Flying with Medical Conditions

This information refers to considerations regarding fitness to fly as a passenger. Where asked to advise or certificate an aviator's fitness to fly, please refer to the internet link below from the Civil Aviation Authority (the United Kingdom's aviation regulatory authority) and look under their 'Medical' section.

The information given is general and not exhaustive; the links to the individual guidelines should be used to examine issues in more detail. Individual patients may need to have several conditions taken into account and different airlines have varied policies. More difficult cases are best considered with specialist advice and/or liaison with the particular airline's medical advisors. The sources of advice used are only guidelines and clinical judgement should always be used in their interpretation.

Some airlines require medical certificates confirming that a patient is currently stable and fit to fly. They may ask for a medical information form (MEDIF). The BMA advises doctors 'to word statements on a person's fitness to fly carefully, indicating the information on which the advice is based, rather than positively certifying a person's fitness'. For example:

• 'I know of no obvious reason why this person should not fly' OR
• 'There is nothing in the medical record to indicate that flying is risky for this patient'.

This ensures that the doctor is not guaranteeing in any way that this patient can travel without any problem but rather saying that on the available evidence, there is nothing to indicate a greater risk for this person than for others. However, the doctor is partly dependent on what the patient chooses to disclose to them about past health problems.¹

The main factors to take into account are whether air travel could adversely affect a pre-existing medical condition and whether or not a patient's condition could adversely affect the comfort and safety of the other passengers, or the operation of the flight. Regardless of a doctor's opinion on this latter question, the ultimate sanction to refuse travel lies with the airline and captain of the flight. If they consider there is a risk to the aircraft or its passengers, they may refuse to carry a particular passenger.

Basic considerations when assessing a patient's fitness-to-fly include:

• The effect of mild hypoxia and decreased air pressure in the cabin.
• The effect of immobility.
• The ability to adopt the brace position in emergency landing.
• The timing of regular medication for long-haul/transmeridian travel.
• The ability of the patient to cope mentally and physically with travel to and through airport to reach the flight and on disembarkation.
• Will the patient's medical condition adversely affect the comfort or safety of the other passengers and the operation of the aircraft?
• What health insurance cover does the patient have in case of problems?

Cardiovascular contraindications to commercial airline flight include:²

• Uncomplicated MI within 2–3 weeks
• Complicated MI within 6 weeks
• Unstable angina
• Severe, decompensated congestive cardiac failure
• Uncontrolled hypertension
• CABG within 10–14 days
• CVA within 2 weeks
• Uncontrolled tachyarrhythmia/significant bradycardia
• Eisenmenger syndrome
• Severe symptomatic valvular heart disease

Indications for in-flight oxygen in cardiovascular disease:²

• Need for oxygen at baseline altitude
• Heart failure NYHA class III–IV or baseline PaO₂ < 70 mmHg
• Angina CCS class III–IV
• Cyanotic congenital heart disease
• Primary pulmonary hypertension
• Other cardiovascular diseases associated with known baseline hypoxia

• The World Health Organisation published the results of phase I of their WRIGHT (WHO Research into global hazards of travel) in 2007.³
• These results show that the risk of venous thromboembolism (VTE) approximately doubles after a long-haul flight (> 4 hours). The risk increases with the duration of the travel and with multiple flights within a short period.
• The risk also increases significantly in the presence of other known risk factors for VTE (obesity, extremes of height, use of oral contraceptives and the presence of prothrombotic blood abnormalities).
• The absolute risk of VTE per flight longer than 4 hours in a cohort of healthy individuals was 1 in 6000.
• Effective preventive measures will comprise phase II of the WRIGHT project.

DVT prophylaxis

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

• Remain adequately hydrated
• Exercise the calves
• Spend periods out of their seat
• Avoid excess alcohol
• Avoid tight fitting socks or stockings
• Perhaps use graduated compression stockings

Advice about any more specific DVT prophylaxis should be based on relevant risk stratification and clinical judgement. The table below outlines advice from the Aerospace Medical Association.⁴ Please also refer to the article entitled 'Prevention of Deep Vein Thrombosis' which outlines Department of Health and Clinical Knowledge Summaries (CKS) guidance. The latter states that there is no evidence for the use of aspirin.⁵ There is also a link to the British Committee for Standards in Haematology advice to passengers below.

