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Guideline update
Managing passengers with stable respiratory disease planning air travel: British Thoracic Society recommendations
  1. Dinesh Shrikrishna1,
  2. Robina K Coker2 on behalf of the Air Travel Working Party of the British Thoracic Society Standards of Care Committee
  1. 1National Heart & Lung Institute, Royal Brompton Hospital and Imperial College London, UK
  2. 2National Heart & Lung Institute, Hammersmith Hospital and Imperial College London, UK
  1. Correspondence to Dr Dinesh Shrikrishna, Royal Brompton Hospital, Department of Respiratory Medicine, London SW3 6NP, UK; dinesh.shrikrishna{at}


This article summarises the key points from the 2011 British Thoracic Society (BTS) recommendations on managing passengers with respiratory disease planning air travel. The guidance aims to provide practical advice for respiratory specialists in secondary care and serves as a valuable reference for other healthcare professionals managing these patients. A greater awareness of the challenges posed by air travel will allow improved clinical assessment and practical advice to encourage patients to fly safely wherever possible.

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Need for new recommendations for passengers with respiratory disease planning air travel

The question of how best to assess and advise on the safety of passengers with lung disease planning air travel is an increasingly common one faced by respiratory physicians and other healthcare professionals. Since the first BTS recommendations published in 20021 and web updated in 2004,2 a number of studies have confirmed that neither resting sea level oxygen saturations nor forced expiratory volume in 1 s (FEV1) reliably predict hypoxaemia, or complications of air travel, in passengers with respiratory disease.3–5 It has become clear that no reliable threshold in these variables can accurately determine the safety of air travel or the need for in-flight oxygen. Despite this, a North American service offering radio link assistance for in-flight medical emergencies logs >17 000 calls a year, with respiratory events accounting for 10–12% of such calls from 2004 to 2008 (personal communication Dr Paulo Alves, MedAire, 2009). Therefore, physicians must be aware of the potential effects of the flight environment in those with lung disease, and the need for practical recommendations remains.

The 2011 guidance document now covers bronchiectasis, cancer, obesity, hyperventilation and dysfunctional breathing, pulmonary arteriovenous malformations and sinus and middle ear disease; and has expanded sections on infection and co-morbidity with cardiac disease. The recommendations are an expert consensus view based on literature reviews and aim to provide practical advice for respiratory specialists in secondary care, as well as providing a valuable reference for other healthcare professionals. The advice applies to commercial flights only (including scheduled repatriation with a medical or nurse escort), and excludes emergency aeromedical evacuations. However, if medical practitioners do assist at an in-flight medical emergency, most airlines will indemnify them, the aircraft will have medical equipment and they can often access specialist advice from ground-based support.

Purpose of recommendations

  • To enhance safety for passengers with lung disease travelling on commercial flights and reduce respiratory complications.

  • To promote further understanding among healthcare professionals that patients with respiratory disease may require clinical assessment and advice before air travel.

  • To provide an authoritative up-to-date literature review of the latest available evidence.

  • To provide consistent, practical and comprehensive advice for healthcare professionals managing these patients.

  • To formulate key research questions to provoke further investigation, thereby providing a strengthened high quality evidence base for future guidelines.

  • To promote the development of methods for monitoring the size of the problem.

A summary of key points from the new recommendations (table 1) and an algorithm for managing adult passengers with respiratory disease planning air travel (figure 1) are included here for practical reference in the clinic setting.

Table 1

Summary of key points and recommendations

Figure 1

Algorithm for managing adult passengers with respiratory disease planning air travel. LTOT, long-term oxygen therapy; VTE, venous thromboembolism.



  • Competing interests None.

  • Provenance and peer review Not commissioned; internally peer reviewed.