Pneumothorax

Guidance for medical examiners when assessing a patient for either a general topic or condition - Pneumothorax.

Definition

This guidance applies to:

  1. Spontaneous pneumothorax (occurring in the absence of trauma). Subcategorised into primary (no known cause) and secondary (associated with underlying respiratory pathology- most commonly COPD, also chronic infections such as TB, Cystic Fibrosis, lung cancer)
  2. Traumatic Pneumothorax (a result of blunt or penetrating trauma to the chest wall, secondary to surgery or other medical procedures, or as a consequence of sudden decompression at high altitude).

Resolution of air from the pleural cavity and prevention of future occurrences most important in aviation safety.

Aeromedical implications

Effect of aviation on condition

  • Decreased barometric pressure causing gas expansion at altitude, causing compression effects
  • Increased sensitivity to hypoxia

Effect of condition on aviation

  • Distraction
    • Sudden onset of pain and/or shortness of breath
  • Overt incapacitation.

Approach to medical certification

Based on the condition

  • Cause- traumatic or spontaneous, primary or secondary
  • First episode or recurrence
  • Presence of HRCT abnormalities in same or contralateral lung

Based on treatment

  • Surgical prevention with VATS pleurodesis (including blebs over sewing/bullae resection as required) reduces the risk of recurrence
  • Chemical pleurodesis is associated with higher recurrence rates than surgical treatment
  • Smoking cessation required as treatment strategy

Demonstrated stability

  • Time since episode
  • Evidence complete resolution of pneumothorax
  • Treatment (if undertaken) and recovery over at least 6 weeks
  • Management of risk factors for recurrence

Risk assessment protocol - information required

New cases

  • Respiratory Physician/Thoracic Surgeon report:
    • confirmed diagnosis (traumatic versus spontaneous, primary or secondary)
    • clinical status
    • results of Investigations:
      • HRCT required
      • lung function tests (if clinically relevant)
    • management
    • follow-up recommendations/risk of recurrence.

Renewal

  • Treating specialist report re progress, any further events:
    • confirmed diagnosis (as prior)
    • clinical status
    • results of Investigations (if any)
    • risk of recurrence
    • follow-up recommendations.

Indicative outcomes

Favourable

  • First episode plus recurrence prevention
  • Bilateral VATS plus pleurodesis
  • No underlying lung pathology in either lung (demonstrated by HRCT)
  • Traumatic pneumothorax completely resolved and >6 weeks post resolution

Unfavourable

  • More than one episode
  • Unilateral treatment only VATS +/- pleurodesis with bilateral lung pathology
  • Underlying lung pathology
  • Smoking

Pilot information

There are two main causes for pneumothorax – trauma or spontaneous.

Traumatic pneumothorax usually heals without extra surgery, and once fully resolved, flying may be considered again after at least 6 weeks.

Spontaneous pneumothorax happens without warning, and can be quite dangerous, particularly in the aviation environment. Pressure changes at altitude will expand gas and may cause serious pressure problems.

Incapacitating symptoms include severe pain, shortness of breath, and low oxygen.

There are surgical treatments available for pneumothorax. Treatment will be guided by your specialist. We know that after treatment, another pneumothorax is unlikely. However, it is important to know whether the other lung is at risk. A high resolution CT scan is required to exclude abnormalities.

Without treatment, grounding is usually needed because of the high risk of another pneumothorax on either lung. Restrictions may continue for several years because of the ongoing risk.

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Disclaimer

The clinical practice guidelines is provided by way of guidance only and subject to the clinical practice guidelines disclaimer.

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