Abstract
Introduction People with bronchiectasis frequently request specialist advice to prepare for travelling, but there are few publications providing advice on safe travel with bronchiectasis. There is a need for recommendations on adapting everyday treatment to the requirements during travelling.
Methods A panel of 13 patient volunteers formulated questions regarding different aspects of travelling, including safety of travel, maintaining regular treatment during travel, and dealing with deterioration while away. Patient input was used to derive a questionnaire and circulated among a panel of bronchiectasis experts. Where 80% or more experts agreed on a response, a recommendation was made.
Results A total of 26 bronchiectasis experts answered the questionnaire. Recommendations were made on safety of travel, choice of destinations and activities, choice of travel insurance, carrying medications and devices, maintaining regular treatments in transport, documentation to be provided and oxygen requirements. Some statements did not reach an 80% agreement; in many cases these statements may be valid for some, but not all bronchiectasis patients.
Conclusions The general agreement was that it is considered safe for most people with bronchiectasis to travel. Careful planning and preparation with robust communication between patients and their healthcare provider prior to travel for different scenarios is fundamental to a successful journey.
Abstract
It is safe for most people with bronchiectasis to travel. Careful planning and preparation for different scenarios are fundamental to a successful journey. http://bit.ly/2yWEowA
Introduction
With increasing availability of transportation, many people of older age and with chronic health conditions are travelling for work or leisure. Bronchiectasis is a chronic condition punctuated by episodes of exacerbations, and treated regularly with oral and inhaled medications and airway clearance [1, 2]. The requirement for uninterrupted treatment to maintain lung health, the risk of a pulmonary exacerbation, and presence of daily symptoms may all interfere with travel. However, maintaining an active life including travel is important for people with bronchiectasis in order to keep working, maintain family and social relationships, and otherwise enjoy what life has to offer. People with bronchiectasis frequently seek advice from healthcare providers before travel regarding safety of travelling, maintenance of a treatment routine while travelling, providing documentation for airline companies and insurance, security screening, obtaining permission for extra hand luggage when flying, and planning to engage in recreational activities.
EMBARC, the European Multicenter Bronchiectasis Audit and Research Collaboration, is an ERS clinical research collaboration dedicated to advancing research and care of patients with bronchiectasis [3]. One of the aspects of this collaboration involves working with patient volunteers, coordinated by the European Lung Foundation (ELF) to involve people with bronchiectasis in research and promotion of care [4]. Some aspects of this collaboration resulted in patient and caregiver-focused documents [5].
Finding recommendations to prepare people with bronchiectasis for travel was an initiative of individuals who are part of the ELF bronchiectasis patient advisory group (PAG). International guidelines on bronchiectasis care do not refer to care while travelling; recommendations for travelling for people with cystic fibrosis (CF) [6] may not always apply for bronchiectasis, as typically people with bronchiectasis are older and suffer from more prevalent comorbidities than people with CF, and that treatment recommendations in general, including access to drugs and devices, are different between CF and bronchiectasis.
Methods
Creating a set of recommendations for travel was one of the EMBARC–ELF PAG initiatives. A group of 13 people with bronchiectasis, volunteering as part of the ELF bronchiectasis PAG, together with three bronchiectasis experts (PG, MS and JDC) developed a list of questions that patients may have regarding various aspects of travelling. The questions were circulated among a wider (45 members) PAG and revised according to further recommendations and comments. A questionnaire was then formed incorporating all questions (table 1; similar items were unified into one question) with suggested responses based on the literature and common practice. The questionnaire was then turned into an online survey. An invitation to participate, along with previous similar documents [6–8] were sent to 37 bronchiectasis experts that were globally based and affiliated to EMBARC. The questionnaire contained 10 questions with a total of 41 statements. Experts were asked for an “agree/disagree” response and free-text comments were encouraged for each statement. Responses were recorded and recommendations made where a statement reached 80% agreement or higher.
Statements included in the questionnaire for experts and percentage agreement
In addition, a systematic PubMed search was conducted for the terms: “bronchiectasis”; “non cystic fibrosis bronchiectasis”; “travel”; “high altitude”; supplemental oxygen”; “SCUBA diving”; “cross infection”, and also “cystic fibrosis” and “travel” to identify any previous publications on travelling with bronchiectasis.
