COPD patients’ pre-flight check: A narrative review

Image by <a href=";utm_medium=referral&amp;utm_campaign=image&amp;utm_content=2104594">Lukas Bieri</a> from <a href=";utm_medium=referral&amp;utm_campaign=image&amp;utm_content=2104594">Pixabay</a>
Published: March 14, 2022
Abstract Views: 1612
PDF: 657
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.


 For most of the people with stable and well-controlled chronic obstructive pulmonary disease (COPD), air travel is safe and comfortable, but the flight environment may pose clinical challenges. This narrative review aims to update the requirements for allowance to fly of people with COPD without chronic respiratory failure.  A literature review was performed on platforms: Pubmed, Scopus and Ovid, for citations in English from 2000 to 2021. The following key words were used: COPD AND: air-travel, in-flight hypoxemia, fitness to air travel.  Official regulatory documents and guidelines were also examined. Current air travel statements recommend supplemental oxygen when in flight arterial oxygen tension (PaO2) is expected to fall below 6.6 or 7.3 kPa. Several lung function variables, prediction equations and algorithms have been proposed to estimate in-flight PaO2, the need for in-flight supplemental oxygen, and to select individuals needing more advanced pre-flight testing, such as the hypoxia-altitude simulation test. Exercise induced desaturation and aerobic capacity correlate significantly with in-flight PaO2. COPD patients with late intensification of disease, new changes in medications, recent acute exacerbation/ hospitalization or anticipated emotional and physical stress during the proposed air-travel should be carefully evaluated by the caring family or specialist physician.



PlumX Metrics


Download data is not yet available.


