Pneumothorax and air travel
- Lawrence C Mohr, MD, FACP, FCCP
Lawrence C Mohr, MD, FACP, FCCP
- Professor of Medicine, Biometry & Epidemiology
- Medical University of South Carolina
- Section Editors
- James K Stoller, MD, MS
James K Stoller, MD, MS
- Section Editor — Chronic Obstructive Pulmonary Disease
- Jean Wall Bennett Professor of Medicine, Samson Global Leadership Academy Endowed Chair
- Cleveland Clinic Lerner College of Medicine
- Chairman, Education Institute, Cleveland Clinic
- V Courtney Broaddus, MD
V Courtney Broaddus, MD
- Section Editor — Pleural Disease
- Professor of Medicine
- University of California San Francisco
It is estimated that over one billion passengers travel by air each year [1-3]. Although up to 5 percent of passengers have some form of disability or chronic medical illness, in-flight emergencies are infrequent . Only one of every 39,000 passengers (0.003 percent) experiences an in-flight medical problem serious enough to come to the attention of emergency personnel [5,6]. Death during commercial flight is even rarer. During the year July 1998 to July 1999, the Federal Aviation Administration (FAA) collected medical events data, and 43 deaths occurred in-flight out of 600 million passengers .
The incidence, pathogenesis, and management of in-flight and previous pneumothorax/pneumomediastinum (PTX/PMD) will be reviewed here. Pre-flight medical assessment, the prevention of in-flight hypoxemia in patients with underlying lung disease, and the management of spontaneous PTX are discussed separately. (See "Assessment of adult patients for air travel" and "Traveling with oxygen aboard commercial air carriers" and "Primary spontaneous pneumothorax in adults" and "Secondary spontaneous pneumothorax in adults" and "Imaging of pneumothorax" and "Placement and management of thoracostomy tubes".)
The exact incidence of pneumothorax/pneumomediastinum (PTX/PMD) during commercial air travel is unknown due to non-standardized reporting requirements for in-flight medical emergencies, difficulty in making an in-flight diagnosis, and possible delay in symptoms . Anecdotal reports of in-flight pneumothoraces have been published [9-11]. However, in-flight PTX must be rare, because it is not mentioned in most reports addressing in-flight emergencies [5,6,12-14].
A few reports have described the experience of individuals at high risk for pulmonary complications during air travel [15-17]:
●In a series of 1115 passengers referred to an airline medical advisory service for pre-flight evaluation, 704 had chronic obstructive pulmonary disease (COPD) or another pulmonary disorder . Over 90 percent were "cleared" for transport. None of those cleared for air travel was known to have experienced a significant in-flight medical problem.
- Gendreau MA, DeJohn C. Responding to medical events during commercial airline flights. N Engl J Med 2002; 346:1067.
- Goodwin T. In-flight medical emergencies: an overview. BMJ 2000; 321:1338.
- British Thoracic Society. Managing passengers with respiratory disease planning air travel http://www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Air%20Travel/Guidelines/FlightRevision04.pdf (Accessed on October 11, 2010).
- Gong H Jr. Air travel and oxygen therapy in cardiopulmonary patients. Chest 1992; 101:1104.
- Cummins RO, Schubach JA. Frequency and types of medical emergencies among commercial air travelers. JAMA 1989; 261:1295.
- Speizer C, Rennie CJ 3rd, Breton H. Prevalence of in-flight medical emergencies on commercial airlines. Ann Emerg Med 1989; 18:26.
- Aerospace Medical Association Medical Guidelines Task Force. Medical Guidelines for Airline Travel, 2nd ed. Aviat Space Environ Med 2003; 74:A1.
- Postmus PE, Johannesma PC, Menko FH, Paul MA. In-flight pneumothorax: diagnosis may be missed because of symptom delay. Am J Respir Crit Care Med 2014; 190:704.
- Flux M, Dille JR. Inflight spontaneous pneumothorax: a case report. Aerosp Med 1969; 40:660.
- Neidhart P, Suter PM. Pulmonary bulla and sudden death in a young aeroplane passenger. Intensive Care Med 1985; 11:45.
- AMDUR RD. Recurrent spontaneous pneumothorax caused by aerial flight; report of case. J Aviat Med 1956; 27:456.
- Lyznicki JM, Williams MA, Deitchman SD, et al. Inflight medical emergencies. Aviat Space Environ Med 2000; 71:832.
- Jagoda A, Pietrzak M. Medical emergencies in commercial air travel. Emerg Med Clin North Am 1997; 15:251.
- Rosenberg CA, Pak F. Emergencies in the air: problems, management, and prevention. J Emerg Med 1997; 15:159.
- Gong H Jr, Mark JA, Cowan MN. Preflight medical screenings of patients. Analysis of health and flight characteristics. Chest 1993; 104:788.
- Kramer MR, Jakobson DJ, Springer C, Donchin Y. The safety of air transportation of patients with advanced lung disease. Experience with 21 patients requiring lung transplantation or pulmonary thromboendarterectomy. Chest 1995; 108:1292.
- Hordinsky, JR, George MH. Response capability during civil air carrier inflight medical emergencies (Report No. DOT/FAA/AM-91/3). National Technical Information Service, Springfield, VA 22161.
- Melton LJ 3rd, Hepper NG, Offord KP. Influence of height on the risk of spontaneous pneumothorax. Mayo Clin Proc 1981; 56:678.
