Medical Advice for Commercial Air Travel
Am Fam Physician. 2021 Oct ;104(4):403-410.
Author disclosure: No relevant financial affiliations.
- Pulmonary Conditions
- Cardiac Conditions
- Ear, Nose, and Throat Conditions
- Diabetes Mellitus
- Gastrointestinal Conditions
- Hematologic Conditions
- Psychiatric and Intellectual Disability Conditions
- Neurologic Conditions
- Obstetric Conditions
- Ophthalmologic Conditions
- Orthopedic Conditions
- Urologic Conditions
- Special Considerations for Children
- Other Air Travel Considerations
Air travel is generally safe, but the flight environment poses unique physiologic challenges such as relative hypoxia that may trigger adverse myocardial or pulmonary outcomes. To optimize health outcomes, communication must take place between the traveler, family physician, and airline carrier when there is any doubt about fitness for air travel. Travelers should carry current medications in their original containers and a list of their medical conditions and allergies; they should adjust timing of medications as needed based on time zone changes. The Hypoxia Altitude Simulation Test can be used to determine specific in-flight oxygen requirements for patients who have pulmonary complications or for those for whom safe air travel remains in doubt. Patients with pulmonary conditions who are unable to walk 50 m or for those whose usual oxygen requirements exceed 4 L per minute should be advised not to fly. Trapped gases that expand at high altitude can cause problems for travelers with recent surgery; casting; ear, nose, and throat issues; or dental issues. Insulin requirements may change based on duration and direction of travel. Travelers can minimize risk for deep venous thrombosis by adequately hydrating, avoiding alcohol, walking for 10 to 15 minutes every two hours of travel time, and performing seated isometric exercises. Wearing compression stockings can prevent asymptomatic deep venous thrombosis and superficial venous thrombosis for flights five hours or longer in duration. Physicians and travelers can review relevant pretravel health information, including required and recommended immunizations, health concerns, and other travel resources appropriate for any destination worldwide on the Centers for Disease Control and Prevention travel website.
Air travel has become increasingly popular over time, despite decreases during the COVID-19 pandemic, with 1.1 billion total passengers in 2019 and most Americans having flown at least once in the past three years.1 Air travel is generally safe, but especially for the aging U.S. population, the flight environment poses unique physiologic challenges, particularly relative hypoxia, which may trigger adverse myocardial or pulmonary outcomes. To optimize health outcomes, communication must take place between the traveler, family physician, and airline carrier when any doubt occurs about fitness for air travel. Travelers should carry current medications in their original containers as well as a list of their medical conditions and allergies and should adjust timing of medications as needed based on time zone changes. Travelers should also consider available medical resources at their travel destinations and layover locations. Family physicians and travelers can review relevant pretravel health information, including required and recommended immunizations, health concerns, and other travel resources appropriate for any destination worldwide at https://wwwnc.cdc.gov/travel/destinations/list.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
|Clinical recommendation||Evidence rating||Comments|
Consensus/expert opinion; smaller studies looking at travel after two weeks or longer
Cochrane review of variable-quality randomized controlled trials
Insulin requirements may change based on the direction of travel and crossing time zones; fast-acting insulin should be considered for all travelers during flight due to its flexibility and responsiveness.23
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
|Clinical recommendation||Evidence rating||Comments|
Referencesshow all references
1. Airlines for America. Air travelers in America: annual survey. Accessed May 1, 2021. https://www.airlines.org/dataset/air-travelers-in-america-annual-survey/#...
2. 14 Code of Federal Regulations §25.841—pressurized cabins. Accessed May 1, 2021. https://www.govinfo.gov/app/details/CFR-2012-title14-vol1/CFR-2012-title14-vol1-sec25-841
3. Ahmedzai S, Balfour-Lynn IM, Bewick T, et al.; British Thoracic Society Standards of Care Committee. Managing passengers with stable respiratory disease planning air travel. Thorax. 2011;66(suppl 1):i1–i30.
4. Respiratory disease. In: Green N, Gaydos S, Hutchinson E, et al., eds. Handbook of Aviation and Space Medicine. CRC Press; 2019:329–333.
