When a man infected with the coronavirus died of acute respiratory failure on a United Airlines flight from Orlando to Los Angeles on Dec. 14, he was not the first individual to die of covid-19 on a plane. In July, a Texas woman died of the disease on a Spirit Airlines flight that was diverted when she was found to be unresponsive and not breathing. In both cases, the passengers were given CPR on the plane but could not be revived.
The likely medical problem in both these instances, doctors say, is that low air pressure — which is standard in plane cabins — creates dangerously low blood-oxygen levels in people with respiratory conditions. Covid-19, the illness caused by the coronavirus, is a respiratory disease that often attacks the lungs and heart.
Nicholas Hill, pulmonary chief at Tufts Medical Center in Boston, says there is “no question” that the air condition in plane cabins poses a risk to passengers with covid-19 and that flying was probably factor in the deaths of the passengers infected with the virus.
“If you get on a plane with covid, or anything else respiratory-related, you are going to be at a considerably higher risk when you go to altitude,” Hill says. “This is not something unique to covid; it’s true of anybody that’s got an acute or respiratory condition. This change in oxygen from sea level can provoke crises in the air.”
Plane cabins are pressurized so passengers are able to breathe at altitudes over 30,000 feet, but the air pressure is still about 25 percent lower in a plane cabin than it is at sea level. Flying has long given respiratory-troubled patients medical crises in the air. Covid-19 is no different. Flying with it can impact blood oxygen levels to a degree that requires immediate medical attention.
David Freedman, an epidemiologist at the University of Alabama at Birmingham, says covid-infected patients are at the same risk as people with non-coronavirus lung and heart conditions that impact their breathing. Airlines are prepared for those kinds of respiratory emergencies with supplemental oxygen onboard.
“The oxygen concentration [on planes] is much lower than on the ground, and all patients with severe lung or heart disease know this and know that they will need supplemental oxygen on board even if they don’t require it normally,” Freedman says. “All planes do carry an oxygen tank on board for emergencies like this.”
Delta Air Lines says that respiratory emergencies make up about 10 percent of in-flight medical events and that all aircraft are equipped with supplemental oxygen.
All airline flight attendants receive annual training in CPR, Taylor Garland, a spokesperson for the Association of Flight Attendants labor union, told The Washington Post in an email. Flight crew are also in close contact with medical services on the ground that can meet the aircraft in the event of an emergency landing.
But those efforts all fell short in the July and December deaths. Hill says passengers do not necessarily need to be experiencing shortness of breath before takeoff to become breathing-impaired in-flight. Blood oxygen levels can be low in covid-19 patients who are not experiencing trouble breathing, making getting on a plane with the virus — even if you’re pre-symptomatic or asymptomatic — a high-risk endeavor.
“Early on in the pandemic there were descriptions of ‘happy hypoxia’ patients, covid patients who come in with pretty low oxygen levels but wouldn’t be short of breath,” Hill says. “Most people who have low oxygen levels are also complaining of shortness of breath, but it is possible initially to not have those symptoms.”
Tony Aldapa, an off-duty medical worker on the Dec. 14 United flight who gave chest compressions to the unresponsive man, said last week that he was experiencing coronavirus symptoms after helping the flight crew with CPR. He was not notified about his exposure to the virus by contact tracers until 10 days after the flight.
“I knew we were pretty far from where we needed to land at, and CPR is exhausting with one person or two people. Even with three or four people, it’s not an easy thing to do,” Aldapa, 31, told the Los Angeles Times of the incident. “Regardless of COVID … he needed CPR to save his life.”