MODULE

Air Travel and Fitness to Fly

Prepared by I Md. Ady Wirawan, MD, ACCAM, MPH, PhD
for the Special Topic Block Course on Travel Medicine and Bali International Summer
School (BISS)

Aim
To acquaint the readers with the principles supporting the decision-making process
regarding commercial passenger fitness to fly

Objectives
By the end of this module you should be able to:

• state the principles of flight environment

• understand the physiological effects of exposure to altitude
• understand the principles of clinical pre-flight assessment
• recognize the fitness to fly conditions
• recognize diseases or conditions with potential complication for air travel


Introduction

Each year, approximately 3.3 billion people are estimated to travel by aircraft.
Furthermore, the passenger numbers are expected to reach 7.3 billion by 2034, as
predicted by the International Air Transport Association (IATA). (1) While many of
these people have medical conditions that pose no risk to themselves or to other
passengers, there are some medical conditions that should preclude flying or require
pre-flight evaluation. (2)

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 A worldwide upsurge in travel, as well as an increase in the number of elderly
population in many countries, makes it rational to assume that there will be a
substantial rise in elder travelers and travelers with medical disorders. Patients
commonly query their doctors whether or not it is suitable for them to travel by
aircraft, and what considerations should be taken into account. Therefore, to be able
to appropriately inform patients, physicians need to understand basic concepts of
flight environment, altitude physiology, principles of pre-flight assessment, and most
importantly guidelines for assessing passenger fitness to fly.
Eventually, it is the airline’s decision whether to permit any certain passenger
to fly on their aircraft. However, as a physician, it is our responsibility to provide
proper travel advice to the passengers. This module will cover the evidence based
information related to factors affecting commercial airline passenger health and
international guidance for the assessment of fitness to fly.

Flight Environment and Altitude Physiology

There are many factors related to flight environment that can possibly have an
impact on the passenger’s physiology, i.e. hypoxemia, gas expansion, low humidity,
circadian dysrhythmia, physical factors, and psychological stresses. (3)

Hypoxemia
Most of commercial aircraft cruise at an altitude of between 35000 and 40000
feet (10668 m and 12192 m), which lets aircraft to fly at higher altitudes, so that they
are both fuel efficient and more comfortable due to less turbulence. Modern aircraft
however, are pressurized so that the cabin altitude will be between 5000 and 8000
feet (1524 m and 2438 m). However, these levels of altitude mean that the barometric
pressure at the cabin is lower than that at the sea level. As described by Boyles’ law
that when the temperature is constant, decrease in pressure will increase the volume
of a gas. (4)

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 In the aircraft cabin, where the environment is equivalent to the 5000 – 8000
feet altitude, there is a substantial decline in barometric pressure, compared to the
barometric pressure at sea level. This will result in decrease in the partial pressure of
alveolar, then decrease in arterial oxygen (PaO2), that will lead to hypoxemic condition
in passengers. At cabin altitude, oxygen saturation will be approximately 85–91%,
which is equal to breathing 15.1% oxygen at sea level. Normally, we breath 20.9%
oxygen at mean sea level.

Figure 1 Oxyhemoglobin dissociation curve (4)

Figure 1 shows that at the highest cabin altitude of 8000 feet:
• Barometric pressure will be 565 mm Hg (compared to 760 mm Hg at sea level)
• PaO2 (arterial O2 pressure) will be 55 mm Hg (compared to 98 mm Hg at sea
level)
• Blood oxygen saturation will be about 90% (compared to 98% at sea level)

Most healthy travellers can normally compensate for this amount of hypoxemia.
However, passengers with cardiac and/or respiratory diseases may develop problems
with this condition.

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Gas Expansion

According to Boyle’s law, as the aircraft ascends, the cabin pressure reduces
compared to sea level. As a consequence, gas volumes will be expanded by up to 30%.
In the places where gas can move easily, take the airways for example, these gas
expansions will not result in any harms or problems. However, where gas cannot move
freely or trapped, these gas volume expansions may cause discomfort or even tissue
damage. Some conditions such as recent medical intervention or surgery can bring gas
into the abdominal cavity or other body cavities. Gas can also inflate if it has been
confined in the small cavity such as sinuses and ears, causing discomfort and potential
injury of the tympanic membrane. In addition, a tiny pocket of air trapped after recent
tooth filling, can cause severe pain known as aerodontalgia or barondontalgia. (2)

Low Humidity

To date, there is no evidence of change in the aircraft cabin osmolality, thus the
flight environment does not cause dehydration. However, modern aircraft have very
low cabin humidity, generally in the range of 10 to 20%. As a comparison, ideal rooms
have humidity between 40% and 50%. As a result, there can be a drying effect of the
mucous membranes, especially if wearing contact lenses, the skin, and the airway
passages. This condition is inevitable because air is drawn into the cabin from the
outside and at high altitude it is fully devoid of moisture.

