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Travel with Chronic Medical Conditions
In addition to travel by rail, ship, and automobile, almost 2 billion people travel by air annually. It is generally expected that primary care providers as well as travel medicine clinic personnel will identify individuals who are unfit for air travel and provide them with advice. Studies show that more than 95% of travelers with health problems who travel by air would like to receive additional medical advice from their providers prior to travel. The age of travelers is ever increasing as the population ages. Currently in the United States 14% of people are over 65 years of age. A recent Swiss study, by , reported that 10% of visits to a travel medicine clinic for pre-travel advice were made by travelers over the age of 60; 40% of these travelers reported a chronic medical condition.
It is important for the elderly traveler or those with chronic medical conditions to consider factors such as access to medical care, the possible increased demands for aerobic exercise, changes in diet, availability of medical supplies, and the effects of altitude when planning a trip to a foreign destination; thus, advance planning is essential for persons in this category of travelers. Another factor that could make a significant difference in the success of a journey is the ability to travel with a companion. The traveling companion need not be medically trained but could provide invaluable help in getting professional assistance should an urgent medical need arise. There are also commercial companies, such as Accessible Journeys, that maintain a directory of healthcare professionals willing to use vacation time from their jobs to accompany a traveler. It is important to advise the traveler to check the professional credentials and references of travel companion programs. A website that features a number of companies and travel agents that can assist with special travel services is www.disabledtravelers.com . Additionally, the US Transportation Security Administration (TSA) has a website that offers helpful information for travelers with medical conditions, as well as a TSA Cares Help Line. They advise that callers call at least 72 hours prior to travel, thus allowing the TSA Customer Service Manager advance notice that a specific traveler may need assistance. This information can be found at www.tsa.gov/traveler-information/travelers-disabilities-and-medical-conditions .
There are many remote areas of the world where medical care may be hours or days away from a traveler stricken by illness or complications of a pre-existing condition. If an elderly individual or one with a chronic disease is very stressed by the thought of remote travel and lack of access to care, it may be justified to counsel that traveler to adjust his or her itinerary to one that includes the availability of adequate medical care. The traveler with chronic medical conditions has to consider whether the anticipated benefits of the planned travel experience are worth the potential health risks associated with a given itinerary. This said, travel can be an extremely rewarding and confidence-building exercise for those limited by a chronic condition. The clinician advising the traveler must take into account the positive impact travel can have on an individual's sense of well-being while being realistic and practical when providing travel advice. The clinician advising the elderly traveler should recognize that the aging process brings with it changes that necessitate careful planning prior to travel. For example, it is prudent to advise the elderly traveler to get a thorough dental exam prior to embarking on a long trip. More than 50% of people will develop hypertension by the age of 65. Muscles begin to atrophy after the age of 40, and by the age of 80, one has lost between one-quarter and one-half of one's muscle mass. When advising the traveler at the far end of the lifespan on appropriate travel itineraries, their current state of health should be kept in mind; whether the individual has been relatively healthy or an infrequent user of health services, he or she may have underlying issues that could impact health without being aware of these based on the aging process alone. Aging can lead to immunosenescence, which impairs the host's ability to develop adequate immune responses to vaccines. Additionally, for the same reason teeth and bones are at risk due to lack of mineralization. Lack of bone mass, or osteopenia, is a major risk factor for fractures. A fracture on a trip can certainly ruin a trip, prolong disability for many months, and be a lifelong affliction in the elderly. Advise the elderly traveler to have a bone scan and assessment of risk for osteoporosis, and make recommendations based on the study. There is little we can do medically to slow the aging process, so prudent thought should go into the advice one gives elderly travelers, who may not readily want to admit their limitations or, indeed, may not even know they have them. On the other hand, research by reveals that because elderly travels tend to comply with health recommendations and are more careful about health-risk behaviors such as eating street food or drinking open drinks while abroad, their risk for illness during travel was significantly lower than that of younger travelers.
