Air Travel : Fit to Flight

I Putu Adiartha Griadhi

Physiology Department of Medical
School of Udayana University

Physics of The Atmosphere

Composition
Nitrogen : 80 % -- inert gas in the body,
stored in tissues and cells.
Oxygen : 20 % -- essential for life,
support body metabolism
Other : trace such as Argon, Neon,
Helium, Krypton, Xenon, Hidrogen,
Carbon Dioxide

Atmospheric Pressure
The unit of pressure could be in
Pascal (Pa), Bar, pounds per square
inch (psi), and atmosphere (atm)
At sea level the atmospheric
pressure will be : 100 kPa = 1 atm =
1 bar = 14,7 psi
Within the atmosphere the presure
will decrease 1 milibar every 9
meters (30 feet) ~ in diving 1 bar
every 10 meters (33 feet)

Physiological Zones of The

Atmosphere
Zones
Physiologic
al Efficient
Zone

Altitudes
Sea level 12.500
feet

Pressure
760 523
mmHg

Characteristic
Body adapted well
Minor trapped gas
Shortness of
breath, dizziness,
headache, fatigue

Physiologic 12.500 feet 50.000 523 87

al Deficient feet
mmHg
Zone

Fliying zone,
hypoxia and
decompression
sickness

Space
Equivalent
Zone

Hostile
environment to
human
Body fluid start to
boil

50.000 feet 1000

miles

87 0 mmHg

Physical Gas Law and Its

Application
Gas Law

Explanation

Aviation Application

Daltons Law
PT = P1 + P2
+ ...PN

The total pressure of

a mixture gas is
equal to the sum of
the partial pressure
of each gas

Hipoxia

Boyles Law
P1
= V1
P2
V2

A volume of a gas is
inversely
proportional to the
pressure to which it
is subjected, in
constant
temperature

Trapped Gas

Henrys Law
P1 = A1
P2
A2

The amount of gas

dissolved in a
solution varies

Decompression
Sickness

Explain how ascent

altitude reduce the total
atmospheric pressure as
well as each of partial
pressures asociated with
the total atmospheric
pressure.
Explain how pressure
change allow the gas to
expand and contract in
body cavities (ear,
sinuses, and GI Tract)

Specific Condition

Hypoxia
The most physiological problem
during flight is hypoxia
Hypoxia is describe as a state of
oxygen deficiency in the blood,
tissues, and cells sufficient to cause
impairement of body function.
Many condition can interrupt the
normal flow of oxygen to the cells.

Hypoxia Signs and

Symptoms
SIGNS

SYMPTOMS

Rapid Breathing
Cyanosis
Poor Coordination
Lethargy
Executing Poor
Judgement

Air Hunger
Fatigue
Nausea
Headache
Dizziness
Hot and Cold Flashes
Tingling
Visual Impairment
Euphoria

Trapped Gas
Gas readily expand with any decrease in pressure.
Gas expand in accordance with Boyles Law :
A volume of gas inversly proportional to the
pressure to which it is subjected, in constant temperature

If you reduce pressure, as in ascending altitude,

gases increase in volume and vice versa in descent
Human body has several cavity that contain
variying amount of gas. Most of them have an
opening that will allow gas to enter and escape.
If the opening reduced in size or closed, the the gas
is trapped.

Trapped Gas
Body Area

Problem Phase of
Flight

Physiology

Middle Ear

DESCENT

On ascent the air and pressure of

expanding gas will escape via
eustachian tube, the base is
collapsed which act as a one way
valve. On descent the gas then
trapped.

Sinuses

DESCENT or
ASCENT (rare)

In the upper respiratory infection

the opening of the sinus will be
swollen and possibly closed.

Teeth

ASCENT

It very rare. This can occur

if you have had recent
filling of cavity. If there is
any airspace trapped
between the filling and
pulp it will expand during
ascent.

Trapped Gas
Body Area

Problem Phase of
Flight

Physiology

Gastrointesti
nal

ASCENT

This part of body will

always contain a variying
amount of gas. This gas is
ussually a result of
digestion process and can
escape by either
flatulation or belching.

Is your passanger fit to fly ?

Depend on many things :
The
The
The
The
The

patient
condition
flight
aircraft
reason for travel

Some general principles can be used

to asnwer this question

Fitness to Fly
Complex interaction between clinical
condition and flight environment
Flight environtment :
Basically a hostile one
Reduced atmospheric pressure
Very reduced oxygen content
Hypoxia, cold, and decompression
illness

Specific Condition
CARDIOVASCULAR DISEASE
Hypobaric Hypoxia
The decrease in oxygen saturation will
compensated by the patient by
increasing their ventilation and mild
tachycardia. These will increase
myocardial oxygen demand.
Patient with limited cardiac reserve need
supplemental oxygen.

