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  1. Air Travel and Lung Diseases Dr. Levent Tabak

  2. Epidemiology • 1-2 billion passenger/year • Increase in numbers expected • Older passengers • 5% ambulatory passengers • Moderate hypoxemia is generally well tolerated in Alpins Managing passengers with respiratory disease planning air travel: British Thoracic Society recommendations. Thorax 2002; 57: 289-304

  3. Airplane Travel-Disease • Cardiac diseases • Respiratory diseases • Diabetes • Pregnancy • Sickle cell anemia • Colostomi • Contact lense • Mental disorders

  4. How big is the problem? • In-flight deaths 0.31x10-6 • Cardiopulmonary • Neurologic Cummins, R. O., P. J. C. Chapman, D. A. Chamberlain, J. A. Schubach, and P. E. Litwin. In-flight deaths during commercial air travel: how big is the problem? J.A.M.A.1988; 259: 1983-1988 • 1977-1984, 120 airlines • 577deaths (72 / per year) • 399/577 (77%) reported no health problems • 253/399 sudden cardiac deaths • 8500 telefon başvurusu, %11 solunum problemi

  5. Environment Differences • Low pressure, low PaO2 • Noise, vibration, turbulans • Bad air quality, different circulation • Heat,low humidity (2% vs 50%) • Body circadian rhtym difference • Immobilization • Low dose radiation exposure

  6. Atmosphere Gas Composition

  7. Barometric and Gas Pressure

  8. BAROMETRIC PRESSURE AND O2 PARTIAL PRESSURE Altitude Pressure PAO2 PaO2 meter feet mmHg mmHg mmHg Deniz 0 760 149 98 1000 3281 674 131 81 2000 6562 596 115 75 2438 8000 560 105 65 3000 9843 526 95 55 4000 13123 462 87 47 5000 16404 405 75 45

  9. Physiology • Cabin pressure 8000 ft (2438 m) • Concorde 6000 ft (1829 m) • Sea Level %21 147-CO2X1.2 90-100 • Cabin %15 105-CO2X1.2 55-65 %17 ! • Compansation: hyperventilation, tachycardia

  10. Conditions Adversely Affected by Hypoxia •     •    Acute bronchospasm    •    Cyanosis    •    Dyspnea at rest or during exercise    •    Pneumonia or acute upper respiratory tract infection    •    Pulmonary hypertension, with or without cor pulmonale    •    Severe anemia (hemoglobin < 7.5 g/dL)    •    Unstable, coexisting cardiac disorders such as arrhythmias, angina pectoris, and myocardial infarction within the previous 3 to 4 weeks

  11. Conditions Adversely Affected by Pressure Changes • Thoracic surgery in the preceding 3 weeks •    Noncommunicating lung cysts •    Otitis media, sinusitis, or recent middle-ear surgery •    Pneumothorax or pneumomediastinum •    Inadequate pulmonary function Diffusing capacity <50% of predicted Vital capacity <50% of predicted             Hypercapnia (PaCO2 >50 mm Hg)            Hypoxemia breathing room air (PaO2 <50 mm Hg)

  12. The following groups should be assessed: • Pulmonary tuberculosis; [C] • Severe COPD or asthma; [B] • Severe restrictive disease (including chest wall and respiratory muscle disease), especially with hypoxemia and/or hypercapnia; [C] • Patients with cystic fibrosis; [C] • History of air travel intolerance with respiratory symptoms (dyspnea, chest pain, confusion or syncope); [C] • Co-morbidity with other conditions worsened by hypoxemia (cerebrovascular or coronary artery disease, heart failure); [C] • Pre-existing requirement for oxygen or ventilator support. [C] • Within 6 w’s of hospital discharge for acute respiratory illness; [C] • Risk of or previous venous thromboembolism; [B] • Recent pneumothorax; [B] Managing passengers with respiratory disease planning air travel: British Thoracic Society recommendations. Thorax 2002; 57: 289-304

  13. Airplane Flight and Tuberculosis • Driver CR et al. Transmission of M. tuberculosis associated with air travel.Journal of the American Medical Association, 1994, 272: 1031–1035. . • McFarland JW et al. Exposure to Mycobacterium tuberculosis during air travel.Lancet, 1993, 342:112–113. • Exposure of passengers and flight crew to Mycobacterium Tuberculosis on commercial aircraft, 1992–1995. Morbidity and Mortality Weekly Report, 1995, 44:137–140. • Miller MA, Valway SE, Onorato IM..Tuberculosis risk after exposure on airplanes. Tubercle and Lung Disease, 1996, 77:414–419. • Kenyon TA et al. Transmission of multidrug-resistant Mycobacterium tuberculosis during a long airplane flight. New England Journal of Medicine, 1996, 334:933–938.

