Contraindications to air travel

Travel by air is normally contraindicated in the following cases:

Infants less than 48 h old.

Women after the 36th week of pregnancy (32nd week for multiple pregnancies).

Those suffering from:

a. angina pectoris or chest pain at rest;

b. any active communicable disease;

c. decompression sickness after diving;

d. increased intracranial pressure due to haemorrhage, trauma or infection;

e. infections of the sinuses or of the ear and nose, particularly if the Eustachian tube is blocked;

f. recent myocardial infarction and stroke (elapsed time since the event depending on severity of

illness and duration of travel);

g. recent surgery or injury where trapped air or gas may be present, especially abdominal trauma and

gastrointestinal surgery, craniofacial and ocular injuries, brain operations, and eye operations

involving penetration of the eyeball;

h. severe chronic respiratory disease, breathlessness at rest, or unresolved pneumothorax;

i. sickle-cell anaemia;

j. psychotic illness, except when fully controlled.

The above list is not comprehensive, and fitness for travel should be decided on a case-by-case

basis.

Larangan menjadi pilot AME-FAA

1. A personality disorder severe enough to have repeatedly manifested

itself by overt acts

2. A psychosis

3. A bipolar disorder

4. Substance dependence

5. Substance abuse

6. Epilepsy

7. A disturbance of consciousness without satisfactory medical

explanation of the cause

8. A transient loss of nervous system function(s) without satisfactory

medical explanation of the cause

9. Myocardial infarction

10. Angina Pectoris

11. Coronary heart disease that requires treatment, or if untreated,

that has been symptomatic or requires treatment

12. Cardiac valve replacement

13. Permanent cardiac pacemaker implantation

14. Heart replacement, and

15. Diabetes mellitus that requires insulin or any other hypoglycemic

for control.8

MEDICAL CLEARANCE GUIDELINES

The objective of medical clearance is to provide safe and healthy

travel, and to prevent delays and diversions to the flight as a result of

deterioration of a passengers medical situation. It is often up to individual

physicians to provide this information, since not all airlines

have medical departments that are able to give guidance in this area.

There are excellent recent guidelines developed by the Aerospace

Medical Association (AsMA)1,2 WHO27 and IATA,9 and will only be

briefly described in this chapter. Other professional organizations,

such as the Canadian Cardiovascular Society and the British Medical

Association, have also made recommendations.13,24

IATA has published a Medical Information Form (MEDIF) (Fig. 3),

which has a passenger and a physician section. Many airlines require

this to be completed well in advance of flight so that proper arrangements

can be made for passengers with additional needs. Although

there is some variation in opinions among the experts pertaining to

medical clearance issues, the following recommendations are based

on the Medical Guidelines for Airline Travel (second edition) compiled

by AsMA in 2003.1 These recommendations are intended for

flight, but additional consideration should be used in evaluating a

patients ability to navigate a crowded airport.

Cardiovascular disease should be carefully evaluated prior to each

flight unless it is very stable, with co-morbid conditions taken into

consideration.

1. Angina: As long as the stress of air travel is not likely to precipitate

symptoms, most stable patients can fly. They must be cautious

to carry their medications with them on-board. Unstable

angina is a clear contraindication to flight.

2. Myocardial infarction (MI): For the uncomplicated MI, patients

should not fly for at least two to three weeks and until they have

resumed normal activities. Patients with complicated MI, especially

those with limited mobility, should wait longer until they

are stabilized medically. Symptom-limited stress testing can be

very helpful in estimating ability to fly.

3. Congestive heart failure (CH): Severe decompensated heart failure

is a contraindication to flight. Individuals with stable CHF

with NYHA Class IIIIV or with baseline PaO2 of 70 mmHg or

less should be advised to arrange for supplemental oxygen.

4. Coronary artery bypass graft: If surgery is uncomplicated, fully

recovered CABG patients should wait 1014 days post surgery to

allow for surgically introduced intrathoracic air to be absorbed.

5. Percutaneous coronary artery interventions: Uncomplicated

angioplasty or stent operations usually carry a low risk, provided

the patient is medically stable and has returned to his or her

normal activities.

