Sarcoidosis

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

Definition

This guidance applies to applicants Sarcoidosis affecting any organ system, whether active or quiescent.

Aeromedical implications 

Effect of aviation on condition

  • Fatigue
  • Sleep deprivation
  • Increased cardiac workload during stressful phases of flight
  • Hypoxic, hypobaric, low relative humidity flight environment

Effect of condition on aviation

  • Overt incapacitation
    • distracting pain
    • acute shortness of breath
    • pulmonary embolism
    • heart failure
    • arrhythmia
    • seizure
    • sudden death
  • Cognitive impairment
  • Vision impairment
  • Fatigue.

Effect of treatment on aviation

  • Neuropsychological impairment secondary to steroid treatment
  • Risk of infection

Approach to medical certification

Based on the condition

  • Confirmed diagnosis
  • Absence of significantly impaired respiratory, ocular, neurological, renal or cardiac involvement
  • Reports and investigations will be dependent upon if primarily pulmonary sarcoidosis or if there is extrapulmonary involvement

Based on treatment

  • Acceptable, stable treatment without significant side effects

Demonstrated stability

  • Adequate period of grounding before new aviation medical assessment until demonstrated stability and absence of symptoms or complications
  • Absence of symptoms eg shortness of breath

Risk assessment protocol - information required

New cases

CASA requires a report from the treating specialist(s) - eg. Respiratory physician, Cardiologist, Ophthalmologist etc, depending on organ involvement. The report(s) should detail:

  • Confirmed diagnosis
  • Clinical status
    • symptoms such as breathlessness, pain, palpitations, visual disturbance, neurological symptoms, etc.
    • progress
  • Investigation reports (for relevant affected organ systems)
    • Respiratory
      • chest x-ray
      • spirometry
      • histopathology report
      • blood test results
      • If clinically indicated, full pulmonary function testing, diffusion capacity, blood gases
    • Cardiac
      • ECG
      • Echocardiogram with ejection fraction
      • 24 or 48 hour Holter
      • If clinically indicated, stress test
    • Ophthalmic
      • slit lamp examination
      • tonometry
      • results of computerised visual field plot
  • Other investigations if clinically indicated
    • cardiac MRI
    • cardiac stress test
    • CT-KUB
    • montreal Cognitive Assessment (MOCA)
    • high resolution CT of lungs
  • Management
    • treatment
    • side-effects
  • Proposed monitoring and follow-up plan. Please detail periodic investigations required.

Renewal for confirmed disease

CASA requires a report from the doctor monitoring the applicant's sarcoidosis. CASA will require further reports from other specialists if other organs are involved. The specialist report should detail:

  • Clinical status
    • symptoms such as breathlessness, pain, palpitations, visual disturbance, neurological symptoms, etc.
    • involvement of critical target organs e.g. brain, heart, lungs, kidneys
    • progress
  • Investigations conducted as recommended by specialist, e.g.
    • pulmonary function test, including spirometry and DLCO
    • chest x-ray, if clinically indicated
    • relevant blood tests
    • ECG
    • 24 or 48 hour Holter
    • DAO or CO report with slit lamp examination, tonometry and results of computerised visual field plot
  • Management
    • treatment
    • side-effects
  • Proposed monitoring and follow-up plan.

Indicative outcomes

  • Initial notification to CASA and grounding until demonstrated stability and absence of symptoms or complications
  • Unrestricted certification is possible if asymptomatic with absence of or risk of significant impairment

Favourable

  • Absence of significant symptoms
  • Disease control. (NB Prednisolone equivalent daily dose acceptable at 10mg or less if tolerated)
  • Absence of side-effects from treatment
  • Absence of cardiac, ocular, neurological or renal involvement

Unfavourable

  • Dyspnoea at rest
  • Pulmonary hypertension
  • Any calculi in the collecting system (irrespective of location) or ureteric obstruction
  • Visual disturbance
  • Overlapping visual field defect.
  • Headache, seizure, ataxia, cognitive impairment, etc
  • Evidence of rhythm disturbance
  • LV ejection fraction <50% or significant abnormality of wall motion on echocardiogram
  • Implantable Cardiac Defibrillator
  • Treatment

Pilot and controller information

  • Annual review will be required for a minimum of 3 years after diagnosis (as >50% remission during this period). Ongoing annual review after 3 years will be dependent upon extent of organ involvement
  • Multi-crew restriction may be required for pilots
  • An Implantable Cardiac Defibrillator is considered safety relevant
  • Treatment may impact the ability to exercise the privileges of your medical certificate. Be advised that Prednisolone up to 10mg daily may be acceptable on a case by case basis

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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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