Circadian Dysrhythmia
Circadian dysrhythmia or circadian desynchronosis or commonly known as jet
lag is due to desynchronization of the body clock with the external environment. There
are a number of factors that can influence jet lag including number of time zones
crossed, environmental stimulation (exposure to light can reduce jet lag symptoms),
social contact, quantity and quality of sleep, and individual factors such as age. With
regards to time zone, the direction of flight is also an important factor. Westward

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flights are generally compensated better than eastward flights. One of consideration
related to time differences is its impact on medication times, particularly with diabetic
passengers who are treated with insulin.

Physical and Physiological Factors

A number of physical factors may affect passenger’s fitness such as carrying
luggage, being delayed, hassles of airport security, and walking long distance.
Moreover, small and cramped seating as well as less opportunity to walk, stretch, and
get up, may predispose passengers to deep vein thrombosis, particularly on long haul
flights.
In addition to physical stressors, some psychological factors may affect
passengers during flight. Flight delays often create anxiety and annoyance. Fear of
flying, worries about arriving at a new and unfamiliar destination are also among those
psychological stressors that need to be anticipated.

Clinical Pre-flight Assessment

The aims of medical pre-flight assessment are to give suggestion to passengers
on fitness to fly. This will be expected to prevent delays and diversion of the flight due
to decline in the passenger’s health. For this reason, doctors should consider
passenger’s general health and how air travel may affect the patient’s health and
safety. This means that the decision should balance the right to fly against the possible
risk of harm. The main questions are whether air travel worsens passenger’s medical
condition, and whether the comfort or safety of the other passengers or the flight
operation will be affected by the passenger’s medical condition.
Major airlines generally have medical advisors to assess the fitness to fly for
those who need it. Furthermore, most guidelines are based on the Aerospace Medical
Association (AsMA) publication on fitness to fly in 2003. In addition, the International
Air Transport Association (IATA) recommended the use of Medical Information Form

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(MEDIF), which is generally available from airlines’ websites. This form should be
completed by the passenger’s medical attendant and submitted during ticket booking
to guarantee timely medical clearance.

Medical clearance is generally required for the following conditions:
• Fitness to fly is in suspicion due to recent sickness, surgery, medical
interventions, hospitalization, or other serious medical conditions
• Specific services are needed, such as accompanying medical equipment
(nebulizer, oxygen, etc)

Outside the above categories, medical clearance is not required. Passengers who are
not able to perform their basic personal needs, such as feeding, will be requested to
have an accompanying adult who can help.

Activity 1

• Please look carefully at the two examples of airline medical travel clearance
forms!
• Work in a group and highlight what are the main components of each form!
• Discuss any differences found!

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Guidelines for Assessing Fitness to Fly
This section covers the basic guidelines for the assessment of passenger’s
fitness to fly and guidance for assessing specific diseases or conditions, which are
derived from the AsMA’s medical guidelines for air travel.

Some basic guidelines
The following are some basic guidelines that can be applied in assessing fitness
to fly of a passenger:
• Severe illnesses that would be significantly exacerbated by travel (e.g.
decompression sickness or significant pneumothorax)
• Any infectious diseases during the period of infectivity (e.g. chicken pox)
• Any diseases or ailments that would cause serious offense to other passengers
(e.g. infections or tumors with foul-smelling discharges)
• Individuals with an unstable medical condition, as assessed by their treating
physician, should not fly.

Hypoxia and ischemic conditions
For patients with hypoxia of other ischemic conditions, fitness to fly
assessment is based on:
• History (especially of previous air travel). Those with previous travel history
without medical problems during flight, are more likely to be fit during the next
travels
• Exercise tolerance, as usually tested by treadmill test, to indicate
cardiorespiratory fitness
• Blood gas measurements, as generally measured by pulse oximetry
For passengers with chronic stable lung disease, the following guidance can be
considered:
• Ability to walk 100 meters on flat surface without stopping, or
• Ability to walk 50 meters on flat surface without stopping and climb 15 stairs

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 • Patients with oxygen arterial partial pressure (PaO2) of more than 70 mm Hg do
not require supplementary oxygen for airline travel, and vice versa.

