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Air Travel for Patients with Respiratory Disease

Feb 7, 2007 | COPD , Other Infections , Pulmonary Hypertension , Thoracic Surgery |

Air travel over long distances has become commonplace for many individuals. The oxygen-dependent patient is no exception.

Flight Environment The proportion of atmospheric oxygen inside a pressurized aircraft remains the same as that in ambient air at about 21%. With increasing altitude, oxygen pressure decreases. Cabin pressure in a jet airliner is generally maintained at approximately 445 mm Hg above the outside barometric pressure; hence, cabin pressure is generally 567 to 692 mm Hg, similar to the pressure at altitudes of approximately 914 m to 2.4 km. 1 The US Federal Aviation Administration requires aircraft to maintain a 2.4-km cabin altitude at the highest operating altitude. 2 Regulations for actual flight operations, however, are more complicated and flexible, allowing for temporarily higher flight and cabin altitudes during turbulence or adverse weather. Cabin altitudes greater than 3 km are effectively prohibited, since all crew members and passengers would then be required to use supplemental oxygen. 3 The average cabin temperature is 20 to 22.2°C, and the relative humidity is 10% to 12%. The air in the cabin is completely exchanged every 3 minutes. 4

Altitude Hypoxia In high-flying commercial aircraft, environmental changes are offset, to some extent, by compressors that draw in external air and deliver it to the cabin. The outflow of cabin air is regulated so that an appropriate pressure differential is maintained between the cabin and the outside. Each type of aircraft is designed to fly at a different maximum altitude and has a different cabin-pressurization capability. Healthy passengers usually have little difficulty in tolerating moderate changes in altitude. Hypoxia and concomitant hypoxemia associated with ascent initiate a variety of reflex responses designed to reduce the pressure gradient between the oxygen in the atmosphere and that in body tissues. 4

A reduction of PO2 to less than 60 mm Hg generally stimulates peripheral chemoreceptors (carotid bodies), which then induce hyperventilation. The threshold and magnitude of hyperventilation vary from person to person, and the resulting respiratory alkalosis may attenuate hypoxemia. Hyperventilation is the most important reflex response to hypoxemia, and it maximizes PaO2 and alveolar PO2, assuming that oxygen consumption is stable. Minute ventilation increases, primarily as a result of increased tidal volume (rather than tachypnea). 3,4

The effect of altitude changes in patients with chronic obstructive pulmonary disease (COPD) depends on the final altitude reached, which determines the maximum available oxygen pressure. It also depends on the rate of ascent and the duration of the flight at the final altitude. Patients with severe COPD may be unable to adapt to altitude stress. Despite marked hypoxemia, their ability to hyperventilate may be mechanically impaired or limited by a diminished hypoxic ventilatory drive. Preexisting hypoxemia may be worsened by anemia, carboxyhemoglobinemia, sleep, exercise, and the ingestion of alcohol. Concomitant cardiac dysfunction and pulmonary hypertension may prevent any increase in cardiac output necessary for adequate systemic oxygen transport during such stress.

Another effect of prolonged air travel is immobilization, which increases the risk of developing pulmonary thromboembolic disease. Patients with COPD are already at increased risk for deep vein thrombosis and should be warned about prolonged immobilization when traveling.

Preflight Evaluation When examining a patient with COPD to determine whether he or she can travel safely by air, it is important to assess how changes in atmospheric pressure are likely to affect the patient. Other factors to consider include how the patient will cope with the noise, turbulence, limited space, fatigue, and psychological stress associated with air travel. The examination should begin with a thorough review of the patient’s medical history and current treatment regimen. A thorough physical examination should be performed. Electrocardiography and hematological studies may help detect any clinical contraindications to air travel (Table 1). Chest radiographs may be helpful if there is a suspicion of pneumonia, pulmonary edema, or pneumothorax.

Relative contraindications to air travel include a vital capacity or diffusing capacity of less than 50% of the predicted value, a maximum voluntary ventilation of less than 40 L/min, respiratory acidosis, and a PaO2 of less than 50 mm Hg. 5 These values, however, may be misleading, since they relate to the patient’s ground environment and do not take into account the use of supplemental oxygen aloft. Measuring the PaO2 as close to the time of flight as possible is an excellent way to predict what the PaO2 will be at altitudes of up to 8,000 feet in normocapnic COPD patients. 4

In-Flight Oxygen The most effective treatment of significant altitude hypoxemia is supplemental oxygen. (See sidebar below on standard airline policies.) The goal of oxygen therapy at altitude is to maintain adequate tissue oxygenation and prevent hypoxemic complications. Although no specific criteria exist for recommending supplemental oxygen during flight, some experts recommend prescribing supplemental oxygen for COPD patients whose PaO2 values might fall below 50 mm Hg at any altitude.

With the proper preparation, supplemental oxygen may be used safely in flight. Patients requiring supplemental oxygen or other medical devices during flight should communicate with their physicians, oxygen vendors, travel agencies, airlines, and trip companions. Airlines require notification at least 2 to 14 days prior to flight departure, depending on whether the trip involves domestic or international travel. Domestic carriers usually charge a fee per flight segment for supplemental oxygen and usually have only a limited selection of flow rates (2, 4, and 8 L/min). They typically do not allow patients to use their own oxygen delivery equipment, nor do they arrange for oxygen at stopovers. Therefore, precise oxygen arrangements should be made at each stopover for patients who are dependent on supplemental oxygen 24 hours a day. Some commuter airlines do not allow any supplemental oxygen.

Most airlines permit portable mechanical ventilators onboard as long as they fit beneath the seat and have a backup battery that is either a dry-cell or a gel-cell type. It will be necessary for the patient or the companion to carry all medications and delivery devices (including spacers, portable nebulizers, and suction equipment) onto the plane. Battery-powered equipment is preferred because some nebulizers and suction equipment may interfere with the aircraft’s navigational systems and may not be allowed on board. 6

Spare parts (nuts, bolts, scissors, tape, and nasal cannulae), as well as a voltage converter, may be useful. Arrangements to have seats near the restroom (and time to empty the patient’s bladder before boarding) may be helpful in decreasing the amount of walking required during the flight. It is prudent to obtain the names of physicians at each destination and to carry a description of medical facilities available at each airport.

A list of practical tips for the COPD patient who is planning to travel by air is presented in Table 2 (page 26). Successful air travel for the oxygen-dependent patient is possible, but it requires advance preparation that involves communication with physicians, airlines, and vendors of oxygen and equipment.

Conclusion Perhaps the most important thing that the patient with respiratory disease who is contemplating air travel can do is discuss travel plans with his or her physician before the flight. The physician can tell the patient whether air travel is a good idea, and can discuss any special needs. With careful preparation, a sufficient oxygen supply, and a medical escort, almost any patient with respiratory disease can travel by air to virtually any destination.

John D. Zoidis, MD, is a contributing writer for RT.

References 1. AMA Commission on Emergency Medical Service. Medical aspects of transportation aboard commercial aircraft. JAMA. 1982;247:1007-1011. 2. 24 CFR §25.841. 3. Gong H Jr. Air travel and oxygen therapy in cardiopulmonary patients. Chest. 1992;101:1104-1113. 4. Gong H Jr. Should your patient be allowed to fly? Advising COPD patients about commercial air travel. J Respir Dis. 1984;5:28-39. 5. Mortazavi A, Eisenberg MJ, Langleben D, Ernst P, Schiff RL. Altitude-related hypoxia: risk assessment and management for passengers on commercial aircraft. Aviat Space Environ Med. 2003;74:922-927. 6. Krieger BP. Travel for the technology-dependent patient with lung disease. Clinics in Pulmonary Medicine. 1995;2:1-9. 7. Stoller JK. Travel for the technology-dependent individual. Respir Care. 1994;39:347-362. 8. American AIrlines. Planing ahead. Available at: http://aa.com/content/travel Information/travelHelp/planningAhead.jhtml. Accessed June 28, 2004.

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To ensure safe travels for these passengers, proper precautions must be taken. One way to ensure changes in oxygen level do not affect passengers is to take a low oxygen simulation test prior to air travel. This test will determine the need for oxygen supplements onboard an airplane—where oxygen levels are typically 25% lower than at ground level. Patients with heart and lung conditions should also consult with their clinician prior to making travel arrangements to ensure that they are healthy enough to fly.

Those people requiring portable oxygen concentrators (POCs) must contact their airline prior to their desired travel date to make arrangements for oxygen supplements on board. While all airlines operating in the United States are now required to allow Department of Transportation (DOT) approved POCs to be carried on and used onboard, policies may vary between airlines. To ensure smooth travels, always verify these policies with the airline when you make your reservation.

For information on which devices are approved by the DOT and specific airline information, visit www.airlineoxygencouncil.org .

            Lung disease and air travel - August, 2008

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March 12, 2014 Preparing for Airline Travel For sufferers of chronic lung conditions such as emphysema, chronic bronchitis and chronic obstructive pulmonary disease (COPD), the use of supplemental oxygen may be necessary at some point in your treatment plan.

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How Can I Make Traveling With COPD Easier?

COPD can impact your travel plans, but a little preparation may reduce the challenge.

For many people, retirement means traveling. After working so hard for so long, getting to see the world can be an exciting and enjoyable way to spend your golden years. But for people with chronic obstructive pulmonary disease , an incurable and progressive lung disease that's often the result of years of smoking and is more common in older adults, traveling to far-flung locations can seem like an unrealizable dream.

