1. Are all Older People Fit to Fly ? Dr M Browne

2. “The ease and accessibility of air travel to an ageing population means that there are those who inevitably wish to fly who may not cope with the hostile physical environment of the airport or the physiological environment of the pressurised air cabin It is important for medical professionals to be aware of the relevant factors and for unreliable public expectations to be avoided”

3. From British Airways Health Services Your patient and air travel A guide to Physicians

4. The key Issues Undeclared / undiagnosed problems Eg COPD Fear of Flying Failure to take medication on the day of travel Delayed departure times Lack of sleep Forgetting to take regular medications while in Lourdes

5. The Suggested Solutions Before travel While @ Lourdes On the way back In flight emergencies

6. Advance Planning Visit the prospective pilgrim Get as much information as possible; some gps will charge for providing this With patient’s consent,ask for reports from hospital consultants if you feel this is required

7. Medication Need full information about this ; at a minimum a copy of the repeat prescription Dosette boxes can pose problems, if filled by a family member, as the pills may not be identifiable For some patients it may be a lot safer to request that all pills come in packets

8. The Patient with Copd, Pulmonary Fibrosis or other conditions Ask are they able to walk > 50 m or up a flight of stairs without dyspnoea You need to know if they use O2 on a regular basis, is this PRN or continuous Do they use a Cylinder or a Concentrator ?

9. Some of these pts may be able to fly However most air carriers will charge for O2 on the flight They may insist on use of a mask, not nasal cannulae Some Airlines may allow use of a concentrator How do I find out which ?

10. Check with the Tour Operator as to which air carrier they will be using ; we often cant get an answer as they don’t know this very far in advance ; this is a real problem The European Lung foundation lists 120 airlines, including charter companies, and gives details of their rules re O2 on board

11. The patient who does not normally require O2, but might require it How do I assess this patient ? Enquire re any recent hospital admissions Ask for copies of discharge summaries as they may mention blood gas results Check whether pt has had a recent LTOT assessment

12. Suggest that the person should have a Fit to Fly test This is available in many depts of Respiratory Medicine and subjects the pt to 30 minutes in a room with lower than 21% 02 and assesses their response. There may be a charge, but it may provide reassurance that the pt does not need O2 in flight

13. If the pt requires O2 for the flight, this must be ordered well in advance The pt should bring their doctor's prescription for O2 with them and a doctor’s letter approving they are safe to travel If using a Concentrator, need to check if it is battery or power operated and the battery life

14. Delayed flights are a huge problem, if pts have concentrators with short battery time Also it must be noted that some pts with cerebrovascular disease can become acutely confused when cabin pressure drops and behaviour can be bizarre !

15. On arrival in Lourdes For those on complex medication regimes or on O2 it is well worth getting a doctor to check all their medications, as problems are easier to deal with, if spotted early on If pts use nebulisers or CPAP machine, ideally they should have a room of their own as CPAP machines are very noisy

16. On The Way Back At this stage you know your pts better However some may have developed new problems while in Lourdes And well people may have become ill Plane seating may need to re-organised ; tour operators don’t like this

17. Those who can’t return with the group A sick person or helper admitted to hospital Or someone who cant fly back because of recent surgery What are rules about this ? British Airways guidance is very helpful They are based on IATA guidelines

18. Key Points Physiology Reduced cabin pressure means trapped gas will expand in volume by 30 % This can cause pain or perforation of the ear, if the Eustachian tubes are blocked OR stretching of suture lines following abdominal surgery

19. Summary of contra- indications Anaemia; hb < 75; Cardiac failure, uncontrolled, Cerebral infarction within 3 days ; Contagious or communicable diseases DVT, acute; Fractures, unstable / untreated Haemorrhage, recent GI; Jaw, fractured with fixed wiring Myocardial infarction within last 7 days Operations within 5-10 days, depending on nature of surgery; Otitis media Pneumothorax, suspected or confirmed

20. Pregnancy after 36 weeks Psychiatric disorders, and those whose behaviour is unpredictable, aggressive or may disrupt the flight Respiratory disease, with marked breathlessness at rest Sickling crisis, recent Sinusitis, severe

21. A few other conditions Pts with a recent hip fracture will require a stretcher Post CABG ; can fly after 10 days Pneumothorax, 2 weeks after successful drainage CVA, require formal medical clearance,if travel is within 10 days of stroke

22. Those with full length plaster or above knee plasters may require extra seating Recent abdo surgery, in which a hollow viscus has been sutured are @risk of perforation or haemorrhage Laparoscopic surgery, wait 24 hours post op Terminal illness, is complex

23. In Flight Emergencies; Some are predictable ; others are not Our flights are short but……….. Pilot will not agree to divert a plane at the request of a doctor but he will connect the doctor to MEDLINK, in USA This allows the doctor to speak to a Specialist who can provide clear advice as to what to do and may avoid a diversion. We don’t know, in advance, whether any of the Charter Airlines carry a defibrillator ; if they do usually only their staff are allowed to use it

24. Useful sources of information British Airways Health Services European Lung Foundation CCAT ; runs courses for health professionals eg MEF ; medical emergencies in flight National Home Oxygen Patients Association =American website Civil Aviation Authority ; guidance on various medical conditions eg cardiovascular disease

25. In conclusion Advance planning is the key But we have to be prepared for emergencies also