Travelling with Bronchiectasis
One of the major concerns for people with a chronic respiratory condition is the in-flight spread of infection from other passengers. In modern aircraft, cabin air is recirculated through high efficiency particulate air filters (HEPA) which are designed to extract droplet and particulate matter.
Respiratory pathogens usually spread by large droplets (which drop quickly to the ground and are extracted by the filtration system) or airborne tiny droplet nuclei. HEPA filters are 100% effective in removing the large droplets and 99.9% effective in removing the smaller particles. Individual’s concern about cross infection has shown to be minimal .
There are no published studies associated with hypoxaemia during air travel in people with bronchiectasis but some people with bronchiectasis have co-morbidities which will predispose them to hypoxaemia at high altitudes (BTS Air Travel Guidelines: Ahmedzai et al 2011).
A small percentage of people with a chronic lung condition, who have low blood oxygen levels, may have difficulty travelling by air due to the reduced air pressure in the aircraft cabin, which is equivalent to being at 6000 feet on a mountain. At high altitudes, blood oxygen levels fall which can make some people feel breathless. If a person can walk for 50 metres on the level (without using oxygen), at a steady pace, without feeling short of breath or needing to stop, they are not likely to be troubled by the reduced pressure in aircraft cabins.
In some large hospitals, hypoxic challenge tests can be performed to assess the need for in-flight oxygen. If these tests show that blood oxygen levels are too low to travel by air, supplementary oxygen can be organised through travel agents and the airlines at a cost. This needs to be organised at least a month before the date of travel.
Deep vein thrombosis (DVT)
Longer flights place people at a higher risk of developing a DVT (Hamada et al 2002). It is recommended for people to:
wear flight stockings
exercise the legs at regular intervals during the flight (either pumping the calves in sitting or walking up and down the aisles during the flight)
take anticoagulant medication if they are at increased risk of developing a DVT
drink fluids regularly during the flight, with minimal alcohol
If equipment is required during a flight, such as CPAP devices or nebulisers, they need to be battery driven and cannot be used during take-off or landing.
Permission should be sought from the airline, prior to travel, for use of medical devices in-flight.
Sinus issues are common in people with bronchiectasis. Adults with chronic sinusitis should receive an oral decongestant before travel and a nasal decongestant spray during the flight, in particular just prior to descent.
For sinus relief on long haul flights some patients report benefits from using:
NeilMed pre-mixed sinus irrigation “Saline on the Go” 15ml ampoules
FESS Frequent flyer nasal spray for regular use during the flight
When travelling by air, hydration and humidification can be a major issue. To prevent dehydration during a long-haul flight it is important to drink water regularly and to avoid alcohol.
The humidity of an aircraft cabin is also an issue. At ground level at a temperature of 22 degrees, the relative humidity is generally around 50%. In an aircraft cabin, at high altitudes, the relative humidity is approximately 21%.
Airways do not function well in low humidity. After a short time the ciliary cells suspend their transport function, inhibiting the muco-ciliary escalator efficiency of muco-ciliary clearance. Under such circumstances, bacterial germinal colonization is facilitated with the possible consequence of pulmonary infection(Möller et al 2006) .
If adequate fluids are also not consumed during the flight the person may become dehydrated. Dehydration causes lethargy and other symptoms. In a dehydrated lung, the mucus in the airways becomes thicker which contributes to inefficient muco-ciliary clearance.
It is possible that in some people, respiratory infections following air travel are not a result of pathogens from other passengers but from the suppressed natural cleaning mechanisms of the lung.
Some patients’ report that the Humidiflyer device, a full face mask worn for a majority of the flight, is beneficial (Fig. 1). The Humidiflyer has been shown to provide a relative humidity of 58% when worn correctly.
There is no evidence for the use of this device for people with respiratory conditions so it should be prescribed by the patients’ GP or physician.
Fig. 1 Humidiflyer
Frequent travellers’ medical card
Patients with medical needs, who fly frequently, can obtain a Frequent Travellers’ Medical Card which records their information and replaces the need to fill in forms for each flight.
Patients should visit their GP or a travel clinic to check if immunisations are required for their destination. Ideally, this should be organised well in advance so that immunisations can be given when the patient is well rather than when recovering from an exacerbation which is not a good time to be immunised.
It is recommended for all patients to be up-to-date with influenza and pneumonia vaccinations (British Thoracic Society Guidelines).
Travel insurance is essential as medical expenses can be very high in some countries. Take care that the small print covers any medical costs associated with pre-existing conditions. Some policies will not cover aspects of travel for people over 70 years of age.
Many policies will only provide cover for previous lung conditions if the patient has written confirmation from their doctor stating that they are fit to fly.
For some people, it may be important to check if the travel insurance policy includes the cost of a return by air ambulance if a commercial flight is not possible.
Make sure that adequate medications are packed for every day of the trip and that they are stored as per the manufacturers’ recommendations.
For essential medications (including inhalers) it is advisable to carry some in the hand luggage and some in the suitcase in case the luggage does not initially arrive at the destination.
All patients should travel with a letter from their doctor detailing their condition and list of medications. This will be necessary in case of an exacerbation and will also provide proof for the packed medications.
It is advisable to take an emergency supply of antibiotics, and any other medications that may be required, in case of an exacerbation.
An appropriate airway clearance program should be continued at all times. For some people it is more difficult when on holidays as the routine is interrupted but patients must be encouraged to continue, as normal, if possible.
If a nebuliser is required, several brands are available that are appropriate for travel (see Inhalation via a Nebuliser section).
On a long flight, it is advisable to do an airway clearance routine more frequently than normal due to the lack of humidification and likely inactivity for extended periods.
Activity increases air flow which assists with the removal of excess secretions in the lungs. With inactivity, it is advisable to do some long slow deep breaths (through the nose if possible) every waking hour during the flight.
If possible, walk up and down the aisle of the aircraft as often as is practical, taking deep breaths. This is important for the circulation and will also assist with airway clearance.
The purpose of exercise training in bronchiectasis is to improve exercise tolerance, reduce symptoms of fatigue and improve quality of life. For some individuals, exercise may also assist in clearing secretions.
The minimal requirements for exercise training for individuals with bronchiectasis is 30 minutes of moderate intensity activity, 3 times per week (consistent with general health recommendations).
When travelling, the normal exercise routine may need to be adapted. This should be discussed with a health professional, trained in exercise for people with bronchiectasis, prior to travel.
Before commencing a holiday, a patient should visit their GP or respiratory specialist to discuss the management of their condition whilst they are away.
An action plan should be made with the patient to provide a management strategy for exacerbations (see Action Plans).