Results
No studies were identified that assessed the safety of travel, including air travel, in people with bronchiectasis. Consensus statements regarding travel in people with CF [6] and air travel in chronic obstructive pulmonary disease (COPD) [9] exist but do not make specific recommendations for people with bronchiectasis without CF or COPD, respectively. Documents regarding air travel [10] and SCUBA diving [11] make references to bronchiectasis.
A total of 26 respondents based at institutions in Europe (n=19), United States (n=3), Australia and New Zealand (n=2), India (n=1), and Israel (n=1) completed an online survey. The questions and percentage of responders that agreed are listed in table 1.
Is it safe for all people with bronchiectasis to travel?
Recommendations:
1) Most people with bronchiectasis can safely travel for vacation or business (96% agreement).
2) It is best to avoid travelling during periods of unstable disease, such as during exacerbations (92% agreement).
3) People with bronchiectasis should consult their healthcare providers and plan for travel (85% agreement).
Other statement considered:
People with very severe bronchiectasis (e.g. candidates for lung transplantation and with frequent hospitalisations) should be advised not to travel abroad (73% agreement).
There is scarce evidence regarding safety of travel in people with bronchiectasis, and these recommendations are mostly based on a common-sense approach considering the nature of bronchiectasis. Most people with bronchiectasis should have no limitations and often do not seek expert advice before travelling. In other cases, an individual approach should be made, taking into consideration the severity of the condition, oxygen requirements and frequency of exacerbations. Patients and healthcare providers should also consider the length of travel, mode of transportation and the conditions and access to medical care at the destination. Considerations may be different for patients required to travel for business. In such cases, it is the responsibility of the advising physician to support their decision to avoid travelling if such a journey may compromise their health condition. In other cases, the emphasis should be on supporting people, even with life-limiting conditions, to enjoy travel by planning ahead.
Planning travel: are there destinations and conditions that certain people with bronchiectasis should avoid?
Recommendation:
4) People with bronchiectasis should consult their healthcare professional regarding staying at high altitudes (85% agreement).
Other statements considered:
People with bronchiectasis should try to avoid travelling to places with high levels of air pollution (73% agreement).
People with bronchiectasis should try to avoid travelling to places with a high prevalence of nontuberculous mycobacteria (NTM) such as Hawaii, USA (38% agreement).
People with bronchiectasis should try to avoid travelling during influenza season (35% agreement).
Travelling to high-altitude destinations (above 3050 m/10 000 ft) should be avoided in people with bronchiectasis (32% agreement).
People with bronchiectasis should preferably travel to destinations with a nearby bronchiectasis centre (31% agreement).
When staying at high altitudes above 2000 m, several environmental changes may have consequences in people with chronic lung disease and bronchiectasis in particular. Most importantly, as barometric pressure decreases, oxygen concentration decreases. This predisposes all individuals ascending to high-altitude destinations to several acute illnesses, including high-altitude pulmonary oedema [12]. In individuals with chronic respiratory conditions causing hypoxaemia at sea level, ascending to high altitudes may worsen hypoxaemia and predispose to respiratory and cardiac failure. While there is no literature on people with bronchiectasis travelling to high-altitude destinations, recommendations regarding individuals with chronic lung diseases such as asthma, COPD and CF exist [9, 12, 13] and are largely based on exposure to high altitude during air travel. However, although the oxygen concentration during a commercial flight is comparable to that of altitudes of ∼2000 m, there are differences in the conditions between air travel and staying at elevated-altitude destinations, mainly the level of physical exertion, and length of exposure to high altitude.