Because COPD leaves patients breathless much of the time, it often makes routine activities challenging and travel even more so. Traveling with COPD can be particularly difficult if you're flying to your vacation destination. A 2010 study in the journal Respiratory Medicine found that 25 percent of COPD patients experienced hypoxia-related symptoms while traveling by air compared to just 9 percent of study participants who did not have COPD. Hypoxia occurs when not enough oxygen reaches tissues and cells, and it can cause shortness of breath, decreased ability to engage in physical activity, wheezing and coughing, and a bluish discoloration of the skin.

[See: 7 Lifestyle Tips to Manage Your Asthma .]

The study also found that COPD patients who traveled by air "had a more than three-fold higher risk of experiencing hypoxia-related symptoms than those without COPD. For the respiratory symptoms, dyspnea or air hunger, the risk was nearly seven-fold." Dyspnea refers to shortness of breath.

But travel doesn't have to be such a challenge or a scary experience, says Dr. David Beuther, a pulmonologist and associate professor of medicine at National Jewish Health in Denver. "We're trying to get people away from the idea that 'I can't do this, and I can't do that. I can't travel, I can't go to the soccer game, I'm too short of breath.' We spend a lot of time trying to shift the thinking to 'how can I travel?' Sometimes the answer is 'no,' but more often than not, it's 'what preparation is needed?'"

Many COPD patients – even those who are on supplemental oxygen as part of their treatment – can still travel, even by air. But the way to do it safely and without increasing risk of hospitalization for an exacerbation , a worsening of your COPD, is through preparation and opening up communication with your doctor about your plans. The Respiratory Medicine study found that a mere 5.9 percent of the 391 study participants with COPD had consulted with their physicians prior to traveling by air.

Although you may not need supplemental oxygen under normal circumstances, it's important to remember that while traveling by air, the air pressure in the cabin mimics the lower-oxygen environment that's found at elevations of 5,000 to 8,000 feet, says Dr. Umur Hatipoglu, director of the COPD Center at the Respiratory Institute at Cleveland Clinic . If you're already on oxygen therapy, speak with your doctor about whether you'll need to increase your oxygen flow during the trip. If you don't use oxygen normally or have not traveled recently, speak with your doctor about whether or not you'll need oxygen on the plane.

"You may not need oxygen at sea level, but you might actually need that in that pressurized cabin in the sky," Hatipoglu says. This is because there's simply less oxygen in the air at that altitude, which can make breathing difficult for some people. "Even though you may have normal oxygen at sea level, you're not going to have the same level of oxygen in your blood in the cabin," which can create problems, Hatipoglu says. Your pulmonologist can test you for that before you fly and help you develop a plan for dealing with it if it could become an issue. "We have guidelines for in-flight oxygen therapy, and patients can be reassured that if they abide by the guidelines in the evaluation, they'll be fine traveling," he says.

If you need to travel with oxygen, Hatipoglu says, it's "actually not that difficult," but requires a call to the airline ahead of time to find out whether they can accommodate you. Oxygen is highly flammable, so as a safety precaution, "you cannot travel with your oxygen on the plane." In their place, airlines "have portable [oxygen] concentrators that can be rented or are approved that you'll have to take on board," he says.

[See: 16 Ways Your Body Adjusts to a New Climate .]

In addition, regardless of whether you drove, arrived by ship or flew there, depending on where you're headed, your ability to breathe comfortably once you reach your destination can be impacted. Fumes and air pollution can make breathing more difficult for COPD patients , so urban traveling may pose a greater challenge than heading for a rural setting. Plus, the higher the altitude at your vacation location, the more likely you'll experience breathing difficulties. This means if you're headed to the mountains or to Denver, for example, you may need supplemental oxygen or another adjustment to your treatment plan while you're visiting.

Beyond oxygen, it's critical to make sure you have enough of all of your medications in hand for the duration of the trip before you take off, says Dr. Evan Stepp, a pulmonologist and assistant professor in the department of medicine in the division of pulmonary, critical care and sleep medicine at National Jewish Health in Denver. "This isn't just specific to COPD medications," Stepp says, but extends to any and all medications you're taking.

You should also "make sure you're up-to-date on all your vaccinations. The [Centers for Disease Control and Prevention] recommends a flu vaccination every year," for everyone six months and older, Stepp says. You should also be sure your pneumococcal vaccination is current. That's the shot that can prevent pneumonia, a common cause of COPD exacerbations. The CDC now recommends that all adults over age 65 get vaccinated with two different pneumonia vaccines about a year apart. Some doctors will recommend you get a booster again in five to 10 years depending on your overall health.

[See: 7 Things You Didn't Know About Lung Cancer .]

These simple preventive measures can go a long way toward making your journey more enjoyable, Stepp says, because "travel usually involves some stage or another where you'll be setting foot in a petri dish of sorts. You may be waiting in a crowded area," surrounded by lots of people with lots of germs that could make you sick.

Lastly, Stepp says that "if you're having a flare-up of your disease, that's not a good time to travel." He says that traveling can put more stress on the lungs, so if you're already experiencing an exacerbation of any sort, "that's a good reason to delay the trip until the illness has settled down."

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COPD and Air Travel—What Should Be Considered?

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So many of us with COPD have loved ones spread across this wonderful world and/or places we want to see, events we want/need to attend. Often flying is one of the fastest ways (sometimes the only way) of getting between distances.

What should be kept in mind in for air travel with COPD? What are some tests? How should patients be evaluated to see whether they need supplemental oxygen to fly?

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• Chronic obstructive pulmonary disease • 11: Fitness to fly with COPD
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• Correspondence to: A O C Johnson, Department of General and Respiratory Medicine, Pontefract General Infirmary, Pontefract WF8 1PL, UK; owen.johnson{at}panp-tr.northy.nhs.uk

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For most passengers, even those with respiratory disease, air travel is safe and comfortable. Some patients with COPD may be at risk but, with screening, these patients can be identified and most can travel safely with supplemental oxygen.

A House of Lords Select Committee on Science and Technology published a report entitled “Air Travel and Health” in November 2000. 1 They concluded that air travel was safe for the vast majority of passengers but that a few were at risk, and the Government, regulators and the airline industry were open to criticism for failing to give “sufficient active attention to health”. One of the key recommendations of the report was that more information should be available to intending air travellers so that they could make informed choices about the risks (even though these may be minor) of air travel. Another recommendation was that intending air travellers should be urged to consult their doctor if they had any doubt regarding their fitness to fly.

A recent survey of chest physicians providing advice to patients with respiratory disease who wished to travel by air concluded that “the risk of hypoxia at altitude is recognised by most respiratory physicians in England and Wales, but assessment methods and criteria for recommending oxygen vary widely”. 2 The article suggested that evidence based guidelines were required.

The British Thoracic Society has recently produced guidelines on fitness to fly in patients with respiratory disease which concentrates on intending air travellers with chronic obstructive pulmonary disease (COPD). 3 It provides a concise summary of the field with an extensive literature list.

ALTITUDE AND HYPOXIA

The other main effect of altitude is that of Boyle’s law which states that the volume of gas varies inversely with the surrounding pressure at constant temperature. One litre of gas at sea level will expand to about 1.4 litres at an altitude of 2450 m. 6 This is clearly only of medical relevance if gas is trapped in a confined space such as the pleural cavity, the middle ear, or in a body cavity after surgery.

EFFECTS ON PASSENGERS

In healthy passengers the hypobaric hypoxia of the aircraft cabin will result in only mild hypoxaemia; arterial oxygen tension (Pa o 2 ) falls to about 8 kPa but the shape of the oxyhaemoglobin dissociation curve prevents any fall in oxygen saturation (Sa o 2 ) below about 92%. 6

However, some patients with chronic lung disease may not tolerate this mild degree of hypoxia and may become significantly hypoxaemic. Schwartz et al 7 studied 13 subjects with COPD exposed to an altitude of 2250 m in whom arterial blood gas tensions were measured at sea level and at altitude. Mean Pa o 2 fell from 9.0 kPa at sea level to 5.9 kPa, a level which most physicians would regard as undesirable although none of these subjects developed any symptoms. Pa co 2 fell from 5.4 kPa to 4.8 kPa.

The effect of acute hypoxaemia on patients with stable COPD is not well studied and, subjectively, many patients appear to tolerate hypoxaemia well. 6, 8, 9 However, some patients may develop respiratory symptoms and arrhythmias even at rest. 10 The effect of hypoxaemia combined with exercise has not been studied and, in addition, many patients with COPD will have co-existing cardiac disease which may limit normal cardiovascular responses to hypoxaemia. While the effects of acute hypoxaemia during air travel have not been fully explored, most authors consider it reasonable to choose an arbitrary level of hypoxaemia (usually Pa o 2 of 6.6 kPa) below which it is considered unsafe to fly without supplemental oxygen therapy. 8 This approach seems to work in practice to ensure safe and comfortable air travel. 11

By far the most common effect of altitude induced gas expansion is ear pain associated with poor ventilation of the middle ear. However, gas expansion is clearly of relevance to passengers with a pneumothorax which is regarded as one of the few absolute contraindications to air travel. Gas expansion within the pleural cavity can become life threatening, as illustrated in 1995 by the well publicised case of a woman with a pneumothorax which was treated over the Himalayas by doctors using a scalpel, knife and fork, a coat hanger and a urinary catheter. 12 Airlines recommend that a pneumothorax should have settled completely before air travel and that flying should be avoided for at least 6 weeks. However, there appears to be no evidence to support the 6 week recommendation, which takes no account of the type of treatment which may have been given.

