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Allergic and hypersensitivity reactions such as anaphylaxis and asthma exacerbations may occur during air travel. Although the exact incidence of in-flight asthma and allergic emergencies is not known, we have concerns that this subject has not received the attention it warrants. There is a need to provide passengers at risk and airlines with the necessary measures to prevent and manage these emergencies. A review of the epidemiology, management and approaches to prevention of allergic and asthma emergencies during air travel is presented with the goal of increasing awareness about these important, potentially preventable medical events.
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R E V I E W Open Access
In-flight allergic emergencies
Mario Sánchez-Borges
1,17*
,VictoriaCardona
2,3
,MargittaWorm
4
, Richard F. Lockey
5
,AzizSheikh
6
,PaulA.Greenberger
7
,
Ignacio J. Ansotegui
8
,MotohiroEbisawa
9
, Yehia El-Gamal
10
, Stanley Fineman
11
, Mario Geller
12
,
Alexei Gonzalez-Estrada
13
, Luciana Tanno
14,15
, Bernard Y. Thong
16
and on behalf of the WAO Anaphylaxis Committee
Abstract
Allergic and hypersensitivity reactions such as anaphylaxis and asthma exacerbations may occur during air travel.
Although the exact incidence of in-flight asthma and allergic emergencies is not known, we have concerns that this
subject has not received the attention it warrants. There is a need to provide passengers at risk and airlines with the
necessary measures to prevent and manage these emergencies. A review of the epidemiology, management and
approaches to prevention of allergic and asthma emergencies during air travel is presented with the goal of increasing
awareness about these important, potentially preventable medical events.
Keywords: Aircraft, Air travel, Allergic reaction, Anaphylaxis, Asthma, Emergency, Flight, Food allergy
Background
About 2.75 billion passengers are transported worldwide
by airlines every year. Many of these people will have
pre-existing long-term conditions including asthma
and/or allergy which put them at risk of an in-flight
medical emergency. In a smaller minority of people,
these conditions may develop for the first time (i.e. inci-
dent cases) while in flight. It is expected that by 2030,
half of all aircraft passengers will be over 50 years of age
[1]. Up to 44,000 in-flight medical emergencies occur
each year [2], and data suggest that about 17% of such
cases are transferred to a hospital, with 4% resulting in
hospitalization or death.
Systemic allergic reactions (SAR) (a serious systemic al-
lergic reaction is defined as anaphylaxis) and asthma exac-
erbations (AE) may occur during air travel. We have
concerns that to date, these have not received sufficient at-
tention from passengers, airlines, and the medical com-
munity. In view of the potentially avoidable morbidity and
mortality, a review about the epidemiology, management
and prevention of allergic and asthma emergencies during
air travel is needed to increase awareness about these re-
actions and how to prevent and treat them. Likewise,
travel for the allergic and asthmatic passenger poses a
number of problems, in particular for those with a history
of a food-induced SAR or who have asthma. Patients may
experience, among other, fear of suffering an allergic
reaction or AE, problems regarding which medications to
carry on board, how to use them, or not receiving appro-
priate attention when seeking support from airline
personnel about their potential needs [3].
The frequency of these reactions among susceptible
passengers is unknown; however, data from peanut aller-
gic individuals indicate that approximately 9% of them
have experienced some sort of allergic reaction during
flights [4, 5].
Medical emergencies during air travel
In-flight medical emergencies occur in 1 per 11,000 pas-
sengers [6] or 1 in every 604 flights [2]. A number of
reasons are proposed to explain the incidence of medical
and allergic events during air travel, and those are sum-
marized in Table 1. The most common in-flight medical
events include syncope, gastrointestinal and cardiac
problems [2, 7, 8].
