Pulmonary Embolus

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

Aeromedical implications

Effect of aviation on condition

  • Long periods of immobility
  • Dehydration
  • Hypoxic cabin environment

Effect of condition on aviation

  • Overt incapacitation
    • distracting pain
    • acute shortness of breath
    • sudden death
  • Subtle incapacitation
    • impaired lung function.

Effect of treatment on aviation

  • Risk of distraction due to bleeding
  • Risk of incapacitation secondary to bleeding

Approach to medical certification

Based on the condition

  • Confirmed diagnosis of pulmonary embolus
  • Absence of significant sequelae
  • Presence of other diagnoses eg pro-thrombotic malignancy, haematological disease
  • Acceptable prognosis - risk of recurrence, risk of incapacitation

Based on treatment

  • Acceptable, stable treatment without significant side effects
  • Demonstration of adherence:
    1. If commencing warfarin, a minimum of three INRs are required at least one week apart and must be within the therapeutic range-(see guidelines for Anticoagulation – Warfarin)
    2. If commencing NOAC then confirmation of adherence to medication (see guideline for Anticoagulation - NOACs)

Demonstrated stability

  • Absence of symptoms eg chest pain and shortness of breath
  • Interval ultrasound evidence of deep vein thrombus stabilisation (if applicable)

Risk assessment protocol - information required

New cases

  • Confirmed diagnosis
    • provoked or unprovoked Pulmonary Embolus
    • isolated Pulmonary Embolus or Pulmonary Embolus with DVT
    • pre-disposing co-morbidities
  • Clinical status
    • history of condition
    • details of any symptoms
    • absence of significant sequelae (e.g. assessment for right ventricular dysfunction)
  • Investigations conducted
    • pro-coagulant screen (conducted before or after anticoagulant treatment)
    • ultrasound or CT scans
  • Management
    • treatment: response to treatment and side effects
    • monitoring regimen including adherence with and stability of
    • anticoagulant medication
    • (e.g. serial INR results or proof of NOAC adherence)
    • any side-effects
  • Underlying cause of thrombosis
  • Estimate of annualised percentage risk of recurrence
  • Estimate of annualised percentage risk of incapacitation
  • Follow-up plan.

Interval assessment at 6 - 12 months

  • Clinical status
    • history of condition
    • pre-disposing co-morbidities
    • details of any symptoms
  • Investigations conducted
    • pro-coagulant screen (if not done prior)
    • ultrasound or CT scans
    • assessment for right ventricular dysfunction
  • Management
    • treatment: response to treatment and side effects
    • monitoring regimen including adherence with and stability of anticoagulant medication
    • (e.g. serial INR results (performed at least monthly and must be within the target range)
    • any side-effects
  • Underlying cause of thrombosis
  • Estimate of annualised percentage risk of recurrence
  • Estimate of annualised percentage risk of incapacitation
  • Follow-up plan.

Renewal

DAME comments. (Additional reports may be needed for long-term treatment.)

Indicative outcomes

  • PE may indicate a poor prognosis in the short and long term
  • CASA will conduct a risk assessment based on history of PE and co-morbidities
  • Initial notification to CASA and grounding required on diagnosis
  • Clearance by CASA required before exercising privileges
  • Interval assessment at 6 months
  • Audit will be required with review at 12 months
  • Both due to the risk of recurrent DVT/PE and anticoagulation treatment, certificates may be subject to long term multi-crew/proximity restriction (Class 1 and 3)
  • See guidelines for Anticoagulation – Warfarin and Anticoagulation - NOACs

Favourable

  • Successful treatment of provoked pulmonary embolus
  • Absence of cardiac/pulmonary complications
  • Absence of co-morbid conditions
  • Acceptable recurrence risk

Unfavourable

  • Clexane (other than initial treatment - for DVT during grounding period)
  • Poor adherence to anticoagulation treatment
  • Unstable or out of target range INR
  • Side effects of treatment (e.g. epistaxis, gastrointestinal haemorrhage, stroke)
  • Recurrent thrombosis or pulmonary embolus
  • Positive procoagulant screen
  • Presence of co-morbid conditions

Pilot and controller information

  • PE is an aero-medically significant medical condition because it affects lung and heart function. A new PE can cause significant pain.
  • Pilots and controllers who have been diagnosed with PE are required to ground themselves and notify this condition to their DAME or CASA
  • Anticoagulant medication is associated with well recognised hazards (e.g. bleeding) which must be considered as a separate risk to aviation safety
  • Effective and stable treatment is critical in reducing these risks
  • If cleared to exercise the privileges of a medical certificate, long term multi-crew/proximity restriction and audit may be required (Class 1 and 3)

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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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