Based on studies in people with COPD during commercial flights and adapting these findings to high-altitude destinations, Stream et al. [12] recommended that travel to altitudes above 3050 m (10 000 ft) should be avoided in people with COPD. Individuals already on supplemental oxygen should continue to use it during their high-altitude stay, but should increase the flow at rest and during exertion. Patients with an forced expiratory volume in 1 s (FEV1) <1.5 L who are not receiving supplemental oxygen should undergo a pre-travel evaluation (using hypoxia simulation or prediction equations; table 2) to determine their need for supplemental oxygen at high altitude, with oxygen prescribed if the PaO2 is predicted to fall below 50 mmHg [10]. While there are many differences between COPD and bronchiectasis, due to scarcity of data on bronchiectasis, and because of similar age and comorbidities as people with COPD, these recommendations can be adopted for people with severe bronchiectasis. However, the recommendation on avoiding altitudes above 3050 m altogether did not reach agreement for all people with bronchiectasis, and should be individualised on the basis of severity.
Examples of equations for predicting hypoxaemia
Pulmonary exacerbations in people with bronchiectasis are temporally linked to periods of air pollution [14, 15]. It therefore makes sense to advise people with bronchiectasis against travelling to places with heavy air pollution. This recommendation reached 73% agreement, with a comment that only those with moderate to severe bronchiectasis and those who are prone to exacerbations [16] should avoid highly polluted places. Information regarding global air quality from multiple monitoring stations is found at: www.aqicn.org/map.
People with bronchiectasis are at risk of acquiring infections with NTM [17–21] with prevalence rates that range from 5% [17] to 50% in different series [19]. Series from the United States, especially Hawaii, repeatedly report an elevated prevalence of NTM pulmonary disease. However, little is known about the risk of acquiring infection when travelling to locations with a high risk of NTM for a holiday or even for an extended period of time. It is therefore not recommended for people with bronchiectasis to avoid travelling to places with a high prevalence of NTM. However, this recommendation may be individualised for people with severe bronchiectasis and features of a high risk of NTM infection [17].
When ill during travel, people with bronchiectasis may need to consult local healthcare professionals. For people with very severe bronchiectasis, it may be advised to locate a bronchiectasis centre close to the travel destination and even contact a specialist to inform them about the individual travelling to their area. However, since most people with bronchiectasis may be instructed to self-manage during exacerbations, it is not advised to restrict all individuals to travel exclusively to places with bronchiectasis centres.
Air travel can be associated with an elevated risk of airborne infections, such as viruses. It is reasonable to suspect that travelling during a period of a respiratory disease outbreak (such as influenza) can increase the risk of acquiring influenza and a pulmonary exacerbation. However, while annual influenza immunisation is advised in bronchiectasis guidelines [22], the expert panel does not recommend that people with bronchiectasis avoid travel during influenza season. General precautions for hand hygiene and lung health, including cough etiquette should be followed.
What travel insurance should people with bronchiectasis acquire?
Recommendation:
5) People with bronchiectasis should acquire health insurance with a coverage of deterioration of a chronic condition (100% agreement).
6) People with bronchiectasis should acquire health insurance with a coverage of hospital admission and emergency room visits (100% agreement).
Other statement considered:
People with bronchiectasis should acquire health insurance with coverage of repatriation (68% agreement).
Bronchiectasis is a chronic illness punctuated by episodes of increasing signs and symptom exacerbations, requiring a change in treatment. While most people with bronchiectasis can self-manage mild exacerbations, the need for specialist care while away may not always be predicted. It is therefore advised to acquire medical insurance that covers a deterioration of a chronic condition, including hospital admission and emergency room visits, especially for those with frequent exacerbations or hospitalisations (100% agreement). While obtaining travel insurance with a coverage of repatriation was recommended by the majority of experts, it did not reach our consensus definition. Some experts gave the reasoning that repatriation is not a medical need and therefore cannot be recommended. It remains at the decision of the individual travelling to obtain this coverage.
What medications and devices should people with bronchiectasis carry with them when travelling?
Recommendations:
7) When travelling, it is recommended that people with bronchiectasis should continue taking their regular treatments and make arrangements to take enough medications and equipment for the duration of their travel (100% agreement).
8) When travelling, people with bronchiectasis should consult their healthcare professional or respiratory physiotherapist regarding possible alternatives to heavy or large equipment such as nebulisers (100% agreement).
