Flying With Oxygen

Updated February 5, 2009

by Mark Pettigrew

In the past people in Canada who require oxygen to travel by air have, in many cases, found the exercise confusing, difficult, unreliable, expensive and sometimes downright scary. Detailed planning has been required to insure a seamless supply from home to the airport, during boarding, disembarking and stopovers and from the destination airport to the final destination. Between March 2000 and June 2005 there were twenty-six complaints filed within the Canadian Transportation Agency (CTA) by or on behalf of people who require oxygen while traveling by air. Twenty-five complaints were against Air Canada and one was against WestJet.

The CTA states, “any federally regulated transportation system must not present an undue obstacle to the mobility of a person with a disability.”

The complaints addressed several issues: In the case of WestJet a passenger was flatly refused passage on a flight to Mexico because WestJet was not certified to provide oxygen “to, from or within” the USA as required by the Federal Aviation Administration (FAA). In December 2005 the CTA decided that to refuse persons with disabilities accommodation on transborder and international flights was a significant obstacle to their mobility.

With respect to Air Canada, the Agency found that, although the carrier accommodates persons with disabilities by providing an oxygen service on all of its domestic, transborder and international flights, there were systemic problems identified as obstacles in the delivery of this service which led to the conclusion that the accommodation provided by Air Canada may not be reasonable. Specifically, the systemic obstacles to mobility found in Air Canada's oxygen policies, procedures and practices were as follows:

1. the policy that requires that persons request Air Canada's oxygen service as well as its portable onboard oxygen service in advance of travel;
2. the requirement that Fitness for Travel (FFT) forms be completed by the physicians of persons who use oxygen, including the related cost and the level of information to be disclosed; Many people, including some doctors, are unaware of the difference between the atmosphere on ground and the atmosphere inside an aircraft at 30,000 ft. altitude. Some people who require medical oxygen may be stable at ground level but at a great health risk in the reduced oxygen and pressure environment of an aircraft cabin. Air Canada as well as other airlines have knowledge about these cabin conditions and their health risks and believe they have the right to medical information about passengers requiring oxygen in order to determine their fitness for travel.
3. the policy on oxygen fees which escalated to $150 per flight segment on Air Canada flights;
4. the non-provision of oxygen prior to boarding, during connections/stopovers and upon arrival at the final destination;
5. the failure to ensure the availability of a portable oxygen cylinder dedicated to persons who require oxygen to leave their seat to use the washroom;
6. the policies and procedures of placing the oxygen cylinder under the seat in front of the passenger, which encroaches on the person's floor space; and
7. the policy of not providing humidifiers on request to persons who use oxygen on all of its flights.
   

There were also other incidents where Air Canada failed to provide pre-requested oxygen, where they failed to provide an adequate supply of oxygen, where oxygen requests were not communicated and where oxygen was not supplied during a delayed connection.

The CTA at this point needed to rule on the “undueness” of the obstacles. What this means is that there must be a balance between the rights of persons with disabilities, the rights of other passengers and the ability of the carrier to provide accommodation to people with disabilities without undue hardship to the airline. In other words would we require an airline to provide an onboard surgical room with surgeons, nurses and modern surgical equipment to address medical emergencies on an aircraft? I think most people would agree that with all the expense required and the space needed on the aircraft this could be considered an undue hardship to the airline.

For twelve days between October 29 and November 22, 2007 the CTA held hearings in Ottawa to address the undueness of the obstacles. The issue of medical oxygen on aircraft is complicated. There are many concerns including safety (oxygen is a dangerous good and in certain conditions and circumstances could be the cause of catastrophic aircraft accidents if not handled properly), security, international agreements and the laws of foreign countries where Canadian aircraft will be crossing or landing. Their investigation and decision making process was very thorough and included many expert witnesses including our own Dr. Ken Chapman. Their decision was issued June 26, 2008 and can be viewed in full at: http://www.cta-otc.gc.ca/rulings-decisions/decisions/2008/A/AT/336-AT-A-2008_e.html

The focus of the CTA decision was on the emerging technology of portable oxygen concentrators (POC’S). A POC is a portable device that extracts oxygen from the ambient air and delivers it to the patient, usually in pulse doses. They operate on 115v A/C current, 12v D/C outlets or batteries and are light enough to be carried or, in some cases, pulled on a cart. Since there is very little oxygen in the device at any given time they do not fall under dangerous goods regulations.  The FAA in the United States has approved five models for use on aircraft. (AirSep LifeStyle, AirSep FreeStyle, Inogen One, SeQual Eclipse and Respironics EverGo) Although compressed medical oxygen is allowed on aircraft in the USA it must be supplied by the airline. POC’s are the only method that can be passenger supplied in the USA. In Canada compressed gaseous oxygen and POC’s may be passenger supplied although the airline may decide which method of oxygen delivery suits its operational needs.