The pressure changes during air travel will not precipitate a pneumothorax, but reduced access to health care on board an aircraft makes a recurrence of a pneumothorax undesirable. There is little evidence available on the time frame for recurrence of a pneumothorax but, in the absence of a pleurectomy or talc pleurodesis at thoracotomy, 13– 15 the risk of recurrence remains high (possibly up to 50–70%), with the highest risk occurring in the first year and in patients with underlying COPD. 16– 20 Potential passengers will need careful medical assessment and may wish to take recurrence rates into account when deciding on air travel plans.

EPIDEMIOLOGY OF IN-FLIGHT EMERGENCIES

Death during air travel is unusual. A recent study of in-flight medical emergencies examined the in-flight treatment and follow up diagnosis in 1132 incidents dealt with by MediAire—a company which provides ground based medical assistance to a number of US carriers. 21 The reported fatality rate of 0.107 per million passenger embarkations was less than other similar surveys. Qantas reported a fatality rate of 0.38, 22 and 42 IATA member airlines reported a rate of 0.31. 23 The majority of in-flight deaths appear to be due to cardiac causes, but there may be associated respiratory symptoms. 21

Respiratory problems account for 2–10% of all in-flight medical emergencies and usually make up the second or third most common group of serious medical emergencies (with cardiac and neurological incidents). 21– 28 However, in the CAMI/MediAire study oxygen was administered in 58% of the medical incidents and resulted in an improvement in the condition of the passenger in 81% of cases.

Thus, although respiratory incidents appear to account for a small proportion of all in-flight medical emergencies, respiratory problems make up a significant number of the more serious emergencies and unrecognised hypoxaemia may well account for a number of the other incidents such as “vasovagal” episodes or non-specific events which then improve with supplemental oxygen therapy.

The frequency and outcome of air travel in patients with COPD has not been well studied. One North American study reported on a cohort of 100 patients with COPD, 29 44 of whom chose to travel by air over the 28 month period of the study. Those who did not travel had a lower mean forced expiratory volume in 1 second (FEV 1 ), which suggests that many patients with more severe COPD choose not to travel by air. Eight of the 44 developed transient symptoms during the flight. A similar British study reported similar findings: of 97 subjects with COPD, 34 had travelled by air within 24 months and nine developed transient respiratory symptoms during the flight but all arrived safely. 30

PRE-FLIGHT ASSESSMENT

The aim of pre-flight assessment is to identify passengers likely to develop respiratory symptoms during air travel. Given the current state of knowledge, most guidelines suggest trying to identify those likely to develop significant hypoxaemia. Three methods of pre-flight assessment have been suggested.

The first method has been put forward by the airline industry and consists of asking passengers whether they are capable of walking 50 metres on the flat. If the answer is “yes”, they are probably fit to fly.

The second method consists of applying one of a number of prediction equations which have been developed from studies in which subjects with COPD were exposed to hypobaric or normobaric hypoxia and arterial blood gas tensions were measured. Some equations only require measurement of Pa o 2 at sea level and then allow calculation of a predicted Pa o 2 at altitude. Examples include the formula produced by Henry et al 31 :

and that produced by Gong et al 8 :

where Pa o 2 alt is the predicted Pa o 2 at altitude in mm Hg, cabinalt is the cabin altitude to be used in thousands of feet, and Pa o 2 grnd is the Pa o 2 at sea level in mm Hg.

Other authors have used spirometric values in addition to sea level Pa o 2 in an attempt to reduce variation. Examples here include the formula from Dillard et al 32 :

and another more complicated formula from Dillard et al 33 :

Another approach is to use a purely mathematical model which allows calculation of a predicted altitude Pa o 2 from sea level Pa o 2 and Pa co 2 by assuming that the arterial-to-alveolar oxygen ratio remains constant at altitude. 34

The third method of pre-flight assessment involves measuring the subject’s response to a simulated aircraft cabin environment. In this investigation—termed the hypoxic challenge test—the subject is usually exposed to an inspired oxygen tension of 15 kPa which is the expected worst case scenario for the aircraft passenger. This can be achieved at sea level by administering 15% oxygen in nitrogen using a face mask and non-rebreathing circuit, 8 or by filling a body plethysmograph with 15% oxygen. 35 A modification of this latter technique is to use a hood over the subject’s head and shoulders which is ventilated with a constant supply of 15% oxygen. Alternatively, 15% oxygen can be administered simply by using a 40% Venturi mask with nitrogen as the driving gas. The Venturi dilutes the nitrogen with air so that 15% oxygen is produced. 36, 37 During the hypoxic challenge the subject is monitored continuously with pulse oximetry to prevent severe hypoxaemia and blood gas tensions are measured before and at the end of the hypoxic exposure. Some authors recommend ECG monitoring to detect asymptomatic arrhythmias. 8 Usually a predicted Pa o 2 of 6.6 kPa (which was derived from 50 mm Hg in the original study) is used as the cut off below which supplemental oxygen is recommended for air travel. 8

The 50 metre walk test has the advantage of being an individualised test of cardiorespiratory function but, despite its widespread use by airline medical departments, does not appear to have any evidence base. In addition, potential passengers are usually simply asked if they can walk 50 metres and are not formally tested. A recent audit in our department suggests that neither patients nor healthcare staff are good at assessing distance.

Mean predicted altitude Pa o 2 derived from predicted equations appears to compare well with mean predicted Pa o 2 from both hypobaric and normobaric hypoxic challenge in groups of subjects with COPD. 38 However, it is not clear whether prediction equations provide information which is sufficiently robust to allow the decision of whether or not to recommend in-flight oxygen therapy. Prediction equations appear to be infrequently used by practising physicians in UK. 2

Hypoxic challenge has the advantage of assessing an individual’s response to hypoxia and affords the opportunity of monitoring symptoms and other responses to hypoxaemia such as hyperventilation, cardiac arrhythmias, or angina. 8, 38 Cardiac disease often co-exists with COPD and yet is usually an exclusion criterion for studies of pre-flight assessment.

The results of pre-flight prediction of hypoxaemia have not been compared with actual hypoxaemia during air travel, nor with the development of respiratory or cardiac symptoms. The cut off level of Pa o 2 of 6.6 kPa appears to be empirical with no evidence base, but has been generally accepted as a reasonable compromise.

The above data suggest that the hypoxic challenge test is the gold standard for pre-flight assessment. However, the test is not widely available and increasing numbers of patients with COPD are considering air travel. Clearly, widespread use of the hypoxic challenge test is inappropriate. The BTS guidelines 3 suggest that saturation measured by pulse oximetry can be used to identify groups of potential passengers who will definitely require oxygen (sea level Sp o 2 <92% or already on long term oxygen therapy) or who are very unlikely to require oxygen (either sea level Sp o 2 >95% or sea level Sp o 2 >92% without any additional risk factors such as severe COPD, hypercapnia, recent exacerbation or relevant co-existing disease). These groups would not need testing but the intermediate group (Sp o 2 <95% and >92% with risk factors) would need to have a hypoxic challenge test.

PRESCRIBING IN-FLIGHT OXYGEN THERAPY

Berg et al 39 investigated the effects of oxygen supplementation in 18 patients with non-hypercapnic COPD in a hypobaric chamber. Oxygen was supplied by nasal cannula at 4 l/min, 24% Venturi mask, and 28% Venturi mask. The conclusion was that all forms of oxygen therapy improved Pa o 2 , but the Venturi masks did not fully correct Pa o 2 to the sea level baseline (Pa o 2 0.7 kPa below baseline with the 28% mask and 1.6 kPa below baseline with the 24% mask) whereas the nasal cannula slightly overcorrected (Pa o 2 1.3 kPa above baseline). All the oxygen devices raised Pa o 2 over 6.6 kPa and were therefore all felt to be appropriate for in-flight use; the choice of device may depend on the subject’s propensity to carbon dioxide retention when given oxygen. If oxygenation is felt to be critical, an accurate assessment of the requirement can be made by titrating oxygen by mask or cannulae in a body box filled with 15% oxygen 35 or, ideally, in a hypobaric chamber if available. 39 In practice, most aircraft oxygen systems are only capable of providing 2 or 4 l/min; a flow rate of 2 l/min is suitable for most passengers, but those already on long term oxygen therapy may be advised to increase it by 2 l/min above their normal flow rate.

Most airlines are able to provide supplemental oxygen therapy although the charge for this varies widely. 40 Some UK based tour operators will not provide oxygen so it is important that potential passengers check with the airline before booking (personal communication). Other airlines provide restriction on the duration of oxygen that can be provided and all will want to know the flow rate required and whether the oxygen is for intermittent or continuous use. Oxygen is usually provided from cylinders so the duration of oxygen therapy is needed to calculate the number of cylinders required. Some airlines use the aircraft’s mains oxygen system. 41 Many will provide nasal cannulae but some provide masks. 40

The altitude of stopover airports and the final destination needs to be considered. Passengers who are identified as being hypoxaemic at the moderate altitude of the aircraft cabin may also be hypoxaemic at high altitude destinations such as Mexico City (2239 m). Most airlines will not provide oxygen for stopovers and direct flights are preferred.

Most airlines will indicate that 48 hours notice is sufficient to organise supplemental oxygen but this is seldom the case in practice. Passengers may not carry their own oxygen supply on the aircraft unless they wish to take an empty cylinder to be refilled for use at their destination. 40

For most passengers, even those with respiratory disease, air travel is safe and comfortable. Some patients with COPD may be at risk but, with screening, these patients can be identified and most can travel safely with supplemental oxygen. There are large gaps in the evidence base for advising potential air travellers. More research is needed, especially on the effects of real air travel on passengers with lung disease rather than the effect of simulated hypoxia which can only reproduce part of the stress of air travel. A summary and general advice for potential air travellers with COPD is given in box 1.

