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Autonomic Neuroscience: Basic and Clinical 129 (2006) 80 85

www.elsevier.com/locate/autneu

Review

Passenger well-being in airplanes


H. Hinninghofen , P. Enck
University Hospitals Tbingen, Internal Medicine VI, Psychosomatic Medicine and Psychotherapy, Fronsbergstrae 23, D-72070 Tbingen, Germany

Abstract
Passenger well-being is influenced by cabin environmental conditions which interact with individual passenger characteristics like age
and health conditions. Cabin environment is composed of different aspects, some of which have a direct influence on gastrointestinal
functions and may directly generate nausea, such as cabin pressure, oxygen saturation, and motion or vibration. For example, it has been
shown that available cabin pressure during normal flight altitude can significantly inhibit gastric emptying and induce dyspepsia-like
symptoms when associated with a fibre-rich meal. Other aspects of the cabin environment such as space and variability of seating, air quality,
and noise, also have been shown to modulate (reduce or increase) discomfort and nausea during flights. Individual passenger characteristics
and health status also have been demonstrated to increase vulnerability to adverse health outcomes and discomfort.
2006 Elsevier B.V. All rights reserved.
Keywords: Aircraft cabins; Atmospheric pressure; Air quality; Humidity; Deep vein thrombosis (DVT); Hypoxia

Contents
1.
2.
3.

Introduction . . . . . . . . . . . . .
Cabin pressure and oxygen saturation
Cabin pressure and gas expansion . .
3.1. Other effects of pressure . . .
4. Motion and vibration of the aircraft .
5. Seating and immobility. . . . . . . .
6. Deep vein thrombosis . . . . . . . .
7. Cabin air quality . . . . . . . . . . .
7.1. CO2 concentration. . . . . . .
7.2. Humidity . . . . . . . . . . .
7.3. Noise . . . . . . . . . . . . .
8. Conclusions . . . . . . . . . . . . .
9. Future perspectives . . . . . . . . . .
References . . . . . . . . . . . . . . . . .

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1. Introduction

Corresponding author. Tel.: +49 7071 9387372; fax: +49 7071 9387379.
E-mail address: Heidemarie.Hinninghofen@uni-tuebingen.de
(H. Hinninghofen).
1566-0702/$ - see front matter 2006 Elsevier B.V. All rights reserved.
doi:10.1016/j.autneu.2006.07.018

Modern commercial airplanes are quiet and comfortable


compared with previous generations of aircrafts. Nevertheless, there are still some aspects of the cabin environment
which may cause stress and affect health in vulnerable
individuals. Stressors in flight include cabin pressure and

H. Hinninghofen, P. Enck / Autonomic Neuroscience: Basic and Clinical 129 (2006) 8085

oxygen saturation, motion and vibration of the aircraft, space


and variability of seating, air quality and humidity, and noise.
While pressure or oxygen and motion or vibration may
exhibit direct effects on gastrointestinal function that may
result in nausea and vomiting, other factors may modulate
well-being and amplify or reduce these direct effects.
2. Cabin pressure and oxygen saturation
Relevant to passenger health are flight altitude and cabin
altitude (Fig. 1). Modern airplanes cruise normally at an altitude
between 30,000 and 40,000 ft (9150 and 12,200 m) where the
atmospheric pressure is less than 30% of that at sea level. In
pressurized airplanes, cabin pressure will vary from sea level
(760 mmHg) to 8000 ft (564 mmHg), depending upon aircraft
altitude and pressurization schedules. These pressure guidelines
were established in the early days of pressurized cabins
(McFarland, 1953), based on medical knowledge, aeroengineering requirements, and economics (Ernsting, 1978).
The ambient pressure of oxygen is approximately 20% of
barometric pressure. Because the ambient oxygen concentration remains fixed, any decrease in atmospheric pressure
will lead to decreases in inspired oxygen tensions (PAO2) and
arterial oxygen tension. The physiologic response to lowered
PAO2 is hyperventilation as a first step to meet the body's
needs. Continuing hypoxia is compensated for with tachycardia to increase cardiac output. Hypoxia is also a stimulus
for atrial arrhythmias and is associated with premature
ventricular contractions (Gong, 1992). The blood haemoglobin oxygen saturation level is normally 95% for healthy
people at sea level. At higher altitudes (and lower pressure),
saturation levels fall. Oxygen saturation levels less than 85%
may lead to impairment of mental function, and appreciable
handicaps will occur at 70% saturation (Peacock, 1998).
Oxygen saturation in resting people in an airplane cabin with