Alterations in passenger cabin during flight:
implications of physiological changes during air
travel to allergic and hypersensitivity diseases
There are two major concerns about allergic and respira-
tory diseases when traveling by air. The first is related to
theconcentrationofoxygeninthecabin.Whileinflight,
the cabin pressure is equivalent to an altitude of 6000 to
* Correspondence: sanchezbmario@gmail.com
1
Allergy and Clinical Immunology Department, Centro Médico Docente La
Trinidad, Caracas, Venezuela
17
Clínica El Avila, 6a.transversal Urb. Altamira, piso 8, consultorio 803, Caracas
1060, Venezuela
Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Sánchez-Borges et al. World Allergy Organization Journal (2017) 10:15
DOI 10.1186/s40413-017-0148-1
8000 ft, exposing passengers to a partial pressure of arterial
oxygen of 60 mm Hg compared to 75 to 100 mm Hg at sea
level. Thus, the partial pressure of oxygen in the cabin air
at cruising altitude is 2530% lower than at sea level. A
slight fall in oxygen blood saturation occurs, ranging from
92 to 95%, followed by compensatory hyperventilation and
tachycardia [9]. These physical alterations may affect pas-
sengers who have cardiac, respiratory or hematologic
(anemia) diseases, theoretically increasing the risk of exac-
erbations of allergic and hypersensitivity reactions such as
anaphylaxis.
These pressure changes can also result in blocked
ears or sinusesor, occasionally, barotitis or barosinusi-
tis. These conditions can usually be prevented by yawn-
ing, chewing gum during the flight, and by using a
sympathomimetic nasal spray such as oxymetazoline be-
fore ascent and descent.
The dry cabin atmosphere (with humidity 618%) can
also irritate the mucosal membranes of the mouth and
upper respiratory tract. Likewise, dehydration can occur,
especially in a passenger taking a diuretic. Therefore,
drinking plenty of extra fluids is recommended during
flight [10].
Asthma and allergic reactions
Allergic reactions account for an estimated 24% of
medical problems on board commercial airliners
(Table 2) [5, 1113]. Buehrle and Gabler observed that
allergywas the 7th most common cause of in-flight
medical problems between 2002 and 2007, ranging from
1.5 to 2.5% [1]. During the same period asthmatic events
were 14th in frequency (0.6 to 3.2%).
Some authors propose that an AE is the most com-
mon, and potentially the most life-threatening condition
reported by major airlines. According to Dowdalls study,
serious allergic reactions rarely occur. Respiratory events
were the 5th cause of aircraft medical conditions,
whereas allergic diseases, including urticaria, angio-
edema, additional forms of acute dermatitis, AE, and
SAR were the 11th most common [6]. SAR in airplanes
are most commonly triggered by foods (peanuts, tree
nuts, and seafood) or medications. Very rarely these are
triggered by insect stings or an insecticide spray [14].
There are reports of passengers having experienced
idiopathic anaphylaxis while in flight, administering self-
injected epinephrine (adrenaline) in the lavatory, and
not notifying the flight attendant (Greenberger P, per-
sonal communication). There are also reports of attacks
that have necessitated plane diversion to the closest
airport.
Other publications report that allergic emergencies are
responsible for 2.2% of all medical problems and result
in 4.5% of aircraft diversions [2]. Allergic reactions were
the 7th most frequent cause of medical events, and der-
matologic manifestations, including skin rashes, the 9th
most common cause in Baltszeks study [11].
An article by Nable et al. on in-flight medical emer-
gencies did not discuss allergic conditions or SAR, al-
though it did mention a 12% incidence of respiratory
reactions [8]. This prompted Casale and Lemanske to
submit a letter to The New England Journal of Medicine
highlighting the need to consider anaphylaxisas a re-
action likely to occur during flights [15].
The lack of recognition of allergic reactions as an im-
portant cause of medical events during air travel could
be due to the fact that they are rare, or because they are
under-recognized, or diagnosed and not reported, since
methods to report such reactions are different and not
standardized [16, 17]. This is an area that therefore war-
rants further study. As previously stated, passengers
often do not report medical problems during flight [5].
In-flight treatment of allergic emergencies and
asthma
Treating medical emergencies during flight is a major
challenge and air travel is an important concern for sub-
jects with asthma and a history of a SAR.
The resources to treat allergic emergencies are some-
what limited. In the United States, the Federal Aviation
Administration requires the inclusion of epinephrine in
medical kits carried on board [18]. These emergency med-
ical kits typically contain the following medications [19]:
Table 1 Rick factors for medical and allergic events during air
travel
An increase of passengers age
Flight stress and anxiety, including
increased security procedures
Disruption of routine
Changes in the cabin environment
(temperature, humidity, air pressure)
Decreased seat space
Flight delays
Alcohol/drug intake
Longer flights
Altered circadian rhythm
Jet lag
Pre-existing medical conditions
Table 2 Prevalence of in-flight allergic reactions
Authors (year of publication) Prevalence (%) Reference
Szmajer et al. (2001) [13] 2.4 13
Delaune et al. (2003) [12] 2.8 12
Baltsezk (2008) [11] 3.7 11
Sand et al. (2012) [16] 2.2 17
Sánchez-Borges et al. World Allergy Organization Journal (2017) 10:15 Page 2 of 5
Aqueous epinephrine (adrenaline) 1:10000 and
1:1000 dilution.