5. Dine CJ, Kreider ME. Hypoxia altitude simulation test. Chest. 2008;133(4):1002–1005.
6. Matthys H. Fit for high altitude: are hypoxic challenge tests useful? Multidiscip Respir Med. 2011;6(1):38–46.
7. Bagshaw M. Commercial passenger fitness to fly. In: Gradwell DP, Rainford DJ, eds. Ernsting's Aviation and Space Medicine. 5th ed. CRC Press; 2016:631–640.
8. Josephs LK, Coker RK, Thomas M; BTS Air Travel Working Group; British Thoracic Society. Managing patients with stable respiratory disease planning air travel. Prim Care Respir J. 2013;22(2):234–238.
9. Rayman RB, Williams KA. The passenger and the patient inflight. In: DeHart RL, Davis JR, eds. Fundamentals of Aerospace Medicine. 3rd ed. Lippincott Williams & Wilkins; 2002:453–469.
10. Aerospace Medical Association. Surgical conditions. May 2003. Accessed May 1, 2021. http://www.asma.org/asma/media/asma/Travel-Publications/Medical%20Guidelines/Surgical-Conditions.pdf
11. Smith D, Toff W, Joy M, et al. Fitness to fly for passengers with cardiovascular disease. Heart. 2010;96(suppl 2):ii1–ii16.
12. Thomas MD, Hinds R, Walker C, et al. Safety of aeromedical repatriation after myocardial infarction: a retrospective study. Heart. 2006;92(12):1864–1865.
13. Roby H, Lee A, Hopkins A. Safety of air travel following acute myocardial infarction. Aviat Space Environ Med. 2002;73(2):91–96.
14. Zahger D, Leibowitz D, Tabb IK, et al. Long-distance air travel soon after an acute coronary syndrome: a prospective evaluation of a triage protocol. Am Heart J. 2000;140(2):241–242.
15. Cox GR, Peterson J, Bouchel L, et al. Safety of commercial air travel following myocardial infarction. Aviat Space Environ Med. 1996;67(10):976–982.
16. Transportation Security Administration. Frequently asked questions. Accessed May 1, 2021. https://tsa.gov/travel/frequently-asked-questions
17. Steven S, Frenis K, Kalinovic S, et al. Exacerbation of adverse cardiovascular effects of aircraft noise in an animal model of arterial hypertension. Redox Biol. 2020;34:101515.
18. Aerospace Medical Association. Ear, nose, and throat. May 2003. Accessed May 1, 2021. https://www.asma.org/asma/media/asma/Travel-Publications/Medical%20Guidelines/Ear-Nose-and-Throat.pdf
19. Shaikh N, Wald ER, Pi M. Decongestants, antihistamines and nasal irrigation for acute sinusitis in children. Cochrane Database Syst Rev. 2014;(10):CD007909.
20. Pinto JA, Dos Santos Sobreira Nunes H, Soeli Dos Santos R, et al. Otitis media with effusion in aircrew members. Aerosp Med Hum Perform. 2019;90(5):462–465.
21. Aerospace Medical Association. Travel with children. May 2003. Accessed May 1, 2021. https://www.asma.org/asma/media/asma/Travel-Publications/Medical%20Guidelines/Travel-With-Children.pdf
22. Spinks A, Wasiak J. Scopolamine (hyoscine) for preventing and treating motion sickness. Cochrane Database Syst Rev. 2011;(6):CD002851.
23. Aerospace Medical Association. Diabetes. May 2003. Accessed May 1, 2021. http://www.asma.org/asma/media/asma/Travel-Publications/Medical%20Guidelines/Diabetes.pdf
24. Passenger fitness to fly. In: Green N, Gaydos S, Hutchinson E, et al., eds. Handbook of Aviation and Space Medicine. CRC Press; 2019:263–266.
25. Watson HG, Baglin TP. Guidelines on travel-related venous thrombosis. Br J Haematol. 2011;152(1):31–34.
26. Possick SE, Barry M. Evaluation and management of the cardiovascular patient embarking on air travel. Ann Intern Med. 2004;141(2):148–154.
27. Clarke MJ, Broderick C, Hopewell S, et al. Compression stockings for preventing deep vein thrombosis in airline passengers. Cochrane Database Syst Rev. 2021;(4):CD004002.
