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and do not smoke, may be considered for restricted certification or even, in certain cases, for
unrestricted certification.
Pneumothorax
The primary form of spontaneous pneumothorax is most common in young, healthy males between
20 and 30 years of age and occurs not infrequently in the pilot population. The assessment of applicants
with a recent history of spontaneous pneumothorax should take into account not only clinical recovery
after treatment (conservative and/or surgical), but primarily the risk of recurrence. There are significant
first, second and third recurrence rates with conservative treatment of 10%-60%, 17%-80% and
80%-100% of cases, respectively. After chemical pleurodesis, the recurrence rate is 25-30%; after
mechanical pleurodesis or pleurectomy, the rate is 1-5%.
In the case of an initial applicant, a history of spontaneous pneumothorax need not be disqualifying
provided that the applicant has had only one attack with complete clinical recovery, and that the medical
investigation has revealed no evidence of predisposing disease such as bullous emphysema.
A history of two or more attacks should be considered as constituting a more serious risk. In such cases
an applicant should be assessed as unfit until at least three months after surgery (i.e. wedge resection or
pleurectomy).
It should be noted that many thoracic centres have abandoned the use of chemical pleurodesis since this
procedure has been shown to result in a relatively high recurrence rate. A final decision should be made
by the medical assessor and based on a thorough investigation and evaluation in accordance with best
medical practice.
Bronchial Asthma
Bronchial asthma is caused by airway inflammation and characterized by recurring acute attacks of
wheezing, coughing, and shortness of breath. Between attacks the patient is frequently asymptomatic and
often has normal pulmonary function.
6.3.2.11 Applicants with asthma causing significant symptoms or likely to cause incapacitating symptoms
during normal or emergency operations shall be assessed as unfit.
ICAO Preliminary Unedited Version — October 2008 III-2-5
6.3.2.11.1 The use of drugs for control of asthma shall be disqualifying except for those drugs, the use of
which is compatible with the safe exercise of the applicant’s licence and rating privileges.
Asthmatic attacks, which can be caused by allergens, infection, exercise, emotional distress, and various
irritants, is more or less incapacitating. Treatment with anti-inflammatory agents includes cromolyn,
nedocromil and corticosteroids. Beta-agonists, theophyllines and ipratropium are frequently used but have
severe side-effects, such as dizziness, cardiac arrhythmia, and anticholinergic effects. Cromolyn and
inhaled corticosteroids have hardly any side-effects and may be relied upon to control the disease, but
recurring attacks may still happen and they may be unpredictable and incapacitating.
Consequently, applicants with asthma should in general be assessed as unfit. However, if the clinical
course is mild and drug treatment is not required, or treatment with acceptable drugs has been
demonstrated to reliably prevent attacks, restricted certification may be considered.
Post-operative effects of thoracic surgery
These conditions should always be assessed individually based on comprehensive pulmonary function
studies.
The pathology requiring the surgical intervention, the residual functional capacity, cardiovascular
function and possible displacement of the mediastinum, which might be aggravated by pressure
differences during flight, require careful consideration. The over-all prognosis is a factor which must be
borne in mind.
In general, such cases should not be assessed as fit until four to six months have elapsed following major
surgical procedures. The aeromedical decision should be made by the medical assessor and based on a
thorough investigation and evaluation in accordance with best medical practice.
Pulmonary sarcoidosis
Most cases come to light because of an abnormal chest radiograph, while almost as many present with
banal respiratory symptoms. Most cases are accompanied by enlarged hilar and mediastinal lymph-nodes.
Some patients have granulomas in the lungs, causing radiographically evident changes. Usually the
enlargement of lymph nodes subsides within three years, sometimes faster. In patients with pulmonary
granulomas, the development of fibrosis may lead to increasing dyspnoea and abnormal lung function
tests. Sometimes a severe defect in gas transfer may be found. In half to two-thirds of patients, pulmonary
sarcoidosis resolves, leaving radiographically clear lungs.
Many patients with sarcoidosis develop uveitis. In some patients, the heart may be affected, causing
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Manual of Civil Aviation Medicine 1(115)
