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When the applicant has been under observation under this scheme for a total period of at least two years
and comparison of all the radiographic records shows no changes or only retrogression of the lesion, the
1 Multidrug-resistant tuberculosis: tuberculosis with resistance to at least isoniazid and rifampin (first-line drugs)
2 Extensively drug-resistant tuberculosis: cases in persons with tuberculosis whose isolates were resistant to
isoniazid and rifampin and at least three of the six main classes of second line drugs (aminoglycosides, polypeptides,
fluoroquinolones, thioamides, cycloserine, and para-aminosalicylic acid).
ICAO Preliminary Unedited Version — October 2008 III-2-3
lesion should be regarded as “quiescent” or “healed”.
In case of an applicant undergoing treatment, the general principles of drug treatment with regard to flight
safety, undesirable side effects, allergies and idiosyncrasies should be taken into account. Common
adverse effects of first-line drugs against tuberculosis are as follows:
Isoniazid: hepatitis, peripheral neuropathy
Rifampin: gastrointestinal upset, hepatitis, skin eruptions
Ethambutol: retrobulbar neuritis, blurred vision, scotomata
Pyrazinamide: hepatitis, hyperuricaemia
Streptomycin: ototoxicity with vertigo and hearing loss.
When active tuberculosis has been diagnosed in a patient, isoniazid is frequently used as
chemoprophylaxis for the other members of the household.
As isoniazid only rarely gives rise to side effects and these, if they occur, do not cause acute,
incapacitating symptoms, prophylactic treatment does not entail unfitness.
Chronic obstructive pulmonary disease
6.3.2.10 Applicants with chronic obstructive pulmonary disease shall be assessed as unfit unless the
applicant’s condition has been investigated and evaluated in accordance with best medical practice and is
assessed not likely to interfere with the safe exercise of the applicant’s licence or rating privileges.
Chronic obstructive pulmonary disease (COPD) is a heterogeneous condition, combining features of
emphysema and chronic bronchitis. Emphysema is characterized by destruction of the parenchyma of the
lung, resulting both in wasted ventilation and in a loss of elastic support to the internal airways, which
leads to dynamic collapse on exhalation. Chronic bronchitis is characterized by inflammation of the
airways, with mucosal thickening, copious sputum production, and ventilation-perfusion mismatching,
which in some cases may be difficult to reliably separate from chronic asthma. Although most individuals
with COPD will have some features of each disorder, the majority will have predominant emphysema or
predominant chronic bronchitis, with the former being the more common pattern.
Emphysema-predominant COPD is characterized by the following features:
a) dyspnoea on exertion, often severe
b) obstruction to expiratory flow, not significantly improving after bronchodilator challenge
c) decrease (often marked) in diffusion capacity
d) increased total lung capacity (TLC), and increased residual volume (RV) to TLC fraction
e) usually modest decrease in arterial oxygen saturation, with normal carbon dioxide tension
f) bullous changes on radiography
Bronchitis-predominant COPD is characterized by the following features:
a) variable dyspnoea, depending on presence of bronchitic exacerbation
b) obstruction to expiratory flow, with significant but incomplete improvement after bronchodilator
challenge
c) modest decrease in diffusing capacity
d) increased RV to TLC fraction
ICAO Preliminary Unedited Version — October 2008 III-2-4
e) arterial hypoxaemia, often marked, with carbon dioxide retention and pulmonary hypertension in
later stages
f) relatively normal radiography (in the absence of heart failure)
In the aviation environment, emphysematous patients are at particular risk from barometric changes,
whereas bronchitic patients are more likely to be affected by ambient hypoxia, although as noted earlier,
most COLD patients have some features of both disorders. The degree of functional impairment due to
any or all of the above factors determines whether an applicant may be assessed as fit for aviation duties.
In addition, most patients with moderate or advanced COPD are treated with drugs, often the same as
those used for asthma (vide infra), and these may have adverse effects that preclude safe flying.
Because of decreased tolerance to the hypoxic environment, bullous changes, pulmonary hypertension,
and adverse effects from drug treatment, most COPD patients are unfit for all classes of certification.
Applicants with early COPD who are physically fit and have no or only mild symptoms, a normal chest Xray,
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Manual of Civil Aviation Medicine 1(114)