6. Symptomatic valvular heart disease: This is a relative contraindication

to flight, so these patients should be carefully assessed.

Fitness to fly is determined by severity of symptoms, functional

status, left ventricular ejection fraction, and whether or not

pulmonary hypertension and baseline hypoxia exist.

7. Hypertension: As long as the hypertension is under reasonable

control, there is no contraindication to flight.

8. Pacemakers and implantable cardiac defibrillators (ICD): These

devices are low risk for commercial airline travel, once the

patient is medically stable after having the device implanted.

The commonly used bipolar devices are very unlikely to have

electromagnetic interferences with airline or security devices,

and even the older unifocal devices are unlikely to cause interference

problems. [Note that any equipment carried on-board

an aircraft must meet the radio frequency interference requirements

of the regulatory authority (e.g., FAA or EASA).]

Passengers with these devices should carry copies of their electrocardiogram

(ECG) (both with and without magnets) as well as

copies of their pacemaker or ICD cards. The reason for this

is that it might not be possible to transmit electronic telephone

checks of pacemaker function via international satellite

telephone systems.

9. Deep venous thrombosis: DVT per se is not a dangerous condition,

but the sequel of pulmonary embolism (PE) can be life

threatening. Provided the condition is stable and the passenger

is on appropriate anti-coagulation with resolution of the clot,

there is no contraindication to flying. Passengers with risk factors

(Fig. 4) for DVT should be counseled about preventive activities

such as walking in the cabin aisles during flight, in-seat stretching

exercises, and adequate hydration. Depending on the severity of

their risk factors, they might consult with their physician about

medical preventive therapy (Fig. 4). All passengers should

be educated about the signs and symptoms of DVT, with

instructions given as to how to seek medical assistance at

their destination, as DVT and PE can develop hours or days

afterwards.7

10. Miscellaneous contraindicated cardiovascular medical conditions:

This includes cardiovascular accidents within two

weeks of flight, uncontrolled ventricular or supraventricular

tachycardia, and Eisenmengers syndrome. Of course, all cardiac

patients should be reminded to carry a list of their medications

with them, and make certain that they have more than

sufficient quantities of medications to last them through their

entire trip.

Consideration must be made to accommodate for limited

physical reserve by reducing long airport walks and heavy baggage.

It goes without saying that if there are special needs, such

as wheelchairs, special seats or meal requirements, arrangements

need to be made with the carrier well in advance. Even though

special meals are ordered, they are not always available. Thus,

those with special meal requirements should carry emergency

foodstuffs.

Pulmonary diseases require attention to the possible need for supplemental

oxygen and rescue medications in case of exacerbations.

The physician should consider the type, reversibility, and functional

severity of the pulmonary disorder, evaluate altitude tolerance, and

determine the anticipated altitude and duration of the flight.

Pulmonary function tests and arterial blood gas determinations can

be very helpful in this evaluation. As stated in the cardiac section, the

baseline PaO2 is the most useful indicator of altitude tolerance.

A more sophisticated test is the hypoxia altitude simulation test

(HAST), which determines the patients PaO2 while breathing mixed

gases simulating the aircraft cabin environment at altitude. A PaO2 of

less than 55 mmHg saturation at simulated cabin altitude requires

supplemental oxygen during flight. Individuals with PaO2 less than

70 mmHg may also warrant supplemental oxygen.

1. Asthma: Air travel is contraindicated for patients with severe, labile

disease that requires frequent hospitalization. For stable individuals,

it is important to remind them that they must hand-carry

their medications, particularly their inhalers. A course of oral

steroids might be indicated for all but the mildest asthmatics.

2. Bronchiectasis and cystic fibrosis: These patients should be carefully

evaluated, with measures taken to effectively loosen and

clear secretions. Infections should be treated and stabilized prior to

flight, and in-flight oxygen therapy might be essential. Aerosolized

enzyme deoxyribonuclease should be considered prior to, and

possibly also during flight.