9) People with bronchiectasis who suffer frequent pulmonary exacerbations should consult their specialist regarding carrying antibiotics to be used in case of a pulmonary exacerbation when travelling (100% agreement).
10) Medications taken for travel should be properly stored according to manufacturer's recommendations, particularly storage temperature and light exposure (100% agreement).
11) Electricity requirements (e.g. for a nebuliser) and cleaning instructions should be known prior to travelling and proper adaptations, including checking batteries should be planned (100% agreement).
It is advisable to provide patients with bronchiectasis with an action plan to be carried when travelling regarding specific medications to be taken when stable and during exacerbations. Antibiotics for an exacerbation should be based on prior sputum cultures and past exacerbation history. Instructions for storage of common medications for bronchiectasis are summarised in table 3, and it is always advisable for patients to refer to the package insert/summary of product characteristics. In general, it is advisable to take the routine medication for daily care as cabin baggage due to the risk of loss when baggage has been checked in. In addition, medication supply should exceed the planned duration of travel for 1 or 2 weeks in order to be prepared for unexpected delays in return. Nebulisers and chest wall oscillators may be heavy and inconvenient to carry; electricity requirements may vary from place to place and operation by batteries is only possible for some nebulisers. The appropriate means for cleaning and sterilising medical equipment (e.g. nebulisers and mucus-clearance devices) should be available when travelling.
Storage conditions for common medications for bronchiectasis
Likewise, carrying parenteral antibiotics may require special storage conditions. It should be discussed with the healthcare provider whether maintaining inhalation therapy is required for the time away, and if possible, switching to a portable nebuliser or metered dose inhaler if appropriate.
Airway clearance during travel needs to be individualised. Some patients can skip a day or two of airway clearance, others can modify to a “simpler” programme for a few days, whereas other patients need to be strictly adherent to their airway clearance program whether at home or travelling. It is possible to switch to an airway clearance regime that requires small, lightweight devices. For example, it may be easy to perform autogenic drainage (which does not require carrying any equipment), or alternatively carrying small and lightweight positive expiratory pressure devices. Some airway clearance techniques can make use of inexpensive everyday objects (tube-in water bottle positive expiratory pressure or drinking straws). Planning ahead is always recommended and should be done with the advice and direction of the healthcare provider.
How can people with bronchiectasis maintain regular treatment when in transport?
Statements considered:
It is advised that airway clearance and inhalations be performed while waiting at airports before and after flights. This is best planned ahead and checked with the airport for the best place to do this (77% agreement).
While it is not advised to take cough suppressants for bronchiectasis, it may be considered for long flights where a cough may be disturbing to other passengers (35% agreement).
Some patients may want to avoid coughing and having to clear secretions during flights (or long travel by bus or train). In these cases, airway clearance may best be performed before and after flights. Since most airports may not have private facilities, practicing airway clearance at the airport should be planned ahead. Although no evidence exists on safety of cough suppressants, they are ill advised in bronchiectasis, and cannot be recommended, even during flights: 65% of experts specifically advised against the use of cough suppressants.
Do people with bronchiectasis need to prepare and carry certain documents?
Recommendations:
12) It is advised that people with bronchiectasis carry documentation from their last clinic/hospitalisation visit, translated into English and preferably also into the language of the country of destination (81% agreement).
13) A document for travel may be prepared and should include: patient's health status, allergies, chronic bacterial infections, regular medications and devices used regularly, and recommended medications during exacerbations (100% agreement).
14) It is advised that people with bronchiectasis carry a translation of a disability card (such as a European Union disability parking card) if eligible and where available (84% agreement).
Other statement considered:
When travelling in a guided tour, it is advised that people with bronchiectasis should notify the travel company of their condition (69% agreement).
Documentation may be required for airport security staff and customs officials regarding medical equipment, but also for medical professionals in case of need. A recommended template for such documentation adapted from Hirche et al. [6] is provided in the supplement. The need to notify the travel company would depend on the severity of the disease and need for supplemental oxygen or disability. Likewise, it is advisable to check for custom requirements regarding medication and technical equipment with airport or custom authorities or travel agencies in advance. During guided tours, patients may need special consideration regarding the time and place for performing daily treatments and may wish to notify the guided tour organisers.
