TEL AVIV, ISRAEL—People with asthma who do not have good control of their disease while at home are at high risk for exacerbations during travel, particularly if their trips include high-intensity exercise or adventure. In a recent study, Yoav Golan, MD, and colleagues found that 43% of asthma patients suffered acute attacks during their journeys.[1] The two factors that were independently associated with the development of acute asthma attacks during travel were the need for inhaled bronchodilators three or more times per week before the trip and intense physical exertion during treks.

This is the first study of the effects of travel on a chronic condition such as asthma. “In general, the field of travel medicine … has focused on infectious disease factors, such as vaccinations, and preventing endemic infections,” said Dr. Golan, now Assistant Professor of Medicine in the Division of Geographic Medicine and Infectious Disease, Tufts–New England Medical Center in Boston. “We need guidelines for chronic diseases such as asthma, which may even be more problematic during travel than endemic infections,” he continued.

Dr. Golan and colleagues conducted the prospective study among young travelers with mild to moderate disease, many of whom were visiting developing countries. About two thirds of the travelers took trips that included intensive high-altitude trekking. “This type of asthma is common among adventure travelers,” said Dr. Golan. “This is an otherwise healthy population. Those who have severe disease don’t usually engage in this type of travel.”

PRETRAVEL AND POSTTRAVEL EVALUATIONS

The researchers enrolled 203 eligible patients who visited 56 countries for an average of 13 weeks. The most frequently visited countries were Thailand, India, and Nepal. Mean age for all patients was about 24, and all had sought pretravel consultation from a clinic in Tel Aviv, Israel. To determine risk factors for exacerbation, the patient’s ability to foresee disease severity during travel, and what, if any, precautions were subsequently taken, data were gathered both before travel and after return.

During the initial consultation, Dr. Golan recorded a general medical history, detailed asthma and allergy history, demographic variables, and patient estimations of the likelihood of asthma occurrences during travel. Tests, including lung auscultation and spirometry, were conducted. Patients whose forced expiratory volume in one second was greater than 65% were also given an exercise test.

After his or her return, each patient was interviewed via telephone about the details of the trip, allergies, and asthma attacks. To assess asthma during travel versus asthma under normal circumstances, patients were also asked the following three questions:
• Compared with a similar duration of time prior to travel, was your asthma severity during travel better, the same, or worse?
• Compared with a similar duration of time prior to travel, was the frequency of your asthma attacks less, the same, or more?
• Compared with the worst asthma attack you had ever experienced before travel, was the worst attack during travel less severe, the same, or the worst attack in your life?

TRAVELOGUE

Of the 203 travelers, 88 (43%) had an asthma attack during travel. Of these 88 patients, 34 (37%) said that the attack was “the worst in their life,” and 40 (45%) said that their asthma was worse during travel than at home. Eleven (13%) experienced a life-threatening attack.

Pretravel interviews showed that 138 (68%) patients had reported exercise as a trigger for asthma, but only five had said that it limited their activities. Few of the travelers were able to predict an exacerbation or take precautions to prevent one—only 18 (20%) of the 88 who suffered an attack had changed their planned itineraries to avoid potentially dangerous routes.

In a multivariate analysis, those patients who had used an inhaled bronchodilator three times or more per week before their trip were three times as likely to suffer an asthma attack as were the other patients. Participation in intense physical exertion while trekking raised the risk twofold. Combining these two risk factors increased the relative risk to more than five times. However, a history of exercise-induced asthma did not predict the development of acute attacks during travel.

A SAFE ADVENTURE?

“We expected these results in patients with uncontrolled asthma, as defined by frequent bronchodilator use,” said Dr. Golan. What was surprising was that “we couldn’t show that a history of exercise-induced asthma was predictive of asthma attacks while traveling,” he continued.

However, this lack of association may make diagnosis and counseling easier in clinical practice. Dr. Golan pointed out, “Thus, you don’t need special tests to evaluate patients who will be traveling. You just need to ask a few questions.” Asthma control and type of travel would be the primary concerns.

Counseling asthma patients before travel is essential. The most important factor is that “patients should have control before they travel,” he stressed. Asthma patients should also be warned that intense trekking may not be a safe activity for them.

In cases of stubborn patients who won’t heed medical advice and insist on strenuous activity while traveling, Dr. Golan suggested, “They need to have a rescue plan—an Epi Pen®, bronchodilators, short- and long-term inhaled corticosteroids, and oral steroids.” He also pointed out that such people should be reminded that they may get in trouble while they are far from a doctor. “How you would medicate yourself in that situation is different than in a city where you’re able to get to a doctor within an hour,” he said.

—Lisa Pallatroni