at least 10 to 14 days after most major surgical procedures [3,24]. This delay should provide enough time for trapped air in the intrathoracic, intraabdominal, or other cavities to be resorbed and reduce this risk. (See "Pneumothorax and air travel".)

Laparoscopic abdominal procedures are less often associated with ileus than open procedures. The carbon dioxide introduced into the peritoneum during the procedure rapidly diffuses into the tissues, and patients can usually fly the next day if they do not have bloating. However, this has not been evaluated in a clinical trial.

Patients who have undergone a colonoscopy, with or without polypectomy, have a large amount of gas in the colon as a result of the procedure. They should wait at least 24 hours before flying to allow elimination of this excess gas. (See "Overview of colonoscopy in adults", section on 'Adverse events'.)

Patients with colostomies are not at increased risk inflight, but increased fecal output resulting from gaseous distention may necessitate a larger bag or frequent bag changes [3].

Ophthalmological conditions — Patients who have had intraocular retinal surgery within eight weeks need to consult with their ophthalmologist before flying, as certain procedures will introduce intraocular gas, which needs to be completely reabsorbed before flight. Complete reabsorption could take up to six to eight weeks, depending on the type of gas used [3]. Flying on a plane with an intraocular gas bubble in the eye will result in sudden expansion of the bubble, which can result in increased intraocular pressure and possible blindness.

Patients with glaucoma can safely travel if their disease is reasonably controlled and they have access to use their medications as directed, including during flight. Eye drops for glaucoma should be used according to the patient’s normal schedule.

Fractures — Patients with full-leg casts may be required, for safety reasons, to travel by stretcher, purchase an extra seat, or fly business or first class. Casts applied within 48 hours should be split lengthwise along each side (ie, bivalved) to avoid injury from the expansion of air trapped between the skin and the cast if the limb swells [3]. Pneumatic splints should be partially deflated to avoid rupture from expanding gas or excessive compression of the affected limb.

Patients with a fractured jaw that is wired require travel with wire cutters and an escort familiar with what to do, unless the individual is fitted with self-quick-release wiring. Emergency release of wires may be needed in the event of a compromised airway. Due to security requirements, a patient needing to carry wire cutters should get clearance from the airline in advance.

Anemia — Patients with hemoglobin below 8.5 g/dL generally should be given supplemental oxygen, unless the anemia is known to be well-compensated. Anemic patients are at risk for lightheadedness and loss of consciousness during flight, even with minimal exertion, eg, walking to the lavatory [3].

The subject of air travel in people with sickle cell disease is discussed separately. (See "Overview of the management and prognosis of sickle cell disease", section on 'Travel advice'.)

SCUBA diving and decompression sickness — A person who has recently been SCUBA diving is at increased risk for developing decompression sickness (DCS) inflight. Prevention and symptoms of DCS are discussed separately. (See "Complications of SCUBA diving", section on 'Decompression sickness'.)

Diabetes — Diabetic patients generally tolerate travel without difficulty. Wearing a medical alert bracelet is recommended. Preflight planning is important to ensure ready access to simple sugars and to the patient’s diabetes medications, especially if they include insulin, and to adjust insulin and some other diabetes medication dosing schedules [3]. (See 'Timing of medications' above.)

As a general rule, when traveling east among time zones, the day is shortened and less insulin may be needed during the actual travel period; when traveling west among time zones, the day is lengthened and more insulin may be needed during the actual travel period.

Clinicians should emphasize the importance of carrying one’s own supply of glucose-raising treatments (eg, snacks), since regular meal ingestion and access to food may be limited during travel. Patients who require insulin should carry insulin with all necessary equipment in carry-on baggage when flying. It is also important for patients to know that insulin will denature if exposed to extreme cold and should not be checked as baggage. According to the American Diabetes Association, unrefrigerated insulin remains usable for up to one month if kept at temperatures below 30˚C (86˚F).

Mental illness — Patients with psychiatric disorders that predispose to violent, disruptive, unsafe, or unpredictable behavior should not travel by air, nor should patients at risk for alcohol or drug withdrawal. Help for patients with phobias or fears related to flying is discussed elsewhere. (See "Specific phobia in adults: Treatment overview" and "Specific phobia in adults: Cognitive-behavioral therapy".)