Box 1 Key points

Increased awareness of the need for and methods of pre-flight assessment is required as the number of air travellers with chronic lung disease increases.

Patients should seek advice regarding the advisability of air travel before booking their journey as not all airlines will provide oxygen and others have restrictions.

Doctors need to be aware of the aircraft cabin environment and need to give consistent advice.

If screening indicates the need for in-flight supplemental oxygen, the passenger should consider the cost of oxygen when comparing air ticket prices. It is best to give the airline plenty of notice and to check the day before travel that the necessary arrangements have been made.

Communication with the airline is often through a MEDIF (medical information) form which will require details of the patient’s diagnosis, the reason for supplemental oxygen, and the duration of oxygen therapy (intermittent or continuous) with a further section for information on the patient’s mobility and need for special boarding or seating arrangements. Most airlines have a medical department which may be very helpful although getting through can be time consuming. 40

Passengers should carry any necessary medication in their hand luggage and may need to carry a prescription with them. A letter confirming the medical necessity of any electrical equipment such as nebuliser compressors, CPAP machines, or oxygen concentrators is essential with current tight airline security. Insurance can pose a problem but patients may receive helpful advice regarding insurers from medical charities.

Passengers with lung disease should be advised to avoid smoking and alcohol before and during air travel. Like all passengers they should carry out regular leg exercises, but those passengers requiring oxygen should request a seat near the toilets to avoid long walks.

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Air travel for patients with chronic obstructive pulmonary disease: a case report

Introduction.

This case report aims to assist primary care physicians in managing borderline hypoxemic patients with chronic obstructive pulmonary disease (COPD), enabling them to fly safely.

CASE REPORT

A 63-year-old female smoker (80 pack years) travelled from Athens, Greece to Amsterdam in The Netherlands. She had been diagnosed with hypertension, moderate COPD, mild cardiac failure, and severe osteoarthritis in the left knee. Thirty minutes after take-off she started to experience severe dyspnea, without tachycardia or chest pain, that required immediate medical attention. After administering oxygen at 2L/min, the symptoms slowly improved and she arrived safely in Amsterdam.

The patient had experienced similar symptoms during other flights in the past. Her GP thought that she should be examined by cardiologists and pulmonologists to assess the possible need for in-flight oxygen supplementation. The cardiologist conducted a full clinical examination, as well as an electrocardiogram and heart ultrasound, and decided that, as the cause of the oxygen desaturation during flight was not from her heart, she should be referred to pulmonologists for further assessment.

The pulmonologists conducted spirometry and an arterial saturated oxygen (SaO 2 ) test. The results were: a forced expiratory volume in 1second (FEV1) of 60% predicted; an FEV1/forced vital capacity (FVC) of 0.65; and a SaO 2 of 94%. The patient did not perform a 6-minute walking distance test (6MWT) as this was not possible due to the severe osteoarthritis of her left knee. As a hypoxia inhalation test was not available, even in the tertiary hospital, the pulmonologist said that the patient would probably need in-flight oxygen supplementation. This was based only on the available calculations (equations) for determining the need for oxygen supplementation in flight. The pulmonologist did not give precise advice to the patient and, as a result, the patient experienced the same dyspnea during flight as she had done before.

As the patient had experienced severe dyspnoea in previous flights, should her doctors be more careful and prepare her journey in a safer way?

COPD is a major public-health problem that, it is estimated, will be the fourth leading cause of death by 2030. 1 Two billion passengers travel each year by airplane; 2 18–44% have COPD. 3 , 4 Patients with moderate to severe COPD often develop symptoms due to hypoxia during flight, and most of them do not consult a physician before air travel as they have non-clinically significant hypoxemia at sea level. 3 A study in Norway showed that 25% of the patients with COPD developed hypoxia-related symptoms in flight. 4

Air pressure drops as altitude increases. The effects of increased altitude and the associated hypobaric features can result in hypoxia. Healthy individuals respond to hypoxia by increasing ventilation, balancing the hypobaric changes without any symptoms. Ventilation can be increased by increasing tidal volume and/or increasing respiratory rate. 5 However, increasing tidal volume for patients with respiratory problems, and especially for those with COPD, is a difficult task as they are often hyperinflated. Patients with respiratory failure will always need in-flight oxygen; it is highly likely that patients with moderate to severe COPD need in-flight oxygen as well.

Investigations

In patients with COPD, previous experiences during flights, medical history including GOLD-stage status, dyspnea assessment, and clinical examination should all be assessed. The physiological tests to assess fitness for flight that are currently available are:

• spirometry;
• diffusing capacity tests;
• arterial blood gas tests;
• saturation;
• hypoxemia prediction equations; and
• the hypoxia inhalation test.

Although the practical usefulness of FEV1, partial pressure of oxygen in the blood (PaO 2 ), and SaO 2 tests in successfully assessing the need for oxygen supplementation is questioned in several publications, 6 , 7 a rule of thumb is that patients with an SaO 2 of >95% will probably not need oxygen during flight, while those with an SaO 2 of <92% will. Patients with an SaO 2 of 92–95% are considered borderline. 8 The need for oxygen supplementation in patients with COPD during flights can be calculated using different equations. For example:

Although this equation is usually reliable, it might be inaccurate in borderline situations. In such cases, the most accurate test is the hypoxia inhalation test by breathing an oxygen fraction of 15% at sea level; however, this is seldom performed in clinical practice. Patients with a post-hypoxia inhalation test saturation of <85% need in-flight oxygen. Independently, if a hypoxia-altitude simulation test or a hypobaric chamber is used to achieve hypoxia conditions, special caution to oxygen titration is needed — using a nasal cannula underestimates the oxygen dose required. The oxygen delivery equipment can result in the same PaO 2 when a continuous-flow or oxygen-conserving device is used, whereas PaO 2 is lower when portable oxygen concentrators (POCs) are used. 10

In-flight oxygen is usually prescribed at a rate of 2–4L/min and should be given by nasal cannulae. 7 This will partially reverse altitude-induced hypoxemia symptoms in patients with COPD. 11 Nowadays, many airlines allow POCs on board, but often only specific types. 7 Box 1 shows a practical guidance to help ensure safe air travel for patients with COPD.

Box 1. Guidance to help ensure safe air travel for patients with COPD

For patients.

• Plan routes and carriers, and ask for their policy regarding oxygen
• Ask your doctor for the appropriate assessment(s)
• Inform carriers and airport authorities 1 week before departure about your requirements for oxygen during the flight, and transportation to and from the aircraft

For doctors

• Take a full history from patients with respiratory diseases, including previous symptoms during flights, medical history, and comorbidities
• Assess your patient 1 month before departure, taking into account specific trip details
• Provide your patient with formal papers stating the disease and estimated oxygen flow necessary on board
• Use the Frequent Traveller's Medical Card in order to obtain extensive details on medical history for patients who travel frequently by air

For patients and doctors

• Visit the website of the European Lung Foundation (ELF, www.european-lung-foundation.org ). The ELF has created a database that gives information and individual oxygen policies for over 300 major airlines in Europe. This is useful as airline policies can vary greatly.

The patient has provided written consent for this article to be published.

Freely submitted; externally peer reviewed.

Competing interests

The authors have declared no competing interests.

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Should I stay or should I go? COPD and air travel

Affiliations.

• 1 Dept of Pulmonary and Critical Care, School of Medicine, Dokuz Eylul University, Izmir, Turkey.
• 2 Dept of Pulmonary Diseases, School of Medicine, Ataturk University, Erzurum, Turkey.
• 3 Dept of Clinical, Integrated and Experimental Medicine (DIMES), Respiratory and Critical Care Unit, S. Orsola-Malpighi Hospital, Alma Mater University, Bologna, Italy.
• PMID: 29898904
• PMCID: PMC9489124
• DOI: 10.1183/16000617.0030-2018

Chronic obstructive pulmonary disease (COPD) is a challenging respiratory problem throughout the world. Although survival is prolonged with new therapies and better management, the magnitude of the burden resulting from moderate-to-severe disease is increasing. One of the major aims of the disease management is to try to break the vicious cycle of patients being homebound and to promote an active lifestyle. A fundamental component of active daily life is, of course, travelling. Today, the world is getting smaller with the option of travelling by air. Air travel is usually the most preferred choice as it is easy, time saving, and relatively inexpensive. Although it is a safe choice for many passengers, the environment inside the aeroplane may sometimes have adverse effects on health. Hypobaric hypoxaemia due to cabin altitude may cause health risks in COPD patients who have limited cardiopulmonary reserve. Addressing the potential risks of air travel, promoting proactive strategies including pre-flight assessment, and education of COPD patients about the "fitness to fly" concept are essential. Thus, in this narrative review, we evaluated the current evidence for potential risks of air travel in COPD and tried to give a perspective for how to plan safe air travel for COPD patients.

Copyright ©ERS 2018.

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Can You Fly with COPD? 10 Expert Tips for Your Next Flight

Air travel has become progressively more common nowadays. However, it would be nice if it is safe and comfortable for anyone with medical conditions, especially for chronic obstructive pulmonary disease (COPD) passengers.

Flying can put people with severe respiratory and lung problems at high risk of life-threatening complications, which are made even worse if they cannot get sufficient oxygen therapy while they are up in the sky. Even healthy individuals sometimes need supplemental oxygen at high altitudes.