3. Interstitial lung disease: Most of these patients can generally tolerate

air travel, although supplemental oxygen therapy might be necessary.

4. Malignancies: Lung cancer is not contraindicated for flight, provided

the passenger is otherwise medically stable. Medications

during flight might be needed to relieve pain, and supplemental

oxygen might be necessary.

5. Neuromuscular disease: Patients who have neurological or

skeletal disorders that affect breathing can require manual

and/or mechanical assistance, which can be problematic for

long flights. Often they require an assistant to accompany them.

The low humidity in the aircraft can exacerbate excessive dryness

of the respiratory mucosa. These cases should be thoroughly discussed

with the air carrier in advance of flight.

6. Pulmonary infections: Those with actively contagious infections

are unsuitable for air travel until documented control of the

infection can be obtained. To avoid spread of the virus to nearby

passengers and cabin crew, individuals with even mild viral

infections should not be allowed on-board

7. Pneumothorax: The presence of pneumothorax or pneumomediastinum

is a contraindication as these conditions can progress to

a tension pneumothorax by gas expansion during flight. Treated

patients can usually travel within two to three weeks of successful

drainage. Patients with recurrent spontaneous pneumothorax

should be individually counseled; end-expiratory chest radiographs

can be helpful in identification of suspicious cases.

8. Pleural effusions: Large collections require drainage prior to

flight, with at least 14 days recovery for both diagnostic and therapeutic

reasons. A chest radiograph might be needed prior to

flight to rule out reaccumulation or induced pneumothorax.

9. Pulmonary vascular disease: Patients with preexisting PE or pulmonary

hypertension are at risk for hypoxia-induced pulmonary

vasoconstriction with an ultimate reduction in cardiac output.

These patients necessitate careful preflight evaluation, as they

might need a combination of anticoagulation, medical oxygen,

restricted exertion, compression stockings, and in-seat isometric

exercises.

10. Sleep apnea: Passenger who use CPAP devices often take them

along on long-haul flights. They must pass TSA inspection, so the

passenger should call the airline in advance for information

regarding bringing these devices on-board.

11. Special conditions: These patients require close coordination

between the physician and the air carrier if unusual or special

medical equipment is required on-board.

Recent surgery should be evaluated individually. With the increase

of ambulatory surgery, patients frequently fly home after an outpatient

procedure. General anesthesia per se is not a contraindication

for flight, as the gases used do not predispose one to decompression

illness. However, it should be kept in mind that post-operative

patients have increased oxygen consumption due to the trauma of

surgery, and oxygen delivery might be impaired. Post-operative anemia

must be assessed. Patients with recent thoracic surgery are especially

sensitive to intrathoracic pressure changes, as gas expands

2530% at cabin altitude. Neurosurgical patients must be shown to

have no trapped intracranial air, and patients with any cerebrospinal

leak should avoid flying because of the possibility of backflow and

bacterial contamination during pressure changes. This gas expansion

also puts post-abdominal surgery patients at risk, therefore air travel

should be discouraged for at least one to two weeks for individuals

who have had an intestinal lumen opened. Even after a simple

colonoscopy with polypectomy procedure, flight should be delayed

for at least 24 hours. Laparoscopic procedures are less likely to cause

problems because of the rapid diffusion of the residual CO2. Travelers

with colostomy bags are not at increased risk during air travel, but

might need larger bags due to the increased fecal output produced

by intestinal distention and gas expansion.

Consideration should also be given to wound care requirements,

pressure-sensitive tubing, IV fluids, and medications, along with

ambulatory and positional requirements.

Pregnancy in general is compatible with airline flight. Because of the

properties of fetal hemoglobin, fetal PaO2 changes very little, despite

a potential substantial drop in maternal PaO2 at altitude. However,

the physical changes associated with pregnancy can make flight

more challenging, in that motion sickness might be aggravated, intraabdominal

gas expansion might be worse than in the non-pregnant

female, and orthostatic changes can be accentuated. High risk pregnancies

at risk for preterm labor should be discouraged from prolonged

flight. First trimester travelers should not fly if they have either

bleeding or pain associated with their pregnancy. Most airlines

require medical certification from the obstetrician to allow flight after

the 36th gestational week (32nd in the case of a multiple pregnancy)

in order to avoid the onset of labor during flight.