81

a cabin altitude of 8000 ft will be around 90% with a range of


85%93% after 30 min. In dozing subjects saturation levels
of around 80% were found (Simons and Krol, 1996). In
general, mild hypoxia with an oxygen saturation level of 90%
is of no significance to healthy individuals, but due to wide
individual differences, prediction of hypoxemia in an
individual air traveller is difficult.
Of concern nowadays is that in-flight cabin measurements
show that cabin altitudes substantially higher than 8000 ft may
be allowed (Cotrell, 1988) with consequent lowering of oxygen saturation that may be dangerous for those with ischemic
heart disease, chronic respiratory disease and anaemia, or
sickle cell anaemia (Gendreau and DeJohn, 2002). In passengers with such conditions, the consequences of lack of
oxygen may include angina, acute myocardial infarction and
congestive cardiac failure. Cardiac disorders are the most
common cause of in-flight death (Cummins et al., 1988). Older
passengers are at increased risk because arterial oxygen tension tends to fall after 40 years of age (James, 1996).
3. Cabin pressure and gas expansion
Low cabin pressure also leads to expansion of gases: in
accordance with Boyle's law, gases expand up to 35% when
ascending from sea level to 8000 ft of altitude (Table 1).
The body has a number of air-filled cavities: the middle
ear and sinuses, the gut, pleural cavities, tooth fillings and
the skull. Because pressure changes during ascent and descent occur very slowly, the majority of travellers experience
no adverse effects apart from slight bloating or a sensation in
the middle ear. Nevertheless, gas in body cavities can cause
discomfort if equilibration with the ambient barometric
pressure is not possible.
Expansion of gas in the stomach or duodenum can lead to
discomfort, nausea or vomiting. Gas expansion within the gut

Fig. 1. Cruising altitude and corresponding cabin altitude. Cruising altitude of modern airplanes is shown on the left Y-axis, while cabin altitude is shown on the
right Y-axis.

82

H. Hinninghofen, P. Enck / Autonomic Neuroscience: Basic and Clinical 129 (2006) 8085

Table 1
Gas expansion in body cavities in relation to environmental pressure
(Hagelsten and Nolte, 1963)
Cabin altitude
Meters

Feet

Sea level
1600
3300
5000
6600

Sea level
5000
10 000
15 000
20 000

Relative volume of
gas in body cavities
1.0
1.2
1.5
1.9
2.4

contributed to significant increase in dyspeptic symptoms


among flying staff compared with ground personnel of a
commercial airliner (Enck et al., 1995). On long-distance
flights, cabin crew reported significantly more bloating as
compared to a ground-based period (Vejvoda et al., 2000).
Fiber intake is often increased to compensate flight-related
intestinal problems such as constipation (Enck et al., 1995).
High fibre diets may in turn contribute to intestinal gas volume
and amplify the pressure-induced problems.
In an attempt to identify the mechanisms by which dyspeptic symptoms (bloating, nausea) are generated during
flights, we simulated an 8-h flight in a hypobaric chamber in 16
healthy males (25.5 5.9 years), subjected to two meal conditions on separate days in randomized sequence (with and
without a fibre-supplemented standard meal, 2 g or 20 g,
respectively), but randomly assigned to either a flight altitude
of 2500 m (8200 ft = 565 mmHg cabin pressure) or 1000 m
(3280 ft = 637 mmHg). The subjects were uninformed about
altitude and fibre content of the meal. Gastrointestinal symptom ratings were taken every hour, and gastric emptying was
assessed by conventional 13C-octanoic acid breath-test. The
test based on the use of 13C-octanoic acid, a medium chain fatty
acid which after ingestion is rapidly absorbed in the duodenum
and metabolised in the liver. Following oxidation, the resulting
13CO2 is excreted into breath at a level which can be detected
and measured by infrared spectrometry. In a separate experiment, we examined the effect of the two test meals (2 g vs. 20 g
of fibre) on the same measures in 30 healthy males (26.7
6.2 years) under conventional laboratory conditions. We found
(Hinninghofen et al., 2006), gastric emptying (half emptying
time =T1/2) was significantly delayed at 2500 m altitude when a
high fibre meal was given (146.3 58.4 min vs. 193.9
54.3 min) (Fig. 2). Symptom reports of gastric distension and
bloating were increased at 2500 m for the high fibre meal
compared with the low fibre meal. There were no differences
between groups on any measure for the ground control condition. This supports the claim that cabin pressure and oxygen
saturation affect gastrointestinal functions such as gastric
emptying and this may mediate dyspeptic symptoms such as
bloating, distension or nausea during flights.
3.1. Other effects of pressure
Failure to equalize pressure within the middle ear and the
environment can cause otitic barotrauma. In up to 9% of air