If you are an oxygen patient or know someone planning to air travel, this article can help both of you answer the question, “can you fly with COPD?” Read through to learn more!

Can You Fly With COPD?

Yes, you can get on a plane even if you have COPD. Instead of being homebound, people with lung diseases, such as COPD, can typically continue their daily routines with proper disease management. This includes playing sports, going out, and of course, traveling!

Medical technology developments have made COPD treatments more accommodating to physically active and mobile lifestyles. Most scientists and doctors agree that COPD patients can fly safely on a plane.

Commercial airlines and carriers have policies regarding onboard and in-flight oxygen to ensure the safety and comfort of at-risk patients. All you have to do is prepare the requirements before buying the tickets.

10 Tips for Flying With COPD

No one wants to be left unprepared in a medical emergency, especially at a high altitude. For people with chronic respiratory or lung diseases, air travel increases the  risk of experiencing life-threatening complications. This can lead to a dire situation, especially if the appropriate oxygen therapy is not available on the flight.

To have an uncomplicated air trip, practice these ten tips for flying with COPD.

1. Consult your physician

Chronic obstructive pulmonary disease (COPD) is a medical term covering various respiratory or lung diseases, such as Chronic Bronchitis and Emphysema. Varying disease states and case severities means your flying experience can differ significantly from other COPD patients. 

It is crucial for anyone with a medical condition to consult a doctor before planning the departure date. Your physician will advise you on what you need to bring, including plans for a suitable portable oxygen concentrator. No one can assist with your COPD needs better than them.

2. Contact the airline

It is essential to contact the airline for their specific rules and regulations for oxygen therapy patients. Some airlines request COPD patients bring extra batteries for their oxygen devices, enough to last at least 150% of flight duration. 

Take note that some airlines do not allow large oxygen tanks. This is where you should collaborate with your physician to navigate such restrictions. They can advise you to bring a portable oxygen concentrator instead.

If you are a frequent air traveler with COPD, you may already be familiar with the inconsistency of regulations regarding flying with COPD. Confirm and understand the airline requirements days or weeks before your flight.

3. Know the FAA requirements

The Federal Aviation Administration (FAA) has already established the criteria for the accepted POCs on board. You should be aware of specific FAA requirements , such as:

• Portable oxygen concentrators (POCs) must be legally marketed in the United States and backed by the Food and Drug Administration (FDA).
• The POC device must not emit radio frequencies that can interfere with the aircraft’s systems.
• The POC device must not generate compressed gas.
• The POC device must have the required POC labeling.
• The POC device must not include any unsafe materials.

Find the complete list of FAA-approved portable oxygen concentrators here .

4. Take necessary pre-flight assessments

One of the most common pre-flight health tests for COPD patients is the 6-minute walk test. It is one way to test how your lungs and heart respond to light activities at your usual pace for only six minutes. The outcomes might lead to additional testing or a treatment plan.

Another test is the hypoxic altitude simulation test (HAST) , simply the hypoxic challenge test. This test lets physicians know whether their patients require supplemental oxygen to fly. Further, since the pressurized cabin reduces the oxygen level in the air to 15%, patients with lung conditions must have an extra oxygen supply for safe air travel. 

5. Check oxygen saturation level

COPD passengers with an oxygen saturation greater than 95% at sea level are approved to fly without further tests. On the other hand, if your oxygen saturation is between 92% to 95%, you must have supplemental in-flight oxygen just in case.

6. Inspect your oxygen concentrator unit

Before booking the flight, ensure that your oxygen device works perfectly fine and that the flow rate is on the correct liter flow per minute. On top of that, add extra batteries for long-duration flights. 

7. Make flight arrangements ahead of time

Call your chosen airline to verify and clarify all the necessary information on your flight. For extra measures, ensure all oxygen arrangements in advance and always arrive at the airport early. 

8. Sit close to the comfort room

Take the plane seat near the lavatory. It’s not uncommon for COPD patients to lose bladder control , especially when experiencing shortness of breath. Always choose the best seat that can add to your flight convenience.

It is highly advisable for patients with oxygen concentrator devices to avoid sitting near exit rows, bulkhead rows or, in seats blocking aisle access. 

9. Avoid alcohol while on a flight

Although it is generally alright for COPD patients to drink in moderation , alcohol consumption poses a risk of COPD-related complications flaring up during a flight..

10. Take direct flights whenever possible

It is beneficial for passengers with respiratory problems to take direct, non-stop flights. Aside from being cheaper, direct flights also decrease opportunities for flight-related  complications. It also provides little to no hassle for all passengers, eliminating the need to wait for an extended period of time between flights.

What To Bring With You When Flying With COPD?

Chronic obstructive pulmonary disease (COPD) does not necessarily mean you have to give up exploring the outside world, on land or by air. However, unlike healthy passengers, you need extra time to plan everything for a fun, safe, healthy air trip!

Here’s a checklist of things you need to fly safely with COPD.

1. Medications

Always ensure you have all your medications refilled — enough to last your entire trip or more. Tell your pharmacy about the journey in case it is too early to acquire a refill. For additional convenience, keep all prescriptions in your carry-on bag.

2. Extra batteries

Bring extra batteries for your portable oxygen devices. After all, it is better to carry more rather than lack one.

Nowadays, most airports have many electrical outlets that allow passengers to charge between flights. For extra measures, bring your electric outlet extender. 

3. Travel partner

Bring a travel partner along with you . They should know what you need for the ride and be ready to help you if something happens.

Additionally, your travel partner must understand everything about your medications, including the oxygen system to use, and be knowledgeable enough to adjust settings and change batteries.

4. List of important contact information

The list must contain your emergency family contact and your health care provider. On top of this, you should include the airline you are traveling with. You can keep this list on your phone or in your travel folder.

5. Emergency medical information card

This card must contain all information concerning your medications, including your medical devices, sensitivities and allergies, preferred therapy and treatment-medical providers, and vital contact persons. This tag can provide a quick response in case of an emergency.

Frequently Asked Questions

Does flying make copd worse.

Air travels put patients with COPD at risk for a variety of disease-related complications . For example, there is an increased risk of significant hypoxemia and for arterial oxygen saturations to fall below critical limits. 

However, with proper assessments and precautions, you should be able to fly safely. Make sure to visit your physician first before booking a flight.

Is it safe to fly on a plane with COPD? 

Yes. You can have safe air travels with your doctor’s approval. Some airlines require a doctor’s clearance for verification purposes. This can help patients and airlines with the arrangements necessary for safe flights. 

Also, airlines, in general, do not offer medical oxygen onboard. But they do allow COPD passengers to bring their portable oxygen concentrators .

Is COPD affected by altitude? 

Yes. High altitudes can manifest COPD complications. Your body needs to work harder at a higher altitude, which places more strain on the lungs and makes breathing more difficult. 

Additionally, increased ventilation from hypoxemia and irritation of the lower airways may exacerbate respiratory symptoms. COPD patients may experience hyperventilation, chest pain, air hunger, and lightheadedness during a flight. 

Does your oxygen level drop when flying?

Yes. Traveling by plane involves decreases in air pressure and lower than average oxygen levels. 

Sudden changes may only be noticeable for some passengers. In particular, small atmospheric fluxes can potentially harm those with underlying respiratory ailments. 

Can you fly with moderate COPD?

Yes. Stage 2 or moderate COPD does not typically prevent you from traveling via air. You can travel safely and soundly even if you have breathing complications like asthma , but you must take the necessary precautions. 

Travel by Plane Even With COPD

The question “can you fly with COPD” can undoubtedly be answered with a yes! Although air voyages put COPD patients at risk of adverse outcomes, your chosen airline and physician can quickly help you arrange a safe and comfortable flight.

Touring with oxygen is now made more manageable, all thanks to the development of portable oxygen concentrators . Aside from its lightweight feature, you do not have to refill them. Bring extra batteries to last your trip, and you are good to go!

References:

• NHS. (n.d.). Hypoxic Challenge Test. NHS choices. Retrieved November 21, 2022, from https://www.cuh.nhs.uk/our-services/respiratory-medicine-lungs/lung-function-unit/hypoxic-challenge-test/
• Rodriguez, T. (2022, October 5). Traveling by airplane with COPD: Expert advice. Pulmonology Advisor. Retrieved November 21, 2022, from https://www.pulmonologyadvisor.com/home/topics/copd/traveling-by-airplane-with-copd-expert-advice/
• Johnson, A. O. C. (2003, August 1). Chronic obstructive pulmonary disease • 11: Fitness to fly with COPD. Thorax. Retrieved November 21, 2022, from https://thorax.bmj.com/content/58/8/729

Written by Andy Flynn

Medically reviewed by aaron gravely, m.d..

Roger Perks - March 9, 2023 Thanks for the information provided but I have a concern. Manufacturers of oxygen concentrators and info websites say it’s ok to fly with an oxygen concentrator and they’re FAA approved however most oxygen concentrators operate at up to 10,000 ft yet domestic flights fly at around 30.000ft. This gives me cause for concern as manufacturers and information groups such as yours are still telling us it’s ok to fly with an oxygen concentrator. My question is…….Do oxygen concentrators operate effectively at altitudes higher than 10,000ft?

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Air travel may affect insulin pump delivery in people with type 1 diabetes

by Diabetologia

Altitude changes during commercial flights may affect the blood glucose levels of people with type 1 diabetes who are treated with insulin pump therapy, according to new research to be presented at this year's Annual Meeting of The European Association for the Study of Diabetes (EASD) , Madrid (9-13 Sept).

