Question

75-year-old man, and his 73-year-old wife traveling to Nigeria in three weeks. The wife is a
known case of chronic obstructive pulmonary disease –COPD- on treatment. The man is a known
case with chronic kidney diseases and also arthritis of lower limbs and taking medications for
both diseases since 2005 and lost to follow up by Nephrology. this is all information I have

1. Mention three issues need to be raised and informed to this couple in the pre-travel
consultation.

2. Please (discuss the issue in detail and support them with evidence).

Answer 1

73 year old female have COPD i.e chronic obstructive pulmonary disease. COPD has been cited as the most common reason for pre-flight medical screening.

AIR TRAVEL RISKS INCLUDE -

• Higher risk for significant hypoxemia, with the potential for arterial oxygen saturation (PaO2) to fall below critical limits.

• Hypoxemia-induced hyperventilation leading to hyperinflation and thus increased intrinsic positive end-expiratory pressure, which is mainly responsible for respiratory muscle fatigue in severe COPD especially during long-haul flights.

• Pronounced increases in pulmonary artery pressure, which could result in increased right ventricle afterload and dysfunction.

• Increased sympathetic activation due to acute hypoxemia, which may lead to cardiac arrhythmias and ischemia in vulnerable patients.

• Significant desaturation resulting from sleep during flights.

• Problems related to the expansion of gases during the aircraft's ascend.

* Patients with COPD may also experience air hunger, hyperventilation, chest pain, palpitations, lightheadedness, and tingling in the extremities. Any physical activity such as walking to the lavatory may further increase symptoms. In addition, irritation of the lower airways as a result of low in-flight air humidity and increased ventilation from hypoxemia may cause respiratory symptoms.

*## 75 year old man has CKD i.e. chronic kidney disease and lower limb arthritis. The risk of long-travel periods in chronic kidney disease may include -

• Traveler's thrombosis - Traveler's thrombosis is defined as travel-related venous thromboembolism , i.e. deep vein thrombosis and subsequent pulmonary thromboembolism.

• Altitude sickness - Altitude sickness is a general term for physical symptoms caused by low oxygen levels at altitudes above 2500 m. Causes of altitude sickness include organ edema owing to reduced pressure at high altitudes and a decrease in oxygen partial pressure, creating a systemic hypoxic state. At high altitudes, peripheral veins contract and the central blood volume increases, with pressure stimulus, secretion of antidiuretic hormone and aldosterone is suppressed, resulting in diuresis. These physiological changes are related to high-altitude adaptation as is bicarbonate diuresis that occurs as compensation for respiratory alkalosis caused by hypoxia.

** Renal function at high altitude is affected by various factors including respiration, cardiac output, sympathetic activity, and erythropoietin. When a sharp drop in oxygen partial pressure occurs, natriuresis and increased potassium and bicarbonate excretion develop via peripheral oxygen receptors. The respiratory compensation and natriuresis responses to hypoxia take place during the 24–48 h that follow hypoxic exposure and vary by as much as 10-fold between individuals. Hypoxia and hypocapnia caused by high altitude increase the following - adrenosympathetic activity, epinephrine, atrial natriuretic peptide, brain natriuretic peptide, and endogenous digitalis. Kidney hypoxia increases endothelin-1 and adrenomedullin and results in decreased levels of antidiuretic hormone, renal sensitivity to antidiuretic hormone, renin, aldosterone, and renal sympathetic nerve activity. These mechanisms result in increased natriuresis and diuresis.

** At high altitudes, patients with CKD have an increased risk of secreting an excess of body fluid owing to reduced urinary sodium excretion, improper functioning of sodium excretion in patients receiving hemodialysis increases the risk of pulmonary edema. Indeed, the higher the altitude at which a hemodialysis patient is, the higher the weight gain between dialyses. CKD patients therefore require daily body weight monitoring, if excess fluid retention associated with AMS occurs, then an increased dosage of diuretics is necessary. The monitoring of blood pressure and blood sugar is recommended.

• Traveller's diarrhoea - Traveler's diarrhea is chiefly a bacterial infection associated with the ingestion of contaminated water or food. It is defined as four or more bouts of diarrhea within 24 h, or three or more bouts of diarrhea within 8 h, along with abdominal pain and vomiting.

## CKD patients are believed to be at a higher risk than healthy individuals when they travel, owing to the aforementioned concerns about the impact on their mental and physical well-being; thus, travel is something that should be weighed carefully. However, there is almost no epidemiological evidence regarding the effect of travel on CKD patients, and the pathophysiology of travel-related illness in this population remains poorly understood.