Is a patient with a history of pneumothorax (collapsed lung) fit to fly?

Flying After Pneumothorax: Guidelines for Flight Fitness

Patients with a history of pneumothorax should not fly until complete radiographic resolution of the pneumothorax, and then should wait at least 7 days after confirmed resolution before air travel. 1

Assessment of Flight Fitness

Timing of Air Travel After Pneumothorax

• Patients with a persistent closed pneumothorax (incompletely resolved on chest X-ray) should not travel on commercial flights until complete radiographic resolution 1
• After confirmed radiological resolution, patients should wait 7 days before flying to exclude early recurrence 1
• Some guidelines suggest extending this waiting period to 2-6 weeks after resolution, particularly for secondary pneumothorax 1
• Patients with cystic fibrosis should not fly for at least 2 weeks after pneumothorax resolution 1

Special Considerations

• For airline pilots, military personnel, and other at-risk professionals, elective surgery (such as pleurectomy) may be considered after the first pneumothorax episode to prevent recurrence 1
• Patients with a loculated or chronic localized air collection that has been very carefully evaluated may be exceptions to these guidelines 1
• Recent evidence suggests air travel might be safe sooner than current guidelines recommend, but this remains controversial and not yet incorporated into official recommendations 2

Long-term Recommendations

Permanent Restrictions

• Scuba diving should be permanently avoided after a pneumothorax unless the patient has undergone a secure definitive prevention strategy such as surgical pleurectomy 1
• This restriction is particularly important as the pressure changes during diving can cause more severe consequences than those experienced during air travel 1, 3

Follow-up and Monitoring

• All patients should be followed up by a respiratory physician to ensure resolution of the pneumothorax 1
• A follow-up chest X-ray should be performed after 2-4 weeks to confirm complete resolution 1
• Patients should be educated about the risk of recurrence and possible need for surgical intervention 1

Common Pitfalls and Caveats

• The presence of an active pneumothorax is an absolute contraindication to air travel due to the risk of expansion at altitude based on Boyle's law 4, 5
• Recommendations for air travel after thoracic surgery are similar, with guidelines suggesting a delay of 2-3 weeks following uncomplicated thoracic surgery 6
• There is significant variability in clinical practice, with some thoracic surgeons allowing patients to fly with some degree of pneumothorax, contrary to published guidelines 6
• BiPAP should be withheld from patients with pneumothorax as long as the pneumothorax is present, as it may worsen the condition 1
• Patients should also avoid heavy lifting (>5 pounds) and spirometry for at least 2 weeks after pneumothorax resolution 1

Special Populations

• For trauma patients who have had tube thoracostomy, some evidence suggests air travel may be safe 72 hours after tube removal if a post-removal chest X-ray shows no pneumothorax 7
• Patients with cystic fibrosis require more aggressive management of pneumothorax, with surgical intervention often considered after the first episode 1, 3

The evidence supporting these recommendations is largely based on expert consensus and theoretical concerns rather than robust clinical trials. However, given the potential serious consequences of pneumothorax expansion during flight, a cautious approach is warranted to prioritize patient safety and minimize morbidity and mortality risks.