What are the oxygen requirements on the flight and at the travel destination?
Recommendations:
15) Oxygen requirements during commercial flights should be predicted before the flight (100% agreement).
16) When planning travel to destinations between 2000 and 3050 m, considerations as for commercial flights should be made (92% agreement).
Other statements considered:
In people with an FEV1 <55% or oxygen saturation <93% at ambient air, a hypoxic challenge test should be performed (77% agreement).
In people with FEV1 <1.5 l, hypoxia inhalation test should be performed (56% disagreed)
In commercial flights, cabin air pressure is similar to 2000 m elevation; therefore conditions may aggravate hypoxemia in people with chronic lung conditions. Prediction of hypoxemia during flight may be advised for people with low lung capacity not already using oxygen supplementation, and supplemental oxygen prescribed if predicted arterial oxygen pressure is below 50 mmHg [10]. In some countries the hypoxia challenge test is not widely available; in such circumstances, the prediction of hypoxaemia at cabin altitude using equations is possible (table 2). For patients already using oxygen, it is advised to increase the flow. It is always necessary to notify the airline company in advance regarding oxygen requirements during flight. Information regarding air travel for people with chronic lung diseases is available at the ELF website: www.europeanlung.org/en/lung-disease-and-information/air-travel/ and www.europeanlung.org/assets/files/en/publications/air-travel-web.pdf (available in 18 languages).
How else can people with bronchiectasis be prepared to travel?
Recommendations:
17) It is recommended that people with bronchiectasis seek advice for travellers and follow recommended immunisations for the destination (100% agreement).
18) Recommended medications while travelling (such as for the prevention of malaria) should be checked for interactions with regular treatments and with treatments during exacerbations (100% agreement).
19) It is recommended that people with bronchiectasis should be stable prior to travelling, if symptoms typical for an exacerbation develop shortly before travelling, treatment should be started and travel postponed if possible (96% agreement).
Other statement considered:
People with severe bronchiectasis and chronic Pseudomonas aeruginosa infection may be advised to receive treatment with an intravenous antibiotic course shortly before travelling to prevent an exacerbation while away (50% agreement).
When travelling to areas endemic for infectious diseases, people with bronchiectasis should consult expert advice and/or travel clinic healthcare workers regarding immunisations and medications for preventing infections. In people with bronchiectasis secondary to a primary immune deficiency, there is a need to consider both the safety of live attenuated vaccines (yellow fever vaccine for example) [24], and the efficacy of vaccinations. Mefloquine for the prevention of malaria has the potential to elongate the QT-interval, and may increase the risk for cardiac arrhythmias especially if combined with fluoroquinolones or azithromycin. Some patients with chronic Pseudomonas infection feel better for several weeks after a course of anti-pseudomonal antibiotic (intravenous or oral). In very certain cases of people with frequent exacerbations, treatment with such an antibiotic course may be considered before travelling to prevent an exacerbation, but there is no evidence to recommend this, with the concern for causing an emergence of resistant strains with unnecessary antibiotic treatment.
What kind of activities can people with bronchiectasis engage in while travelling and what precautions are recommended?
Recommendations:
20) It is recommended that people with bronchiectasis should use sun protection while using medications that increase photosensitivity, such as ciprofloxacin and doxycycline (100% agreement).
21) It is recommended that people with bronchiectasis take measures to avoid dehydration while in a hot climate (100% agreement).
22) It is advised that people with bronchiectasis maintain general measures of hygiene to prevent cross-infection, such as hand hygiene in crowded places (88%).
23) It may be safe for people with bronchiectasis to SCUBA dive if they are asymptomatic (no sputum or shortness of breath at the time of diving), do not have cystic bronchiectasis, and lung function is normal (FEV1 and peak expiratory flow should both be >80%, FEV1/forced vital capacity>75%) (85% agreement).
Other statement considered:
It is recommended that all people with bronchiectasis refrain from SCUBA diving (35% agreement).