  14. However, of the 257 persons who traveled from Chicago to Honolulu (8 hours, 38 minutes), TSTs were positive in 15 (6%), including six who had converted; two of these six persons apparently had a boosted immune response, while the other four had been seated in the same section of the plane as the index patient. • Because of TST conversions among U.S.-born passengers, the investigation indicated that passenger-to-passenger transmission of M. tuberculosis probably had occurred.

  15. Experts Disagree on Whether TB Patient Needed to Be IsolatedBy Steven Reinberg, New York City; May 30, 2007HealthDay Reporter • A leading tuberculosis expert believes U.S. health officials were right to quarantine a Georgia man with a dangerous form of the respiratory disease who took two trans-Atlantic flights, possibly infecting fellow passengers in the process. Tawanda Gumbo, M.D., assistant professor of internal medicine, University of Texas • But a second TB expert said the U.S. Centers for Disease Control and Prevention's decision to isolate the man in an Atlanta hospital was unwarranted, contending that the man is "minimally infectious.“ Dr. Martin Cetron, the CDC's director of the Division of Global Migration and Quarantine

  16. WHO/HTM/TB/2006.363 • There is evidence that transmission of Mycobacterium Tuberculosis infection may occur during long flights from an infectious source (a passenger or crew with infectious pulmonary or laryngeal TB) to other passengers or crew members. • However, no case of clinical or bacteriologically confirmed TB disease has been identified as a result of air travel-related exposure during flight.

  17. Infectivity Grade • 0 = Negligible Infectivity Extrapulmonary disease • 1 = Low Infectivity Smear and culture negative pulmonary disease • 2 = Medium Infectivity Smear negative, culture positive pulmonary disease • 3 = High Infectivity Smear positive, culture positive pulmonary disease or culture positive, cavitating pulmonary disease or culture positive laryngeal disease Tuberculosis - air travel for patients with TB guidelines for GPs

  18. Tuberculosis • "Transmission in an airplane is very unlikely, owing to the intrinsic difficulty of transmitting TB and to the relatively high rate of filtration of airplane cabin air," • The risk of transmission is considered to be very low; however, we cannot say definitively that the risk is zero and therefore we are undertaking certain public health measures,"

  19. The following groups should be assessed: • Pulmonary tuberculosis; [C] • Severe COPD or asthma; [B] • Severe restrictive disease (including chest wall and respiratory muscle disease), especially with hypoxemia and/or hypercapnia; [C] • Patients with cystic fibrosis; [C] • History of air travel intolerance with respiratory symptoms (dyspnea, chest pain, confusion or syncope); [C] • Co-morbidity with other conditions worsened by hypoxemia (cerebrovascular or coronary artery disease, heart failure); [C] • Pre-existing requirement for oxygen or ventilator support. [C] • Within 6 w’s of hospital discharge for acute respiratory illness; [C] • Risk of or previous venous thromboembolism; [B] • Recent pneumothorax; [B] Managing passengers with respiratory disease planning air travel: British Thoracic Society recommendations. Thorax 2002; 57: 289-304

  20. Equations used for the calculation of PaO2 (Alt) • PaO2 (Alt) (mmHg) = 0.410 x PaO2 (ground) (mmHg) + 1.7652 • PaO2 (Alt) (mmHg) = 0.519 x PaO2 (ground) (mmHg) + 11.855 FEV1 (l) – 1.760 • PaO2 (Alt) (mmHg) = 0.453 x PaO2 (ground) (mmHg) + 0.386 x (FEV1%) + 2.44 • PaO2 (Alt) (mmHg) = 22.8 – (2.74 x altitude in thousands of feet) + 0.68 x PaO2 (ground) (mmHg).

