Dr. Yousuf Al Kaabi Family Medicine resident Oman Medical Specialty Board - Are you fit to fly

Are you fit to fly ?????????????

 Dr. Yousuf Al Kaabi Family Medicine resident
           Oman Medical Specialty Board

   Physiology during flight

   Basic considerations

   Cardiovascular disease

   Deep vein thrombosis

   Respiratory disease

   Pregnancy

   Infants and children

   Anaemia

   Ear, nose and throat problems

   Postsurgical patients

   Diabetes mellitus

   Every year 2 billion people fly

   Cheap travel started 30 years ago

   40-50 yr olds now 70-80 yrs

   Older people have more disposable income

   Families spread round globe

   Sick and disabled want to fly too

   Cabin pressure decreases from 100kPa to
    75kPa

   Gas expands as pressure fall

   Oxygen pressure falls

   Air drawn from outside aircraft

   Air is cold

   Very little moisture – dry eyes etc

   Seats tightly packed

   Immobility

   Cramped seating

   Spread of ariborne diseases

   Flights over large oceans no where to divert
    to

   Medical kit limited

   No Doctor

   Difficult environment to cope with medical
    emergency

   Aircraft are not pressurised to sea level
    equivalent. which means that there is a
    reduction in the partial pressure of alveolar
    oxygen (PaO2).


    Sometimes during flight oxygen saturation
    levels can fall to around 90% which can be
    tolerated by normal individual but not by
    someone with cardiac or respiratory conditions
    or with anaemia.

   Reduced pressure in the cabin can cause gas
    volume expansion.


   This can cause a problem in pt with recent
    surgery that has introduced gas into the
    abdominal cavity or the eye. Gas can also
    expand if it has been trapped in the ear.

1.   The effect of mild hypoxia and decreased air
     pressure in the cabin.
2.   The effect of immobility.
3.   The ability to adopt the brace position in
     emergency landing.

4.   The timing of regular medication for long- flight

5.   The ability of the patient to cope mentally and
     physically with travel to and through the airport
     to reach the flight and on disembarkation.

6.   Will the patient's medical condition adversely
     affect the comfort or safety of the other
     passengers and the operation of the aircraft?

1.   Uncomplicated myocardial infarction (MI) within 7 days.
2.   Complicated MI within 4-6 weeks.
3.   angioplasty with stent placement within 5 days
4.   Coronary artery bypass graft within 10 days.
5.   Cerebrovascular accident within 10 days

individual assessment is needed after that to ensure fitness
    and stability.

   Unstable angina.

   Decompensated congestive cardiac failure.

   Uncontrolled hypertension.

   Uncontrolled cardiac arrhythmia.

   Severe symptomatic valvular heart disease.

1.   Need for oxygen at baseline altitude.
2.   Heart failure - New York Heart Association's
     (NYHA) Class III-IV or baseline PaO2

   Patients with pacemakers and implantable
    cardioverter defibrillators


   can fly once medically stable.

   WHO study : WRIGHT ( WHO research into
    global hazards of travel)

    1.   The risk of DVT approximately doubles after a long-
         flight (>4 hours) and increases with the duration of
         the travel and with multiple flights within a short
         period.

    2. The cause of the increase risk is immobilisation

    3.   The risk also increases with other risk factors for
         DVT (obesity, use of oral contraceptives and the
         presence of prothrombotic blood abnormalities).

    It is wise for anyone undertaking a long- flight
     to take precautions, such as to:

1.    Remain adequately hydrated.
2.    Exercise the calves.
3.    Spend periods out of their seat.
4.    Avoid excess alcohol.
5.    Avoid tight-fitting socks or stockings.
6.    Perhaps use graduated compression
      stockings

   Pt with DVT, doing well on warfarin , can fly
    after 10 to 14 days

   Pts breathless at rest should not fly without
    oxygen.

   A simple fitness-to-fly test is the ability of a
    patient to walk 50 metres unaided at a normal
    pace, or to ascend one flight of stairs, without
    becoming severely dyspnoeic. However, there is
    no evidence base to support this test.

   If a person's oxygen saturation is => 95%, no
    need oxygen for flying

   Pts with an active exacerbation of respiratory
    disease or active respiratory infection such as
    pneumonia, should wait until their respiratory
    condition has improved, before flying


   severe or complex cases, referral indicated

   Untreated pneumothorax is an absolute
    contra-indication to air travel. Pts can travel
    two weeks after effective treatment,
    provided there has been full expansion of the
    lung.

   Patients with stable asthma should be able to
    fly with no problems. However, they should
    keep their medication to hand.

   Most airlines prohibit travel after the end of
    the 36th week in uncomplicated singleton
    pregnancies. Because of increasing risk of
    premature labor


   Pts with complicated pregnancies or with a
    history of premature delivery should not
    travel after 32 weeks.1

   The risk of increased exposure to cosmic
    ionising radiation for the fetus is not thought
    to be significant, but is unquantifiable and
    must be taken at the mother's discretion. The
    risk may be increased if flying several times a
    week.

   Postpartum , she can travel after 7 to 10 days

   Advises is to wait 1 week after birth before
    flying to ensure the infant is healthy.


   Infants born prematurely who have had
    complications should not fly under the age of 6
    months post-expected date of delivery.


   Infants with a history of neonatal respiratory
    illness and children with chronic lung disease
    should referred

   Patients with a haemoglobin

   Active middle-ear infections, effusions, or
    recent ear surgery are contra-indications to
    flying unless the patient is cleared fit by
    (ENT) specialist.


   Acute sinusitis, large nasal polyps and recent
    nasal surgery are relative contra-indications.

   Patients should not fly for 10 days following
    abdominal surgery.

   Flying is not advised for 24 hours after a
    colonoscopy or laparoscopy.

   Patients with colostomies may need to use a
    larger bag as intestinal distension during the
    flight may increase faecal output.

   Air travel should be avoided for 7 days following
    neurosurgery due to the possibility of residual
    gas being trapped in the skull.

   Patients operated for retinal detachment
    should not travel for 2-6 weeks


   But patients can travel after one week from
    other ophthalmological procedures or
    penetrating eye trauma.

   Patients should wait for 24 hours following
    application of a plaster cast, for flights of less
    than 2 hours and for 48 hours on longer
    flights because air may be trapped beneath
    the cast.


   If urgent travel is necessary, a bi-valved
    plaster cast can be used.

   There are no restrictions on flying with well-
    controlled diabetes.


   Insulin-dependent diabetics are normally
    required to have a letter of authorisation
    from their doctor to allow carriage of needles
    in their hand luggage.


   Insulin should be carried in a cool bag

   Insulin dosing regimens on long- flights, depending on
    the direction of travel and movement across time
    zones. Advice from a diabetes specialist may be
    needed. However, as a general rule:

    
 When travelling east and if more than 2 hours are lost, it
      may be necessary to take fewer units with intermediate or
      long-acting insulin.

    
 When travelling west and the day is extended by more
      than 2 hours, supplemental short-acting insulin, or an
      increased dose of intermediate-acting insulin may be
      needed.