• Deciding on fitness to fly for those with pre-existing respiratory disease can be difficult.
• A combination of history, examination, lung function tests, hypoxic challenge testing and arterial blood gases may be needed in difficult cases and in deciding on whether in-flight oxygen is needed.
• Those 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 normal pace, or to ascend one flight of stairs, without becoming severely dyspnoeic. However, there is no evidence-base to support this test.⁶
• Anyone with an active exacerbation of respiratory disease would be wise to wait until their respiratory condition has improved before flying.
• It is often worth seeking the advice of a respiratory physician in severe or complex cases, to define criteria and relevant investigations on which a patient should be judged as fit to fly, particularly with regard to the need for oxygen.
• Untreated pneumothorax is an absolute contraindication to air travel.
• British Thoracic Society recommendations on managing passengers with respiratory disease planning air travel can be viewed using the link below.⁷

• Due to the increasing risk of an in-flight delivery, most airlines prohibit travel after the end of the 36th week in uncomplicated singleton pregnancies.¹ Earlier limits apply for multiple/complicated pregnancies or with a history of premature delivery.
• Most airlines require confirmation of dates from healthcare providers for pregnancies > 28 weeks; the standard shared antenatal care documentation used in the NHS is usually sufficient for this.
• The risk of DVT is increased in pregnancy but it is unclear how this risk is affected by flying. Sensible precautions should be taken as for any traveller and compression stockings should be considered. If there are additional risk factors for thrombosis, specialist advice may need to be taken.
• 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.²

• The British Thoracic Society advises waiting 1 week after birth before flying to ensure the infant is healthy.
• Infants born prematurely who have had complications should probably 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 have pre-flight hypoxic challenge testing.

• Someone with a haemoglobin < 8.5 g/dl has a risk of hypoxia and in-flight oxygen should be considered.
• The degree of adaptation to the anaemia will affect the likelihood of problems. Patients with chronic anaemia will tolerate hypoxia better than those who have had a recent haemorrhage.
• Patients with sickle cell disease should have access to in-flight oxygen. Patients with sickle cell trait can usually travel without restriction.

• Active middle ear infections, effusions, or recent ear surgery are contraindications to flying unless the patient is deemed fit-to-fly by an ENT specialist.
• Acute sinusitis, large nasal polyps and recent nasal surgery are relative contraindications.
• Seek advice from an otolaryngologist if uncertain.

• Patients should not fly for 1-2 weeks after open abdominal surgery.²
• Flying is not advised for 24 hours after a colonoscopy and polypectomy.²
• Travellers with colostomies may need to use a larger bag as intestinal distension during the flight may increase faecal output.²
• British Airways have a list of guidelines outlining the minimum time before it is advisable to travel after surgery (see link below). Different airlines may have different policies.

• Fitness-to-fly is best considered on an individual basis and with expert advice if there is uncertainty. The freedoms of the affected individual to travel must be balanced against those of other passengers and safety considerations.
• Acutely disturbed or psychotic patients should not travel.
• Patients with controlled epilepsy can generally fly safely. However, they should be made aware of the potential seizure threshold-lowering effects of fatigue, delayed meals, hypoxia and disturbed circadian rhythm. Care should be taken that medication is not omitted inadvertently when travelling through different time zones.²

• This is a relative contraindication to travel depending on the nature of the condition and its transmissibility at that phase of the illness.
• Tuberculosis is a particular concern. A passenger should have had adequate treatment and be non-infectious prior to the flight.²

• There are no restrictions to flying with well-controlled diabetes.^1,2
• 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 or precooled vacuum flask.
• Insulin should not be stored in the hold as temperatures may cause it to freeze and denature.
• Special consideration needs to be given to insulin dosing regimens on long-haul flights, depending on the direction of travel and movement across time zones. Advice from a diabetes specialist may be needed. Tables of appropriate regimens are available in the link to the second reference for this article.²
• Sugar tablets and snacks to prevent episodes of hypoglycaemia should be carried.