The Air Carrier Access Act of 1986 resulted in the US Department of Transportation developing regulations to assure that persons with disabilities and chronic medical conditions are treated without discrimination. However, air travel can be stressful because of noise, turbulence, crowding, limited seating space, and psychological factors (fear of flying, fear of terrorism, etc.). Air travel may present high-altitude barometric and oxygen stresses ( Chapter 4 ), as well as rapidly transport the traveler across many time zones, necessitating special changes in the timing of medications. Travel by land or sea routes may be less stressful for people with medical conditions but still requires advanced planning. Regardless of mode of transportation, if special medical equipment must be taken along (wheelchairs, dialysis equipment and fluids, oversize or excess baggage for supplies, etc.), travelers should contact the medical departments of major airline, railroad, or cruise ship companies for specific information and guidance before confirming reservations. Travelers with mobility issues may have additional concerns as they plan their travel itinerary. The Centers for Disease Control and Prevention recommends that travelers with medical conditions or mobility issues due to age or other factors should seek pre-travel consultation at least 4 weeks before departure (2016, CDC Yellow Book, chapter 8 ).
Some commonsense approaches to pre-planning for travel with a medical condition will go a long way toward the prevention of problems while en route as well as at one's destination. It is important to advise the traveler to have an updated list of medications and doses as well as an adequate supply of medications to cover the duration of their journey.
Chronic Obstructive Pulmonary Disease, Asthma, and Other Respiratory Conditions
The effects of exercise, exposure to cold, altitude, and extreme heat can be significant stressors for the traveler with underlying lung disease. The presence of environmental allergens and pollution in various cities of the world, such as Delhi, Beijing, Mexico City, and Kathmandu, to name a few, are additional significant considerations.
The Federal Airline Regulations require that airlines maintain a cabin pressure simulating an altitude between 5000 ft (1524 m) (e.g., Denver) and 8000 ft (2438 m) (e.g., Mexico City). Healthy passengers can tolerate this change in altitude, but patients with pulmonary disease may have increased hypoxemia owing not only to diminished oxygen pressure, but also to impaired hypoxic ventilatory drive, decreased cardiac reserve, and mechanical limitations. A study of adults in a simulation of a 20-hour flight revealed that the frequency of reported complaints associated with acute mountain sickness (fatigue, headache, lightheadedness, and nausea) increased with increasing altitude and duration of flight. This peaked at 7498 ft (2438 m) and became apparent between 3 and 9 hours of exposure ( ).
The relatively low humidity inside the passenger cabin (10-12%) may cause difficulty for patients with thick pulmonary secretions or tracheostomies, so adequate individual hydration must be maintained. Water is the best beverage to maintain hydration while in the air or at altitude.
In general, overeating, alcoholic beverages, sedatives, and cigarette smoking should be avoided by patients with respiratory conditions during air travel and once at destination. While smoking on commercial aircraft is illegal, it is important that travelers who are concerned about environmental exposure to tobacco smoke be aware that smoking by others could present a problem in restaurants, hotels, banks, conference rooms, and other public places of business, as well as on buses and other modes of public transportation. The prevalence of smoking among the residents of the areas to be visited and the existence of smoke-free environments may influence the choice of itinerary for this group of travelers. Fortunately, smoking is prohibited in eating establishments and bars in the United Kingdom and Europe, but this does not apply to the many outdoor cafes or seating areas.
Table 16.1 presents some pulmonary contraindications to air travel. However, these contraindications are general, and certain individuals with chronic lung disease who fall into one of these categories may be able to travel on the advice of their medical providers. Most experts recommend supplemental oxygen during air travel for people with a baseline oxygen saturation of 95% or less. Several methods and equations are available to assess the need for in-flight oxygen, and some guidelines suggest a hypoxic challenge test in individuals with an oxygen saturation of 92-95%. Predictive equations do not always accurately estimate the need for in-flight oxygen. Sea-level blood gas or pulmonary function testing with a hypoxic challenge remain the gold standard, with oxygen recommended for those with a PaO 2 of 70 mmHg or less or with an in-flight PaO 2 expected at 55 mmHg or less. Guidelines established by the British Thoracic Society in 2002 suggest that in-flight oxygen is not needed if the patient's resting SpO 2 (O 2 saturation) measured with room air is >95% and there are no additional risk factors. If a patient has a resting room air SpO 2 <92% at sea level, he or she will require in-flight oxygen. These studies are ideally performed on a clinically stable subject as close to the travel date as possible. Table 16.2 shows the drop in the arterial PO 2 going from sea level to an altitude of 8000 ft in healthy young adults and in a group of patients with chronic obstructive pulmonary disease (COPD). Anyone requiring oxygen supplementation on the ground will obviously need it for air travel. British Thoracic Society or Aerospace Medical Association guidelines should be used for patients affected by pulmonary or cardiac disease who desire to travel by air.
