Wearing Compression Garments While Flying

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 harmful.

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 lymphedema.

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 risk”.

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.

A pubmed search of “lymphedema and flying” results in three articles:

http://www.ncbi.nlm.nih.gov/pubmed/19927904

From Lymphology, 2009, a woman with lymphedema measured her arm with bioimpedance before and after 20 flights, and her measurements worsened with flight.

An article in Breast 2002 that reported that compression garments are potentially harmful is profoundly flawed:

http://www.ncbi.nlm.nih.gov/pubmed/14965648

The author 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:

http://www.ncbi.nlm.nih.gov/pubmed/20180016

These women 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.

Andrea Cheville, MD of Mayo Clinic gave a podcast for Living Beyond Breast Cancer in 2009 and discussed air travel and compression:

http://www.lbbc.org/Event-Archive/2009-02-20-Lymphedema

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 lymphedema.

So, should you wear a sleeve/gauntlet/glove when you fly?

Definitely yes if you have lymphedema.

Strongly consider it if you are at risk.

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 reduction.

Andrea Cheville discusses this on the Lymphadivas website: http://lymphedivas.com/lymphedema/gauntletandsleeve/

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).  http://en.wikipedia.org/wiki/Atmospheric_pressure

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 reverse. http://www.airspacemag.com/flight-today/cit-larson.html

The Mystery Of Expanding Snack Bags

During airplane flights, sealed snack bags expand and appear blown up. Why does that happen?

 Air pressure on the ground is greater that at higher altitudes. A plane flying at 35,000 feet would have extremely low air pressure with not enough oxygen for people to survive. Modern planes, therefore, keep air pressure at the 8,000 feet level which is enough to breathe comfortably. But the air pressure at 8,000 feet is still significantly lower than at ground level.

 The air inside snack bags has ground level pressure, so as the cabin pressure is reduced to the 8,000 feet level, the air in the bag presses out and therefore the bag expands.

To experience the reverse phenomenon, put the cap on a soda bottle during a flight. When you land, the bottle will be pressed in. It's really cool! 

There was a program on PBS's NOVA show about the design of space suits. The first four minutes of that program is the best explanation of the effects of air pressure that we have seen.  Check it out:

http://www.pbs.org/wgbh/nova/space/space-suits.html

Next to the picture of that cute aerospace scientist wearing her classy new-fangled spacesuit, click on "Launch Video" and watch at least the first four minutes.

If you keep in mind they're talking about people with normally-functioning lymph systems, you begin to see how air pressure can be a special disaster for those of us with compromised lymph systems.

Controversial Study on Wearing Compression Garments While Flying Coming out of SABCS, December, 2008

A controversial study has come out of the San Antonio Breast Cancer Symposium, December, 2008.  Air Travel Holds Little Lymphedema Risk for Breast Cancer Survivors.

Note that this study was published as an abstract and presented orally at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.  

Also note these prior studies:  Lymphedema initiated by aircraft flights.  Casley-Smith JR, Casley-Smith JR.  Henry Thomas Laboratory, University of Adelaide, S.A., Australia.  Precipitating factors in lymphedema : Myths and realities, Author, ROCKSON S. G

Here's the press release:

http://www.medpagetoday.com/MeetingCoverage/SABCS/12142

A study was presented at the 2008 San Antonio Breast Cancer Symposium (SABCS) about the risk of lymphedema when flying.  A news release about that study came out in the on-line newsletter, MedPageToday. 

According to the news release, the study found that women who've had breast cancer surgery "need not worry" about developing lymphedema when flying.

But, that isn't what the researchers said in their report.  The results and conclusions in their SABCS meeting abstract (Abstract #1119) are different from what the news release says.  Here's a link to a page with a search engine that can be used to type in the abstract number and access the abstract of the study: http://www.abstracts2view.com/sabcs/sessionindex.php

The study involved 75 women who had recovered from breast cancer surgery and were flying to Queensland, Australia, to participate in a dragon boat regatta.   The researchers used "bioimpedance" to measure extracellular fluid in the arms of the women before and after the airplane flights.

One problem with the study is that bioimpedance was the only method the researchers used to see if the women had developed lymphedema.  Some lymphedema researchers and clinicians think bioimpedance might not be sensitive enough to detect lymphedema until it reaches a severe form (Stage III).  So, swelling that was less severe might not have been detected in this study.

According to the news release in MedPage Today, 5% of the women in the study did develop a "clinically significant" increase in arm fluid, as judged by bioimpedance.  Five percent seems like enough of a risk to warrant taking precautions when flying.  What is odd is that the researchers reported a different number in their abstract--not 5%--for the prevalence of "clinically significant" arm fluid.  They said 15 of the 75 women developed a "clinically significant" increase; and 15 of 75 is 20%, not 5%.  Twenty percent is considerable risk.  Most women would probably think a risk of 20% was worth "worrying about," and worth taking precautions.

But not all the women in the study were at equal risk of developing lymphedema.  Of the 75 women, 12 took fairly short flights to Queensland from other locations in Australia.  Only one of those 12 women had a "clinically significant" accumulation of arm fluid.  The other 63 women in the study flew all the way to Australia from Canada, which was a much longer flight--a "long haul" flight, according to the researchers.  Among the 63 women who took the trans-oceanic flights, 14 had a "clinically significant" increase in arm fluid.  So, the women on the longer flights had a 14/63 = 22% chance of developing a "clinically significant" increase in arm fluid.  That number would likely attract most women's attention and cause them concern.

According to the researchers, 8 of the 15 women who had a "clinically significant" increase in arm fluid had enough of an increase for it to be diagnostic of lymphedema (i.e., they actually developed lymphedema).  All 8 of those women were on the flights from Canada.  That means 8/63 = 12.7% of the women who took the trans-oceanic flights developed bona fide lymphedema in association with their flights.  The news release said all but 2 of those women had been diagnosed with lymphedema previously.  That statement implies that lymphedema triggered by flying is somehow less important if it is a recurrence than if it is a new case.  In contrast to that statement in the news release, the number of new cases reported in the abstract was much higher.  The researchers said in their abstract that 6 of the 8 women diagnosed with bona fide lymphedema in association with the flight had not had arm swelling prior to the flight--this was a new diagnosis of lymphedema for them.

Finally, the news release failed to emphasize an important point:  The women in this study were traveling to Australia to participate in a dragon boat regatta.  According to the researchers, 94% of the women in the study had "trained at a moderate to vigorous intensity for the regatta."   We can probably assume they were in pretty good shape--their upper-body conditioning was likely much better than that of most women after breast cancer treatment.  Several studies have shown that a supervised exercise program involving upper-body strength training can reduce the risk of lymphedema after breast cancer surgery.  Wouldn't that mean the women in this study were at lower risk of developing lymphedema in the first place?  So, why would the news release mislead their readers by generalizing the findings to all women?

The first sentence in the news release says, "Women who've had breast cancer surgery need not worry that pressure changes in an airplane cabin will bring on lymphedema, researchers found."  But that's very different from what the researchers concluded in their abstract.  Here's what the abstract said:   "For the majority of women who undertake moderate to vigorous upper limb exercise, airplane travel did not have a significant impact on extracellular fluid ratio."

Those two statements mean very different things.  The discrepancies in representation of the results of this study are troubling, and should be clarified for the benefit of all women who have been treated for breast cancer and are facing the risk of lymphedema.
 

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