"We investigated the effect atmospheric pressure changes during flight can have on insulin pumps following concerns that glucose levels may drop below the normal ranges during or immediately after flights," explained lead author Dr. Ka Siu Fan from the Royal Surry County Hospital and University of Surrey, UK.

In the study, insulin delivery from 26 insulin pumps was tested in Europe's largest hypobaric chamber to mimic the atmospheric changes during a normal commercial flight.

The hypobaric chamber was depressurized to 550 mmHg over a 20-minute ascent, maintained at a 30-minute cruise (mimicking an airline pressurized cabin altitude of 8,000 feet), followed by a 20-minute descent to the ground (with an ambient pressure increase to 750 mmHg).

During the simulated flights, insulin infusion was set at 0.60 units per hour to represent a rate used in adult and pediatric practice and to allow accurate measurements on multiple flights.

Insulin delivery rates and bubble formation (caused by air coming out of a solution and forming bubbles when pressure decreases) were recorded by attaching infusion sets to open-ended 100 microliter capillary tubes against 1mm grid paper.

Insulin infusion sets without pumps were also tested under a separate pressure protocol to simulate rapid decompression. This mimics the sudden loss of cabin pressure, which occurs in emergencies.

The researchers found that full insulin cartridges over-delivered 0.60 units of insulin over a 20-minute ascent (ambient pressure decrease) compared to ground-level performance. While this may slightly reduce blood glucose, the authors do not anticipate that this would lead to clinically significant or symptomatic hypoglycemia.

During descent (ambient pressure increase), cartridges under-delivered 0.51 units of insulin. This may lead to blood glucose being higher than usual but does not pose the same concern as the hypoglycemic effects of too much insulin.

Strikingly, rapid decompression resulted in fluid delivery equivalent to 5.6 units of excess insulin. In the rare event of a sudden decompression of the cabin at altitude, an insulin overdose could cause blood sugar levels to fall to such an extent that it could cause significant hypoglycemia. However, in such emergencies—for instance when an aircraft loses a door mid-flight—there would be time to ingest extra short-acting carbohydrates to counter this.

As Dr. Fan explained, "Individuals who use insulin pumps should be aware of the potential impact of changes in the cabin air pressure on insulin delivery. The drop in cabin pressure during ascent may lead to a slight increase in insulin delivery as a result of the formation of air bubbles which displace excess insulin out of the cartridge.

"A slight reduction in insulin delivery is also possible during descent as the increasing air pressure dissolves the air bubbles, sucking insulin back into the pump. Whether these abnormalities in insulin delivery during flights cause clinical effects will depend on several factors, including an individual's insulin sensitivity, food intake, and glycemic control."

He cautioned, "To prevent any unintended metabolic consequences, we recommend that individuals who use insulin pumps consider temporarily disconnecting their pumps before takeoff, and removing air bubbles before reconnecting them at cruising altitude."

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UK flight chaos continues with dozens more cancellations at Gatwick and Heathrow

Exclusive: british airways and easyjet have grounded dozens more flights as ryanair demands the resignation of air-traffic control boss, article bookmarked.

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For a fourth day, thousands of passengers flying to and from the UK have had their flights cancelled after a combination of bad weather and air-traffic control staff shortage led to hundreds of flights being axed .

Around 3,500 passengers expecting to fly to or from London Gatwick on 20 flights on Monday morning have been grounded. Most are booked on easyJet , which cancelled its first flight of the day, to Ibiza, and six others including links to Naples and Nice.

Passengers were told the cause was “air-traffic control restrictions” and outside the airline’s control.

The cancellations are in addition to 64 flights grounded by easyJet on Sunday due to short-notice staff shortage in Gatwick’s control tower .

At least 100 flights were cancelled on Sunday evening at Gatwick, and others ran extremely late – such as the Wizz Air flight to Rome that was due to arrive soon after midnight but actually arrived in the Italian capital shortly before 6am, and an easyJet departure to Lyon that ran four hours behind schedule.

It was the third incident of mass cancellations due to staff shortage in the Gatwick control tower in less than a year.

The tower is run by the air-navigation provider Nats , which said on Sunday night it was trying to “keep disruption to a minimum”.

A spokesperson said:“Temporary air-traffic restrictions are currently in place at London Gatwick Airport in order to maintain safety. These restrictions are due to short-notice staff absence at the air traffic control tower and in addition to existing restrictions already in place due to adverse weather across UK and Europe.

“We expect all restrictions to be lifted by the end of the day.”

But as cancellations continued into Monday, Ryanair once again called for the resignation of Martin Rolfe, chief executive of Nats. A spokesperson for Europe’s biggest budget airline said: “This is the latest in a long line of cock-ups by UK Nats, which has yet again disrupted multiple flights and thousands of passengers at Gatwick.”

The Independent has contacted Nats for a response.

EasyJet said on Sunday evening that it was “extremely disappointed that customers are once again being impacted by this”.

A former Labour cabinet minister and acting chair of the Transport Select Committee has called for a “change of leadership” at the Sussex airport.

Ben Bradshaw said: “This is a complete disgrace that’s been for going on for years.

“Gatwick needs a change in leadership. In the mean time I recommend Luton airport – many of the same destinations and minimal delays.”

The Sussex hub is the busiest single-runway airport in the world, with 800 or more flight movements each day.

A Gatwick spokesperson said: “ Nats operate the London Gatwick air-traffic control tower and they have successfully increased the number of air traffic controllers over recent months.

“So far this year (2024) London Gatwick has safely handled more than 170,000 flights through Nats, a four per cent increase on last year.

“The Nats service has been fully available more than 99.6 per cent of the time, operating 24 hours a day.”

“We will continue to work closely with the NATS leadership team to provide passengers and airlines with a good service. London Gatwick would like to apologise to any passengers who experienced disruption yesterday.

In terms of the sheer scale of disruption over one of the busiest weekends of the year, British Airways passengers trying to fly to or from London Heathrow have been worst affected.

Between Friday and Sunday BA cancelled 240 flights , affecting around 40,000 passengers. On Monday the airline had grounded a further eight departures and arrivals at Heathrow, plus six at Gatwick.

One passenger, Mike C, wrote on X: “This morning BA cancelled 1pm flight at 4.15am. Helpline not open till 6am. Had to get refund and book with another carrier – cash flow.”

A spokesperson for British Airways said: “We operate hundreds of flights every day without disruption, successfully getting tens of thousands of our customers to where they need to be.

“Along with other airlines, we’ve had to make some small adjustments to our schedule because of air traffic control restrictions caused by adverse weather.

“Whilst the vast majority of our customers will be unaffected, we apologise for any inconvenience caused and our teams are working hard to help get journeys back on track.”

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Nizhny Novgorod city, Russia

The capital city of Nizhegorodskaya oblast .

Nizhny Novgorod - Overview

Nizhny Novgorod (colloquially often just “Nizhny”; from 1932 to 1990 - Gorky) is a large city located in the center of European Russia, the administrative center of the Volga Federal District and Nizhny Novgorod Oblast.

It is an important economic, industrial, scientific, educational, and cultural center of Russia, the largest transport hub of the Volga Federal District. Nizhny Novgorod is one of the main centers of river tourism in Russia. The historic part of the city is rich in sights and is a popular tourist destination.

The population of Nizhny Novgorod is about 1,234,000 (2022), the area - 411 sq. km.

The phone code - +7 831, the postal codes - 603000-603257.

Nizhny Novgorod city flag

Nizhny novgorod city coat of arms.

Nizhny Novgorod city map, Russia

Nizhny novgorod city latest news and posts from our blog:.

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2 June, 2017 / The Most Beautiful House in Nizhny Novgorod .

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History of Nizhny Novgorod

Foundation of nizhny novgorod.

During the military campaigns of the Russian princes against the Volga Bulgaria, the place where the Oka River flows into the Volga was used as a gathering point for the Murom and Suzdal troops. In 1220, Grand Duke Yuri Vsevolodovich (the grandson of Prince Yuri Dolgoruky, the founder of Moscow) conducted a successful campaign against the Bulgars. After it, he “decided to strengthen this important place for Rus” and founded a town at the mouth of the Oka.

It was named Novgorod, which literally means “new town”. Later, the adjective “nizhny” (“lower”) was added to the name of the town in the Russian annals. This was probably done in order to distinguish it from the town of Novgorod (present Veliky Novgorod) and other Novgorods that existed at that time.

The founding of Nizhny Novgorod was the beginning of an active expansion of Russian influence in the Mordovian lands. Two white-stone churches were built in the fortress, including the Cathedral of the Archangel (1227) - evidence of the special role that the town had in the system of lands of Vladimir-Suzdal Rus. However, the Mongol invasion stopped further development.

Information about Nizhny Novgorod of the 13th century is extremely scarce. But it is known that after the invasion it revived relatively quickly. Nizhny Novgorod is constantly mentioned in Russian chronicles as a major political and economic center of North-Eastern Rus and a spiritual center of Orthodoxy in the Volga region. The town was often the object of conflicts between Moscow and Tver.

In 1392, the Moscow prince Vasily I received a jarlig for the Nizhny Novgorod Principality and captured Nizhny Novgorod. The final annexation of Nizhny Novgorod to the possessions of Moscow took place in the late 1440s.

More Historical Facts…

Nizhny Novgorod in the 16th-18th centuries

Under Ivan III and Vasily III, the town played the role of a border post and was a gathering place for military campaigns against the Kazan Khanate. In 1508-1515, the stone kremlin was built. After the capture of Kazan by Ivan the Terrible, the border role of Nizhny Novgorod became insignificant. At the same time, Nizhny Novgorod became the center of trade between Russia and the East and a large shipbuilding center.