TABLE 16.1
Respiratory Contraindications to Air Travel a
From: Gong, H. Jr., 1990. Advising COPD patients about commercial air travel. J. Respir. Dis. 11, 484–499.
|
a These contraindications are relative, since patients may significantly improve with appropriate therapy and supplemental oxygen.
TABLE 16.2
Decline in Blood Oxygen Tension with Increase in Altitude in Two Patient Groups
From: Dillard, T.A., Berg, B.W., Rajagopol, K.R. et al., 1989. Hypoxia during air travel in patients with chronic obstructive pulmonary disease. Ann Intern Med 111, 362–367.
| Group | PaO 2 Sea Level | PaO 2 5500 ft | PaO 2 8000 ft a |
|---|---|---|---|
| Healthy young adults | 98 mmHg | 68 mmHg | 60-63 mmHg |
| Patients with COPD | 72.4 mmHg | – | 47.7 mmHg b |
COPD , Chronic obstructive pulmonary disease.
a A given cruising altitude of 35,000 ft above sea level will result in a cabin altitude varying from 5000 to 8000 ft among different aircraft models, according to pressurization schedules.
b After 45 min steady-state hypobaric exposure, equivalent to 8000 ft above sea level.
Supplemental Oxygen
Passengers who require supplementary oxygen during flight can now bring their own Department of Transportation-approved portable oxygen-concentrating devices on-board most airlines. These must be “approved devices” and currently include a variety of portable oxygen concentrators. Passengers are responsible for making oxygen arrangements with the airplanes. At the time of writing, domestic airlines no longer provide supplemental oxygen, and one must utilize a third party supplier, such as Oxygen to Go, which will facilitate all of the procedures necessary and provide rental units and supplies. A company such as this, which arranges all aspects of the oxygen needs and has been in the business of doing so for more than 10 years, may be an excellent starting place for the traveler requiring supplemental oxygen ( www.oxygentogo.com ). Most carriers require an advance notice of 48-72 hours, but some can require 10 days to 2 weeks advance notice. Passengers should also consider the need for oxygen use during any layover stop(s) and at their final destination. They must also make arrangements (with the airline, friends, or relatives) with a local supplier for removal of the canister from the originating airport's gate area immediately after the gate is exited to board the aircraft. FAA regulations require that for all passengers requesting supplemental oxygen, airlines must obtain a signed physician's statement (specific to each airline), which must be provided by the traveler at least 48 hours prior to travel. This statement will include information such as the desired flow rate, type of mask, and whether the oxygen is to be used intermittently or continuously. The fees for rental of portable oxygen concentrators and the associated batteries and services can range from US$350 for a short flight and 1-week rental upward to US$1200 depending on the length of the trip. Airlines require that passengers requiring oxygen have 150% additional battery power above that supplied with the unit. Other respiratory equipment such as mechanical ventilators or nebulizers may be allowed on board, but their use must be pre-approved. These supplies must conform to applicable FAA regulations in order to avoid interference with sensitive aviation electronic equipment. Additional information on airline accommodations for supplemental oxygen can be found at the National Home Oxygen Patient's Association website ( www.homeoxygen.org ).
Special arrangements have to be made with oxygen distributors at each airport for supplies of oxygen needed on the ground during layovers and airport transfers to connecting flights, and even for the final destination if it is more than 5000 ft above sea level. Passengers should contact a local full-service oxygen supplier that can deliver oxygen not only at the home origin but at the destination and layover city with advance notice of at least 72 hours to ensure delivery. Travelers with moderate to severe COPD who are hypoxic at ambient conditions at home should not plan trips to high altitudes. The risk for high-altitude pulmonary edema is significant in these individuals.
The traveling companion should be instructed that visual impairment, fatigue, headache, sleepiness, dizziness, personality changes, and impaired memory, judgment, and/or coordination may be signs of oxygen deficiency and that medical assistance may be needed.
Travelers with Asthma
In 2007, the National Heart, Lung, and Blood Institute estimated that 22 million people, more than 6 million of them children, have chronic asthma in the United States. Respiratory infections are among the common ailments of travelers, with personal stress, air travel, contact with strangers, and environmental contamination all contributing to the risk of exposure. Thus, it is important for the traveler with asthma and other chronic respiratory conditions to have annual immunization against influenza and to be up-to-date on all other recommended vaccines (including pneumococcal vaccine and pertussis [DTaP]). Travelers over the age of 65 should have the pneumococcal pneumonia vaccine at least 1 month before travel as well as the shingles vaccine.
