Topic 3.5 Resp Med & Cases AVMO 0019 STUDY CARD 18022017

Home > Preview

The flashcards below were created by user david_hughm on FreezingBlue Flashcards.


  1. Discuss the aeromedical implications of respiratory disorders with respect to:
    • • The impact of the condition on the operating environment
    • • The impact of the aviation environment on the condition
    • • Outline what clinical information is required, including investigations and referrals, for determination of aeromedical disposition.
    • • Describe the aeromedical implications of possible treatments for respiratory disorders.
    • • Discuss prognostic considerations that may impact on future fitness.
    • • Propose a likely MECR process and aeromedical disposition for respiratory disorders.
    • • Apply an evidence-based aeromedical decision making framework to the aeromedical management of disorders affecting the respiratory system.
  2. FLTLT Jo Wedgetail, 26 y.o. B737 pilot
    • Mild dyspnoea and wheeze with exercise
    • Pre & post spirometry shows reversibility
    • Now controlled on Pulmicort 400mcg bd
    • Normal BCT on treatment
  3. Effect of the Environment on
    • Respiratory Disorders
    • • Decreased oxygen partial pressure
    • • Use of oxygen delivery systems
    • • Cold dry air or oxygen
    • • Use of pressure breathing, and PPBG
    • • Exposure to smoke and fumes
    • • Hypobaria – gas expansion, gas trapping
    • • Acceleration and V/Q mismatching
    • • Anti-G straining
    • • Shiftwork and time zones
    • • Exertion
  4. Effect of Respiratory Disorders on Aviation Operations
    • Distraction from symptoms
    • Incapacitation, insidious or acute
    • Multisystem disorders
    • Cognitive disturbance
    • Impaired alertness/fatigue
    • Treatment side effects and logistics
  5. What environmental factors are relevant to her condition?
    How could the condition impact on her role?
  6. Asthma
    • Environment vs Condition
    • Cold dry air/oxygen
    • Smoke and fumes
    • Reduced oxygen partial pressure
    • Pressure breathing
    • Gas trapping, barotrauma
    • Exertion
  7. Condition vs Aviation
    • Distracting symptoms
    • Potentially incapacitating
    • Managing medications
    • Obtaining Clinical Information
  8. Aim to:
    • Establish the diagnosis
    • identify aviation-relevant factors
    • Determine risk of incapacitation
    • Quantify risk of progression or recurrence
    • Determine impact of treatments on aviation safety
  9. Obtaining Clinical Information
    • Clinical History
    • Onset
    • Underlying causes or precipitants
    • Progression over time, recurrence
    • Hospitalisations
    • Treatments
    • Targeted but thorough examination
  10. FSGT Orion, AEA, 34 y.o
    • Dry cough, lethargy
    • CXR finding of widened mediastinum
    • CT shows mediastinal lymphadenopathy
    • Radiologist thinks sarcoidosis
    • Referrals and Investigations
    • Respiration physician reports
    • physician reports
    • Other specialists as required
    • Respiratory function testing
    • Spirometry
    • Bronchial challenge test (saline)
    • Blood gases
    • Radiology – CXR, HRCT
    • Polysomnography
  11. Spirometry
    • -Pre- and post- bronchodilator
    • -PEF
    • -FEV1
    • -Is there significant reversibility of FEV1(>12% or 200ml)?
  12. Bronchial Challenge Tests
    • Direct: methacholine, histamine
    • 20% fall in FEV1 (PC20) at 8mg/ml
    • High false positive rate
    • -Indirect:
    • adenosine
    • mannitol
    • hypertonic saline is preferred
    • Referring to specialists
    • -Ask specific questions!
    • -What is the diagnosis
    • -What is the % risk of incapacitation per year
    • -What is the prognosis and risk of recurrence
    • -What treatment, and what side effects?
    • -What follow-up or monitoring is required?
