EDUCATIONAL MATERIAL

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1 ERS Annual Congress Amsterdam September 2015 EDUCATIONAL MATERIAL Meet the expert 8 Effect of air travel and altitude in patients with respiratory conditions Thank you for viewing this document. We would like to remind you that this material is the property of the author. It is provided to you by the ERS for your personal use only, as submitted by the author by the author Tuesday, 29 September :00 14:00 Room G110 RAI

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3 EUROPEAN LUNG FOUNDATION Bringing together patients and the public with respiratory professionals To help you provide advice to your patients, ELF produces factsheets on lung health and disease. These are informed by patient and professional interviews and written in language that is easy to understand. You can download an electronic version of all the factsheets from the ELF website. There are over 30 titles, covering a range of topics, in more than 8 different languages. Recent factsheets: Exercise and air quality: 10 top tips Vaccination and lung disease Chronic cough Smoking when you have a lung condition Primary spontaneous pneumothorax E-cigarettes Work-related lung conditions Severe and difficult-to-treat asthma 3

4 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 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. 4

5 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, 2 nd 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: 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 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 5

6 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 6

7 29/09/2015 7

8 ERS 2015, Amsterdam Meet-the-Expert Session, September 29, 2015 EFFECT OF AIR TRAVEL AND ALTITUDE IN PATIENTS WITH RESPIRATORY CONDITIONS Prof. Konrad E. Bloch, MD Pulmonary Division, University Hospital of Zurich Zurich, Switzerland 8

9 Faculty disclosure I have no conflict of interest in relation to this presentation 9

10 INTRODUCTION AIMS At the end of this session participants should know The physiologic mechanisms of adaptation to hypobaric hypoxia The major altitude related illnesses How to prevent and treat adverse health effects of altitude and air travel in patients with respiratory conditions with particular focus on COPD 10

11 FITNESS FOR FLIGHT ASSESSMENT 11

12 FITNESS FOR FLIGHT ASSESSMENT Does the patient have contraindications to air flight? yes no advise against air travel Is the patient in a high risk group? Is the patient receving long-term oxygen? Is SpO 2 <95% on room air, at sea level? Prescribe in-flight oxygen or Perform hypoxic challenge test! no yes Result of hypoxic challenge test: PaO2 <6.6 kpa or SpO 2 <85%? no In-flight oxygen 2l/min per nasal cannula or more Physician judgement on advice to fly British Thoracic Society Guidelines, Thorax 2011;66:i1 Optimize usual care advice on thrombosis prophylaxis 12

13 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 13

14 ! 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 14

15 OXYGEN DURING AIR TRAVEL SpO 2 >95% SpO 2 <95% Already receiving LTOT No oxygen required In-flight oxygen depending on Hypoxia Challenge Test (prescribe in-flight oxygen if SpO 2 <85%) In-flight oxygen at double flow rate Own portable oxygen concentrator (POC) can be carried along, has to be announced Bottled oxygen from airline company, to be ordered in advance (CHF ) British Thoracic Society Guidelines, Thorax 2011;66:i1 15

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21 SPO2 DURING SIMULATED FLIGHT 200m 1219m 1829m 2134m 2438m ~100 persons per group Muhm et al NEJM 2007;357:18 21

22 MEDICAL EMERGENCIES DURING FLIGHT 226 incidents/10 6 pax 17 require immediate landing 1 death per 10 6 pax Delaune et al. Aviat Space Environ Med 2003;74:62 22

23 AIR TRAVEL IN COPD PATIENTS 18 COPD patients cruising altitude m, ft SpO 2 % PCO PCO PCO Akero et al Thorax 2005;25:725 23

24 AIR TRAVEL IN COPD PATIENTS Stable on optimized treatment (LABA & ICS, LAAC) Avoid excessive physical exertion Supplemental oxygen If needed at sea level: increase dose x2 If SpO 2 at sea level <95% and risk factor (low FEV1, comorbidity): 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 24

25 RECOMMENDATIONS FOR ASTHMATICS 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 Cogo & Fiorenzano High Alt Med Biol 2009;10:117 25

26 THROMBOSIS RISK DURING FLIGHT Meta-analaysis of studies including DVT cases +26% increase per 2 h flight duration 0 relative risk = 1 8 h flight Chandra et al Ann Int Med 2009;151:180 26

27 IN-FLIGHT THROMBOEMBOLISM Specific measures only recommended for long distance flights >8 Std. Low risk Avoid excessive alcohol and caffeinated drinks Moderate risk be mobile/exercise legs during flight 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, estrogen therapy, <2 weeks post partum High risk Hx of idiopathic VTE <6 weeks post major surgery or trauma active malignancy In addition to above: Below knee elastic compression stockings, no sedatives In addition to above: Consider LMW heparin or oral anticoagulation British Thoracic Society Guidelines, Thorax 2011;66:i1 27

28 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 28

29 Low risk CARDIOVASCULAR PATIENTS <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 29

30 RECOMMENDATION FOR PATIENTS WITH PULMONARY 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 30

31 PREVENTION AND TREATMENT OF ALTITUDE RELATED ILLNESS 31

32 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 32

33 ALTITUDE, BAROMETRIC PRESSURE AND OXYGEN SATURATION IN A HEALTHY SUBJECT Mt. Rosa m Alpine resorts, airflight Mountain huts in the Alps & Rockies Everest 10 3 m 33

34 acute HIGH ALTITUDE ILLNESS acute mountain sickness high altitude cerebral edema high altitude pulmonary edema chronic chronic mountain sickness high altitude pulmonary hypertension 34

35 ACUTE MOUNTAIN SICKNESS Symptom Lake Louise Score 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 Clinically relevant AMS: headache + symptom score of at least 3 after recent ascent to altitude Roach et al. Lake Louise Consensus Conference Proceedings,

36 RISK OF SEVERE HIGH ALTITUDE ILLNESS ventilatory response to hypoxia during exercise DSpO2 exercise heart rate response to hypoxia during 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% CI model based on data from 1326 respondents 10 Richalet et al. AJRCCM 2012;185:192 36

37 PREVENTION & TREATMENT OF HIGH ALTITUDE RELATED ILLNESS Prophylaxis acclimatization, low sleeping altitude avoidance of extreme exertion acetazolamide 2x mg/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: Bartsch & Swenson NEJM 2013;369:1666

38 PATIENTS WITH OSAS AT ALTITUDE Patients with OSAS travelling to altitude experience exacerbated breathing disturbances with freuqent central apneas Suggested treatment is autocpap combined with acetazolamide 2x250 mg/d 38

39 Faculty disclosures There are no faculty disclosures for this session. 39

40 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 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