- Bense L, Eklund G, Wiman LG. Smoking and the increased risk of contracting spontaneous pneumothorax. Chest 1987; 92:1009.
- Nicol E, Davies G, Jayakumar P, Green ND. Pneumopericardium and pneumomediastinum in a passenger on a commercial flight. Aviat Space Environ Med 2007; 78:435.
- Morgan J, Sadler MA, Yeghiayan P. Spontaneous pneumomediastinum in a patient with recent air travel. Emerg Radiol 2007; 14:457.
- Jung S, Wiest R, Frigerio S, et al. Cerebral air embolism caused by a bronchogenic cyst. Pract Neurol 2010; 10:164.
- Cottrell JJ. Altitude exposures during aircraft flight. Flying higher. Chest 1988; 93:81.
- Zaugg M, Kaplan V, Widmer U, et al. Fatal air embolism in an airplane passenger with a giant intrapulmonary bronchogenic cyst. Am J Respir Crit Care Med 1998; 157:1686.
- PARKER GW, STONEHILL RB. Further considerations of the roentgenologic evaluation of flying personnel at simulated altitude. Aerosp Med 1961; 32:501.
- Fundamentals of Aerospace Medicine, Dehart RL (Ed), Lea and Febiger, Philadelphia 1985. p.152.
- Mohr LC. Hypoxia during air travel in adults with pulmonary disease. Am J Med Sci 2008; 335:71.
- Ahmedzai S, Balfour-Lynn IM, Bewick T, et al. Managing passengers with stable respiratory disease planning air travel: British Thoracic Society recommendations. Thorax 2011; 66 Suppl 1:i1.
- Astin TW, Penman RW. Airway obstruction due to hypoxemia in patients with chronic lung disease. Am Rev Respir Dis 1967; 95:567.
- DERMKSIAN G, LAMB LE. Spontaneous pneumothorax in apparently healthy flying personnel. Ann Intern Med 1959; 51:39.
- Fuchs HS. Idiopathic spontaneous pneumothorax and flying. With particular reference to the etiological role of decreased atmospheric pressure, pressure breathing, increased gravitational forces, and anti-G-suit action. Aerosp Med 1967; 38:1283.
- Medical aspects of transportation aboard commercial aircraft. AMA commission on emergency medical services. JAMA 1982; 247:1007.
- Robb DJ. Cases from the aerospace medicine residents' teaching file. Case H57. Complete spontaneous pneumothorax in-flight in an F-16 pilot during a high-G maneuver. Aviat Space Environ Med 1994; 65:170.
- McCormick TJ, Lyons TJ. Medical causes of in-flight incapacitation: USAF experience 1978-1987. Aviat Space Environ Med 1991; 62:884.
- Caceres M, Ali SZ, Braud R, et al. Spontaneous pneumomediastinum: a comparative study and review of the literature. Ann Thorac Surg 2008; 86:962.
- Macia I, Moya J, Ramos R, et al. Spontaneous pneumomediastinum: 41 cases. Eur J Cardiothorac Surg 2007; 31:1110.
- Wallace TW, Wong T, O'Bichere A, Ellis BW. Managing in flight emergencies. BMJ 1995; 311:374.
- Tam A, Singh P, Ensor JE, et al. Air travel after biopsy-related pneumothorax: is it safe to fly? J Vasc Interv Radiol 2011; 22:595.
- Stonehill RB, Fess SW. Commercial air transportation of a patient recovering from pneumothorax. Chest 1973; 63:300.
- Haid MM, Paladini P, Maccherini M, et al. Air transport and the fate of pneumothorax in pleural adhesions. Thorax 1992; 47:833.
- Szymanski TJ, Jaklitsch MT, Jacobson F, et al. Expansion of postoperative pneumothorax and pneumomediastinum: determining when it is safe to fly. Aviat Space Environ Med 2010; 81:423.
- Sacco F, Calero KR. Safety of early air travel after treatment of traumatic pneumothorax. Int J Circumpolar Health 2014; 73:1.
- Cheatham ML, Safcsak K. Air travel following traumatic pneumothorax: when is it safe? Am Surg 1999; 65:1160.
- British Thoracic Society Standards of Care Committee. Managing passengers with respiratory disease planning air travel: British Thoracic Society recommendations. Thorax 2002; 57:289.
- Lippert HL, Lund O, Blegvad S, Larsen HV. Independent risk factors for cumulative recurrence rate after first spontaneous pneumothorax. Eur Respir J 1991; 4:324.
- Franquet T, Giménez A, Torrubia S, et al. Spontaneous pneumothorax and pneumomediastinum in IPF. Eur Radiol 2000; 10:108.
- Taveira-DaSilva AM, Burstein D, Hathaway OM, et al. Pneumothorax after air travel in lymphangioleiomyomatosis, idiopathic pulmonary fibrosis, and sarcoidosis. Chest 2009; 136:665.
- CLINICAL MANIFESTATIONS
- IN-FLIGHT MANAGEMENT OF PTX/PMD
- AIR TRAVEL WITH A PTX/PMD
- TIMING OF AIR TRAVEL AFTER PTX/PMD
- TIMING OF AIR TRAVEL AFTER CARDIOTHORACIC SURGERY
- DISEASE-SPECIFIC MANAGEMENT
- Bullous emphysema
- Interstitial lung disease
- Intrapulmonary bronchogenic cyst
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS