Aviation Medicine and Respiratory DiseaseAviation Medicine and Respiratory DiseaseDiploma in Aviation Medicine Course No 44Diploma in Aviation Medicine Course No 44

Wg Cdr Gary DaviesWg Cdr Gary Davies

RAF Consultant Advisor in Respiratory MedicineRAF Consultant Advisor in Respiratory Medicine

Consultant Respiratory Physician, Chelsea & Consultant Respiratory Physician, Chelsea & Westminster HospitalWestminster Hospital

IntroductionIntroduction

• Commonest cause of morbidity and Commonest cause of morbidity and time off work in general populationtime off work in general population

• 22ndnd most common medical cause of most common medical cause of loss of flying timeloss of flying time

• Often thought to be incompatible Often thought to be incompatible with flyingwith flying

Diseases to be coveredDiseases to be covered

• AsthmaAsthma• SarcoidosisSarcoidosis• PneumothoraxPneumothorax• Pulmonary thrombo-embolic diseasePulmonary thrombo-embolic disease• Obstructive Sleep Apnoea Obstructive Sleep Apnoea • Interstitial Lung DiseaseInterstitial Lung Disease• BronchiectasisBronchiectasis• COPDCOPD• Pulmonary TuberculosisPulmonary Tuberculosis• Atypical MycobacteriumAtypical Mycobacterium• Pulmonary MalignanciesPulmonary Malignancies

AsthmAsthmaa

Asthma - IntroductionAsthma - Introduction

• Widespread airway obstruction of a Widespread airway obstruction of a variable naturevariable nature

• Variation – Spontaneous, stimulus Variation – Spontaneous, stimulus (allergic) or treatment(allergic) or treatment

• Asthma and flying thought by some Asthma and flying thought by some to be incompatibleto be incompatible

Asthma – Natural HistoryAsthma – Natural History

• Wide variety of clinical patternsWide variety of clinical patterns

• 5-10% of UK adults5-10% of UK adults

• Increasing prevelanceIncreasing prevelance

• Link with childhood asthma and adult Link with childhood asthma and adult asthmaasthma

• Early treatment Early treatment → better prognosis→ better prognosis

Aviation Management Aviation Management ProblemsProblems

• INDIVIDUALINDIVIDUAL

• ConcernsConcerns– Sudden IncapacitationSudden Incapacitation

• At risk individualsAt risk individuals– Previous life-threatening attackPrevious life-threatening attack– Variable PEF on treatmentVariable PEF on treatment– Repeated admissionsRepeated admissions

Asthma - SymptomsAsthma - Symptoms

• Very variableVery variable

• Cough / wheeze / SOB / Nocturnal Cough / wheeze / SOB / Nocturnal wakening / chest tightnesswakening / chest tightness

• Look for stimuliLook for stimuli

• History very important but use History very important but use OBJECTIVE assessmentsOBJECTIVE assessments

Specific HistorySpecific History

• Gestation and birth weightGestation and birth weight

• Recurrent respiratory or sinus Recurrent respiratory or sinus infections during childhoodinfections during childhood

• Whooping cough in young childhoodWhooping cough in young childhood

• Persistent symptoms after the age of Persistent symptoms after the age of 5 years5 years

• Maternal smokingMaternal smoking

Asthma - InvestigationAsthma - Investigation

• PEF diaryPEF diary• Basic SpirometryBasic Spirometry• Gas transfer and RVGas transfer and RV• Reversibility testing / Steroid challengeReversibility testing / Steroid challenge• Exercise spirometryExercise spirometry• Methacholine (Histamine) challenge testingMethacholine (Histamine) challenge testing• Allergy testingAllergy testing

• Exhaled NOExhaled NO• Breath condensateBreath condensate

STEP 1Inhaled short-acting β2-agonist (or other bronchodilator)

STEP 2 Add inhaled steroid: 800 μg/day adult 400 μg/day children******** Symbicort SMART *********

STEP 4 Add any or all of the following as determined by empirical trial: increase inhaled steroid up to 2000 μg/day, leukotriene receptor antagonist, theophylline, cromone

STEP 5 Add daily oral steroid or regular booster courses of oral steroid

Treatment

STEP 3 Add long-acting β2-agonist

Adapted from draft BTS /SIGN asthma guidelines 3. BTS/SIGN draft guidelines.