Specific Condition
CARDIOVASCULAR DISEASE
Angina Pectoris
Is ussualy not problem in flight
May travel 7 10 days if there is no
complication

Coronary artery bypass grafting

No intrinsic risk in the flight as long as
the patient fully recovered w/o
complication
Approximately 10 14 days

Specific Condition
RESPIRATORY DISEASE
It will depend on the type and
reversibility of the underliying
disease and as assessment of
tolerance
HYPOXIC CHALLANGE : stimulates
with cabin environment, if it result in
Pa O2 < 55 mmHg supplement
oxygen needed

Specific Condition
Practical fitness to fly testing :
assess whether the patient can walk
50 yards/meters at normal pace or
climb one flight or stairs without
severe dyspnoea.
If this can be accomplished, it is
likely that the patient will tolerate
the normal aircraft environment.

Specific Condition
Asthma
No specific challange from cabin environment as
long as the asthma is stable.
Ensure that all medication is carried out in hand
baggage.

COPD
Walking test or hypoxic challange appropriate to
determine the passanger requirement for
supplemental oxygen in flight.
Flow rate of 2 4 litres per minutes are ussualy
available in some airlines

Specific Condition
Bronchiectasis and Cystic Fibrosis
Control of lung infection to loosen and clear
the secretion. Appropriate antibiotics therapy
and medical oxygen

Infection
Patient with active infection are unsuitable for
travel until there is documented control of the
infection and they are no longer infectious.
No residual infection and satisfactory result of
exercise tolerance test.

Specific Condition
Pneumothorax
The presence of a pneumothorax is an absolute
contraindication to air travel as trapped air may
expand and result in a tension pneumothorax.
In general, it should be safe to travel
approximately 2 weeks after successful
drainage of a pneumothorax with full expansion
of the lung.
If there is a need to travel earlier, safe travel is
possible using a one-way Heimlich valve
attached to the chest drain.

Specific Condition
Pregnancy
The commercial aircraft environment is not
generally considered hazardous to a normal
pregnancy.
Because of the favourable properties of foetal
haemoglobin (HbF) including increased oxygen carrying
potential together with a high foetal haematocrit and the
Bohr effect, foetal PaO2 changes very little.

Delivery in flight, is undesirable. Most airlines

do not allow travel after 36 weeks for a single
pregnancy and after 32 weeks for a multiple
pregnancy.

Specific Condition
Diabetes
Air travel should not pose significant problems for
patients with well-controlled diabetes.
It is essential that the diabetic passenger carries
adequate equipment and medication in their hand
baggage.
It is important that insulin is not packed in the hold
baggage even if it is not being used during the flight as
insulin in the hold may be exposed to temperatures that
could degrade it and there is the potential risk of loss of
baggage en-route.
Insulin may be satisfactorily carried in a cool bag for
even the longest sector.

Specific Condition
When travelling east, the day will be
shortened and if more than two hours are
lost, it may be necessary to take fewer units
with intermediate or long-acting insulin.
When travelling west, the travel day will be
extended and if this is more than 2 hours it
may be necessary to supplement this with
additional injections of short-acting insulin
or an increased dose of intermediate-acting
insulin.

Specific Condition
Haematological disorders
Patients with a haemoglobin of greater
than 8 g/dl may travel without problems
assuming there is no coexisting condition
such as cardiovascular or respiratory
disease.
If the haemoglobin is less than 7.5 g/dl,
special assessment should be made and
the use of supplemental oxygen should be
considered.

Specific Condition
DVT
Deep vein thrombosis is not intrinsically dangerous but
the complications of pulmonary embolism can be life
threatening. The risk of thrombosis is increased by
travel of greater than 4 hours.
The Risk Factors :
Thrombophilia enhancing clotting activity, Recent major
surgery, Trauma or surgery of the lower limbs, Family history
of deep vein thrombosis, Age > 40 years, The oral
contraceptive pill

Simple, effective measures are to move about the

aircraft cabin and to carry out the lower limb exercises
shown in airline videos and in-flight magazines.

Specific Condition
Circadian Rhythm JET LAG - and Air
Travel
Most people are sensitive to this travelproduced phase shift experience some
discomfort for several days.
Become : hungry, sleepy, or are awake at
the wrong time with regard to the new
local time. Their "head clock" and
"stomach clock" and elimination system
are confused.

Specific Condition
After transcontinental flights : 3-4 days;
After transatlantic flights : 5-6 days.
Crossing 12 time zones, which leads to
a complete reversal of the day-night
cycle, may take 10-12 days to resynchronize.
As a general rule, most travelers
adjust to a new circadian cycle at a
rate of nearly 1 hour per day.

Contact Us
Compliment for additional slides to
dr. Ady Wirawan
Doctoral Program at Wellington University,
NZ, on Aviation Medicine.

You can Contact Us for further

discussion :
dr. Ady Wirawan. MPH on twitter -- @adywirawan
dr. Adiartha Griadhi, M.Fis. -- @tadiarthag

Thank You !