Many people travel for leisure purposes, during which time they engage in activities, including sports, to which they may be unaccustomed to. Staying and performing strenuous activities, such as hiking, in hot climates carries a risk of dehydration, which is to be avoided in people with bronchiectasis (as hydration is important for mucus clearance). In fact, as a general recommendation, patients with bronchiectasis should avoid dehydration at all times. People with bronchiectasis who take medications which cause photosensitivity, such as ciprofloxacin and doxycycline (table 3) should be advised to use measures for sun protection and avoidance of direct sun exposure. Likewise, interaction with alcoholic beverages should be noted, as in some cases alcohol consumption may be increased during vacations. Staying in crowded places carries a risk of acquiring airborne infections; it is advised to use hand hygiene and avoid sharing items such as blankets, drinking equipment, silverware and earphones. There is no evidence to support the efficacy of wearing face masks. Due to the inconvenience and possibly stigma associated with wearing face masks [5], their use is not recommended.
SCUBA diving is an increasingly popular recreational activity among individuals, including people with chronic conditions and older age [25, 26]. During underwater diving, ambient pressure increases by 1 atm (100 kPa) for every 10 m descended. Gas volumes change with the depth of diving, compressing during descent and expanding during ascent. The partial pressure of gases increases with the increase in hydrostatic pressure. Nitrogen, an inert gas, dissolves in tissues at depth and comes out of solution on ascent. Another aspect of diving is that the work of breathing increases during diving due to increased gas density, increased hydrostatic pressure, and altered respiratory mechanics (increased dead space and resistance to breathing caused by SCUBA breathing apparatus). The risks associated with diving include: 1) barotrauma caused by expansion of gas-filled spaces during ascent; 2) Compression of the lungs during descent which can cause alveolar exudation and haemorrhage; and 3) Expansion of the lungs during ascent that can cause tearing of structures and lead to pneumothorax, pneumomediastinum and arterial gas embolism. In bronchiectasis, mucus in airways or lung cysts can cause air trapping which may be associated with an elevated risk of barotrauma. Recommendations on medical fitness for diving [7] advise against diving in people with pulmonary cysts or bullae, in people with asthma unless they are asymptomatic with a normal spirometry, and in people with CF and pulmonary involvement. Similar recommendations are given by the South Pacific Underwater Medicine Society (www.spums.org.au/content/spums-full-medical-0) while other national diving recommendations recommend against diving in people with bronchiectasis [11]. However, due to the large heterogeneity of bronchiectasis, only 35% of bronchiectasis experts in our survey answered that all people with bronchiectasis should refrain from SCUBA diving. The majority assumed it may be safe for people with mild bronchiectasis to dive provided they are asymptomatic, with normal spirometry and no lung cysts evident on computed tomography (85% agreement).
Although it may be intuitively tempting to advise limiting diving to shallow depths for people with bronchiectasis, there is no physiological basis to support this recommendation: any change in depth poses a similar risk, and most diving-related injuries occur at relatively shallow depths [7, 27].
Many other recreational sports and activities (SCUBA diving included, but also water surfing, hiking, skiing) require levels of exertion that some people with chronic medical conditions may be unaccustomed to: one paper estimated exercise during recreational diving to equal 7 metabolic equivalents of task [28]. It is always prudent for people with bronchiectasis and advising physicians to be aware of functional limitations. If in doubt, a formal exercise test may be performed when planning sports activities.
Where should people with bronchiectasis get help if they become unwell while travelling?
Recommendations
24) Prior to travel, people with bronchiectasis should be advised on increasing airway clearance if suffering an exacerbation while away (96% agreement).
25) Prior to travel, people with bronchiectasis should be advised when to take antibiotics, including a recommendation for an oral antibiotic, dose and duration (100% agreement).
26) People with bronchiectasis should be advised when and where to seek medical care at their destination (88% agreement).
Exacerbations are periods of time when an increase in symptoms (sputum purulence and quantity, dyspnoea, malaise, fever) occur [16, 29]. The aetiology of pulmonary exacerbations is most often presumed to be inflammatory/infectious, although not always known, and some patients are more prone to exacerbations than others [16]. Current guidelines recommend treating pulmonary exacerbations of bronchiectasis with increasing airway clearance and antibiotics directed against pathogenic organisms in sputum, usually for 10–14 days [22].