travellers, otitic barotrauma occurs with attendant ear pain,


tinnitus, vertigo or hearing loss (Csortan et al., 1994). Therefore, individuals with conditions causing a blockade of the
Eustachian tube such as upper respiratory infection, allergy, or
sinusitis should not fly until the blockade is cleared. People
with recent surgery should contact their physician before they
fly. To facilitate the gas equalization during ascent and descent,
passengers should swallow frequently or increase pressure in
the nasopharynx by performing a Valsalva manoeuvre (Hold
the nose closed by pinching, close the mouth and blow gently.
This raises the pressure in the pharynx, forcing air up the
Eustachian tubes into the middle ear).
4. Motion and vibration of the aircraft
Humans normally are in an environment where the force
of gravity is constant in direction and magnitude. During air
travel, passengers may perceive unusual vibration, motion,
and centrifugal forces. Additionally, air turbulence can cause
a linear vertical motion on the vestibular organ. In combinations, these may induce discomfort and motion sickness.
A motion sickness study during air travel found that 0.5% of
the passengers had vomited and 8.4% reported nausea during
flight (Turner et al., 2000). Motion sickness tends to be
severe during exposure to turbulent flight conditions. In
vulnerable individuals, protracted vomiting may cause dehydration and electrolyte imbalance. Predisposed passengers
should be advised to take preventive medication and to
choose a seat over the wings, in the centre of gravity of the
aircraft. Flying at night might be helpful by reducing visual
stimulation (AMA, 1982).
In general, aircraft vibration induced by the engine is usually
well tolerated, but together with aircraft motion, noise and low
humidity, it may cause some degree of discomfort and contribute to travel fatigue. A more detailed description of the
general contribution of motion and vibration to the development
of motion sickness, nausea and vomiting can be found in the
contributions of E. Muth and J. Golding in this volume.

Fig. 2. Displayed gastric emptying time (T1/2) as a function of the fibre


content of the test meals for both simulated altitudes. Gastric emptying was
significantly delayed at 2500 m altitude, if a high fibre diet was given
(p = 0.039) (from: Hinninghofen et al., 2006).

