What are the guidelines for determining fitness to fly in a patient with a history of asthma exacerbations, who has recently experienced an exacerbation and is on medications such as inhaled corticosteroids (e.g. fluticasone) and bronchodilators (e.g. salbutamol)?

Fitness to Fly After Asthma Exacerbation

Patients who have recently experienced an asthma exacerbation should achieve stable control with peak expiratory flow (PEF) >75% of predicted or personal best, minimal symptoms, and stable medication requirements for at least 24 hours before air travel is considered safe. 1

Pre-Flight Assessment Criteria

Before clearing a patient for air travel following an asthma exacerbation, verify the following objective measures:

• PEF must be >75% of predicted or personal best with diurnal variability <25% 1
• Patient should be on stable discharge medications for at least 24 hours before travel 1
• Symptoms should be well-controlled: no more than 2 days per week of symptoms, no nighttime awakenings more than 2 times per month, and no interference with normal activity 1
• Short-acting beta-agonist use should be ≤2 days per week (not counting pre-exercise prophylaxis), as more frequent use indicates inadequate control 1

High-Risk Features That Preclude Flying

Do not clear for air travel if any of the following are present:

• Recent hospitalization or ED visit within the past month 2
• Life-threatening features during the recent exacerbation (PEF <33% predicted, silent chest, cyanosis, altered consciousness, or requiring ICU admission) 1
• Using >2 canisters of short-acting beta-agonist per month, indicating overreliance on rescue medication 2
• Difficulty perceiving asthma symptoms or severity of exacerbations 2
• Persistent symptoms or PEF <75% of predicted despite treatment 1

Medication Optimization Before Travel

Ensure the following medication strategy is in place:

• Inhaled corticosteroids (such as fluticasone) must be continued as maintenance therapy and should have been stable for at least 24 hours 1
• Oral corticosteroids should be completed if prescribed for the exacerbation (typically 3-10 days course) 1, 3
• Patient must carry rescue bronchodilator (salbutamol) and demonstrate proper inhaler technique with spacer device 3
• Consider providing a short course of oral corticosteroids for the patient to carry during travel, particularly for remote destinations 4

Travel-Specific Risk Factors

Asthmatic travelers face increased risk during air travel due to:

• Cold, dry cabin air which can trigger bronchospasm 5
• Reduced cabin pressure equivalent to 6,000-8,000 feet altitude 5
• Frequent use of inhaled bronchodilators before travel (≥3 times weekly) increases risk of exacerbations during travel (RR 3.35) 4
• Intensive physical exertion during travel further increases risk (RR 2.04), and when combined with frequent bronchodilator use, the risk increases to RR 5.52 4

Required Patient Education and Documentation

Before clearing for flight, provide:

• Written asthma action plan detailing how to recognize worsening symptoms and when to escalate treatment 1, 3
• Demonstration and return demonstration of proper MDI technique with spacer device 3
• Peak flow meter for self-monitoring during travel 1
• Clear instructions to seek immediate medical attention if symptoms worsen or PEF drops below 75% of personal best 1
• Documentation for carrying medications through airport security

Follow-Up Requirements

Schedule outpatient follow-up before travel:

• Primary care follow-up within 1 week of the exacerbation 1, 3
• Respiratory specialist follow-up within 4 weeks if not already established 1
• Review of asthma control and potential need to step up maintenance therapy 1, 3

Common Pitfalls to Avoid

Critical errors that compromise flight safety:

• Clearing patients based solely on symptom improvement without objective PEF measurement 1
• Allowing travel before completing the oral corticosteroid course or achieving 24 hours of stability 1, 3
• Failing to provide written action plan and assuming verbal instructions are sufficient 3
• Not verifying proper inhaler technique before travel 3
• Underestimating risk in patients with well-controlled baseline asthma who recently exacerbated 2