There are some limitations with POC’s in terms of oxygen purity, flow rates and battery life. Batteries must be used on aircraft, the use of the aircrafts power outlets is not permitted. Some airlines require that the patient bring 1.5 times the flight duration, including stopovers, in battery capability. I was told that in one case a flight from Toronto to Alaska required 19 hours of batteries. Batteries are very expensive and 19 hours of batteries would be bulky.

POC manufacturers have stated that every manufacturer of POC’s is committed to improving the technology and in the next five years they will become lighter and able to deliver higher flow rates.

Canada lags behind the USA in the use of POC’s (of the 40,000 patients on long-term oxygen in Canada only 2,000 use POC’s). There are two factors that contribute to this lag. One is that suppliers have a large inventory of non-portable concentrators as well as gaseous and liquid oxygen equipment. POC’s are expensive and to replace their present inventory would be cost prohibitive. As the demand for POC’s increases the cost is expected to come down. The other contributing factor is coverage for POC’s by government health insurance plans although this is being addressed and comprehensive coverage may be in the cards.

At present Ontario’s assistive devices program requires oxygen suppliers to provide mobility for clients who are covered by the program but does not specify what equipment must be provided to accomplish this. There are many oxygen suppliers in Ontario and clients may chose the company that best meets their needs.

Effective May 13, 2009 the USA will require all foreign air carriers operating to, from and within the USA to permit the use of approved POC’s in the aircraft cabin.

WestJet currently allows the use of passenger-supplied POCs on all of its flights as well as passenger-supplied gaseous oxygen on its domestic flights although the CTA has ruled that having two systems of addressing the need for medical oxygen goes beyond the requirement of reasonable accommodation. Some carriers have already eliminated the provisioning of gaseous oxygen services altogether and more are expected to follow. WestJet does not operate a compressed oxygen service. WestJet requires a very simple POC physician’s statement, which can be downloaded from their website and completed by the traveler’s doctor. It is to be presented at check-in and carried with the patient for the duration of the flight. This statement is needed for compressed oxygen as well and is valid for up to one year. If you are traveling with compressed oxygen on domestic flights you will need to notify WestJet ahead of time because of limitations on the number of cylinders allowed per flight. You may just show up for any flight if you have an approved POC and a physician’s statement.

Amongst other Canadian airlines there are variations of permissible means of accommodation on domestic, transborder and foreign flights from POC’s to passenger supplied gaseous oxygen to fees being charged for oxygen services. Amongst foreign airlines POC’s are by far the favoured means of accommodation.

Air Canada’s oxygen policies are changing dramatically because of the CTA’s decisions.. POC’s are now allowed on all Air Canada flights provided that enough batteries are present to accommodate the POC for 1.5 times the flight duration including waiting in the secure area, boarding, the flight itself, any stopover, disembarking and exiting past the secure area. Medipak gaseous oxygen services are now provided on domestic flight segments for $17 but remain at $150 for all foreign flights (a medipak is a fairly large strongbox which securely houses an oxygen cylinder and regulator). Beginning in January 2009 oxygen services will be available starting at the security check as well as at stopovers and up to exiting at the destination airport. Also beginning in January any passengers requiring assistance will be provided with a seat for their assistant free of charge. Advance notice of 48 hrs (72 hrs on some flights) will still be required and an FTT form completed by the passenger’s physician will still be required although it is a new form with an altered level of disclosure which takes into account privacy issues. I was unable to acquire a new FTT form from Air Canada. The CTA found no evidence as to why Air Canada could not make a reasonable effort to accommodate a passenger requiring oxygen with less than 48 hours notice wherever possible and that not to make that effort would be considered an undue obstacle. Air Canada now provides a portable oxygen service for passengers who need to use the washroom. The CTA also found that placing the medipaks at the feet of the passenger to be an undue obstacle and Air Canada may modify its overhead bins to accommodate the medipaks.

In a discussion with Air Canada’s medidesk I was told that because of the battery requirements for POC’s that on some flights passengers prefer to pay the $17 or $150 fee for air Canada’s oxygen service. They are still allowed to bring their POC for use to and from the airport and for use at their destination.

Since most oxygen patients prefer to have control over their own oxygen supplies rather than handing over control to a less experienced and less knowledgeable third party it seems that the use of passenger supplied POC’s would be the most reasonable means of accommodation considering foreign regulations, particularly those of the USA.

In conclusion I feel that because of the cost, limited battery life, oxygen purity levels and flow rates of POC’s they are not yet a panacea for air travel. They need to be improved to accommodate people who require higher flow rates and purity levels. They will, however, greatly improve the traveling experience of many people who need oxygen and as the dust settles on the issue the future shows even more promise.

Bon voyage!