H. Hinninghofen, P. Enck / Autonomic Neuroscience: Basic and Clinical 129 (2006) 8085

5. Seating and immobility


Planes today are able to fly non-stop more than 15 h,
which makes seat comfort important for passenger wellbeing. Seat comfort is associated with seat pitch, seat width,
leg room, quality of upholstery, and possible angle of recline.
Seat pitch is the distance between the back of one seat to the
same point on the back of the seat in front. The range for seat
pitch is from 71 cm (28 in., charter planes) to 152 cm (60 in.,
first class). Seat pitch in economy travel is 7686 cm. Close
seat pitch is associated with poor seat comfort and restricts
the degree of tilt of the seat, a feature which is important for
night travel. Seat width is also important for comfortable
seating, with 30% of seats narrower than the recommended
42 cm (17 in.) (Roggla et al., 1999). Cramped seating is not
only uncomfortable. It makes it difficult to leave the seat for
regular exercise, disturbs respiration, restricts the gastrointestinal transit and normal blood circulation, and can cause
oedema and ischemia of the lower limbs. Surveys on charter
and economy class flights have consistently rated seat comfort and leg room as being the two least satisfactory characteristics of air travel (Anonymous, 2000).
6. Deep vein thrombosis
The term economy class syndrome refers to the development of deep vein thrombosis (DVT) and pulmonary embolism (PE) in air travellers flying for long distances in
cramped economy class seats. But, as shown recently, there is
no clear evidence of a specific risk associated with air travel;
DVT and pulmonary embolism are potentially a general problem of prolonged travel in any confined spaces (Bagshaw,
2001). The incidence of pulmonary embolism among 135
million passengers arriving at Charles de Gaule airport was
much greater among those who had travelled more than
10,000 km (4.8 per million) (Ansell, 2001). Flight duration and
individual predisposing seems to be a critical trigger. Both
complications are likely to occur in those with risk factors such
as venous disease, heart failure, nephrotic syndrome, thromboembolic illness, hypercoagulable disorders, diabetes or age.
Women are at higher risk than men (Giangrande, 2000). Leg
oedema (jet flight leg), which may mimic DVT, is usually
benign and resolves after landing. Possible measures to prevent DVT are: in-flight muscle-contracting exercises, regular
walks, use of compression stockings, adequate (non-alcoholic)
fluid intake, and the use of drugs such as aspirin and subcutaneous heparin (Scurr et al., 2001).

83

recycled air in the aircraft cabin environment, the relative


humidity, and the number of people in the cabin. The ventilation rate on board an aircraft is determined to provide fresh
air to dilute odour to an acceptable level for 80% of passengers.
Odours and volatile organic compounds can be added from
furnishings and humans, lubricating oils, hydraulic fluids and
de-icing fluids entering through open doors whilst the plane is
on the ground. Even if not toxic, odorous air can itself cause
nausea, headache and loss of appetite.
7.1. CO2 concentration
Air travellers remain for prolonged time with the smallest
available air space per person of any other current social
setting (Hocking, 1998). Without any air change, it would
take only 2.3 min for the concentration of CO2 in that space
to exceed 1000 ppm. CO2 concentration is normally taken as
an important measure of air quality. Recommended concentration is less than 1000 ppm.
Measurements in business class non-smoking flights not
uncommonly shows concentrations greater than 1000 ppm
with peaks of 2900 ppm (Lee et al., 1999). Extremely high
CO2 concentrations were found during take-off and landing,
when power requirements reduce the amount of ventilation.
Since the 1980s, half of the air exchange consists of recycled
air from the passenger cabin. As the proportion of recirculated
air increases energy savings can be made, but at the same time
health risks are increased. Early experiments on aircraft found
9 L/s/p (Litre/second/person) of fresh air were adequate for the
comfort for most passengers (McFarland, 1953).
Today most commercial aircraft are only capable to provide 2.8 L/s/p of outside air to their passenger cabins. The
airline industry saves more than $30 million annually by
reducing energy costs due to recycling air with inadequate
ventilation (Consumer Reports, 1994). Beside the reported
symptoms, of particular concern is the increased risk of
disease transmission in this setting. Organisms transmitted
by droplets less than 10 m in size, such as measles, influenza viruses, and tuberculosis may spread between

7. Cabin air quality


Acceptable air quality in commercial aircraft is important
for the comfort and well being of passengers and flight crews.
Inadequate air quality may cause symptoms of fatigue, headache, and dizziness, as well as respiratory and ocular discomfort (Pierce et al., 1999). Cabin air quality depends on the
amount of air flow, cabin air distribution, the proportion of

Fig. 3. Humidity and temperature recorded on a flight LondonMailand;


from Barnes (1973).