Treatment worriesTreatment worries

• SABAs as regular solo treatmentSABAs as regular solo treatment Fenoterol (NZ) 1980s – increased mortalityFenoterol (NZ) 1980s – increased mortality Potential increased risk of hospitalisation or death Potential increased risk of hospitalisation or death 1 21 2

Increase PEF variability and bronchial hyper-reactivityIncrease PEF variability and bronchial hyper-reactivity

• LABAs as regular solo treatmentLABAs as regular solo treatment Salmeterol alone Salmeterol alone 3 3

• Potential mechanism Potential mechanism 4 54 5 – Increased brain-derived neurotrophic factor (BDNF)Increased brain-derived neurotrophic factor (BDNF)– IL-6IL-6– cAMP response element (CRE)cAMP response element (CRE)

1. Bronchodilator treatment and deaths from asthma: case control study. Anderson et al. BMJ 2005;330:117.1. Bronchodilator treatment and deaths from asthma: case control study. Anderson et al. BMJ 2005;330:117.2. Excess mortality in patients with asthma on long acting 2. Excess mortality in patients with asthma on long acting ββ2-agonists. Hasford & Virchow. Eur Resp J 2006;28:900-22-agonists. Hasford & Virchow. Eur Resp J 2006;28:900-23. Salmeterol Multicenter Asthma Research Trial (SMART). Nelson et al. Chest 2006; 129:15-263. Salmeterol Multicenter Asthma Research Trial (SMART). Nelson et al. Chest 2006; 129:15-264 mechanism of adverse effects of 4 mechanism of adverse effects of ββ2-agonists in asthma. Johnston & Edwards. Thorax 2009; 64:739-7412-agonists in asthma. Johnston & Edwards. Thorax 2009; 64:739-7415. Adverse effects of salmeterol in asthma: a neuronal perspective. Lommatzsch et al. Thorax 2009; 64:763-7695. Adverse effects of salmeterol in asthma: a neuronal perspective. Lommatzsch et al. Thorax 2009; 64:763-769

New Specialist TreatmentNew Specialist Treatment

• Steroid sparing agentsSteroid sparing agents

• IV ImmunoglobulinIV Immunoglobulin

• Xolair (Omalizumab) – anti-IgEXolair (Omalizumab) – anti-IgE

• Bronchial thermoplastyBronchial thermoplasty

DispositionDisposition

• Pilot RecruitsPilot Recruits– Exclusion criteriaExclusion criteria

•Currently on any treatment for asthma.Currently on any treatment for asthma.•Any asthmatic symptoms including nocturnal Any asthmatic symptoms including nocturnal

cough or exercise-induced wheezing.cough or exercise-induced wheezing.•Regular inhaled steroids for a period > 8 weeks Regular inhaled steroids for a period > 8 weeks

in the 5 years before application.in the 5 years before application.•Hospital attendance, including A&E, for asthma Hospital attendance, including A&E, for asthma

or wheezing in the 5or wheezing in the 5   years before application. years before application.•Required oral steroids for asthma within the 5 Required oral steroids for asthma within the 5

years before application.years before application.•Required admission to an intensive care unit for Required admission to an intensive care unit for

asthma at any time in their life.asthma at any time in their life.•Required a hospital admission > 24 hours for Required a hospital admission > 24 hours for

asthma or wheeze since the age of 5asthma or wheeze since the age of 5

DispositionDisposition

• Pilot RecruitsPilot Recruits– Objective testingObjective testing

• Normal full pulmonary function tests Normal full pulmonary function tests – (spirometry and reversibility, lung volumes and transfer (spirometry and reversibility, lung volumes and transfer

factor).factor).• Methacholine challenge test.Methacholine challenge test.

– > 16mg/ml> 16mg/ml

– ResearchResearch• Exhaled nitric oxide level. Exhaled nitric oxide level. • Allergy skin prick (basic allergen panel)Allergy skin prick (basic allergen panel)

– house dust mite, grass, tree pollen and aspergillus house dust mite, grass, tree pollen and aspergillus – further tests may be required if the history suggests other further tests may be required if the history suggests other

potential allergen.potential allergen.• Total IgE.Total IgE.• Eosinophil countEosinophil count

DispositionDisposition

• Trained Aircrew (At present)Trained Aircrew (At present)

– Can continue with Can continue with RestrictedRestricted flying category flying category ifif

• Resting Lung Function, exercise testing normal on Resting Lung Function, exercise testing normal on treatmenttreatment

• Treatment not > step 2 BTS guidelinesTreatment not > step 2 BTS guidelines• Dual crew aircraftDual crew aircraft• Normal bronchial hyper-responsivenessNormal bronchial hyper-responsiveness• Infrequent exacerbationsInfrequent exacerbations