In September 1611, during the Time of Troubles, the Second People’s Militia was organized in Nizhny Novgorod to fight the Poles who were able to establish control over Moscow. The militia consisted of detachments of townspeople, peasants of the central and northern regions of the Tsardom of Russia. The leaders were the Nizhny Novgorod merchant Kuzma Minin and Prince Dmitry Pozharsky (the monument to them is installed on Red Square in Moscow). In October 1612, the militia was able to completely liberate Moscow.

In the 17th century, a schism occurred in the Orthodox Church under Patriarch Nikon. It led to the formation of numerous settlements of Old Believers in the vicinity of Nizhny Novgorod. In 1695, during his Azov campaign, Peter I arrived in Nizhny Novgorod. In 1719, as a result of his administrative-territorial reforms, the town became the center of a separate Nizhny Novgorod Governorate. In 1722, setting off on the Persian campaign, Nizhny Novgorod was again visited by Peter I. Here he celebrated his 50th birthday.

In 1767, Nizhny Novgorod was visited by Empress Catherine II. During her stay in the town, she met the famous local mechanic and inventor Ivan Kulibin. After her visit, a new regular town plan was approved. The first town theater was built in 1798. Later, it became known as Nikolaevsky, in honor of Emperor Nicholas I.

Nizhny Novgorod in the 19th century

At the turn of the 18th and 19th centuries, Nizhny Novgorod became a major scientific and cultural center of the Russian Empire. In 1811, the population of Nizhny Novgorod was about 14,400 people. In 1817, the Makaryev Fair, the largest fair of the Russian Empire, was moved to the village of Kunavino (one of the districts of today’s Nizhny Novgorod). Before that, it was organized every year near the Makaryevsky Monastery, which burned down a year earlier. From that time on, it began to be called the Nizhny Novgorod Fair. Thanks to it, the rapid economic development of the town and adjacent villages began.

After Emperor Nicholas I visited the town in 1834, the large-scale reconstruction of Nizhny Novgorod began. In 1847, a water supply system appeared in the town and the first fountain was built. Private buildings in the Nizhny Novgorod Kremlin were demolished and new administrative buildings appeared in their place. A lot of new buildings, streets, boulevards, and gardens were built.

In 1849, a large industrial enterprise was founded in the village of Sormovo (another district of today’s Nizhny Novgorod). Later, it became known as the Sormovo plant. It was producing river steamers, various railway cars, steam locomotives, and trams. Thanks to the plant, Sormovo soon turned into a large village of workers. In 1862, the construction of the Moscow-Nizhny Novgorod railway was completed. In 1863, the population of the city was 41,500 people.

In 1896, the city hosted the All-Russian Trade and Industrial Exhibition. The radio receiver of the engineer A.S. Popov, the hyperboloid tower of the engineer V.G. Shukhov were demonstrated at the exhibition, as well as the first Russian car of the Frese and Yakovlev factories.

Nizhny Novgorod in the first half of the 20th century

In 1914, about 111,000 people lived in Nizhny Novgorod. In 1917, during the First World War, the Warsaw Polytechnic Institute was evacuated to this city, on the basis of which the Nizhny Novgorod Polytechnic Institute was created.

On October 7, 1932, Nizhny Novgorod was renamed Gorky due to the 40th anniversary of the literary and social activities of the writer Maxim Gorky. In 1933, the first permanent bridge across the Oka River was built. The railway bridge across the Volga was constructed too. Thanks to this, it became possible to go by rail through Gorky to the Urals and Siberia.

The 1930s were a period of rapid industrialization. In 1932, the largest industrial enterprise in the city was opened - the Gorky Automobile Plant (GAZ), an important object of the Soviet defense industry. In the 1930s-1940s, the city was even referred to as “Russian Detroit”. By 1939, the population of Nizhny Novgorod increased to about 644,000 people.

Every fourth resident of the Gorky region (about 822 thousand people) fought on the fronts of the Second World War. Of these, more than 350 thousand people did not return from the battlefields - they were killed, went missing or died from wounds in hospitals.

In June 1943, three large raids of German bombers were carried out on Gorky. The main target of air strikes was the Gorky Automobile Plant, which as a result was almost completely destroyed. It was rebuilt only in the middle of 1944. Over 500,000 wounded were treated in dozens of hospitals during the war years.

The city was an important center for the production of weapons. During the Second World War, every second Soviet car, every third tank and every fourth artillery piece were produced at Gorky’s plants. In total, about 38 thousand tanks, self-propelled guns, armored vehicles, 43 thousand mortars, 16 thousand aircraft, 22 submarines, 109 thousand cars, more than 85 thousand radio stations, as well as 101 thousand artillery pieces and 1,165 Katyusha multiple rocket launchers were produced in Gorky.

Nizhny Novgorod after the Second World War

In 1946, the first GAZ-M-20 “Pobeda” passenger car and the GAZ-51 truck left the assembly line of the Gorky Automobile Plant. In 1949, the construction of the monumental Chkalov Stairs connecting the Upper Volga and Lower Volga embankments was completed in the historic center of Nizhny Novgorod. On August 4, 1959, the resolution of the Council of Ministers of the USSR “On the closure of the city of Gorky for visiting by foreigners” was issued. In 1962, the population of Gorky exceeded 1 million people.

On January 18, 1970, a radiation accident occurred at the Krasnoe Sormovo plant. During the construction of a nuclear submarine, an unauthorized launch of the reactor took place. After working at prohibitive power for about 10-15 seconds, it partially collapsed. Hundreds of workers were exposed to the radioactive release. In total, over one thousand people took part in the liquidation of the consequences of the accident and were exposed to radiation.

In 1985, a subway was opened in Gorky. In 1980-1986, Andrei Sakharov, a world famous nuclear physicist, Nobel laureate, and activist, was in exile in Gorky to prevent his contacts with foreigners. In the early 1990s, the “closed city” status was lifted and the city became accessible to foreigners. On October 22, 1990, Gorky was renamed back to Nizhny Novgorod. In 1991, the population of the city reached its maximum - 1,445,000 people.

At the end of the 20th century, the information technology sphere began to actively develop in the city. In the 2000s, a transport problem arose because of the insufficient carrying capacity of the Nizhny Novgorod bridges connecting the lower part of the city and the upper one.

In February 2012, the Nizhny Novgorod Volga Aerial Tramway was opened. This 3661-meter-long gondola lift cable car connected Nizhny Novgorod with the town of Bor. Its daily passenger traffic is about 5,000 people. In 2013, the city electric train was launched - an alternative to the subway line from Sormovo to Moskovsky railway station.

Nizhny Novgorod hosted 6 matches of the FIFA World Cup 2018 . A new stadium was built, the old river port was demolished, a new park and embankments were created. Large-scale restoration of old streets and buildings took place, new museums were opened, hotels were built, and parks were reconstructed.

Streets of Nizhny Novgorod

One sunny summer day in Nizhniy Novgorod

Author: Denis Plekhanov

Apartment buildings in Nizhny Novgorod

Author: Eugene Ivanov

On the street in Nizhny Novgorod

Author: Sergey S. Kazenyuk

Nizhny Novgorod - Features

Nizhny Novgorod is located about 425 km east of Moscow, at the confluence of the two largest waterways of the European part of Russia - the Volga and Oka rivers. The city is divided by the Oka into two parts. The length of Nizhny Novgorod along the Oka is 20 km, along the Volga - about 30 km.

The climate in Nizhny Novgorod is moderately continental, with cold, long winters and warm, relatively short summers. The average temperature in January is minus 8.9 degrees Celsius, in July - plus 19.4 degrees Celsius.

A red deer is depicted on the coat of arms and flag of Nizhny Novgorod, which is a symbol of nobility, purity, life, wisdom, and justice. The City Day is celebrated on the 3rd Saturday in August.

In January 2019, Nizhny Novgorod was recognized as the best city in Russia in terms of quality of life. It took first place among Russian cities and 109th in the world in terms of quality of life. The rating was compiled by the site numbeo.com, which specializes in statistics on the cost of living and consumer prices in different countries of the world.

When compiling the rating, the purchasing power of the population, safety, health care, the cost of living, the ratio of real estate prices to the population’s income, traffic congestion, the level of environmental pollution, and climate were taken into account.

The main branches of the local industry are the production of cars and weapons, shipbuilding. Nizhny Novgorod is also one of the IT centers of Russia.

Nizhny Novgorod is a major transport hub. The city has a railway station, a river station, a cargo port, several berths for transshipment of goods. Strigino International Airport named after V.P. Chkalov offers regular flights to such cities as Yekaterinburg, Kazan, Kaliningrad, Moscow, Novosibirsk, Samara, St. Petersburg, Sochi, and a number of others.

Public transport in Nizhny Novgorod plays a very important role in ensuring the life of the city. At the same time, its work is hampered by the distribution of its population on the city’s territory, large daily migrations, a very high concentration of passenger traffic on the bridges across the Oka River, and the lack of an all-encompassing system of high-speed transport. There are municipal buses, fixed-route minibuses, trams, trolleybuses, the city train, and subway.

The tourist potential of Nizhny Novgorod is quite high. According to UNESCO, it is one of the most valuable historical cities in the world. In total, there are more than 600 unique historical, architectural and cultural monuments in Nizhny Novgorod, a variety of museums. The best time to visit Nizhny Novgorod is summer.