84

H. Hinninghofen, P. Enck / Autonomic Neuroscience: Basic and Clinical 129 (2006) 8085

passengers (Kenyon et al., 1996; Olsen et al., 2003). Aircraft


operators should provide a minimum of 7 L/s/p of outside air
per passenger at all times, because this is the minimum
necessary to maintain CO2 concentrations below 1000 ppm.
Use of recirculated air should be limited to not more than
50% (Dechow et al., 1997). Unfortunately, increasing the
amount of fresh air also decreases the relative humidity of
cabin air, because air at high altitude has very low water
content.

sickness such as nausea, dizziness, and headache, or to gastrointestinal distress. Most of the descriptive factors related to
cabin environment are not of significance for a healthy person.
But an interaction of factors and maintained exposure over
more than 12 h may result in adverse effects even in healthy
people. In order to avoid the stresses of air travel and improve
passenger well being, airlines sometimes provide information
to their passengers as to what to do (e.g., drink fluids and inseat exercise) and what to avoid (e.g., alcohol).

7.2. Humidity

9. Future perspectives

Comfortable humidity conditions are considered to be


4070% relative humidity at sea level (Fig. 3). The guidelines
for humidity in aircraft cabins are between 12% and 22%
relative humidity. Cabin air humidity depends upon aircraft
type, cruising altitude, ventilation rate and the number of
people on board. In-flight measurements have shown relative
cabin humidity dropping from at least 47% to 11% within
30 min of ascent (Eng et al., 1982).
At the end of a long distance flight, the humidity can be as
low as 23%. Low humidity leads to dryness of the lips and
skin and other exposed membranes in the nose, eyes, mouth,
and throat. It may lead to dehydration, especially compounded
by diuretic effects of drugs, alcohol or caffeine. Passengers
wearing contact lenses may experience corneal discomfort as a
result of the low humidity, and they should be advised to
consider wearing spectacles during long flights. Questionnaire
surveys on long-haul cabin crews found that 60% felt that the
cabin humidity was too low. The main symptoms reported
were dry, itchy or irritated eyes, dry or stuffy nose, and dryness
of the skin or irritation (Lee et al., 1999). Increased fluid intake,
rather than humidification is recommended (Thibeault and
Krol, 1997).

The aircraft industry is building a new generation of


airplanes with the Dreamliner from Boeing and the A380
from Airbus. Both models are bigger and faster than any
airplane before.
The aircraft manufacturers are interested in improving the
comfort and safety of air travel for passengers and aircraft
crews. In this new generation of airplanes there are some
design improvements that can affect health and comfort. The
A380, the biggest passenger jet ever built, is environmentally
friendly. While carrying 35% more passengers than its competitor, it produces half the noise on take off and burns 12%
less fuel per passenger. Airbus has built the industry's largest
cabin simulator to investigate the consequences of cabin
vibrations and flight motion for passenger comfort. The
Boeing 787 Dreamliner will improve the flying comfort for
passengers and flight crews by offering higher air humidity,
better air quality, lower cabin altitude and also a smoother,
quieter flight. Cabin altitude will be reduced to 2000 ft
(600 m). Economy seats will be more spacious (4 cm wider)
and both aisles will be 6 cm wider (up to 55 cm).
Further research on the interactions of different factors of
cabin environment and individual health conditions reduce
nausea and distress and could contribute further to passenger
comfort and well being.

7.3. Noise
Travelling by aircraft includes exposure to a high level of
engine noise, as well as noise from cabin ventilation systems,
airflow over the external surfaces, service on board, and other
passengers. Although noise within the cabin may sometimes
seem excessive on some commercial aircrafts, in-flight measurements have not revealed prolonged levels above 85 dB, a
level at which ear protection is advisable because of the risk of
acoustic trauma. For sensitive persons or frequent travellers, an
active noise reduction headset may be useful.
8. Conclusions
Some aspects of air travel are associated with adverse health
effects, but major medical incidents are rare during flying.
Reports of minor medical incidents during flights show large
differences between airlines: The range is from 1 : 202,000
passengers to 1 : 1300 passengers (Brundrett, 2001). Not every
symptom will be reported to the flight attendant. Most unreported symptoms are likely related to mild forms of motion

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