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for Class 2 and Class 3 Medical Assessments).
6.3.2.9 There shall be no acute disability of the lungs nor any active disease of the structures of the lungs,
mediastinum or pleurae likely to result in incapacitating symptoms during normal or emergency operations.
6.3.2.9.1 Recommendation. — Chest radiography should form part of the initial examination.
Note. — Periodic chest radiography is usually not necessary but may be a necessity in situations where
asymptomatic pulmonary disease can be expected.
It is, however, understood that a degree of interpretation and flexibility must always be exercised at the
discretion of the medical examiner and the medical assessor, taking into consideration not only medical
but also operational and environmental factors of relevance for the over-all aviation medical fitness of an
applicant.
Note. — The environmental conditions of aviation causing physiological disturbances such as hypoxia
and decompression are detailed in Part II, Chapter 1.
GUIDELINES FOR ASSESSMENT
For aviation duties, it is important to bear in mind that the functional integrity of the respiratory system
and its capability to provide adequate oxygenation during flight is more important than strict anatomical
integrity. Due consideration must be given to the flight operation involved (e.g. pressurized or
unpressurized aircraft) and the capability to perform during a prolonged and difficult flight. In evaluating
the functions of the respiratory system, special attention must be given to its interdependence with the
cardiovascular system. Satisfactory tissue oxygenation during aviation duties can only be achieved with
an adequate capacity and response of the cardiovascular system.
ICAO Preliminary Unedited Version — October 2008 III-2-2
In the evaluation of borderline cases, simple breathing tests will serve a screening purpose to select those
applicants who require further investigation, which might call for more sophisticated techniques. The
examination of the respiratory system should be directed specifically to the early detection of the two
most prevalent pathophysiological manifestations of pulmonary disease, namely:
a) presence and/or degree of restrictive impairment; and
b) presence and/or degree of obstructive impairment.
When assessing the respiratory system, the medical examiner should in particular note the following
groups of diseases.
Pulmonary tuberculosis
Tuberculosis remains one of the world’s leading infectious causes of death among adults. About one-third
of the world’s population, or two billion people, carry mycobacterium tuberculosis. Most do not develop
clinical disease, but about two million people die of tuberculosis each year.
World-wide, 136 new cases/100 000, totaling 8.8 million new cases, were reported to the World Health
Organization in 2005. In the Western world, tuberculosis has become a relatively uncommon disease,
although its association with HIV has given rise to escalating tuberculosis case rates in many countries. In
sub-Saharan Africa up to 70 per cent and in North America close to 90 per cent of patients with sputum
smear-positive pulmonary tuberculosis are HIV-positive. The case rates for pulmonary tuberculosis in
parts of North America, although low at 4.8/100 000, have not gone down since 1996, and between 2003
and 2004 the case rates increased by nine per cent. In addition, the emergence of multidrug-resistant
tuberculosis1 and extremely drug-resistant tuberculosis2 as a threat to public health and tuberculosis
control has raised concerns of a future epidemic of virtually untreatable tuberculosis.
Annex l specifies that:
6.3.2.12 Applicants with active pulmonary tuberculosis shall be assessed as unfit.
6.3.2.12.1 Applicants with quiescent or healed lesions which are known to be tuberculous, or are presumably
tuberculous in origin, may be assessed as fit.
When assessing an applicant suffering from, or undergoing treatment for, pulmonary tuberculosis, the
medical examiner should keep in mind that any doubt about the activity of a lesion (where symptoms of
activity of the disease are clinically lacking) must lead to an assessment as unfit for a period of not less
than three months from the date of the medical examination. At the end of the three-month period, a
further radiographic record should be made and compared carefully with the original. If there is no sign
of extension of the disease and there are neither general symptoms nor symptoms referable to the chest,
the applicant may be assessed as fit for three months. Thereafter, provided there continues to be no sign
of extension of the disease as shown by radiographic examinations carried out at the end of each
three-month period, the validity of the license should be restricted to consecutive periods of three months.
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Manual of Civil Aviation Medicine 1(113)
