ERS Annual Congress Amsterdam

26–30 September 2015

EDUCATIONAL MATERIAL

Meet the expert 8

Effect of air travel and altitude in patients with

respiratory conditions

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Tuesday, 29 September 2015

13:00 – 14:00

Room G110 RAI

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3

Effect of air travel and altitude in patients with respiratory conditions

Prof. Konrad E. Bloch

University Hospital Zurich, Pulmonary Division

Raemistrasse 100

CH-8091 Zurich, Switzerland

konrad.bloch@usz.ch

AIMS: To review current air travel guidelines for COPD patients, the use of pre-flight tests

and the availability of in-flight oxygen

TARGET AUDIENCE: Pulmonologists, nurses, and respiratory technologists.

AIMS

To improve diagnosis, prevention and treatment of altitude related illness in patients with preexisting

respiratory conditions; to reduce the risk of air travel in patients with respiratory conditions.

At the end of this session the participants should know…

The physiological mechanisms of adaptation to hypobaric hypoxia

The major altitude related illnesses

How to prevent and treat adverse health effects of altitude travel in patients with respiratory

disease

How to assess fitness for flight in patients with respiratory conditions

SUMMARY

Altitude and air travel are increasingly popular involving millions of persons worldwide. Many healthy

subjects and patients with respiratory disease seek advice regarding prevention of altitude related health

problems. Typical effects of exposure to hypobaric hypoxia at altitude include a reduced exercise

performance, shortness of breath, poor sleep, and high altitude periodic breathing. Depending on the

altitude reached, the speed of ascent, and individual susceptibility, altitude related illnesses such as acute

mountain sickness, high altitude cerebral oedema, and high altitude pulmonary oedema may develop.

Patients with pre-existing respiratory disease are particularly susceptible to unfavourable effects of

altitude. In patients with COPD altitude exposure increases dyspnoea, reduces exercise performance,

and is associated with poor sleep in the first few nights at altitude. Appropriate preparation, a moderate

ascent rate, and specific preventive measures tailored to the individual need and pre-existing condition

are essential to allow healthy subjects and patients to enjoy altitude travel.

Many respiratory patients seek advice regarding health risks of air travel. Fitness for flight assessments

and counselling patients regarding measures to prevent adverse effects of air travel are therefore an

important part of everyday activities of respiratory physicians. Guidelines and practical issues regarding

air travel of patients with respiratory conditions will be discussed.

44

REFERENCES

1. Nussbaumer-Ochser Y, Bloch KE. Lessons from high-altitude physiology. Breathe 2007; 4:123.

Review of physiologic adaptation to hypobaric hypoxia and altitude-related illnesses.

2. Nussbaumer-Ochser Y, Bloch KE. High-altitude disease. In ERS handbook of respiratory

medicine. Palange P, Simonds AK, edts. Lausanne 2010, 2nd edition, chapter 10:361.

Review of altitude related adverse health effects, prevention of altitude-related illness.

3. Bartsch P, Swenson ER. Clinical practice: high-altitude illnesses. N Engl J Med 2013; 368:2294.

Case-based discussion of current recommendations for prevention and treatment of

altituderelated illnesses.

4. British Thoracic Society Air Travel Working Group. Thorax 2011; 66, suppl 1: i1-i30. Managing

patients with stable respiratory disease planning air travel: British Thoracic Society

Recommendations.

5. Bloch KE, Latshang TD, Ulrich S. Patients with obstructive sleep apnea at altitude. High Alt Med

Biol 2015; 16:110-6.

Review of effects of altitude travel in patients with obstructive sleep apnea and treatment

recommendations.

6. Bloch KE, Buenzli JC, Latshangg TD, Ulrich S. Sleep at high altitude: guesses and facts. J Appl.

Physiol 2015: in presse.

Review of effects of altitude on sleep and breathing.