SarcoidosSarcoidosisis

Sarcoidosis - IntroductionSarcoidosis - Introduction

• Multi-system granulomatous disease Multi-system granulomatous disease of unknown aetiologyof unknown aetiology

• More common than thoughtMore common than thought

• Often incidental finding on routine Often incidental finding on routine medicalmedical

Sarcoidosis – Natural HistorySarcoidosis – Natural History

• Most commonly – asymptomatic BHLMost commonly – asymptomatic BHL• → → Asymptomatic pulmonary infiltratesAsymptomatic pulmonary infiltrates

• Erythema NodosumErythema Nodosum

• If shadowing persists > 1 year, If shadowing persists > 1 year, ↑ risk of ↑ risk of fibrosisfibrosis

• Extra thoracic often more chronic and Extra thoracic often more chronic and indolentindolent

Sarcoidosis – Natural History Sarcoidosis – Natural History (2)(2)

• Stage 1 – BHL onlyStage 1 – BHL only

• Stage 2 – BHL + Pulmonary InfiltratesStage 2 – BHL + Pulmonary Infiltrates

• Stage 3 – Pulmonary Infiltrates onlyStage 3 – Pulmonary Infiltrates only

• Stage 4 – Irreversible fibrosisStage 4 – Irreversible fibrosis

• Cardiac involvement irrespective of Cardiac involvement irrespective of staging staging

Sarcoidosis - InvestigationSarcoidosis - Investigation

• BronchoscopyBronchoscopy– BAL and Trans-bronchial biopsiesBAL and Trans-bronchial biopsies

• Urine and blood calciumUrine and blood calcium

• Biopsy of nodesBiopsy of nodes

• EchocardiogramEchocardiogram

• Serum ACE levelSerum ACE level

Sarcoidosis – TreatmentSarcoidosis – Treatment

• NoneNone

• Corticosteroids (Stage 2 +)Corticosteroids (Stage 2 +)

• AzathioprineAzathioprine

• HydroxychloroquineHydroxychloroquine

• MethotrexateMethotrexate

Aviation Management Aviation Management ProblemsProblems

• Main risk - cardiac arrhythmiaMain risk - cardiac arrhythmia

• Interference with operational Interference with operational effectivenesseffectiveness

• Steroid treatmentSteroid treatment

Sarcoidosis - DispositionSarcoidosis - Disposition

• Pilot TrainingPilot Training– Any History Any History →→ Unfit (risk cardiac sarcoidosis) Unfit (risk cardiac sarcoidosis)

• Trained AircrewTrained Aircrew– Grounded until fully investigatedGrounded until fully investigated– If no cardiac involvement and asymptomatic and no If no cardiac involvement and asymptomatic and no

treatmenttreatment• As or with co-pilot initiallyAs or with co-pilot initially• Upgrade to solo after 1 yearUpgrade to solo after 1 year

– On treatmentOn treatment• Grounded until aboveGrounded until above

– Asymptomatic pulmonary infiltratesAsymptomatic pulmonary infiltrates• REFER RESPIRATORY PHYSICIANREFER RESPIRATORY PHYSICIAN

PneumothorPneumothoraxax

Pneumothorax – Natural Pneumothorax – Natural HistoryHistory• Two peaks of incidenceTwo peaks of incidence

– Young adultsYoung adults– Old adultsOld adults

• Recurrence RateRecurrence Rate– 30% after 1st30% after 1st– 50% after 2nd50% after 2nd– 80% after 3rd80% after 3rd

Pneumothorax - Pneumothorax - InvestigationInvestigation

• CXRCXR

• SpirometrySpirometry

• Hi Res CT ThoraxHi Res CT Thorax

Pneumothorax - TreatmentPneumothorax - Treatment

• Aspiration / chest drainAspiration / chest drain

• Operative treatmentOperative treatment– Open pleurectomyOpen pleurectomy– Thoracoscopic pleurectomyThoracoscopic pleurectomy– Chemical pleurodesis (NOT Chemical pleurodesis (NOT

recommended)recommended)

Aviation Management Aviation Management ProblemsProblems• Sudden incapacitationSudden incapacitation

• Increasing with altitudeIncreasing with altitude

Pneumothorax – DispositionPneumothorax – Disposition

• Pilot TrainingPilot Training– > 2 years ago or following definitive treatment > 2 years ago or following definitive treatment

specialist referral to investigate possible specialist referral to investigate possible underlying diseaseunderlying disease

