UK Civil Aviation Authority guidelines (Flight rules and Fitness to Fly)

Guidelines for medical professionals from the Aviation Health Unit, UK Civil Aviation Authority

Environment of the plane in flight and its effect upon physiology

  1. Lowered atmospheric barometric pressure —> decrease in the partial pressure of alveolar oxygen (PaO2) of approximately 75mm Hg —> fall of oxygen saturation to around 90%.

    The decrease in oxygen saturation may have implications for passengers with cardiorespiratory disease who wish to travel. 

    Patients compensate to an extent for this relative hypoxia by increasing their ventilation and by developing a mild tachycardia.

  2. Lower humidity

  3. Reduced mobility —> increasing risk of DVT and PE

Travel by air is not normally advisable in the following cases:

Peri-partum

  • Infants less than 48 hours old (longer after premature births)

  • Women after the 36th week of pregnancy or 32nd week for multiple pregnancy

(Most airlines require a medical certificate after 28w confirming uncomplicated normally progressing pregnancy and EDD)

Cardiovascular disease

  • Coronary stent/angioplasty (<5 days)

  • Uncomplicated myocardial infarction (<7 days)

  • Coronary artery bypass grafting (CABG) (<10 days, as risk of non-resorbed air in thoracic cavity which could expand in flight and lead to barotrauma)

  • Complicated myocardial infarction (<4-6 weeks)

  • Decompensated congestive heart failure

  • Unstable angina (stable angina is not a contraindication to flying)

  • Severe symptomatic valvular heart disease

  • Uncontrolled hypertension (treated hypertension is not a contraindication to flying)

  • Uncontrolled cardiac arrhythmia

Respiratory disease

Functional test: if patient is able to walk 50m at normal place or climb one flight of stairs and NOT experience severe shortness of breath, then they are likely tolerate the aircraft environment

  • Infection of the sinuses

  • Severe chronic respiratory disease (patients may require supplemental oxygen)

  • Breathlessness at rest

  • Pneumothorax drainage (<2 weeks)

  • Unresolved pneumothorax

Patients with asthma should carry their inhalers and carry rescue oral steroids in case of in-flight deterioration

Neurological disease
Recent cerebrovascular accident/stroke (<3 days)

Haematological disorders

  • Haemoglobin <7.5 g/dL is a relative contraindication, moreover, patient may require supplemental oxygen

  • Sickle cell crisis (<10 days)

  • Sickle cell anaemia —>patient should travel with supplemental oxygen

Psychiatric illness
Psychotic illness (fully controlled psychotic illness not a contraindication to flying)

Pressure-related conditions

  • Decompression sickness after diving

  • Increased intracranial pressure (due to bleeding, injury or infection)

  • Recent (<10 days) abdominal surgery or injury where trapped air or gas may be present (e.g. abdominal trauma/abdominal surgery, gastrointestinal surgery, craniofacial and ocular injuries, neurosurgery)

  • Colonoscopy <24hr

  • Neurosurgery <7 days

  • Eye surgery for retinal detachment (<2 weeks of sulphur hexafluoride or <6 weeks if perfluoropropane gases have been used)

  • Eye intra-ocular procedures and penetrating eye injuries <1 week

  • Plaster cast, any limb (<24hr if flight<2hr duration, <48hr if flight duration>2hr), as risk of compartment syndrome through expansion of trapped air during the flight

Infectious disease
Any active infectious disease, especially fever

Cardiovascular indications for provision of medical oxygen during commercial airline flights

  1. Use of oxygen at baseline altitude

  2. Congestive Heart failure HF NYHA class III - IV or baseline PaO2 less than 70 mm Hg

  3. Angina CCS class III-IV

  4. Cyanotic congenital heart disease

  5. Primary pulmonary hypertension

  6. Other cardiovascular diseases associated with known baseline hypoxemia

CHF - Congestive Heart Failure  
NYHA - York Heart Association  
CCS - Canadian Cardiovascular Society

Deep Vein Thrombosis (DVT)

The risk of travellers’ thrombosis increases with:

  • flight travel >4hr

  • immobilisation

  • pre-existing risk factors for thrombosis: thrombophilia, recent surgery, trauma/surgery to lower limbs, age>40, combined hormonal contraceptive usage/HRT, pregnancy

Specialised prophylaxis measures:

  1. Correctly fitted anti-embolism stockings giving graduated compression to the lower limbs

  2. LMWH (aspirin is NOT recommended)

Diabetes requiring insulin treatment

When travelling East, day will be shortened, may need to lower insulin requirements

When travelling West, day will be lengthened, may need additional insulin injections or increased insulin dose requirements

Communicability periods (infectious interval)

Chicken pox
1-2 days before rash and until all lesions have crusted (usually about 5 days after)

Influenza
Up to 3-5 days from onset of symptoms. Up to 7 days in young children

Measles
From 1 day before initial fever/headache (usually 4 days before rash), to 4 days after rash

Mumps
Up to 7 days before, to 9 days after, onset of parotitis (inflammation of the parotid gland) seen as swelling to the side of the face, maximum infectiousness 2 days before to 4 days after.

Pertussis (whooping cough)
Highly contagious in early catarrhal stage and at beginning of cough stage, the first 2 weeks. Thereafter decreases until negligible at 3 weeks.

Rubella
1 week before and at least 4 days after onset of rash; highly transmissible

Tuberculosis
Until at least 2 weeks following effective treatment.

Fear of Flying

Advice for the Traveller who is Afraid of Flying

Fear of flying is common despite flying being safer than road or rail travel in most developed countries.

Simple measures
Try distraction by talking with other passengers, watching a film, listening to music or reading.
Tell the cabin crew. Reassurance about routine aircraft sounds and in flight activities can help.

Cognitive Behaviour Therapy

Courses on Fear of Flying

Dr Rajesh VarmaFlight rules, UK Civil Aviation Authority guidelines, fitness to fly