It is essential the clinician assure that the patient with asthma wishing to travel have stable and well-controlled asthma before embarking on a journey. Travelers with any remote history of asthma or reactive airway disease should be warned that travel to a new place could trigger asthma, even if they have been asymptomatic for years. Molds and pollens may present new or unidentified triggers for exacerbations of asthma. Dust mites and cockroaches are prevalent in some regions of the world, and exposure to byproducts of these could pose increased risks for triggering asthma attacks in hotel rooms and other dwellings. Air pollution is a significant problem in urban areas of the developing world ( Chapter 2 ) and may cause exacerbations of asthma. Patients with asthma traveling to colder environments should be instructed to wear hats with a face mask or scarf to rewarm inhaled air, and appropriate clothing. Unlike patients with COPD, patients with asthma generally do well at altitude. Some theories for this are that they are less exposed to allergens and other etiologic factors responsible for triggering asthma exacerbations. In addition, patients with asthma may be more sensitive to declines in their respiratory function and may spontaneously limit or decrease their activity levels as this occurs. This may have a protective effect when trekking to altitude and while engaging in other types of physical activities.
Travelers with asthma should hand-carry an adequate supply of medications. Medications should not be placed in checked baggage during travel. All medications should be transported in their original containers, showing medication name, dose, dosing schedule, pharmacy, and prescribing physician. Asthma is a problem worldwide, and while it is best for patients to use medications acquired at home, traveling patients should be informed in case of lost or missing supplies that certain common medications may be available abroad under different brand names but similar formulation. For example, albuterol may be available as salbutamol, and Advair may be available as Seretide in other countries. International equivalents of common prescription drugs can be looked up by the healthcare provider utilizing a reference source, such as MD Consult ( www.drugs.com/international ) or other online databases.
Travelers with asthma should have a peak flow meter (PFM) and know how to use this device for self-assessment of subtle exacerbations of their condition while traveling. Recent evidence-based research has determined that β2-agonists and systemic corticosteroids remain the cornerstone of emergency treatment. Specific instructions on when and how to self-treat an exacerbation, based on PRM measurement, should be given. Depending on the travel itinerary and circumstances, the traveling patient should include short-acting bronchodilator multidose inhalers (MDIs), one or more courses of an oral steroid, and an adequate supply of leukotriene modifiers, if appropriate, as this medication is often unavailable in many countries outside the United States and Europe. National Asthma Education and Prevention Program Guidelines (2007) state there is no evidence to suggest that oral antibiotics are useful in the treatment of acute asthma. Medications for treatment of viral influenza (e.g., oseltamivir) and extra steroid MDIs and oral steroids should be carried in the travel medicine kit ( Chapter 1 ).
To summarize:
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All patients with underlying significant pulmonary disease such as COPD, sarcoidosis, or pulmonary hypertension who will be traveling on flights longer than 1.5 hours in duration should be evaluated for in-flight supplemental oxygen.
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Any patient who uses oxygen at home, even if only at night, will likely require in-flight oxygen supplementation.
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Airlines are no longer required to carry oxygen on board for use in emergencies, and when they do have oxygen, it is often a small canister that would not last very long.
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Third-party oxygen distributers are capable of organizing all aspects of supplemental oxygen, from advising on the correct physician-generated paper work to delivery and collection of oxygen concentrators.
Cardiovascular Disease
In patients with cardiopulmonary disease, the hypoxemia that develops during travel by jet may produce symptoms during prolonged commercial flights. Cardiac events are the most common cause of in-flight emergencies, causing up to 20% in some studies. Supplemental oxygen will be required for any cardiac patient requiring supplemental oxygen at sea level. A recent study of travel safety perceptions and awareness in patients with cardiopulmonary disease revealed that only 19% were aware that the aircraft is pressurized to a cabin altitude of 5000-8000 ft, yet 50% of those studied had symptoms of hypoxia when they traveled by air. Some 81% had dyspnea, and almost 20% some degree of chest discomfort. It is important for the clinician to educate cardiopulmonary patients on the health risks of air travel and assure they are fit to fly and prepared.
Patients should be sure to carry their prescribed medications in their carry-on baggage, as well as copies of recent medical records (electrocardiogram, vital signs, list of diagnoses, list of prescription medication and doses, and names and telephone numbers of their medical providers). Salty foods, carbonated beverages, immoderate consumption of alcoholic beverages, and fatty or spicy foods should be avoided during flight. Bringing healthy snack foods from home is a good precaution against unsuitable airline food. Passengers should walk around the aircraft cabin periodically and/or flex and extend their lower extremities while seated at least once an hour to decrease venous stasis and pooling, keeping in mind that light exercise during air flight can actually worsen hypoxemia in those at risk.