• Trained AircrewTrained Aircrew– Pleurectomy Pleurectomy → 3 months→ 3 months

• VATS procedure or mini-thoracotomy preferablyVATS procedure or mini-thoracotomy preferably

– If no pleurectomy - Grounding 18 months If no pleurectomy - Grounding 18 months minimumminimum

– InvestigationInvestigation

Traumatic PneumothoraxTraumatic Pneumothorax

• No associated bullous lung diseaseNo associated bullous lung disease

• Risk of recurrence – VERY smallRisk of recurrence – VERY small

• No further treatment required after No further treatment required after emergency treatmentemergency treatment

Pulmonary thrombo-embolic Pulmonary thrombo-embolic diseasedisease

Pulmonary thrombo-embolic Pulmonary thrombo-embolic disease – Natural Historydisease – Natural History

• Variation from single life threatening Variation from single life threatening event to insidious breathlessnessevent to insidious breathlessness

• CausesCauses– Short term risksShort term risks– MalignanciesMalignancies– Clotting disordersClotting disorders

Pulmonary thrombo-embolic Pulmonary thrombo-embolic disease - Investigationdisease - Investigation

• CXRCXR

• ECGECG

• Arterial Blood GasesArterial Blood Gases

• CTPA CTPA

• Ventilation/perfusion scanVentilation/perfusion scan

Pulmonary thrombo-embolic Pulmonary thrombo-embolic disease - Treatmentdisease - Treatment

• LMW heparin + warfarin followed by 3 LMW heparin + warfarin followed by 3 - 6 months of warfarin for first event.- 6 months of warfarin for first event.

• Life-long warfarin for recurrent eventsLife-long warfarin for recurrent events

• Thrombolysis in life-threatening Thrombolysis in life-threatening eventsevents

Aviation Management Aviation Management ProblemsProblems

• Risks of sudden incapacitationRisks of sudden incapacitation

• Disabling breathlessnessDisabling breathlessness

Pulmonary thrombo-embolic Pulmonary thrombo-embolic disease - Dispositiondisease - Disposition• Pilot TrainingPilot Training

– Cause unknown or recurrent episodesCause unknown or recurrent episodes→ → DisqualifyingDisqualifying

– Recognised causeRecognised cause → → Individual -> referralIndividual -> referral

• Trained AircrewTrained Aircrew– Grounded while on warfarinGrounded while on warfarin– Single episode with defined cause and normal pro-Single episode with defined cause and normal pro-

coagulation screen coagulation screen → upgraded after treatment→ upgraded after treatment– Recurrent episodes / malignancy / clotting disorder → Recurrent episodes / malignancy / clotting disorder →

permanent groundingpermanent grounding

Obstructive Sleep Obstructive Sleep ApnoeaApnoea

Obstructive Sleep Apnoea –Obstructive Sleep Apnoea –Natural HistoryNatural History• Collapse of upper airway during sleep leading to Collapse of upper airway during sleep leading to

apnoeaapnoea

• Overweight, middle aged men most commonlyOverweight, middle aged men most commonly

• Hypoxia and hypercapniaHypoxia and hypercapnia

• HypersomnolenceHypersomnolence

• Increased risks of cardiac disease if untreatedIncreased risks of cardiac disease if untreated

OSA - InvestigationOSA - Investigation

• Sleep studySleep study

• Epworth Sleepiness ScaleEpworth Sleepiness Scale

OSA - TreatmentOSA - Treatment

• Address aggravating factorsAddress aggravating factors

• CPAPCPAP

• Jaw advancement splintJaw advancement splint

• SurgerySurgery

Aviation Management Aviation Management ProblemsProblems

• Daytime somnolence leading to Daytime somnolence leading to increased accidents and decreased increased accidents and decreased performanceperformance

• Treatment negates this riskTreatment negates this risk

OSA - DispositionOSA - Disposition

• Pilot TrainingPilot Training– DisquallifyingDisquallifying

• Trained AircrewTrained Aircrew– Grounded until response to treatment Grounded until response to treatment

assessedassessed– Effective treatment Effective treatment → full flying category→ full flying category– Help from specialist centreHelp from specialist centre

Interstitial Lung Interstitial Lung DiseaseDisease

Interstitial Lung Disease – Interstitial Lung Disease – Natural HistoryNatural History

• Characterised by diffuse parenchymal Characterised by diffuse parenchymal lung disease distal to the terminal lung disease distal to the terminal bronchiole.bronchiole.

