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)