Albuterol (salbutamol) for nebulization.
Bronchodilator aerosol inhaler.
Cortisol (hydrocortisone).
Antihistamines tablets and injectable (commonly
diphenhydramine).
A recommendation from this World Allergy
Organization (WAO) expert group for in-flight treat-
ment of a SAR and AE is:
a) For AE, inhaled bronchodilator and oxygen.
Consider an oral, intramuscular or intravenous
corticosteroid for moderate to severe symptoms and
intramuscular epinephrine for severe symptoms.
b) For mild, moderate, and severe SAR, intramuscular
epinephrine 0.01 mg/kg up to 0.5 mg of 1:1000
solution IM in the anterior lateral thigh. Repeat as
necessary.
Prevention
Food-induced SAR are increasingly being observed in
many parts of the world. Strategies to reduce the risk of
a SAR while traveling should begin during the early
planning of the plane trip. Advice from their treating
physician or allergist/immunologist should be obtained
about preventive measures to be implemented before or
during the flight. Likewise, a treatment plan should be
instituted in case there is an inadvertent contact with a
known allergen, i.e., a peanut [2025].
Greenberger and Lieberman propose that subjects with
idiopathic anaphylaxis not travel within a week of a previ-
ous episode and recommend the administration for an
adult of prednisone 4060 mg and an H1 antihistamine
by mouth each morning for 1 week before travel. This can
help reduce the frequency and severity of episodes [26]. If
the flight is longer than 1 week after an episode of idio-
pathic anaphylaxis, empiric therapy should be initiated
and continued to reduce the likelihood of an attack while
in flight. For example, the passenger can be converted to
alternate day prednisone.
Medical departments of major airlines can also be con-
sulted about specific questions and recommendations for
air flights on individual carriers. Physicians on board
should be contacted immediately by the airline crew
for any emergency, including allergic emergencies, to
determine what treatment should be instituted and if
the plane should be diverted to the nearest airport. In
addition to medical kits on board and special training
of the crew on the management of medical emergen-
cies, airlines may have remote access to medical ser-
vices which can monitor and give instructions for the
Table 3 Measures that reduce the risk of an in-flight reaction to
peanut and tree nuts
a
1. Passengers requesting any kind of special accommodation
(e.g., peanut/tree nut snacks not be distributed, announcement to not
eat items with peanut/tree nut, request special peanut/tree nut-free
meal, buffer zone, pre-board, request to sit in a certain seat/zone).
2. Peanut/tree nut-free meals.
3. Wiping of tray tables
4. Avoidance of airline pillows or blankets
5. Buffer zones around which peanut or nut products cannot be
consumed
6. Request other passengers not to consume peanut/tree nut-containing
products
7. Announcement that passengers do not eat peanut/tree nut
containing goods
8. Not consuming airline-provided food
a
Modified from reference [28]
Table 4 Airline policies for allergic passengers (Data from 13 air
carriers)
a
Number of airlines
Pre-boarding arrangements
Request a food buffer zone5
No buffer zone3
Request allergen-free meal1
Pre-boarding to wipe down seats
and table trays
Yes 4
No 1
Buffer zone for fragrance sensitivity 2
Announcements to inform customers
there is a peanut or tree-nut allergic
passenger on board or that peanut
products will not be served
Yes 4
No 7
Free snack policy on peanut/nut/sesame
Serving peanuts Yes 2
No 11
Serving nuts and sesameaw Yes 8
No 1
First class warmed nuts 3
Gluten-free meals Yes 11
No 1
Lactose-free meals 1
Shellfish served Yes 4
No 3
Fish served Yes 6
No 1
Buffer zones for passengers allergic to pets 5
a
In general air lines cannot guarantee an entirely peanut-free environment.