When planning travel, practical advice should be given to prepare the individual for the possibility of experiencing a pulmonary exacerbation. In such cases, increasing the frequency of airway clearance is recommended, and prescribing antibiotics which are active against previous pathogen(s) in sputum to be taken in case of a pulmonary exacerbation is useful, especially for those with a history of previous exacerbations. It is likewise recommended to plan with the person with bronchiectasis to step up treatment in different scenarios (e.g. mild or more severe exacerbation, occurrence of haemoptysis). While self-treatment of pulmonary exacerbations may be safe in many cases, it is always useful to know the health facilities in the destination in case self-management fails. It likewise may not be feasible to rely on oral antibiotics in those with very severe bronchiectasis, those with respiratory failure or people chronically infected with highly resistant organisms, for which intravenous antibiotics are indicated in exacerbations. Likewise, people with bronchiectasis should be educated about occurrence of haemoptysis, in which medical care is usually required.
Discussion
People with bronchiectasis frequently travel for leisure or business. It is desirable for people with any chronic illness to engage in activities that keep them socially active, and therefore find ways for them to carry on their travelling plans while not compromising regular treatment. The key to keeping healthy while travelling is planning ahead. This involves considering several key factors: those related to the severity of bronchiectasis (presence of chronic infection, respiratory insufficiency, and frequency of exacerbations); those related to the destination (climate, air quality, endemic microorganisms, availability of healthcare, planned activity), and finally, those related to transportation (including mode of travel (air or surface), time in transport and at airports, and conditions, including storage and access to electricity during travel). Knowing these factors is necessary for “tailoring” recommendations to the patient and the journey.
With very little evidence available on the questions raised, it was not possible to make strong recommendations, and all recommendations are based on “expert opinion”. This document is designed to provide advice to patients and physicians regarding travel and should not be confused with a clinical practice guideline. Although many statements that were considered did not reach a high level of agreement; it should be noted that almost all of these statements may be true for certain people with certain conditions: tailoring these recommendations is necessary when planning travel.
This document is the result of a collaboration between the bronchiectasis PAG volunteers coordinated by the ELF, and bronchiectasis experts affiliated to the EMBARC collaboration. Questions were raised and refined by members of the PAG, who also participated in the writing of this document. Regarding statements that were not included as recommendations: it was commented repeatedly by the respondents that while some of these recommendations may be considered in certain situations, applying them to the entire population of people with bronchiectasis and all travel scenarios may result in unnecessary limitations. It is therefore advised to consider other aspects of travelling not addressed here in advising patients before travel.
Conclusion
Most people with bronchiectasis can safely travel for leisure or business. Planning ahead is essential to maintaining health while enjoying available activities.
Acknowledgements
The authors would like to thank the following bronchiectasis experts who answered the questionnaire. Lucy Morgan (University of Sidney, Sidney, Australia), Montserrat Vendrell (University of Barcelona, Barcelona, Spain), Apostolos Bossios (Karolinska Institute, Stockholm, Sweden), Gregory Tino (University of Pennsylvania, Philadelphia, PA, USA), Anthony De Soyza (Freeman Hospital, Newcastle upon Tyne, UK), Raja Dhar Respiratory and Sleep Medicine, Fortis Hospital, Kolkata, West Bengal, India, Eva Polverino (Pneumology Dept, Hospital Universitari Vall d'Hebron, Barcelona, Spain), Stefano Aliberti ( University of Milan, Milan, Italy), Menno van der Eerden (Erasmus University Rotterdam, the Netherlands), Adam Hill (University of Edinburgh, Edinburgh, UK), Rosario Menendez (Hospital la Fe, Valencia, Spain), Pierre-Régis Burgel (Université Paris Descartes, Paris, France), Robert Wilson (Imperical College, London, UK), Charles Haworth (Royal Papworth Hospital, Cambridge, UK), Francesco Blasi (University of Milan, Milan, Italy), Conroy Wong (Middlemore Hospital, Auckland, New Zealand), Alan Barker (Oregon Health and Science University, Portland, Oregon), Michal Shteinberg (Technion- Israel Institute of Technology, Haifa, Israel), Timothy Aksamit (Mayo clinic, Rochester, MN, USA), Felix Ringshausen (Hannover Medical School, Hannover, Germany), Antoni Torres (AffiliationsThorax Institute, Institute of Biomedical Research August Pi i Sunyer, University of Barcelona, Barcelona, Spain), Katerina Dimakou (5th Dept of Pulmonary Medicine, Sotiria Chest Diseases Hospital, Athens, Greece), Miguel Angel Martinez-Garcia (Valencia University, Valencia, Spain), John Hurst (University College London, London, UK), Michael Loebinger (Imperical College, London, UK), Marc Miravitlles (University Hospital Vall d'Hebron, Barcelona, Spain), James Chalmers (Scottish Centre for Respiratory Research, University of Dundee, Dundee, UK) and Pieter Goeminne (Dept of Respiratory Disease, AZ Nikolaas, Sint Niklaas, Belgium).