EVALUATION

1. Typical manifestations of high altitude illness include the following except?

a. visual disturbances

b. chest pain

c. headache

d. cough

e. fever

2. Which of the followig is correct regarding a COPD patient flying from Zurich to Calgary? (SpO2

on room air at 400 m = 91%)

a. No particular risk beause of pressurized cabin

b. High risk of an in-flight medical event

c. Prescribe prednisone 1 mg/kg body weight before departure

d. Prescribe in-flight supplemental oxygen 2 l/min

e. Recommend hypoxic challenge before flight

3. A 56 yo patients with COPD, FEV1 45% pred., plans to spend a vaccation in the mountains at

2’500 m. When counselling the patient which of the following is appropriate, except?

a. Spirometric values will deteriorate

b. Sleep will be disturbed in the first few nights

c. Acetazolamide might cause dyspnea

d. Use of supplemental oxygen is recommended

e. Exercise performance will be reduced

55

4. Which of the following is true regarding patients with OSA travelling to high altitude?

a. breathing disturbances are reduced because of lower air density

b. nocturnal oxygen supplementation instead of CPAP should be administered

c. theophylline will improve sleep quality

d. acetazolamide and CPAP will improve breathing disturbances

e. CPAP mask pressure should be reduced

5. Asthmatics have an increased risk of altitude related illness because...

a. Hypoxia induces bronchial obstruction

b. Bronchial responsiveness increases at altitude

c. The risk of exacerbation is increased

d. In asthma there is diffusion limitation

e. Asthma is a risk factor for high altitude pulmonary edema

66

29/09/2015

77

EFFECT OF AIR TRAVEL AND ALTITUDE IN PATIENTS WITH RESPIRATORY CONDITIONS

Prof. Konrad E. Bloch, MDPulmonary Division, University Hospital of Zurich

Zurich, Switzerland

konrad.bloch@usz.ch

ERS 2015, AmsterdamMeet-the-Expert Session, September 29, 2015

88

Faculty disclosure

• I have no conflict of interest in relation to this presentation

99

INTRODUCTION

AIMS

At the end of this session participants should know

• The physiologic mechanisms of adaptation to hypobarichypoxia

• The major altitude related illnesses

• How to prevent and treat adverse health effects of altitude and air travel in patients with respiratory conditions withparticular focus on COPD

1010

FITNESS FOR FLIGHT

ASSESSMENT

1111

advise againstair travel

British Thoracic Society Guidelines, Thorax 2011;66:i1

Does the patient have contraindications to air flight ?

Result of hypoxic challenge test:PaO2 <6.6 kPa or SpO2 <85% ?

Prescribe in-flight oxygen orPerform hypoxic challenge test

Physician judgement on advice to fly

Optimize usual careadvice on thrombosis

prophylaxis

yes no

noIs the patient in a high risk group ?

Is the patient receving long-term oxygen ?Is SpO2 <95% on room air, at sea level?

In-flight oxygen2l/min per nasalcannula or more

yesno

!

FITNESS FOR FLIGHT ASSESSMENT

1212

CONTRAINDICATIONS TO AIR TRAVEL

• Infectious tuberculosis

• Ongoing pneumothorax with persistent air leak

• Major hemoptysis

• Patients on long-term oxygen requiring >4 l/min at sea level

• Any acute life-threatening disease

1313

HIGH-RISK PATIENTS

• Previous air travel intolerance

• Severe COPD (FEV1<30% pred) or asthma, bullous disease

• Severe resrictive disease (FVC <1L), especially with hypoxemia or hypocapnia

• Comorbidity with conditions worsened by hypoxemia (cerebrovascular disease, cardiac disease, pulmonary hypertension)

• Risk of or previous thromboembolism

• Requirement of oxygen, CPAP or ventilatory support

• Recent pneumothorax, cystic fibrosis, pulmonary tuberculosis

!

1414

OXYGEN DURING AIR TRAVEL

SpO2 >95% No oxygen required

SpO2 <95% In-flight oxygen depending on Hypoxia Challenge Test (prescribe in-flight oxygen if SpO2<85%)

Already receiving LTOT In-flight oxygen at double flow rate

British Thoracic Society Guidelines, Thorax 2011;66:i1

Own portable oxygen concentrator (POC) can be carried along, has to be announcedBottled oxygen from airline company, to be ordered in advance (CHF 300-400)

