Travel and Cystic Fibrosis

The Leeds Method of Management. April, 2008. Travel and Cystic Fibrosis [online]. Leeds Regional Adult and Paediatric Cystic Fibrosis Units, St James's University Hospital, Leeds, UK. Available from http://www.cysticfibrosismedicine.com

Introduction

This section provides answers to some of the more frequently asked questions about travel and CF.

Insurance: It is important to take out adequate travel insurance. This must include cover for CF. Medical treatment can be very expensive abroad as can repatriation.

Information for customs: A letter from the local CF Unit is essential. It should detail the diagnosis, medication and equipment including syringes and needles.

Informing the CF team: It is important to inform the CF team before booking a flight. You may need a formal flight test to assess if in-flight oxygen is required. This is to avoid potential hypoxaemia (low oxygen) when flying at high altitude.

Health: Travel abroad should only take place if health permits. The local CF team will be able to give advice.

Vaccinations: Appropriate immunisations should be given. The use of live vaccines is contraindicated in immunosuppressed patients (post transplant). This includes the oral polio, mumps, measles, rubella, BCG, and yellow fever vaccines. Always contact your transplant centre for advice.

Malaria prophylaxis: Having CF is not a contraindication to malaria prophylaxis. Mefloquine should not be prescribed to patients with significant liver disease. Chloroquine should be prescribed with caution with hepatic impairment. Co-trimoxazole (Septrin®) and trimethoprim interact with pyrimethamine. Post transplant patients should seek advice from their transplant centre.

Salt depletion: Because of the high sodium and chloride concentrations in sweat, activities which increase sweat production can lead to excess salt depletion. When going to hot climates it is important to take salt supplementation (salt tablets) with adequate fluids. This will avoid the potential complications of heat prostration.

Pneumothorax: Having a pneumothorax (collapsed lung) is a contraindication to flight. Individuals who have recently been treated for a pneumothorax should avoid flying. Your specialist will be able to tell you when it will be safe to fly.

Insulin: Always remember to take adequate supplies of insulin on holiday with you. Ensure that your insulin is not exposed to the heat by storing it in a small coolbag or a wide mouthed thermos flask during the journey. Keep your insulin in your hand luggage as the flight may get delayed and the insulin could freeze in the hold.

Pulmozyme®: When travelling to hot climates it is important to remember that Pulmozyme® should be stored in a refrigerator at 2 - 8°C and protected from strong light. Avoid exposure to excessive heat by keeping the drug in a small coolbag. A single brief exposure to elevated temperatures (less than or equal to 10 hours at up to 30°C) does not affect product stability.
TOBI®: Stable at room temperature below 25 degrees Centigrade for up to 28 days.

Oxygen requirement: Aircraft fly at altitudes of between 9,150 to 12,200 metres. The cabin must therefore be pressurised with cabin altitude approaching around 2,460 metres and with inspired oxygen concentration falling to approximately 15% (Naeije, 2000). In normal circumstances this results in a small and insignificant fall in oxygen blood saturation. While the clinical importance of transient high altitude flight hypoxaemia is unclear and individual tolerance variable, high altitude induced hypoxaemia has been reported in a small number of cases to cause significant clinical deterioration (Naeije, 2000; Speechley-Dick et al, 1992).

In Leeds we routinely undertake a fitness to fly test in patients wishing to fly abroad. This involves measuring capillary blood oxygen levels before and after 20 minutes of breathing 15% oxygen. A fall in PaO2 to 6.7 kPa or a fall in SpO2 to 83% or lower is taken as a positive test. A higher value may be more appropriate for patients especially on long haul flights.

While no specific clinical parameter appears to predict the need for in flight oxygen, those most at risk appear to have either a low FEV1 (<60%), high Northern score (>13) or low baseline PaO2 (<10.5) (Peckham et al, 2002; Ross et al, 2000).

Holiday oxygen

For travel within the UK provision of oxygen for holidays is free. It is important, however, that the patient informs their specialist team of the need for holiday oxygen as soon as possible and certainly a minimum of four weeks prior to departure. Holiday oxygen is then ordered by completing a new HOOF form stating the holiday address within the patient address box and indicating that this is not the permanent home address. The HOOF is then completed in the usual way with the addition of dates of holiday and any additional information documented in box 13. Delivery of oxygen supplies to the holiday destination is then arranged via the local supplier and will be at the destination along with nasal cannulae, masks, etc. This will be collected automatically on the date of departure. If oxygen is required for travel the patient should ensure that they have taken sufficient supplies of ambulatory oxygen from their home supply. Within Northern Ireland oxygen remains free of charge but should be ordered directly with the supplier rather than with a HOOF.

Some patients prefer to take their own supplies on holiday with them. Within the UK this is acceptable. However, concentrators should not be taken abroad as power supplies may vary and support is not available for British equipment abroad if it malfunctions. Concentrators should be transported in an upright position and securely fastened into the car. The amount of ambulatory supplies to be taken should be discussed with the specialist team. The patient should be advised to have the oxygen suppliers emergency number with them at all times during travel and the holiday.

For travel abroad it is firstly important that the specialist team is aware well in advance in order to carry out assessment for fitness to travel. The Leeds Adult CF Unit have found that the easiest way of organising oxygen supplies abroad has been through the Air Products private holiday service. Other local suppliers may also offer this service. Countries covered by Air Products include the Republic of Ireland, Portugal, Madeira, France, Germany, Belgium and areas of Spain. A holiday pack can be obtained from Air Products, or the local oxygen provider, giving full advice on areas and pricing and includes order forms and VAT relief forms which should be completed to reduce costs. For cruises, oxygen supplies are arranged through Omega Advanced Aeromedical www.omegaoxygen.com, or again using the Air Products, or local supplier, holiday pack.

Patients may also arrange oxygen supplies independently by contacting the foreign oxygen companies directly. This may reduce the cost of the supplies as the EHIC (European Health Insurance Card) card can be used through this system. In our experience, however, this can be a complicated process and often the specialist team is called upon when the patient runs into difficulties during the organisational process. We therefore advise contacting the specialist CF team to organise oxygen supplies abroad in the first place.

For areas other than those covered by the local oxygen supplier the foreign supplier should be contacted directly. A list of foreign suppliers is provided in the air products holiday pack. Also the website www.travelo2.com allows the ordering of oxygen supplies throughout the USA and over 150 other countries. Charges for oxygen supplies in foreign countries do vary and should be checked prior to ordering. It should be noted that the cost of holiday oxygen is not covered by the NHS.

References

Naeije R. Preflight medical screening of patients. Eur Respir J. 2000; 16: 197-9. [PubMed]

Peckham D, Watson A, Pollard K, et al. Predictors of desaturation during formal hypoxic challenge in adult patients with cystic fibrosis. J Cystic Fibrosis. Dec 2002:4;281-286. [PubMed]

Ross E, Cramer D, Hodson M E. Fitness to fly assessment in adults with cystic fibrosis. Paed Pulmonol 2000;294.

Speechly-Dick M E, Rimmer S J, Hodson M E. Exacerbation of cystic fibrosis after holidays at high altitude-a cautionary tale. Resp Med 1992;86, 55-56. [PubMed]

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