What are the recommendations for managing common flight symptoms?

Managing Common Flight Symptoms

All passengers should avoid excess alcohol and caffeine-containing drinks, remain mobile or exercise their legs during flight, and those at risk for venous thromboembolism should implement risk-stratified prophylactic measures. 1

Universal Precautions for All Passengers

The British Thoracic Society provides clear guidance that applies to all air travelers, regardless of underlying health conditions:

• Avoid excess alcohol and caffeine before and during the flight, as these contribute to dehydration and may worsen hypoxemia in those with respiratory conditions 1
• Maintain mobility throughout the flight by walking periodically and performing leg exercises while seated 1
• Stay well-hydrated with non-alcoholic, non-caffeinated beverages 1
• Carry all essential medications in hand luggage, including preventative and relieving inhalers for those with asthma 1

A critical caveat: Exercise without supplemental oxygen may paradoxically worsen hypoxemia in passengers with compromised respiratory function, so those most affected should use oxygen while walking on the plane and inform flight attendants of their expected time away from their seat 1.

Venous Thromboembolism (VTE) Risk Stratification

The guidelines provide a tiered approach based on individual risk factors, which is the most common "flight symptom" concern:

Low-Risk Passengers (Slightly Increased Risk)

Risk factors include: age >40, obesity, extensive varicose veins, polycythemia, or minor surgery within 72 hours 1

Management:

• Avoid alcohol and caffeine-containing drinks 1
• Take only short periods of sleep unless normal sleeping position can be attained 1
• Avoid sleeping pills 1
• Consider support tights or non-elasticated long socks 1

Moderate-Risk Passengers

Risk factors include: family history of VTE, recent myocardial infarction, pregnancy, estrogen therapy (including HRT and oral contraceptives), postnatal status within 2 weeks of delivery, lower limb paralysis, recent lower limb trauma, or recent surgery 1

Management:

• All precautions listed above for low-risk passengers 1
• Pre-flight aspirin may be considered 1
• Graduated compression stockings are recommended 1

Research evidence supports this approach, with studies showing compression stockings providing 15-30 mmHg at the ankle reduce asymptomatic DVT incidence in long-haul flights 2, 3.

High-Risk Passengers

Risk factors include: previous VTE, thrombophilia, surgery within previous 6 weeks, history of stroke, or current known malignancy 1

Management:

• If flying cannot be avoided or delayed, consider low molecular weight heparin OR formal anticoagulation with INR 2-3 before departure 1
• Depending on length of stay abroad, passengers may need to remain anticoagulated until the homeward journey 1
• Graduated compression stockings should be worn 1

The evidence base shows that long-duration travel (>8 hours) carries a VTE incidence of approximately 0.5% in low-to-intermediate risk flyers, with severe symptomatic pulmonary embolism being extremely rare (5 per million for flights >12 hours) 3. However, the risk increases substantially in those with pre-existing risk factors 3, 4.

Important Caveats and Pitfalls

Timing of VTE: VTE may be attributable to travel if it occurs up to 8 weeks following the journey, not just immediately after landing 3. This delayed presentation means many cases are underreported.

Aspirin limitations: While aspirin may reduce VTE risk by one-third in high-risk surgical patients 1, research specifically examining air travel does not support routine aspirin use due to significant gastrointestinal adverse effects without proven benefit in this context 2, 3.

Dehydration controversy: Despite common belief, there is no strong evidence linking dehydration to travel-associated VTE, though maintaining hydration is unlikely to be harmful 3.

Global prophylaxis not indicated: Routine use of compression stockings or anticoagulants for all long-distance travelers is not recommended—risk assessment must be individualized based on the stratification above 3.

Special Considerations for Respiratory Conditions

For passengers with underlying respiratory disease (asthma, COPD, pulmonary fibrosis), additional precautions apply:

• Portable nebulizers may be used at the discretion of cabin crew, though spacers are equally effective for asthma treatment 1
• Check medication stability with pharmacists, as extreme temperatures in hold baggage may affect some medicines 1
• Passengers requiring supplemental oxygen should arrange this with the airline at least 48-72 hours in advance, with significant variation in availability and cost between carriers 1, 5