28. Gavish I, Brenner B. Air travel and the risk of thromboembolism. Intern Emerg Med. 2011;6(2):113–116.
29. Tin AH, Rabinowitz P, Fowler H. Emotional support animals: considerations for documentation. Am Fam Physician. 2020;101(5):302–304. Accessed May 1, 2021. https://www.aafp.org/afp/2020/0301/p302.html
30. U.S. Department of Transportation. U.S. Department of Transportation announces final rule on traveling by air with service animals. December 2, 2020. Accessed May 1, 2021. https://www.transportation.gov/briefing-room/us-department-transportation-announces-final-rule-traveling-air-service-animals
31. Trevorrow T. Air travel and seizure frequency for individuals with epilepsy. Seizure. 2006;15(5):320–327.
32. Hastings, JD; Aerospace Medical Association. Medical guidelines for airline travel: air travel for passengers with neurological conditions. September 2014. Accessed May 1, 2021. http://www.asma.org/asma/media/asma/Travel-Publications/Medical%20Guidelines/Neurology-Sep-2014.pdf
33. ACOG Committee opinion no. 746: air travel during pregnancy. Obstet Gynecol. 2018;132(2):e64–e66.
34. Royal College of Obstetricians and Gynaecologists. Air travel and pregnancy: scientific impact paper no. 1. May 2013. Accessed May 1, 2021. http://www.asma.org/asma/media/asma/Travel-Publications/Medical%20Guidelines/RCOG-Pregnancy-and-Air-Travel-Scientific-Impact-Paper.pdf
35. Harvard Medical School. Are full-body airport scanners safe? June 2011. Accessed May 1, 2021. https://www.health.harvard.edu/diseases-and-conditions/are-full-body-airport-scanners-safe#:~:text=he%20authors%20begin%20with%20an,the%20biological%20effects%20of%20radiation
36. Aerospace Medical Association. Ophthalmological conditions. May 2003. Accessed May 1, 2021. http://www.asma.org/asma/media/asma/Travel-Publications/Medical%20Guidelines/Ophthalmological-Conditions.pdf
37. Bettes TN, McKenas DK. Medical advice for commercial air travelers. Am Fam Physician. 1999;60(3):801–808, 810. Accessed May 1, 2021. https://www.aafp.org/afp/1999/0901/p801.html
38. Aerospace Medical Association. Jet lag. May 2003. Accessed May 1, 2021. https://www.asma.org/asma/media/asma/Travel-Publications/Medical%20Guidelines/Jet-Lag.pdf
39. Choy M, Salbu RL. Jet lag: current and potential therapies. PT. 2011;36(4):221–231.
40. Waterhouse J, Reilly T, Atkinson G, et al. Jet lag: trends and coping strategies. Lancet. 2007;369(9567):1117–1129.
41. Herxheimer A, Petrie KJ. Melatonin for the prevention and treatment of jet lag. Cochrane Database Syst Rev. 2002;(2):CD001520.
42. Divers Alert Network. February 1, 2017. Accessed May 11, 2021. https://dan.org/alert-diver/article/flying-after-pool-diving-2/
43. Mitchell GW, Martin GJ. Chapter 19 Infectious diseases. In: Davis JR, Johnson R, Stepanek J, et al. Fundamentals of Aerospace Medicine. 4th ed. Lippincott Williams & Wilkins; 2008:432–446.
44. Centers for Disease Control and Prevention. Domestic travel during COVID-19. Updated April 27, 2021. Accessed April 30, 2021. https://www.cdc.gov/coronavirus/2019-ncov/travelers/travel-during-covid19.html
45. Co M, Ng J, Kwong A. Air travel and postoperative lymph-edema—a systematic review. Clin Breast Cancer. 2018;18(1):e151–e155.
46. Hu JS, Smith JK. In-flight medical emergencies. Am Fam Physician. 2021;103(9):547–552. Accessed April 30, 2021. https://www.aafp.org/afp/2021/0501/p547.html
Copyright © 2021 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact firstname.lastname@example.org for copyright questions and/or permission requests.
Want to use this article elsewhere? Get Permissions