Modified from reference [30]
Sánchez-Borges et al. World Allergy Organization Journal (2017) 10:15 Page 3 of 5
best treatment until the plane arrives at a location
where the passenger can be adequately treated.
Measures to avoid peanut and tree nut exposure for
peanut and tree nut allergic individuals have resulted in
lower odds of in-flight SAR from these foods (Table 3)
[27, 28]. Since these measures may be difficult to imple-
ment, can cause discomfort for some passengers, and re-
sult in higher costs of travel, airlines and some travelers
might be reluctant to implement them.
Airline policies on allergy
Many airline carriers have devised strategies to prevent
SAR and AE during travel (Table 4). However, there are
no standardized measures to do so and each carrier has
its own recommendations. Retrieving first-hand infor-
mation about SAR and AE is difficult [29]. A summary
of proposed airline policies is presented in Table 5 [30].
Conclusions
As greater numbers of people fly, the number of AE and
SAR are likely to increase during flights in the future.
Therefore, passengers at risk should be aware of the ne-
cessary measures to prevent and manage these emergen-
cies. It is also vitally important that airlines are prepared
to deal with these diseases by providing the necessary
strategies to decrease the incidence of SAR and AE. They
also should have the necessary means to treat these reac-
tions when and if they occur. There is a clear opportunity
for airlines to work alongside allergists/immunologists to
implement evidence-based recommendations to prevent
allergic reactions during flight, especially SAR.
Abbreviations
AE: Asthma exacerbation; SAR: Systemic allergic reaction; WAO: World Allergy
Organization
Acknowledgements
This is a product of the Anaphylaxis Committee of the World Allergy
Organization. The authors thank the Board of Directors for approval and
support of the paper.
Funding
Not applicable.
Availability of data and materials
Not applicable.
Authorscontributions
MSB drafted the manuscript. All authors contributed to the conception of
the review and revising it critically for important intellectual content. All
authors read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Consent for publication
Consent for publication was granted by all authors.
Ethics approval and consent to participate
Not applicable.
PublishersNote
Springer Nature remains neutral with regard to jurisdictional claims in
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Author details
1
Allergy and Clinical Immunology Department, Centro Médico Docente La
Trinidad, Caracas, Venezuela.
2
Allergy Section, Department of Internal
Medicine, Hospital Universitari Vall dHebron, Barcelona, Spain.
3
Allergy
Research Group, Institut de Recerca Vall dHebron, Universitat Autònoma de
Barcelona, Barcelona, Spain.
4
Allergie-Centrum-Charité, Klinik für
Dermatologie, Venerologie und Allergologie, Campus Charité Mitte,
Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany.
5
Division of
Allergy and Immunology, Department of Internal Medicine, University of
South Florida Morsani College of Medicine, Tampa, FL, USA.
6
Allergy and
Respiratory Research Group, Usher Institute of Population Health Sciences
and Informatics, The University of Edinburgh, Edinburgh, UK.
7
Division of
Allergy-Immunology, Department of Medicine, Northwestern University
Feinberg School of Medicine, Chicago, IL, USA.
8
Department of Allergy and
Immunology, Hospital Quironsalud Bizkaia, Bizkaia, Spain.
9
Department of
Allergy, Clinical Research Center for Allergy and Rheumatology, Sagamihara
National Hospital, Kanagawa, Japan.
10
Pediatric Allergy & Immunology Unit,
Childrens Hospital, Ain Shams University, Cairo, Egypt.
11
Department of
Pediatric Allergy & Immunology, Emory University School of Medicine,
Atlanta Allergy & Asthma, Atlanta, USA.
12
Division of Medicine, Academy of
Medicine of Rio de Janeiro, Rio de Janeiro, Brazil.
13
Division of Allergy and
Clinical Immunology, Department of Medicine, Quillen College of Medicine
and Center for Excellence for Inflammation, Infectious Disease and Immunity,
East Tennessee State University, Johnson City, TN, USA.
14
Hospital Sírio
Libanês, São Paulo, Brazil.
15
University Hospital of Montpellier, Montpellier,
and Sorbonne Universités, Paris, France.
16
Department of Rheumatology,
Allergy and Immunology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng,
Singapore.
17
Clínica El Avila, 6a.transversal Urb. Altamira, piso 8, consultorio
803, Caracas 1060, Venezuela.