International Civil Aviation Organization [Internet]. The world of air transport in 2019. Accessed February 22, 2021. Available from:
House of Lords, UK Parliament [Internet]. Science and Technology- Fifth Report. Accessed February 22, 2021. Available from:
Bagshaw M, Illig P. 47 - The Aircraft Cabin Environment. In: JS Keystone, P. Kozarsky, BA Connor, HD Nothdurft, M Mendelson, K Leder, Editors. Travel Medicine. Elsevier: Amsterdam; 2019. p. 429-36. DOI:
Martin-Gill C, Doyle TJ, Yealy DM. In-flight medical emergencies: A review. JAMA 2018;320:2580-90. DOI:
Coker RK, Shiner LRJ, Partridge MR. Is air travel safe for those with lung disease? Eur Respir J 2007;30:1057–63. DOI:
Global Initiative for Chronic Obstructive Lung Disease – GOLD [Internet]. 2022 GOLD Reports. Global strategy for prevention, diagnosis, and management of COPD. Accessed February 22, 2021. Available from:
International Air Transport Association - IATA [Internet]. Medical Manual. 2020, 12th Edition. Geneva.
European Parliament. Regulation (EC) No 1107/2006 of the European Parliament and of the Council of 5 July 2006 concerning the rights of disabled persons and persons with reduced mobility when travelling by air (Text with EEA relevance). Accessed February 22, 2021. Available from:
US Department of Transportation. Passengers with Disabilities. Accessed February 22, 2021. Available from:
Federal Aviation Administration – FAA [Internet]. Acceptance Criteria for Portable Oxygen Concentrators. Accessed February 22, 2021. Available from:
Federal Aviation Administration – FAA [Internet]. Oxygen Equipment Use in General Aviation Operations. Accessed February 22, 2021. Available from:
Legal Information Institute Cornell Law School [Internet]. Oxygen and portable oxygen concentrators for medical use by passengers. Accessed February 22, 2021. Available from:
National Research Council. The Airline Cabin Environment and the Health of Passengers and Crew-Consensus Study Report. Washington DC: The National Academics Press; 2002.
Ahmedzai S, Balfour-Lynn IM, Bewick T, et al. Managing passengers with stable respiratory disease planning air travel: British Thoracic Society recommendations. Thorax 2011;66:i1-i30. DOI:
ATS/ERS Task Force for COPD Research. An official American Thoracic Society/ European Respiratory Society statement: research questions in COPD. Eur Respir J 2015;45:879–905.
International Civil Aviation Organization [Internet]. Manual of Civil Aviation Medicine – Doc 8984 AN /895 -International Civil Aviation Authority 3rd Edition 2012. Available from:
Federal Aviation Administration – FAA [Internet]. Introduction to Aviation Physiology - Civil Aerospace Medical Institute Aeromedical Education Division, Oklahoma City; 2016.
Roach RC, Lawley JS, Hackett PH. Mountain Medicine Part 1 - High-Altitude Physiology. Accessed February 22, 2021. Available from:
US National Research Council. Committee on Air Quality in Passenger Cabins of Commercial Aircraft. The airliner cabin environment and the health of passengers and crew. Washington DC: National Academies Press; 2002.
Morris A, Kanner RE, Crapo R, et al. Clinical Pulmonary Function Testing. A Manual of Uniform Laboratory Procedures. Intermountain Thoracic Society: Salt Lake City; 1984.
Sutton JR, Reeves JT, Wagner PD, et al. Operation Everest II: oxygen transport during exercise at extreme simulated altitude. J Appl Physiol 1988;64:1309-21. DOI:
National Air Transportation Center of Excellence for Research in the Intermodal Transport Environment (RITE). Health effects of aircraft cabin pressure in older and vulnerable passengers. Airliner Cabin Environment Research (ACER) Program-November 2011 Final Report No. RITE-ACER-CoE2011. Accessed February 22, 2021. Available from:
Carvalho AM, Poirier V. So you think you can fly? Determining if your emergency department patient is fit for air travel. Can Fam Physician 2009;55:992-5.
Christensen CC, Ryg M, Refvem OK, Skjønsberg OH. Development of severe hypoxaemia in chronic obstructive pulmonary disease patients at 2,438 m (8,000 ft) altitude. Eur Respir J 2000;15:635-9. DOI:
Akerø A, Christensen CC, Edvardsen A, Skjønsberg OH. Hypoxaemia in chronic obstructive pulmonary disease patients during a commercial flight. Eur Respir J 2005;25:725-30. DOI:
Seccombe LM, Kelly PT, Wong CK, et al. Effect of simulated commercial flight on oxygenation in patients with interstitial lung disease and COPD. Thorax 2004;59:966-70. DOI:
Higgins C. Oxygen saturation – better measured than calculated. Accessed February 22, 2021. Available from:
Ergan B, Arikan H, Akgün M. Are pulmonologists well aware of planning safe air? The SAFCOP study. Int J COPD 2019;14:1895–900. DOI:
Josephs LK, Coker RK, Thomas M, et al. Managing patients with stable respiratory disease planning air travel: a primary care summary of the British Thoracic Society recommendations. Prim Care Respir J 2013;22:234-48. DOI:
Mortazavi M, Eisenberg MJ, Langleben D, et al. Altitude-related hypoxia: risk assessment and management for passengers on commercial aircraft. Aviat Space Environ Med 2003;74:922-7.
Silverman D, Gendreau M. Medical issues associated with commercial flights. Lancet 2009;373:2067-77.
Bradi AC, Faughnan ME, Stanbrook MB, et al. Predicting the need for supplemental oxygen during airline flight in patients with chronic pulmonary disease: a comparison of predictive equations and altitude simulation. Can Respir J 2009;16:119-24. DOI:
Robson AG, Lenney J, Innes JA. Using laboratory measurements to predict in-flight desaturation in respiratory patients: are current guidelines appropriate? Respir Med 2008;102:1592-7. DOI:
Gong H Jr, Tashkin DP, Lee EY, Simmons MS. Hypoxia-altitude simulation test. Evaluation of patients with chronic airway obstruction. Am Rev Respir Dis 1984;130:980-6.
Tzani P, Pisi G, Aiello M, et al. Flying with respiratory disease. Respiration 2010;80:161-70. DOI:
Dine CJ, Kreider ME. Hypoxia altitude simulation test. Chest 2008;133:1002-5. DOI:
Edvardsen A, AkerøA, Christensen CC, et al. Air travel and chronic obstructive pulmonary disease: a new algorithm for pre-flight evaluation. Thorax 2012;67:964-9. DOI:
Pilcher J, Ploen L, McKinstry S, et al. A multicentre prospective observational study comparing arterial blood gas values to those obtained by pulse oximeters used in adult patients attending Australian and New Zealand hospitals. BMC Pulm Med 2020;20:7. DOI:
Aerospace Medical Association Medical Guidelines Task Force. Medical Guidelines for Airline Travel. Aviat Space Environ Med 2003;74:A1-19.
Chetta A, Zanini A, Pisi G, et al. Reference values for the 6-min walk test in healthy subjects 20-50 years old. Respir Med 2006;100:1573-8. DOI:
Giannitsi S, Bougiakli M, Bechlioulis A, et al. 6-minute walking test: a useful tool in the management of heart failure patients. Ther Adv Cardiovasc Dis 2019;13:1753944719870084. DOI:
Dillard TA, Rajagopal KR, Slivka WA, et al. Lung function during moderate hypobaric hypoxia in normal subjects and patients with chronic obstructive pulmonary disease. Aviat Space Environ Med 1998;69:979–85.
Kelly PT, Swanney MP, Stanton JD, et al. Resting and exercise response to altitude in patients with chronic obstructive pulmonary disease. Aviat Space Environ Med 2009;80:102-7. DOI:
Ling IT, Singh B, James AL, Hillman DR. Vital capacity and oxygen saturation at rest and after exercise predict hypoxaemia during hypoxic inhalation test in patients with respiratory disease. Respirology 2013;18:507-13. DOI:
O’Donnell DE, Gebke KB. Activity restriction in mild COPD: a challenging clinical problem. Int J Chron Obstruct Pulmon Dis 2014;9:577–88. DOI:
Jorge A, Pombal R, Peixoto H, Lima M. Preflight medical clearance of ill and incapacitated passengers: 3-year retrospective study of experience with a European airline. J Travel Med 2005;12:306-11. DOI:
Silverman D, Gendreau M. Medical issues associated with commercial flights. Lancet 2008;373:2067–77. DOI:
European Federation of Allergy and Airways Diseases – EFA. Enabling air travel with oxygen in Europe: An EFA booklet for patients with chronic respiratory disease. Accessed February 22, 2021. Available from:
US Department of Transportation, Federal Aviation Administration. Portable Oxygen Concentrators - Advisory Circular dated May 24, 2016 AC No: 120-95A. Accessed February 22, 2021. Available from:
Keystone JS, Kozarsky PE, Connor BA, et al. Travel Medicine. Amsterdam: Elsevier; 2019.
Tsiligianni IG, van der Molen T, et al. Air travel for patients with chronic obstructive pulmonary disease: a case report. Br J Gen Pract 2012;62:107-8. DOI:
Kodama D, Yanagawa B, Chung J, Fryatt K, Ackery AD. "Is there a doctor on board?": Practical recommendations for managing in-flight medical emergencies. CMAJ 2018;190:E217-22. DOI:

How to Cite

Khan, Iqbal Akhtar, Paola Pierucci, and Nicolino Ambrosino. 2022. “COPD patients’ Pre-Flight Check: A Narrative Review”. Monaldi Archives for Chest Disease 92 (4).