Travel with children has few caveats. Infants should be at least

seven days old in order to assure lack of serious congenital defects

or respiratory distress. Risk of Eustachian tube dysfunction can be

decreased by having the babies suck on a bottle, breast or pacifier,

and older children can drink from a cup during decent. Just as with

adults, children with respiratory congestion can benefit from

decongestion medications given orally 30 minutes before descent.

Otitis media is not contraindicated, provided appropriate antibiotics

are being used for 36 hours and the Eustachian tube is patent.

Diarrheal illnesses should be remedied with appropriate

electrolyte solutions.

Cerebrovascular disease patients, if otherwise stable, should be able

to travel within a few days of having a cerebral vascular accident

(CVA). For those with cerebral artery insufficiency, the relative

hypoxia in the aircraft might necessitate supplemental oxygen.

Some airlines require medical clearance if traveling within 10 days

of a stroke.

Ear, nose and throat (ENT) disturbances that affect an individuals

ability to equilibrate pressure through the Eustachian tubes or sinuses

might cause barotrauma. Any condition that is associated with vertigo

or motion sickness is likely to be worsened in flight. ENT surgeries

in general should preclude flight for 1014 days, except for ear

tube placements or myringotomy (which ventilate the middle ear).

Patients with tracheo-laryngeal surgeries may need extra moisturization

and possibly removal of thickened secretions caused by the low

humidity of the cabin air. Facial plastic surgery patients can generally

fly once drains are removed. Penetrating eye injuries should not fly

within six days of the injury or surgery due to the danger of gas

expansion inside the globe. Passengers whose jaws are wired shut

should only fly with an escort with appropriate wire cutters, or have

self-quick-release wiring in case of vomiting or aspiration.

Diabetes is not a contraindication to flight, provided passengers can

administer their own medications and understand the problems associated

with time zone and nutritional changes. For insulin dependent

diabetics, insulin vials, syringes, and monitoring supplies should be

carried by the passenger on-board and not in checked baggage. A

prescription or letter from the treating physician will expedite security

clearance. The cabin altitude should not affect the accuracy of

most glucose meters. Journeys across several time zones may shorten

or lengthen the 24-hour day, and adjustments need to be made to

compensate for this. (See Fig. 5 for insulin adjustment schedules.) It

is, of course, important to have snacks available as countermeasure

against hypoglycemia, especially if meal service is delayed.

Passengers should alert cabin crew to their medical condition and

wear medical alert ID tags.

The Transport Security Administration (TSA) in the US requires

specific medical documentation of the need to carry insulin syringes

on-board when going through security checkpoints at the airport.

Only the necessary number of syringes for the length of flight is

acceptable, with any additional syringes packed into the checked

luggage. Insulin dependent diabetics should be reminded not to dispose

of their syringes in areas of the aircraft that might likely injure

others, such as seat back pockets and lavatory waste baskets. Cabin

cleaning crews and fight attendants are often injured by these

syringes; it can cause the worker considerable anxiety if punctured

by one. An alternative is the insulin pen, which is a compact,

portable device that serves exactly the same function as a needle and

syringe, but is handier and more convenient to use. These come preloaded

with the proper amount of soluble insulin, and are very convenient

for frequent travelers.

Non-insulin dependent diabetics do not have the same issues

with medical management. Additional tablets are not usually

required to cover an extended day, and a normal dose might be omitted

in the case of a significantly shortened day. Most important is

careful planning and consultation with their diabetic specialist.