Pregnancy and air travel
At the cabin altitude, maternal haemoglobin remains 90% saturated even
though PaO2 decreases to approximately 64 mm Hg. In this environment, evidence
suggested that fetal PaO2 changes very little. However, there are some rules related to
pregnancy that need to be considered, as follows:
• Pregnancy-related emergencies are most likely in the first and third trimester
• Airline policies vary and sometimes can be negotiated, in general:
– most of airlines allow pregnant women with no later than 36-week
gestational age for single pregnancy or 32-week for multiple pregnancy
– those with gestational age of more than 28-week are generally required
to provide medical certificate, which indicates the pregnancy is normal,
the due date, and other important medical histories.
• In general, the safest time to fly for pregnant women is between 14 and 26
weeks of gestational age
• Women with multiple pregnancies, a history of preterm delivery, cervical
incompetence, bleeding, or increased uterine activity that might result in early
delivery should be encouraged to avoid prolonged air travel
• Travelling by aircraft is best after 2 weeks postpartum.

Other specific conditions
• Gastrointestinal disease
Gas in the gastrointestinal tract will expand in flight, but it is rarely a problem
for healthy passengers. However, flight environment can affect patients with
the following conditions:
– Recent intraperitoneal surgery
– Irreducible hernia
• Ophthalmology

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 The following conditions will preclude passengers to fly:
– Intraocular gas
– Perforating eye injury
– Retinal detachment
• ENT disorders
Patient with the following medical interventions will be precluded to fly:
– Recent middle ear surgery or infection
– Recent severe sinusitis (sinus barotrauma is extremely painful in flight)
– Recurrent ear or sinus barotrauma
• Psychiatric disease
Any unstable patients with psychiatric disease will be not allowed to fly, unless
escorted by an adult who is able to assist.

Activity 2
Case #1
A 26-year-old woman at 29 weeks estimated gestational age of her first pregnancy
presents for a consultation. She has a history of pain and spotting or light bleeding
during the first trimester that resolved. She plans to fly from Denpasar to Amsterdam
which takes about 18 hours including 1 transit.
• Explain how air travel affects pregnancy in general!
• Explain general considerations for pregnant women travelling by aircraft!
• On the above case, what are your considerations and advice? Is she fit to fly?

Case #2
A 60-year-old man with type 2 diabetes mellitus plans to travel by aircraft westward.
He is taking medication to control the diabetes regularly, under physician supervision.
The flight will take approximately 18 hours including transit.
• Explain how long-haul westward air travel will affect this patient!
• What are your considerations and advice? Is he fit to fly?

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Summary

Most airlines have medical passenger policies to determine fitness to fly, in
order to minimize the risk of disruption to other passengers and crew, the likelihood of
the aircraft diversion, and risks to the passenger’s safety. A passenger medical
information form is commonly used, which asks details from both patient and doctor,
about diagnosis, prognosis, desired supplemental oxygen, food, and so forth.
Reduced oxygen tension, pressure changes and reduced space and mobility are
the principal effects on the health of the air-traveler. Modern commercial airliners fly
with a cabin altitude of between 5000 and 8000 feet (1524 and 2438 m) when at
cruising altitude (35.000-40.000 feet), which means a reduction in ambient pressure of
the order of 20% compared with sea level and a consequent reduction in blood oxygen
saturation of about 10%. The cabin air is relatively dry, and the limited room available
in the non-premium cabin may be a factor to be considered.
In determining the passenger’s fitness to fly, a basic knowledge of aviation
physiology and physics can be applied to the pathology. Any trapped gas will expand in
volume by up to 30% during flight, and consideration must be given to the effects of
the relative hypoxia encountered at a cabin altitude of 8000 feet (2400 m) above mean
sea level.

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References and Further Readings

1. International Air Transport Association. Vision 2050. Singapore: IATA; 2011.
2. Bagshaw M. Commercial passenger fitness to fly. In: Rainford D, Gradwell DP,
editors. Ernsting’s aviation medicine. 4th ed. London: Hodder Arnold; 2006. p.
791–9.
3. Patel Y, Simon C. Fitness to fly. InnovAiT. 2010 Oct 1;3(10):606–14.
4. Aerospace Medical Association. Medical guidelines for air travel, 2nd ed. Aviat
Space Environ Med. 2003;74(5):A1–19.

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Appendix 1: Medical Travel Clearance Form – Example 01
Appendix 2: Medical Travel Clearance Form – Example 02
(to be distributed during the course)

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