Footnotes
This article has supplementary material available from openres.ersjournals.com
Conflict of interest: M. Shteinberg reports travel grants and speaker's fees from GSK, travel grants from Novartis, Actelion and Rafa, grants from Trudell pharma, speaker's fees from Astra Zeneca and Teva, an advisory fee from Horizon pharma, and an advisory fee and speaker's fees from Boehringer Ingelheim, outside the submitted work. M. Shteinberg is a member of the EMBARC management board, leading Work Package 6: Patient engagement activities.
Conflict of interest: B. Crossley has nothing to disclose.
Conflict of interest: T. Lavi has nothing to disclose.
Conflict of interest: S. Nadler has nothing to disclose.
Conflict of interest: J. Boyd is an employee of the ELF.
Conflict of interest: F.C. Ringshausen reports research support, consulting, lecture fees and support for (patient) educational events from Bayer HealthCare and Grifols Germany; research support, consulting, lecture fees, support for (patient) educational events and clinical trial participation from Insmed Germany; lecture and consulting fees from AstraZeneca; lecture fees, support for (patient) educational events and clinical trial participation from Chiesi; lecture fees, research support, support of (patient) educational events and clinical trial participation from Novartis; research support and support for (patient) educational events from InfectoPharm; clinical trial participation for Vertex, Parion, Celtaxsys, Corbus and GSK; research support from Polyphor; lecture fees, support for (patient) educational events and clinical trial participation from Boehringer Ingelheim; consulting and clinical trial participation for Zambon; research support and support for (patient) educational events from Baslilea; and clinical trial participation for Algipharma, all outside the submitted work.
Conflict of interest: T. Aksamit has nothing to disclose.
Conflict of interest: J.D. Chalmers reports that he was a member of a Novartis consortium during the conduct of the study. He reports research grants for COPD studies from Glaxosmithkline, Boehringer Ingelheim, AstraZeneca and Pfizer, grants and personal fees for research into bronchiectasis from Bayer Healthcare and Grifols, consulting fees from Napp and the Aradigm Corporation, and grants and personal fees from Insmed, outside the submitted work.
Conflict of interest: P. Goeminne reports personal fees and nonfinancial support from Chiesi, and personal fees from AstraZeneca, outside the submitted work.
Support statement: EMBARC is a European Respiratory Society Clinical Research Collaboration. This work has received support from the EU/EFPIA Innovative Medicines Initiative Joint Undertaking iABC grant agreement number 115721. Funding information for this article has been deposited with the Crossref Funder Registry.
Members of the ELF Bronchiectasis PAG: Tove Berg, Alan Timothy, Thomas Ruddy, Bridget Harris, Marta Almagro, Barbara Crossley, Ernie Lloyd, Annette Posthumus, Nicola Pilkington, Connie Cluderay, Sima Nadler, Pam Carter and Evan Cosgrove.
- Received May 7, 2019.
- Accepted August 3, 2019.
- Copyright ©ERS 2019
This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial Licence 4.0.
References
