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Doc Dutch · 07-24-2009, 07:52

Swat Surgeon,

This is a great question and one we face a lot in civilian practice on the trauma service. I have had to deal with this question in various trauma centers in the United States and have not found a protocol for allowing patients to fly in any of those centers probably because no one knows. I had asked the trauma.org web server sometime ago without any solid advice having been obtained.

Here is the most likely scenario for us to see such a case and the subsequent concern. A patient is brought to the trauma center. They have been involved in either blunt or penetrating trauma. There is a pneumothorax on either the chest x-ray or CT scan. The patient either gets a chest tube if the pneumothorax is large enough and/or if small enough, we watch it until it resolves and the patient is asymptomatic. After the patient is discharged with adequate treatment of the pneumothorax to resolution, the patient returns to the trauma offices or clinic and asks, "Doc, I have to fly to go on "vacation" or "return home" or "go to a wedding"? Whatever the reason, they have to go somewhere and they want to know if their lung will be okay in a pressurized cabin. Obviously, they do not have a chest tube in, so a Heimlich valve is not an option, and as this is not the scenario for a chest tube already in, it negates the discussion of flying with a chest tube in which is pretty simple as that is the treatment for transferring a patient with a large or symptomatic pneumothorax. Now, if the resolved pneumothorax patient gets in trouble in flight over the US or some ocean, it could be minor, perhaps not even perceptible, or major like a tension pneumothorax. None the less, there is a risk even if most likely very small.

So, many years ago we said 6 to 8 weeks before you could fly. Then I heard 4 weeks. Now, I am hearing 2 weeks with x-ray confirmed resolution of pneumothorax. But what is the data?

I called Luke AFB and Travis AFB and received different answers. At Luke the flight surgeon stated 2 weeks with resolution but could not sight a study and that was for passengers as his flyers were a different story. I asked my commander at Phoenix Sky Harbor, a flight surgeon with the 161st and emergency medicine physician, who stated he thinks two weeks after resolution of the pneumothorax on x-ray. Nonetheless, no concrete data, however, there seems to be a growing consensus that this is the way to go.

So, does anyone know of any research articles done on this topic in any of the literature including trauma, emergency medicine, military medicine, etc? Even case reports would be okay. Anecdotally, I do not have any patients that have reported any problems with the longer waiting periods but as this disrupts their lives they are not generally happy. As there is no hard or fast rules in any of the trauma centers I have been in, this is problematic. I would like to believe that somewhere the USAF, NASA or somebody has done a randomized study.

Any help would be great as I too have thought long about this and what to do in these cases. By the way spontaneous cases are really a different group but we should discuss them too.

Thank you,

Dutch

07-24-2009, 07:52	#6
Doc Dutch Trauma Surgeon Join Date: Sep 2007 Posts: 83	Swat Surgeon, This is a great question and one we face a lot in civilian practice on the trauma service. I have had to deal with this question in various trauma centers in the United States and have not found a protocol for allowing patients to fly in any of those centers probably because no one knows. I had asked the trauma.org web server sometime ago without any solid advice having been obtained. Here is the most likely scenario for us to see such a case and the subsequent concern. A patient is brought to the trauma center. They have been involved in either blunt or penetrating trauma. There is a pneumothorax on either the chest x-ray or CT scan. The patient either gets a chest tube if the pneumothorax is large enough and/or if small enough, we watch it until it resolves and the patient is asymptomatic. After the patient is discharged with adequate treatment of the pneumothorax to resolution, the patient returns to the trauma offices or clinic and asks, "Doc, I have to fly to go on "vacation" or "return home" or "go to a wedding"? Whatever the reason, they have to go somewhere and they want to know if their lung will be okay in a pressurized cabin. Obviously, they do not have a chest tube in, so a Heimlich valve is not an option, and as this is not the scenario for a chest tube already in, it negates the discussion of flying with a chest tube in which is pretty simple as that is the treatment for transferring a patient with a large or symptomatic pneumothorax. Now, if the resolved pneumothorax patient gets in trouble in flight over the US or some ocean, it could be minor, perhaps not even perceptible, or major like a tension pneumothorax. None the less, there is a risk even if most likely very small. So, many years ago we said 6 to 8 weeks before you could fly. Then I heard 4 weeks. Now, I am hearing 2 weeks with x-ray confirmed resolution of pneumothorax. But what is the data? I called Luke AFB and Travis AFB and received different answers. At Luke the flight surgeon stated 2 weeks with resolution but could not sight a study and that was for passengers as his flyers were a different story. I asked my commander at Phoenix Sky Harbor, a flight surgeon with the 161st and emergency medicine physician, who stated he thinks two weeks after resolution of the pneumothorax on x-ray. Nonetheless, no concrete data, however, there seems to be a growing consensus that this is the way to go. So, does anyone know of any research articles done on this topic in any of the literature including trauma, emergency medicine, military medicine, etc? Even case reports would be okay. Anecdotally, I do not have any patients that have reported any problems with the longer waiting periods but as this disrupts their lives they are not generally happy. As there is no hard or fast rules in any of the trauma centers I have been in, this is problematic. I would like to believe that somewhere the USAF, NASA or somebody has done a randomized study. Any help would be great as I too have thought long about this and what to do in these cases. By the way spontaneous cases are really a different group but we should discuss them too. Thank you, Dutch
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