• Large number of different disordersLarge number of different disorders

• Progression is dependant on specific Progression is dependant on specific cause.cause.

ILD - InvestigationILD - Investigation

• CXR (little use)CXR (little use)

• Hi res CT scanHi res CT scan

• Refer to specialist centreRefer to specialist centre

ILD - TreatmentILD - Treatment

• Complex and related to cause and Complex and related to cause and pattern of disease.pattern of disease.

• Mainstay treatment involvingMainstay treatment involving– Oral / iv steroidsOral / iv steroids– AzathioprineAzathioprine– CyclophosphamideCyclophosphamide

• May require transplantationMay require transplantation

Aviation Management Aviation Management ProblemsProblems

• Breathlessness and difficulty Breathlessness and difficulty completing dutiescompleting duties

• Risks of side-effects of treatmentRisks of side-effects of treatment

ILD - DispositionILD - Disposition

• Pilot TrainingPilot Training– DisqualifyingDisqualifying

• Trained AircrewTrained Aircrew– Permanent groundingPermanent grounding

BronchiectasBronchiectasisis

Bronchiectasis – Natural Bronchiectasis – Natural HistoryHistory

• Chronic dilatation of one or more Chronic dilatation of one or more bronchibronchi

• Large multitude of causesLarge multitude of causes

• Major variation of symptoms and Major variation of symptoms and progressionprogression

Bronchiectasis - Bronchiectasis - InvestigationInvestigation

• CXRCXR

• Hi Res CT scanHi Res CT scan

• Investigation of underlying causeInvestigation of underlying cause

• Lung function testingLung function testing

Bronchiectasis - TreatmentBronchiectasis - Treatment

• Regular PhysiotherapyRegular Physiotherapy

• Prompt treatment of infectionsPrompt treatment of infections

• Treat any underlying airway Treat any underlying airway inflammationinflammation– Bronchodilators and inhaled Bronchodilators and inhaled

corticosteroidscorticosteroids

• Treat any underlying causeTreat any underlying cause

Aviation Management Aviation Management ProblemsProblems

• Recurrent respiratory tract infectionsRecurrent respiratory tract infections

• Possibility of sudden incapacitationPossibility of sudden incapacitation

Bronchiectasis - DispositionBronchiectasis - Disposition

• Pilot TrainingPilot Training– Disqualifying Disqualifying exceptexcept

•Following surgery for limited disease Following surgery for limited disease (not (not recommended)recommended)

– REFER TO RESPIRATORY PHYSICIANREFER TO RESPIRATORY PHYSICIAN

• Trained AircrewTrained Aircrew– Limited – limited flying dutiesLimited – limited flying duties– More severe – permanent groundingMore severe – permanent grounding

COPDCOPD

• Pilot TrainingPilot Training– Full respiratory assessmentFull respiratory assessment– Unlikely to be acceptedUnlikely to be accepted

• Trained AircrewTrained Aircrew– Mild disease, No bullous disease, normal lung Mild disease, No bullous disease, normal lung

function function →→ unrestricted flying (regular unrestricted flying (regular assessments)assessments)

– Moderate disease → limited flyingModerate disease → limited flying– Severe disease / recurrent exacerbations → Severe disease / recurrent exacerbations →

permanent groundingpermanent grounding

Pulmonary TuberculosisPulmonary Tuberculosis

• Pilot TrainingPilot Training– Appropriate chemotherapy with no lung Appropriate chemotherapy with no lung

damage (radiologically and lung function) damage (radiologically and lung function) → → accepted for trainingaccepted for training

• Trained AircrewTrained Aircrew– Active disease or on treatment Active disease or on treatment → temporally → temporally

unfit flying dutiesunfit flying duties– Residual lung damage → Individual (refer to Residual lung damage → Individual (refer to

respiratory specialist)respiratory specialist)

Atypical MycobacteriumAtypical Mycobacterium

• Pilot TrainingPilot Training– DisqualifiedDisqualified

• Trained AircrewTrained Aircrew– Permanent downgradingPermanent downgrading

Pulmonary MalignancyPulmonary Malignancy

• Pilot TrainingPilot Training– DisqualifyingDisqualifying– Benign tumour – refer Respiratory PhysicianBenign tumour – refer Respiratory Physician

• Trained AircrewTrained Aircrew– Permanent groundingPermanent grounding– Benign tumour – refer Respiratory PhysicianBenign tumour – refer Respiratory Physician

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