1515

WWW.EUROPEANLUNG.ORG

1616

WWW.EUROPEANLUNG.ORG

1717

WWW.EUROPEANLUNG.ORG

1818

1919

2020

Muhm et al NEJM 2007;357:18~100 persons per group

2438m

1829m

1219m

2134m

200m

SPO2 DURING SIMULATED FLIGHT

2121

MEDICAL EMERGENCIES DURING FLIGHT

226 incidents/106 pax17 require immediate landing1 death per 106 pax

Delaune et al. Aviat Space Environ Med 2003;74:62 2222

Akero et al Thorax 2005;25:725

cruising altitude1‘829 m, 6’000 ft

PCO2

5.0

PCO2

4.9PCO2

4.8

18 COPD patients

AIR TRAVEL IN COPD PATIENTS

SpO2

%

2323

• Stable on optimized treatment (LABA & ICS, LAAC)

• Avoid excessive physical exertion

• Supplemental oxygen

– If needed at sea level: increase dose x2

– If SpO2 at sea level <95% and risk factor (low FEV1, co-morbidity): perform hypoxic challenge test

– Oxygen supplementation: by portable concentrator, or from airline

• Emergency medication (inhalers, prednisone, antibiotics), pulse oximeter

• In case of pulmonary hypertension and longer stay at altitude: consider nifedipine prophylaxis (after testing)

• Caution with acetazolamide

AIR TRAVEL IN COPD PATIENTS

2424

• Travel only if asthma controlled• Continue treatment as usual

– Controller: inhal. Corticosteroid +/- LABA– Dry powder inhaler (combined)– As needed: SABA

• Preventive treatment as needed– LABA– Corticosteroid (inhaled or oral)

• Avoid irritants: dry, fume• Cary emergency medication

– Inhalers– Prednisone tbl. or dexamethasone– Antibiotics– Medication of altitude relatied illness

RECOMMENDATIONS FOR ASTHMATICS

Cogo & Fiorenzano High Alt Med Biol 2009;10:117 2525

THROMBOSIS RISK DURING FLIGHT

Chandra et al Ann Int Med 2009;151:180

Meta-analaysis of studies including 4’055 DVT cases

relative risk = 10

+26% increaseper 2 h flight duration

8 h flight

2626

IN-FLIGHT THROMBOEMBOLISM

Low risk • Avoid excessive alcohol and caffeinated drinks

• be mobile/exercise legs during flight

Moderate risk

• Family or personal hx of VTE, thrombophilia

• obesity (BMI >30 kg/m2)

• height <1.6, >1.9m

• significant illness in prev. 6 weeks

• cardiac disease (CHF)

• immobility, pregnancy, estrogentherapy , <2 weeks post partum

In addition to above:

Below knee elastic compression stockings, no sedatives

High risk • Hx of idiopathic VTE

• <6 weeks post major surgery or trauma

• active malignancy

In addition to above:

Consider LMW heparin or oral anticoagulation

Specific measures only recommended for long distance flights >8 Std.

British Thoracic Society Guidelines, Thorax 2011;66:i1 2727

PNEUMOTHORAX AND FITNESS FOR FLIGHT

• Patients with Ptx should not travel on commercial flights

• Resolution of Ptx should be confirmed and travel deferred for at least further 7d

• (similarly: wait at least 7d after thoracic surgery and resolution of Ptx)

• Traumatic Ptx: air travel should be delayed for at least 2 weeks after resolution

2828

CARDIOVASCULAR PATIENTS

• Low risk

– <65 yo, first event, successful reperfusion, no complications, no intervention planned, EF >45%

– EF >40%, no symptoms of CHF, no evidence of inducible ischemia or arhythmia, no intervention planned

• High Risk

– EF <40% with signs and symptoms of CHF, plannend investigation or intervention

Fly within

3 days

Fly within

10 days

WAIT

2929

RECOMMENDATION FOR PATIENTS WITHPULMONARY HYPERTENSION

• NYHA 1-2: air travel without oxygen

• NYHA 3-4: in-flight oxygen 2 l/min

• Stable condition

• Check SpO2, arterial blood gas analysis

• Anticoagulation as indicated in PH

3030

PREVENTION AND

TREATMENT OF ALTITUDE

RELATED ILLNESS

3131

COUNSELLING ALTITUDE TRAVELLERS

• Ascent plan

– Setting

– Altitude reached (expected hypoxemia)