One of the alternative ways to visit Nizhny Novgorod is to take a river cruise along the Volga River. Travelers will find exciting excursions and meals in traditional Russian taverns. It will also be interesting to come during one of the many fairs or ethnographic festivals that are held in the city.

Main Attractions of Nizhny Novgorod

Nizhny Novgorod Kremlin (1508-1515) - a fortress in the historic center of Nizhny Novgorod and its oldest part, the main architectural complex of the city located on the right high bank, at the confluence of the Volga and Oka rivers. To date, all 13 towers of the Nizhny Novgorod Kremlin have been preserved or have been restored. The thickness of the wall at the base reaches 5 meters. There are exhibitions in the towers of the fortress; a section of the wall is open for tourists to visit.

In the past, there were several churches on the territory of the Nizhny Novgorod Kremlin. Today, only the Archangel Michael Cathedral has survived, built no later than the middle of the 16th century and rebuilt in 1628-1631 - the oldest surviving building in the kremlin. There is the grave of Kuzma Minin inside it.

An excellent view of the Volga River and Strelka (the confluence of the Oka and Volga) opens from the walls of the Nizhny Novgorod Kremlin. Here you can also see a collection of military equipment from the Second World War.

Nizhny Novgorod State Art Museum - one of the oldest museums in Russia, the largest museum of fine arts in the Nizhny Novgorod region. The Governor’s Palace on the territory of the Nizhny Novgorod Kremlin houses a permanent exhibition of Russian art and a collection of artistic silver.

In the House of the Merchant and Benefactor D.V. Sirotkin (Verkhnevolzhskaya Embankment, 3), an exposition of Western European art is presented and, separately, the painting by K.E. Makovsky “The appeal of Kuzma Minin to the citizens of Nizhny Novgorod” - one of the largest paintings on a historical theme in Russia (698x594 cm).

Chkalov Stairs (1943-1949) - a monumental staircase in the form of a figure eight in the historic center of Nizhny Novgorod. Connecting the Upper Volga (Verkhnevolzhskaya) and Lower Volga (Nizhnevolzhskaya) embankments, it is one of the longest stairs in Russia. It starts from the observation deck at the monument to Valery Chkalov (the famous Soviet pilot who made the first non-stop flight from the USSR to the USA via the North Pole), next to the St. George Tower of the Nizhny Novgorod Kremlin.

Bolshaya Pokrovskaya Street - the main street of Nizhny Novgorod built up with noble mansions of the past centuries. A large part of Bolshaya Pokrovskaya is reserved for the pedestrian zone and is analogous to the pedestrian Arbat Street in Moscow. There are a lot of historic houses, cafes, souvenir shops, boutiques, monuments, and sculptures here. The length of the street is over 2 km.

The building of the State Bank (Bolshaya Pokrovskaya Street, 26), resembling a medieval palace, is an outstanding architectural monument built in the Russian Revival style in 1911-1913. In the Museum of Old Equipment and Tools (Bolshaya Pokrovskaya Street, 43), you can see unique exhibits, hear their history, and even touch them.

Fedorovsky Embankment - one of the most beautiful embankments in Nizhny Novgorod and the best observation deck in the city. Everything is perfectly visible from this embankment: the old part of the city, the river station with a park, the Kanavinsky bridge - one of the oldest in the city, and, of course, the opposite bank of the Oka River with the Alexander Nevsky Cathedral, the confluence of the Oka and Volga. People also come here to watch the sunset.

Nizhny Novgorod Volga Aerial Tramway . This cable car, 3661 meters long, connects the high right bank of the Volga River, where the historic part of Nizhny Novgorod is located, with the town of Bor. It has the largest unsupported span over the water surface in Europe - 861 meters.

A one way trip during which you can admire the picturesque views of Nizhny Novgorod and the Volga River takes 15 minutes. It is better to use it in good sunny weather, because in windy weather, the movement of the cabins can be stopped. Sennaya Square on Kazanskaya Embankment.

Nizhny Novgorod State Museum of History and Architecture (1875-1877). Also known as the Mansion of S.M. Rukavishnikov, it is an architectural ensemble built in the eclectic style in the historic center of Nizhny Novgorod, one of the most important and famous architectural monuments of this city. Guided tours are held in the premises, allowing you to learn about the life of the former owners of the mansion, as well as look at the historical expositions of different years. Verkhnevolzhskaya Embankment, 7.

Main Palace of Nizhny Novgorod Fair - a luxurious building constructed in the forms of Old Russian architecture of the 17th century. Today, exhibitions of various formats are held here, as well as the multimedia exposition “Russia - my history” dedicated mainly to the history of Nizhny Novgorod starting from the Finno-Ugric peoples. Sovnarkomovskaya Street, 13.

Museum of the History of the Gorky Automobile Plant . The museum houses expositions telling about the history and development of the Gorky Automobile Plant. In total, there are over 40,000 exhibits. Here you can see a collection of Soviet vintage cars, which includes “Chaika”, “Volga”, the truck “GAZ-51”, and a lot of others. Lenina Avenue, 95.

Alexander Nevsky Cathedral (1868-1881) - the most noticeable sight of the lower part of Nizhny Novgorod, which can be seen from all observation decks of the upper city. The church, 87 meters high, was built on the site of the Nizhny Novgorod Fair at the expense of merchants, who wanted to perpetuate the visit of Emperor Alexander II. Strelka Street, 3a.

Church of the Nativity of the Blessed Virgin Mary (1696-1719) - one of the best examples of the Stroganov Baroque, an architectural monument of federal significance. From a distance, this colorful building looks like a sugar gingerbread with “candy” domes and decorated with stone flowers, pears and apples. Rozhdestvenskaya Street, 34.

Pechersky Ascension Monastery - one of the most interesting places in Nizhny Novgorod, where you can feel the spirit of the city. Most of the monastery buildings date back to the first half of the 17th century. A lot of beautiful photographs can be taken here. Privolzhskaya Sloboda Street, 108.

Limpopo Zoo - the first private zoo in Russia. More than 270 species of animals live here, 25 of which are listed in the Red Book of the Russian Federation. It is located on the territory of the Sormovsky Park on an area of 7.1 hectares. Yaroshenko Street, 7b.

Architectural and Ethnographic Museum-Reserve “Shcholokovskiy Khutor” . The exposition of this museum is represented by 16 objects of rural architecture: residential houses, barns, mills and churches of the 17th-19th centuries brought from the northern districts of the Nizhny Novgorod region. The facades of the houses are decorated with traditional relief carvings. In the premises of the houses, interiors with authentic items of peasant life have been restored. Gorbatovskaya Street, 41.

Nizhny Novgorod city of Russia photos

Pictures of nizhny novgorod.

Chkalov Stairs and the Nizhny Novgorod Kremlin

Author: Sergey Bulanov

Alexander Nevsky Cathedral in Nizhny Novgorod

Author: Evgeniy Balashov

Shopping and office center Smart in Nizhny Novgorod

Author: Diman Lazarev

Sights of Nizhny Novgorod

Annunciation Monastery - the oldest monastery in Nizhny Novgorod

Nizhny Novgorod Cathedral Mosque

Church in honor of the icon of the Mother of God Joy of All Who Sorrow in Nizhny Novgorod

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By city rail

The City Rail connects areas where there are no metro lines. Connects with the subway at the Moscow railway station. It has 2 lines: Sormovskaya and Priokskaya. The fare by train costs 28 rubles. According to the Citicard Transport Card, the fare is 26 rubles. Also by train you can get to the nearest suburb, or transfer to suburban trains to Dzerzhinsk, Bor, Semenov or Arzamas.

By bus and trolleybus

As of May 2017 in each district of the city there are several city bus routes. The number of trolleybus routes is much less. In one district of the city there are 1-2 trolleybus routes. Trolleybus routes are completely absent in the Leninsky city district. It is worth noting that trolleybuses do not connect the Lower City to the Upper. This is because the trolleybuses do not have enough power to climb the mountain.

The trolleybus network is divided into 3 parts:

• The upper trolleybus network (it unites all three districts - Nizhegorodsky, Sovetsky and Prioksky) with a turning circle on the Minin Square, near the Kremlin.
• The lower trolleybus network (connects Kanavinsky, Moskovsky and Sormovsky districts)
• The Avtozavod trolleybus network (connects all the distant sleeping microdistricts among themselves)

Throughout the city, land trams run. The longest route of all is 417. It connects the outskirts of Avtozavodsky district with the Moskovsky Rail Terminal. The journey takes about 1 hour and 20 minutes. The route passes through the sleeping areas (approximately 75% of the way). Also in remote neighborhoods there are routes of several more trams, but in most cases, they are in the Upper City. By the way, you can reach there by tram 27 or 10 directly from the Moscow railway station.

By marshrutka

Marshrutkas do not stop at every stop. To indicate your intention to exit a marshrutka, press a button and to indicate your intention to enter a marshrutka en-route, you need to wave your hand.

Nizhny Novgorod has not very developed bicycle infrastructure. Special bike paths exist only on the Upper-Volga and Lower-Volga embankments and on Rozhdestvenskaya Street.

The upper city is very hilly and full of steep inclines and even many locals will get off their bicycles and push their bikes up the hill by foot. Drivers can be reckless and pose a danger to cyclists. The roads can also be icy during the winter. City cyclists solve this problem by replacing summer tires with winter tires.

Also, in 2017 the implementation of a new integrated transport scheme of the city began. It provides for a large number of bicycle paths in the Upper City (including on Bolshaya Pokrovskaya Street) and in the Lower City.

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