This has become a
controversial topic--part of the movement to debunk risk reduction
behaviors, as those who would advocate that compression garments
don’t protect women at risk against the onset of lymphedema with air
travel, cite that the literature hasn’t proven compression to be
helpful—but we need to look carefully at the one or two studies out
there, and the concern that poorly fitting compression could be
A careful review of the
literature provides no proof that compression garments can harm
women at risk for lymphedema or that air travel presents no risk for
At the 2010 NLN
Conference: Sheila Ridner was speaking on the controversies around
risk reduction behaviors and said “When you sit in a lymphedema
support group and woman after woman tells of air flight triggering
lymphedema, it’s hard to ignore.” Two of the directors of this site
had their lymphedema begin after air travel: and they were “low
If you have lymphedema,
there’s no controversy: you should fly with compression—ideally
wrapped, or at the very least, with a glove and sleeve.
search of “lymphedema and flying” results in three articles:
Lymphology, 2009, a woman with lymphedema measured her arm with
bioimpedance before and after 20 flights, and her measurements
worsened with flight.
article in Breast 2002 that reported that compression garments are
potentially harmful is profoundly flawed:
surveyed his own patients about flying and only 24% of his patients
used garments with air travel, he followed his patients, most of
whom had ALND, for 4-11 months and determined that based on
self-reported survey, which he determined was equivalent to 2 arm
measurements, and accurate for diagnosing lymphedema—which is not
proven nor sensitive, that compression increased the rate of
lymphedema. These women were very high risk: most with ALND, many
positive nodes and radiation and the causality of developing
lymphedema after air flight with compression, was not conclusively
proven in this study.
The study most
often cited to disprove need for compression with air flight is the
dragon boat study from 2010 and it is flawed as well:
were assessed by single-frequency bioimpedance, 2 weeks before
travel, on arrival and 6 weeks after travel. Biomimpedance is “not
intended to diagnose or predict lymphedema” and is most useful in
demonstrating excess intracellular fluid in latent stage lymphedema,
and per researchers and the manufacturer, the device is of limited
clinical utility when visible swelling or fibrosis are present. In
this study, 5% of women who traveled the longer distance developed
elevated readings. This study, using a measurement device that
should only be used in conjunction with physical exam, symptoms and
ideally arm volume measurements, was insufficient to conclude that
compression is not helpful in preventing lymphedema, and per the
criteria of this study at least 5% of the women, who were athletic
and fit, did develop lymphedema with long-distance flights.
So, the one
study that purported to prove that compression harmed women at risk
for lymphedema is ten years old, and based on self-reported swelling
or insufficient measurement and of the author’s 293 patients, only
50% had flown, and of these women, only 24% had used compression.
The author failed to prove compression was harmful to his 34 high
risk patients. And, he concluded that longer flights might pose more
risk to his patients.
And the dragon
boat study used a measurement device that, used without other
clinical data, can not diagnose lymphedema, and even these athletic
women developed lymphedema after long air flights.
So, why are
women being told to avoid compression when they fly? We don’t have
evidence to support this advice and we have a lot of clinical
experience to support the use of compression.
Cheville, MD of Mayo Clinic gave a podcast for Living Beyond Breast
Cancer in 2009 and discussed air travel and compression:
An issue that I just realized I
passed is airplane travel. Why all the concern about airplane
travel? That has to do with increasing the lymphatic load. When
we’re in a airplane, even though the cabins are pressured, they’re
still at lower lower pressure than we experience at sea level.
Historically, the belief has been
that in an airplane cabin at [an] altitude [of] 36,000 feet, the
ambient pressure, the pressure that surrounds the arm, is reduced,
and therefore there’s less resistance, less impedance, for fluid to
leak across the walls of the small blood vessels, and so more fluid
accumulates in the arm. Witness the swelling that most of us get in
our feet. If we take a transatlantic or transpacific flight, we
believe it’s because, with the reduced pressure in the cabin,
there’s less of a barrier for that fluid to leak across your blood
vessels and into your tissue.
There are other things that happen
during air travel that are also provocative that can place a women
at risk for lymphedema. These include being sedentary, sitting
without moving for a long time. As I mentioned before, the muscles
are very, very important, the contraction and relaxation of the
muscles for normal lymphatic flow. When we don’t move for a long
period of time, our lymph flow becomes sluggish.
Certainly, if you’re thinking about
using a sleeve for a precaution during air travel, you absolutely
want to move that arm. Squeeze and release your fist, your
hand a few times. Get that elbow moving, so we make sure the
muscles are moving.
The other thing that happens in air
travel, or used to happen when we were actually given food during
airplane flights, is you’re fed very salty food. That will cause the
body to retain water and produce more lymph.
Also, many times women are carrying
luggage, carrying heavy bags, so they’re using their arm in a
vigorous and noncustomary way, which is potentially going to
increase lymph load. They may be carrying luggage with heavy
shoulder straps that cut off that collateral circulation. There
are a number of things
that all relate to the conditions that place a women at risk for
So, should you
wear a sleeve/gauntlet/glove when you fly?
Definitely yes if you have
Strongly consider it if you are at
Poorly fitting compression can trap
fluid and cause a tourniquet effect, so if you decide to wear a
sleeve WITH hand compression for flying, make sure it’s well fitting
and that you wear it before you leave to make sure it doesn’t trap
fluid or irritate your skin.
One experienced therapist has
suggested low level arm compression: 15-20 mm (only made by Jobst),
paired with a 20-30 mm gauntlet or glove.
A sleeve should never be worn
without hand protection: especially if being used for risk
Andrea Cheville discusses this on the Lymphadivas
And, as lymphadema risk is
life-long, this issue should be periodically reviewed: we’ve heard
from women who flew without problems, but then swelled with a
subsequent flight. Be aware of your risk, and how air travel
increases risk and with or without compression: hydrate, deep
breathe, move your arm and hand.
Athmospheric Pressure at Different
Levels of Elevation Above Sea Level
Air pressure at various altitudes is really an issue: There is hard
science behind this,
Atmospheric pressure is the force per unit area exerted into a
surface by the weight of air above that surface in the atmosphere of
Earth (or that of another planet). In most circumstances atmospheric
pressure is closely approximated by the hydrostatic pressure caused
by the mass of air above the measurement point. Low-pressure areas
have less atmospheric mass above their location, whereas
high-pressure areas have more atmospheric mass above their location.
Likewise, as elevation increases, there is less overlying
atmospheric mass, so that pressure decreases with increasing
elevation. On average, a column of air one square centimeter in
cross-section, measured from sea level to the top of the atmosphere,
has a mass of about 1.03 kg and weight of about 10.1 N (2.28 lbf) (A
column one square inch in cross-section would have a mass of about
14.7 lbs and weight of about 65.4 N).
On the ground,
the airplane is unpressurized and the outflow valve is wide open.
During preflight, the pilot sets the cruise altitude on a cabin
pressure controller. As soon as the weight is off the main wheels at
takeoff, the outflow valve begins to close and the cabin starts to
pressurize. The airplane may be climbing at thousands of feet per
minute, but inside the cabin, the rate of “climb” is approximately
what you might experience driving up a hill. It might take an
average airliner about 20 minutes to reach a cruise altitude of,
say, 35,000 feet, at which point the pressurization system might
maintain the cabin at the pressure you’d experience at 7,000 feet:
about 11 pounds per square inch. Your ears may pop, but the effect
is mild because the climb rate is only 350 feet per minute. When the
airplane descends, the pilot sets the system controller to the
altitude of the destination airport, and the process works in