Communicable diseases can be a concern on airplanes, but they are

probably no more likely to be transmitted in aircraft than in other

public areas where people are in close proximity, despite public

opinion to the contrary.24

Communicable diseases need to be investigated if a significant

public health risk exists, such as infectious tuberculosis. Because

of the potential serious consequences in compromised individuals,

certain common childhood diseases in their infectious states should

not be allowed onto aircraft, such as chickenpox, measles, mumps,

rubella, scarlet fever, and pertussis. Similarly, those with other

common highly contagious illnesses, such as influenza, should not

be on-board because of the potential serious sequelae in at-risk

people and the possibility of airborne transmission. Passengers with

less serious infectious illnesses, e.g., the common cold (URI), frequently

fly, because these illnesses are very common. Fortunately,

they pose little risk as a public health hazard. Long haul flights,

primarily international, are of particular concern, as these do

increase the likelihood of even low virulence diseases, such as

tuberculosis, to infect other passengers. Acute food poisoning on

an airplane is particularly problematic, and potentially dangerous

if it affects the flight crew. Although airlines are not allowed to

knowingly board passengers with actively contagious diseases,

passengers are often unwilling to admit their illnesses because of

their motivation to travel. They might also perceive themselves as

being well enough to fly, and ignore the potential of passing the

disease on to others.

Difficulties arise in that many infectious diseases are contagious

during a prodromal stage before symptoms actually develop, and

even influenza may be entirely asymptomatic. Other challenges

occur when dealing with emotionally charged conditions, for example

tuberculosis or certain blood-borne pathogens. The SARS epidemic

in 2003 highlighted the potential for an airborne illness to

rapidly travel around the world.

Terminal illness are not necessarily disqualifying for flight, provided

the illness is stable enough to allow the patient to withstand the

flight. Patients are often discharged from hospitals with terminal illnesses

and then fly home, while others wish to return to their native

countries to die after being diagnosed with a terminal disease.

Orthopedic fractures can be a challenging situation for accommodation

on passenger airlines. Most domestic US carriers do not allow

stretcher cases, and require that a passenger must be able to sit in a

regular seat. Some international carriers that are accustomed to repatriating

sick passengers are able to accommodate stretcher configurations,

and with adequate preparation, may even be able to provide

accompanying medical personnel. It must be kept in mind that just

because a passenger can fit into an airline seat with a short leg cast

does not mean that he or she will tolerate it for several hours.

Following application of a plaster cast, flights under two hours duration

should be avoided for 24 hours, and longer flights for 48 hours.

If the cast is bivalved, these restrictions can be liberalized, although

elevation is still a critical factor. Passengers with air casts should be

advised to bring the air pump in their carry-on baggage, as the air in

the bladders will expand at altitude requiring the removal of some of

the air. Upon descent, as the air contracts, additional air will need to

be placed in the bladders to stabilize the fracture.

Prescription medications with international travel require the original

prescription bottles with labels on them, if traveling to certain countries.

Some countries even require a prescription for pseudoephedrine

hydrochloride, which is a common non-prescription decongestant in

other countries. It is always a good idea to take copies of prescriptions

along, in case of loss of the original medications.

Unattended minors with medical problems or prescription medications

require careful coordination with the airlines. Children

with medical problems, especially those requiring medications en

route, must be discussed with the airlines medical department

in order to avoid medication incidents. Such children, if below an

appropriate developmental age to take their own medications,

should not travel alone. Each airline has its own regulations concerning

unaccompanied minors, and should be investigated before

flight plans are made.

Blood disorders with reduced tolerance to hypoxia also require special

consideration. Patients with hemoglobin levels below

7.5 g/dL should be provided supplemental oxygen, especially if the

anemia has been acute in onset. Sometimes the cause of the anemia

is enough to preclude stability for flight. Sickle cell trait patients

should in general be able to travel without supplemental oxygen, but

those with sickle cell disease should have supplemental oxygen in

flight, and certainly not fly within 10 days of suffering a crisis.

Psychiatric illness, whether acute or chronic, should be stable and

unlikely to deteriorate during flight. In some circumstances, medical

escorts might be required.

Substance abuse cannot be tolerated on-board aircraft. Anyone who

seems impaired or intoxicated should not be allowed on-board.

Personal medical devices need to be cleared in advance of flight, as

not only do the airlines have rules regarding certain devices, but the

security screening agencies may prohibit some being brought onboard.

It is therefore important to discuss this with the airline well in

advance of the flight.