– Time for ascent

– Physical activity

– Sleeping altitude

• Personal health condition

– Pre-existing illness

– Previous altitude exposure, tolerance

– Fitness

3232

ALTITUDE, BAROMETRIC PRESSURE AND OXYGENSATURATION IN A HEALTHY SUBJECT

Alp

ine

reso

rts,

air

flig

ht

Mo

un

tain

hu

ts in

the

Alp

s &

Ro

ckie

s

Ever

est

Mt. Rosa4’559 m

103 m

3333

HIGH ALTITUDE ILLNESS

• acute

– acute mountain sickness

– high altitude cerebral edema

– high altitude pulmonary edema

• chronic

– chronic mountain sickness

– high altitude pulmonaryhypertension

3434

ACUTE MOUNTAIN SICKNESS

Symptom Points

Headache 0-3

Gastro-intestinal symptoms 0-3

Fatigue or weakness 0-3

Dizziness/lightheadedness 0-3

Difficulty sleeping 0-3

Range 0 to 15

Lake Louise Score

Clinically relevant AMS: headache + symptom score of at least 3after recent ascent to altitude

Roach et al. Lake LouiseConsensus Conference Proceedings, 1993 3535

DSpO2 exercise

ventilatory response to hypoxia during exercise

heart rate response to hypoxiaduring exercise

Ascent >400 m/d

History of severe high altitude illness

Regular physical activity

History of migraine

Female gender

Age <46 y

Adjusted OR, 95% CI100.1 1

RISK OF SEVERE HIGH ALTITUDE ILLNESS

Richalet et al. AJRCCM 2012;185:192

model based on data from 1326 respondents

3636

PREVENTION & TREATMENT OF HIGH ALTITUDERELATED ILLNESS

Prophylaxis• acclimatization, low sleeping altitude• avoidance of extreme exertion• acetazolamide 2x 125-250mg/d, >2´500m, starting the day

before ascent• nifedipine (high altitude pulmonary edema susceptibles, 2x

20-30mg, dexamethasone 2x 8mg, Sildenafil 3x 50 mg)

Treatment• descent, oxygen• non-steroidal antirheumatics (ibuprofen 600mg 2-3/j)• acetazolamide 2x 250mg/d• dexamethasone 2x 4-8mg/d• nifedipine (high altitude pulmonary edema, 2x 20-30mg)

Nussbaumer & Bloch, Breathe 2007;4:123Bartsch & Swenson NEJM 2013;369:1666 3737

PATIENTS WITH OSAS AT ALTITUDE

• Patients with OSAS travelling to altitudeexperience exacerbatedbreathing disturbances withfreuqent central apneas

• Suggested treatment isautoCPAP combined withacetazolamide 2x250 mg/d

3838

Faculty disclosures

There are no faculty disclosures for this session.

3939

Answers to evaluation questions

Please find all correct answers in bold below

Effect of air travel and altitude in patients with respiratory conditions –

Prof. Dr Konrad Bloch

1. Typical manifestations of high altitude illness include the following except?

a. visual disturbances

b. chest pain

c. headache

d. cough

e. fever

2. Which of the followig is correct regarding a COPD patient flying from Zurich to Calgary? (SpO2

on room air at 400 m = 91%)

a. No particular risk beause of pressurized cabin

b. High risk of an in-flight medical event

c. Prescribe prednisone 1 mg/kg body weight before departure

d. Prescribe in-flight supplemental oxygen 2 l/min

e. Recommend hypoxic challenge before flight

3. A 56 yo patients with COPD, FEV1 45% pred., plans to spend a vaccation in the mountains at

2’500 m. When counselling the patient which of the following is appropriate, except?

a. Spirometric values will deteriorate

b. Sleep will be disturbed in the first few nights

c. Acetazolamide might cause dyspnea

d. Use of supplemental oxygen is recommended

e. Exercise performance will be reduced

4. Which of the following is true regarding patients with OSA travelling to high altitude?

a. breathing disturbances are reduced because of lower air density

b. nocturnal oxygen supplementation instead of CPAP should be administered

c. theophylline will improve sleep quality

d. acetazolamide and CPAP will improve breathing disturbances

e. CPAP mask pressure should be reduced

5. Asthmatics have an increased risk of altitude related illness because...

a. Hypoxia induces bronchial obstruction

b. Bronchial responsiveness increases at altitude

c. The risk of exacerbation is increased

d. In asthma there is diffusion limitation

e. Asthma is a risk factor for high altitude pulmonary edema