  21. The following assessment is recommended • History and examination with particular reference to cardiorespiratory disease, dyspnea, and previous flying experience; [C] • Spirometric tests (in non-tuberculous patients only); [C] • Measurement of SaO2 by pulse oximetry. ABG's are preferred if hypercapnia is known or suspected. [C] • In those who are screened who have resting SL oximetry between 92% and 95% with additional risk factors, HIT is recommended. [C] Managing passengers with respiratory disease planning air travel: British Thoracic Society recommendations. Thorax 2002; 57: 289-304

  22. COPD inadequate adaptation • Imparied hyperventilation • mechanically impaired; muscle fatique • diminished hypoxic ventilatory drive • Co-morbid diseases • Anemia • Carboxyhemoglobinemia • Sleep • exercise, and the ingestion of alcohol • cardiac dysfunction • pulmonary hypertension

  23. Aircraft cabin simulation—still the only indication of in-flight oxygenation • Predictive equations have been proposed as a simpler alternative to hypoxic challenge testing (HCT) for determining the risk of in-flight hypoxia. • The results suggest that the use of these prediction equations will overestimate in-flight hypoxaemia and will lead to an over-prescription of supplemental oxygen. Martin SE, Buick JB, Bradbury I, Elborn JS. Flight assessment in patients with respiratory disease: hypoxic challenge testing vs predictive equations. QJM 2007;100:361–7

  24. Hypoxic Challange Test • Hypoxic Inhalation Test (HIT) • breathe 15.1%O2 • high flow nitrogen is administered through a 35% ventimask • Cabin simulation • Special chamber with low pressure

  25. Stable COPD • Hypoxaemia in chronic obstructive pulmonary disease patients during a commercial flight • A. Akerø, C. C. Christensen, A. Edvardsen, O. H. Skjønsberg • Eur Respir J 2005; 25:725-730 • 18 COPD patient with O2SAT>94% • Stable except one, decrease during exercise • >4 hour decrease in CO2, cardiac frequency increase, respiratory fatigue !

  26. Air Travel and Lung Disease: Current Guidelines Are InappropriateEUROPEAN RESPIRATORY JOURNAL , Vol. 25, No 4 2005 • For the first time, patients suffering from chronic obstructive pulmonary disease (COPD), were studied during a commercial flight lasting almost six hours. Their blood oxygen content underwent a considerable reduction, more marked than could have been predicted using the currently accepted guidelines. However, the oxygen reduction was generally well tolerated by those subjects who, prior to departure, had a blood oxygen content equal to or greater than the recommended pre-flight value. • A German team, whose study also appears in April's ERJ, conducted similar experiments on patients with cystic fibrosis. They conclude that these patients can also travel on flights of several hours' duration without excessive risk.

  27. Is air travel safe for those with lung disease?R. K. Coker, R. J. Shiner and M. R. PartridgeEur Respir J 2007; 30:1057-1063 • In total, 616 patients were recruited. Of these, 500 (81%) returned questionnaires. The most common diagnoses were airway (54%) and diffuse parenchymal lung disease (23%). • Pre-flight assessment included oximetry (96%), spirometry (95%), hypoxic challenge (45%) and walk test (10%). • In those who flew, unscheduled respiratory healthcare use increased from 9% in the 4 weeks prior to travel to 19% in the 4 weeks after travel. • However, when compared with self-reported data during the preceding year, medical consultations increased by just 2%.

  28. Effect of simulated commercial flight on oxygenation in patients with interstitial lung disease and chronic obstructive pulmonary disease L M Seccombe, P T Kelly, C K Wong, P G Rogers, S Lim, M J PetersThorax 2004;59:966-970 • Even in the presence of acceptable arterial blood gas tensions at sea level, subjects with both ILD and COPD fall below recommended levels of oxygenation when cabin altitude is simulated. This is exacerbated by minimal exercise. Resting sea level arterial blood gas tensions are similarly poor in both COPD and ILD for predicting the response to simulated cabin altitude.