RESOURCES FOR CLINICIANS — The Aerospace Medical Association (AsMA) can provide support for medical information. They provide links to many national and international aerospace medical organizations. Also, websites for individual airlines may provide a section with useful information about resources and procedures to assist passengers with medical conditions.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Management of inflight medical events".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Beyond the Basics topics (see "Patient education: Supplemental oxygen on commercial airlines (Beyond the Basics)" and "Patient education: General travel advice (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Travel for patients taking medication(s) – Patients preparing for air travel should be counseled on adjusting the timing of their medicines. Patients should carry on their person (not checked with baggage) all their medications in their original labeled containers and any monitoring equipment necessary for their medications. They should also carry a list of medications, medical conditions and allergies, and a recent electrocardiogram (ECG) for cardiac patients. (See 'Medications' above.)

●Travel with pre-existing medical conditions

•Cardiovascular disease – Most patients with well-compensated heart disease can travel without difficulty. A variety of practical tips for the cardiopulmonary patient traveling by air are found in the following table (table 1). A discussion of air travel for patients with heart disease is presented separately. (See 'Cardiovascular' above and "Approach to patients with heart disease who wish to travel by air or to high altitude", section on 'Air travel'.)

•Stroke – Patients who have had a stroke should be observed for stability prior to travel. We advise a minimum two-week period for this observation; earlier travel may be reasonable for stable patients at the discretion of their neurologist. (See 'Neurologic' above.)

•Pulmonary disease – Patients with clinically significant chronic obstructive pulmonary disease (COPD) or other pulmonary or cardiopulmonary disease can be severely compromised by the decreased availability of oxygen in the air at higher altitudes that occurs aboard commercial flights and should be evaluated for the need for supplemental oxygen (algorithm 1). Other pulmonary contraindications to flight include severe, unstable asthma, or asthma that required hospitalization within six weeks, and incompletely resolved pneumothorax. (See 'Pulmonary' above and "Evaluation of patients for supplemental oxygen during air travel".)

•Risk of venous thromboembolism – Long-distance travel, either by air or land, confers a small increased risk of venous thromboembolism (VTE). A discussion of factors that increase this risk, as well as interventions to prevent or reduce the risk of VTE, is presented separately (table 1). (See "Prevention of venous thromboembolism in adult travelers".)

•Pregnancy – Pregnant passengers should check with the airline carrier for specific details regarding flying restrictions. Pregnancy and air travel are discussed separately. (See 'Pregnancy' above and "Prenatal care: Patient education, health promotion, and safety of commonly used drugs", section on 'Airline travel'.)

•Infectious diseases

-Patients with certain communicable diseases or who are reasonably believed to have been exposed to a communicable disease that would be a threat to others (eg, Ebola) are prohibited from flying. Active pulmonary tuberculosis is a contraindication to air travel until there is objective evidence of effective treatment. (See 'Infections that prohibit travel' above and 'Tuberculosis' above.)

-Travel by an individual infected with SARS-CoV-2 potentially exposes others to COVID-19 infection. Guidance continues to evolve and should be referenced prior to travel. (See 'COVID-19' above.)

-Patients with upper respiratory infections (URIs) who cannot avoid flying may benefit from an oral decongestant taken before flight and a nasal spray containing a vasoconstrictor used 30 minutes before descent. Air travel is contraindicated for patients with severe sinusitis, recent facial surgery, or recurrent severe epistaxis. (See 'Upper respiratory infection and ear barotrauma' above and 'Nasal and sinus disease' above.)

•Post-surgical – Patients should postpone air travel until at least 10 to 14 days after most open surgical procedures. This delay should provide enough time for air in the intrathoracic, intraabdominal, or other cavities to be resorbed and reduces the risk for barotrauma. Patients who have undergone a colonoscopy should wait at least 24 hours before flying. Patients who have had intraocular retinal surgery within eight weeks need to consult with their ophthalmologist before flying. (See 'Surgery and procedures' above.)

•Severe anemia – Patients with hemoglobin below 8.5 g/dL generally should be given supplemental oxygen unless the anemia is known to be well-compensated. (See 'Anemia' above.)

•SCUBA divers – A person who has recently been SCUBA diving is at increased risk for developing decompression sickness (DCS) inflight. Prevention and symptoms of DCS are discussed separately. (See "Complications of SCUBA diving", section on 'Decompression sickness'.)

ACKNOWLEDGMENT — The editorial staff at UpToDate acknowledge Matthew Prout, MD, Jeffrey Pine, MD, Paulo Alves, MD, and Melissa Mattison, MD, who contributed to an earlier version of this topic review.