Received: 19 December 2016 Accepted: 23 March 2017
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Sánchez-Borges et al. World Allergy Organization Journal (2017) 10:15 Page 5 of 5
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... Os passageiros sendo indivíduos saudáveis, pouco percebem os sintomas da adaptação do corpo humano a redução de pressão e ao ar rarefeito. No caso de passageiros com condições médicas instáveis, estes podem ter algum desconforto durante o deslocamento da aeronave (ALVES; DANZI; GRAYZEL, 2017) (SÁNCHES-BORGES et al., 2017). ...
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... Allergic reactions are reported to account for approximately 2-4% of all medical emergencies on commercial airline flights [1]. This number is likely to be higher, since acute asthma attacks are documented as a respiratory problem and not necessarily as a symptom of a severe allergic reaction [2]. ...
... Severe allergic reactions on commercial flights are primarily caused by foods (peanuts, tree nuts, or seafood) and medications [1]. Anaphylactic shock is the most extreme form of allergic reaction. ...
Article
Full-text available
Introduction Allergic reactions are reported to account for approximately 2–4% of all medical emergencies on commercial airline flights. In 2016, the International Air Transport Association (IATA) published recommendations on risk prevention in severe allergies. Methods Using a written questionnaire and an internet search, an investigation was conducted on the extent to which airlines operating in Germany have implemented the IATA recommendations and, e.g., offer peanut/nut allergy sufferers appropriate measures. Results Only 14 of the 104 airlines contacted responded to the written survey. Of 115 airlines, 72 provided information for allergy sufferers on their homepage, but mostly in insufficient detail. No results were found for the search term “allergy” (or “Allergie”) on the websites of 43 airlines. The information on the individual airlines has been summarized in table form. Discussion The information offered by many airlines for passengers with allergies is insufficient. To offer greater guidance, updated information has been formulated in German and English, and its use is recommended.
... The World Allergy Organization expert group for in-flight treatment of a systemic allergic reaction or asthma exacerbation recommends intramuscular administration of epinephrine, at the dose already described [40]. And a recent publication suggests that EAI may prove to be a valuable tool in treating lifethreatening allergic reactions during flight [41]. ...
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... However, it can be frustrating and associated with impaired quality of life, including bullying of food-allergic children, fear of anaphylaxis during airline travel, and anxiety over restrictions on exercise. 129,130 In medication-triggered anaphylaxis, avoidance of relevant medications, and use of safe substitutes are mandatory. If indicated, skin testing for penicillin allergy, or other drugs, and graded challenge to rule out immediate hypersensitivity or desensitization in the absence of alternative therapies, can be attempted. ...
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To the Editor: Nable et al. (Sept. 3 issue)(1) did not mention that acute allergic reactions may occur on airplanes, probably triggered by a food, especially peanuts (commonly served on flights), a drug, or in rare cases, an insect bite or sting. Food allergies among children increased by approximately 50% between 1997 and 2011.(2) The first-line treatment for anaphylaxis, a severe and often life-threatening reaction, is prompt administration of epinephrine and a hospital visit.(3),(4) Because the need for treatment is often immediate (especially in persons with hypotension or airway compromise) and death may occur before transfer to a hospital, . . .
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To the Editor: Nable et al. (Sept. 3 issue)(1) did not mention that acute allergic reactions may occur on airplanes, probably triggered by a food, especially peanuts (commonly served on flights), a drug, or in rare cases, an insect bite or sting. Food allergies among children increased by approximately 50% between 1997 and 2011.(2) The first-line treatment for anaphylaxis, a severe and often life-threatening reaction, is prompt administration of epinephrine and a hospital visit.(3),(4) Because the need for treatment is often immediate (especially in persons with hypotension or airway compromise) and death may occur before transfer to a hospital, . . .
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To the Editor: Nable et al. (Sept. 3 issue)(1) did not mention that acute allergic reactions may occur on airplanes, probably triggered by a food, especially peanuts (commonly served on flights), a drug, or in rare cases, an insect bite or sting. Food allergies among children increased by approximately 50% between 1997 and 2011.(2) The first-line treatment for anaphylaxis, a severe and often life-threatening reaction, is prompt administration of epinephrine and a hospital visit.(3),(4) Because the need for treatment is often immediate (especially in persons with hypotension or airway compromise) and death may occur before transfer to a hospital, . . .
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