  29. Airplane-Supplemental O2 *Additional risk factors: hypercapnia; FEV1 <50% predicted; lung cancer; restrictive lung disease involving the parenchyma (fibrosis,) chest wall (kyphoscoliosis) or respiratory muscles; ventilator support; cerebrovascular or cardiac disease; within 6 weeks of discharge for an exacerbation of chronic lung or cardiac disease.

  30. Interaction with the physician • Determine whether a need for in-flight oxygen exists. • Get multiple copies of a letter describing the respiratory condition, the liter flow and duration of in-flight oxygen needed, and medication prescriptions. • Consider an emergency supply of antibiotics and corticosteroids. • Ascertain the names of physicians en route and at the destination

  31. Interaction with the airline/travel agent • Notify the airline of the need for oxygen at least 48 hours  before the flight • MEDIF form • Fly nonstop, if possible. • Travel during business hours so vendor personnel will be available • Try to be seated near a restroom during the flight. • Prearrange wheelchair on boarding

  32. The following groups should be assessed: • Pulmonary tuberculosis; [C] • Severe COPD or asthma; [B] • Severe restrictive disease (including chest wall and respiratory muscle disease), especially with hypoxemia and/or hypercapnia; [C] • Patients with cystic fibrosis; [C] • History of air travel intolerance with respiratory symptoms (dyspnea, chest pain, confusion or syncope); [C] • Co-morbidity with other conditions worsened by hypoxemia (cerebrovascular or coronary artery disease, heart failure); [C] • Pre-existing requirement for oxygen or ventilator support. [C] • Within 6 w’s of hospital discharge for acute respiratory illness; [C] • Risk of or previous venous thromboembolism; [B] • Recent pneumothorax; [B] Managing passengers with respiratory disease planning air travel: British Thoracic Society recommendations. Thorax 2002; 57: 289-304

  33. Severe Pulmonary Embolism Associated with Air TravelNEJM 2001;345:779-783 • BackgroundAir travel is believed to be a risk factor for pulmonary embolism, but the relation between pulmonary embolism and distance flown has not been documented. The aim of this study was to investigate whether the duration of air travel is related to the risk of pulmonary embolism. • MethodsFrom November 1993 to December 2000, we systematically reviewed all cases of pulmonary embolism requiring medical care on arrival at France's busiest international airport. • Results • A total of 135.29 million passengers from 145 countries • 56 had confirmed pulmonary embolism. • The incidence of pulmonary embolism • 0.01/milyon < 5000 km • 1.5/milyon > 5000 km • 4.8/milyon > 10.000 km • Conclusions A greater distance traveled is a significant contributing risk factor for pulmonary embolism associated with air travel

  34. Pelvic Surgery and PE • Fatal Acute Pulmonary Embolism in a Patient with Pelvic Lipomatosis After Surgery Performed After Transatlantic Airplane Travel • Gajic O, Sprung J, Hall BA, Lightner DJ. • *Division of Pulmonary and Critical Care Medicine, Mayo

  35. Long Airplane Flight Does Not Appear To Increase Risk Of Blood ClotsScienceDaily (May 17, 2006) • — Researchers simulating conditions of reduced cabin pressure and reduced oxygen levels, such as may be encountered during an 8-hour airplane flight, found no increase in the activation of the blood clotting system among healthy individuals, according to a study in the May 17 issue of JAMA.

  36. Blood clot risk doubles after four-hour plane tripLaura MacInnis ,  ReutersPublished: Friday, June 29, 2007 • GENEVA - The chances of developing deep vein thrombosis double after traveling for four hours or more, the World Health Organization (WHO) said on Friday in a study estimating one in 6,000 long-haul passengers is at risk. • Tall people whose legs are jammed in economy class and the very short whose feet do not touch the ground are particularly vulnerable to potentially dangerous blood clots linked to immobility during travel, the United Nations agency said. • The obese, women on birth control pills and those with blood clotting disorders are also more susceptible, as are frequent travelers and those who take very long journeys.

