**5. Guideline recommendations for lifestyle changes post pneumothorax**

Recommendations for passengers travelling by air after an attack of pneumothorax was largely based on anecdotal case reports [30, 31]. A pneumothorax, especially an undrained one, is however an absolute contraindication to all commercial air travels [32]. Travelling with a chest drain inserted for pneumothorax had no published guidelines or recommendations. It is theoretically safe, but most airlines would not be willing to accept such a risk and would need documented medical input and insurance approval to allow patients to travel.

According to the BTS guidelines, commercial airlines advise individuals to avoid air travel for 6 weeks after an episode of primary spontaneous pneumothorax and stress that patients should not fly until resolution has been confirmed [8].

Although there is no evidence that recurrence is caused by flying, the consequences of a pneumothorax occurring during a flight could be serious because of the lack of medical care. Restrictions on flying may be more justified in patients for whom pneumothorax is associated with higher risk, such as smokers and patients with underlying lung disease (secondary spontaneous pneumothorax). In patients with secondary pneumothorax who have not been treated surgically, air travel should be avoided for 1 year after an episode (grade C recommendation). Patients with a history of pneumothorax who have not been treated surgically should also be advised against practising high-risk sports, such as diving (grade C recommendation) [8].

The performance of a VATS procedure can offer patients more safety to fly or practise diving sports. This makes patients with occupations as pilots and scuba divers candidates for a VATS intervention even with a first-attack pneumothorax. Definitive treatment significantly reduces the risk of recurrence and makes air travel safer from an airline point of view [30]; however, an individual clinical decision is usually made by the treating clinician, considering both airline policy and details of relevant insurance.

There are no specific guidelines regarding lifestyle modification to prevent patients from having another attack of pneumothorax apart from advising all patients to stop smoking. Despite the apparent relationship between smoking and pneumothorax, 80–86% of young patients continue to smoke after their first episode of PSP [33]. Smoking cessation remains the only reversible risk factor known