    • -DO NOT ask if they are fit to fly
  13. FSGT Orion, AEA, 34 y.o
    • What referrals do you arrange?
    • What questions do you ask?
    • What results do you need?
  14. Treatment Considerations
    • Is the clinical condition itself disqualifying?
    • What are the aviation-relevant side effects?
    • Is a ground trial required?
    • Is treatment providing effective control?
    • Does control need to be monitored?
    • Are there logistical treatment issues that interfere with aviation or deployment?
  15. Medications
    • • β-agonists
    • • Short acting acceptable for “rescue”
    • • Long acting (LABA) unacceptable
    • • Inhaled corticosteroids acceptable
    • • Oral steroids
    • • Unacceptable
    • • Maximum 10 mg per day for CASA
  16. Other therapies
    • • Airway splinting for OSA
    • • Mandibular splints: only for mild cases
    • • CPAP: Compliance, maintenance & deployability issues
    • • Surgery
    • • Thorascopic pleurodesis, unilateral vs bilateral
    • • Thoracotomy
    • • UPPP
  17. FLTLT Lockheed, P3-C Pilot
    • • Sudden left chest pain and SOB
    • • Small left PSP
    • • First episode
    • • Now fully resolved
    • • Small bullae bilaterally on HRCT
  18. Prognostic Considerations
    • • Risk of subtle incapacitation
    • • Risk of acute incapacitation
    • • Risk of progression
    • • Risk of recurrence
    • • Likely future treatments
  19. FLTLT Lockheed, P3-C Pilot
    • • What is the prognosis of this condition?
    • • What treatments would you consider?
    • • What would you recommend as his current disposition?
  20. Importance of Prognosis
    • Example of Primary Spontaneous Pneumothor
    • • High recurrence rate if conservatively treated1:
    • • 32% after first PSP
    • • 62% after second PSP
    • • 83% after third PSP
    • • Most recurrences occur within two years2
    • • 15% risk of contralateral pneumothorax2
    • • 1-2% risk of tension
  21. Surgically treated PTX
    • • Bullectomy, pleurectomy, pleural abrasion or pleurodesis
    • • Recurrence rate = 1.5% (0 – 4%)
  22. RESP DISORDER TMUFF?
    Yes
  23. Likelihood of clinical event:
    • •Oxygen systems, PPB
    • •Hypoxia, hypobaria
    • •Smoke, fumes
    • •Dry cold gas
    • •Acceleration
    • Determined from:
    • •History and exam
    • •Respiratory function tests
    • •Respiratory Physician report
    • •CXR/HRCT
    • •Literature/evidence base
  24. Summary
    • Manage Consequences:
    • •As or with
    • •Multi-crew ops
    • •No
  25. Your Clinical Case Challenge!
    • • With the resources available to you, you have 20 minutes to research the following clinical history and provide answers to the questions
    • • A syndicate representative must present the case to the class - maximum of 10 minutes.
    • Dyspnoea in a C-17 pilot
    • • FLTLT Cowling, a 28 y.o. C-17
    • Globemaster pilot, presents to you with shortness of breath only on exertion.
    • • She normally rides her bike about
    • 20 km per week. Over the colder winter months her exercise
    • tolerance has diminished and she feels tight in the chest while riding.
    • • She has a past history of childhood asthma and atopy.
    • • There is no other past history of note, and current medication is only the OCP.
    • • On examination, cardiovascular
    • and respiratory systems are normal. Specifically there is no wheeze and no fever. Her full blood profile is
    • within normal limits.
    • • You suspect asthma.
  26. What is your immediate action?
  27. What information do you now require?
  28. You confirm that she is now TMUFF and obtain
    What further reports investigations would
  29. A respiratory physician referral is arranged.
    • The specialist confirms asthma is the diagnosis and has commenced an inhaled corticosteroid,
    • and recommended SABA for acute symptoms.
  30. • What is the impact of the condition on the operating environment of this pilot?
    • What is the impact of her working environment on the condition?