  37. Risk FactorsFor Clotthing • Adults over 40 years old • History of cancer • Pregnancy (especially during third trimester and first post-partum month) • Heart failure • Recent surgery (within 4 weeks) • Airplane travel (longer than 4 hours) • Immobilization (longer than 3 days) • Estrogen contraceptives and/or hormone replacement therapy (HRT) • Obesity • Smoking • Broken leg with cast • Prior history of coagulation disorder

  38. Tests for Detecting Hereditary Hypercoagulable States • Genetic tests: Factor V Leiden (Activated protein C resistance) Prothrombin gen mutation (G20210A) • Antithrombin activity • Protein C activity • Protein S activity • Starvation plasma homosistein level • Anticardiyolipin antibodies (ACA) • Lupus anticoagulants • Hyperhomosisteinemi • Heparine antibodies

  39. Prevention while Traveling: • Do frequent leg and full-body exercises. • Point foot upward, clench toes and hold. • Stand on one foot while on the heel of the other • While sitting, flex your foot up and down, • Keep your legs uncrossed while seated. • Choose a seat with more room. • Prefer the inside seat to move • Fly business class for extra room and comfort.

  40. Venous Thromboembolism • Low risk • >40 yrs, obesity, varicose veins, polisitemia, minor surg(72 hours) • Rx; exercise,anti-embolic socks, sleep medicine-alkol-kafein Ø • Moderate risk • Family history, MI,Pregnancy , OKS, paralisis of lower ekst /Trauma • Rx; anti-embolic socks, aspirin • High risk • Past history of VTE, trombofili, stroke, malignancy • Rx; aspirin, coumadin, LMWH

  41. The following groups should be assessed: • Pulmonary tuberculosis; [C] • Severe COPD or asthma; [B] • Severe restrictive disease (including chest wall and respiratory muscle disease), especially with hypoxemia and/or hypercapnia; [C] • Patients with cystic fibrosis; [C] • History of air travel intolerance with respiratory symptoms (dyspnea, chest pain, confusion or syncope); [C] • Co-morbidity with other conditions worsened by hypoxemia (cerebrovascular or coronary artery disease, heart failure); [C] • Pre-existing requirement for oxygen or ventilator support. [C] • Within 6 w’s of hospital discharge for acute respiratory illness; [C] • Risk of or previous venous thromboembolism; [B] • Recent pneumothorax; [B] Managing passengers with respiratory disease planning air travel: British Thoracic Society recommendations. Thorax 2002; 57: 289-304

  42. Pneumothorax • Px increase with decreasing pressure • Recent Px and bullous disease should not fly • Wait 6 weeks after Px surgery • Wait 1 year; secondary Px

  43. Air Embolism • Fatal Air Embolism in an Airplane Passenger with a Giant Intrapulmonary Bronchogenic Cyst • Am. J. Respir. Crit. Care Med., Volume 157, Number 5, May 1998, 1686-1689

  44. Intrapulmonary Bronchogenic Cyst and Cerebral Gas Embolism in an Aircraft Flight Passenger*Almeida FA, DeSouza BX, Meyer T, Gregory S, Greenspon L.Chest. 2006;130:575-577.) • Because of the unpredictable long-term prognosis of bronchogenic cysts in adults, these cysts should be surgically resected in every operable candidate • In patients who are not candidates for surgical resection or who decline surgery for treatment of their cysts should be cautioned to abstain from activities leading to considerable changes in ambient pressure, such as flying, diving, or high-altitude climbing.

  45. Fly Jet Lag FreeNew Jetliner Technology Emphasizes Human Factors • February 1, 2007 — The new Boeing 787 Dreamliner will be the first of a new generation of commercial aircraft provided with a number of new technologies to increase comfort and reduce jet-lag. Human-factors engineers have designed LED lighting that can fade slowly to help passengers set their sleep cycles, and better filtration technology for cleaner air. Recreating conditions closer to those at sea level, cabin pressure will be higher and the air will have higher humidity.

  46. Preflight Screening • However, in view of the huge costs and the minimal benefit, rigorous screening for pre-existing lung pathologies in the growing mass of commercial air travelers is neither reasonable nor practicable. Pre-flight screening may only be indicated in ill individuals • Gong H.Jr., Mark JA. L,Cowan MN.Preflight medical screenings of patients: analysis of health and flight characteristics. Chest 1993 ;104: 788-794