A study of medical emergencies among commercial air travelers by found that the flight tower communications center received calls for about 11,920 in-flight medical emergencies among an estimated 744 million airline passengers during the 30-month study period, for a rate of 16 medical emergencies per 1 million passengers, or one in-flight emergency per 604 flights. The most common medical issues were syncope or presyncope (37.4%), respiratory symptoms (12.1%), and nausea or vomiting (9.5%), with some variation across airlines. Approximately 7.9% of flights were diverted due to an in-flight emergency.
Of individuals requiring assistance for a medical problem during travel, the majority of emergencies among air travelers occurred within the air terminal. Only 25% experienced their problem during the flight. Although the rate of medical emergencies for inbound passengers was low, studies suggest that given the volume of passengers involved, a large number of people can be anticipated to experience medical problems requiring emergency assistance during air travel or in the hours immediately before or after the flight. Thirty-eight in-flight cardiac arrests were reported in the Peterson et al. study, and 31 of these resulted in death. Despite the low rate of medical emergencies, almost 1000 lives are lost annually from cardiac arrest in commercial aircrafts and airport terminals. Most of these individuals do not have a prior history of cardiac disease. In June 2001, the FAA mandated that all commercial air carriers carry automated external defibrillators (AEDs) on each aircraft. Since April 2004, all commercial aircraft now have AEDs on-board.
Given the physical and emotional stress on passengers in air terminals as they rush to cover relatively long distances on foot to make connecting flights, and the often lengthy pre-departure security checks, several commonsense tips for air travelers could be given:
- 1.
Allow plenty of time for travel to the airport, airport parking, standing in line at the ticket counter to check in, and passage through security checks to get to the departure gate. Arrive at the airport at least 2 hours ahead of departure time for domestic flights and 3 hours or more ahead of departure time for international flights.
- 2.
At the time the ticket is booked, request an aisle seat, for increased mobility and leg room (although the aisle seat places a passenger at increased risk of injuries from baggage falling out of overhead bins, should the aircraft experience severe turbulence, compared with a window seat).
- 3.
Request special in-flight meals (low salt, vegetarian, etc.) in advance, at the time the ticket is booked. Special meals are almost always delivered prior to the regular food service.
- 4.
Request assistance by wheelchair or airport motor cart for transport within the airport terminal if there are problems with ambulation, exercise tolerance, or any other disabilities.
- 5.
Pack lightly and utilize luggage with wheels or a baggage cart for transport of carry-on bags within the terminal.
- 6.
Wear comfortable clothing in layers that can be added for warmth or removed for cooling, and wear comfortable “broken-in” low-heeled walking shoes for travel. Loosen laces on footwear when settling in for the flight or change into slippers or airline socks. For long-haul flights, special socks that are designed to decrease venous stasis (e.g., T.E.D. antiembolism stockings) are recommended.
- 7.
Do not place medications or products that may require immediate access in the overhead bins. Medicines such as bronchodilators, insulin, glucose tablets, and nitroglycerin should be placed under the seat or in the seat pocket in front of the traveler where they can be easily accessed if needed.
Patients with a history of cardiac disease may want to consider purchasing medical emergency evacuation insurance. They should review the policy to ensure that they will be covered for pre-existing conditions and should determine if the level of evacuation will meet their needs. Some of these companies will provide a fully equipped and staffed air ambulance (fixed-wing or helicopter) to evacuate a cardiac patient to the nearest regional medical center that could provide a level of care similar to the standard of care available in the patient's home country. Other companies will evacuate a patient to the nearest in-country medical center, where the care may or may not approximate prevailing Western standards. Sometimes the outcome of the evacuation is determined by weather, environment, availability of aircraft and fuel, and political factors.
Guidelines of the Aerospace Medical Association state that commercial airline flight is contraindicated within 3 weeks of an uncomplicated myocardial infarction (MI), within 6 weeks of a complicated MI, within 2 weeks of coronary artery bypass surgery, and within 2 weeks of a cerebrovascular accident. Other contraindications to commercial flights include unstable angina, uncontrolled congestive heart failure, and/or uncontrolled cardiac dysrhythmias and severe symptomatic valvular heart disease. Travelers with acute onset of these conditions should defer travel until these conditions have been stable for 3 months.
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