  31. Dyspnoea in a C-17 pilot
    • • You prepare an asthma management plan for FLTLT Cowling. When reviewed her symptoms have improved dramatically, she has not required the SABA and her exercise tolerance has returned to normal.
    • • What impact will different treatment choices have on her ability fly as a military aviator?
    • • 3 months after diagnosis FLTLT Cowling is still TMUFF. She comes for her follow-up visit and enquires about her ability to return to flying duties.
    • • What do you now tell her?
    • • What information do you need before returning her to flying?
    • • A bronchial provocation test with hypertonic saline is normal.
    • • Spirometry pre and post SABA shows an improvement in FEV1 of 5%.
    • • What MECR process is now required?
    • • What are your thoughts regarding her ongoing prognosis and aeromedical disposition?
    • • With the resources available to you, you have 20 minutes to research the following clinical history and provide answers to the questions
    • • A syndicate representative must present the case to the class - maximum of 10 minutes.
  32. Chest pain in a trainee pilot
    • • Ben Garmin is a 19 yr old male training for his CASA Class 1 licence.
    • • He has 60 hours mostly in C172 aircraft.
    • • 6 weeks ago, he sustained a chest injury with 3 left fractured ribs in a cycling accident.
    • • Attended the ED where a CXR showed a 30% left pneumothorax.
  33. Chest pain in a trainee pilot
    • • He was admitted and a left intercostal drain resulted in full resolution of the PTX on CXR.
    • • He says he feels better and has come to see you for a clearance to return to flying. On examination he is still quite tender over the left side of his chest and is requiring panadeine for pain on average twice a day.
    • • How long can a Class 1 pilot be medically unfit before they must tell their DAME?
    • • Is this pilot fit to resume flying? What is your immediate action?
  34. Chest pain in a trainee pilot
    • • You explain that he is TMUFF but he wants to know why. He has a flight test next week.
    • • What is the impact of the condition on the operating environment of this pilot?
    • • What is the impact of his working environment on the condition?
    • Having explained the risks of the condition and medication to the pilot, you now need to
    • quantify the risk and determine a course of action.
    • • What additional information will help you in further aeromedical decision making?
    • • Is referral necessary?
    • • You want to confirm resolution of the pneumothorax and healing of the ribs. You order HRCT chest and request a report from the treating specialist.
    • • HRCT of the chest does not show any residual pneumothorax and the ribs have healed.
    • • What is the prognosis of this condition?
    • • What are the main issues affecting aeromedical disposition at this point?
    • • Specialist review at 8 weeks confirms full healing and minimal risk of recurrent pneumothorax. Ben’s pain has settled and he is now resuming normal activity
    • • If Ben was a RAAF pilot training at BFTS, what MECR process would now be required?
    • • What are your thoughts regarding aeromedical disposition?
  35. • With the resources available to you, you have 20 minutes to research the following clinical history and provide answers to the questions
    • • A syndicate representative must present the case to the class - maximum of 10 minutes.
    • A load of snoring
    • • WOFF Albert is a 49 yr old loadmaster on C-17 aircraft
    • • He has a history of hypertension which has been effectively managed with an ACE2 inhibitor. His BMI has always been a problem and remains 32.
    • • His last FBSL was 5.9, but his OGTT only showed impaired fasting glycaemia.
    • • At his SPECAHE he complains about morning headaches poor sleep, and constant tiredness.
    • • Your enquiry about snoring reveals that his wife insists he sleep in the spare room.
    • • What would you like to know?
    • • You take a thorough sleep and medication history, and administer the Epworth Sleepiness Scale and he scores 14. Your enquiries raise definite concern about OSA.
    • • What is your course of action now?
    • • What further investigations or information do you now need?
    • • You explain that he is TMUFF and he will need further specialist assessment and a sleep study.
    • • What is the impact of the condition and its prognosis on the operating environment of this aircrew member?
    • • What is the impact of his working environment on the condition?
    • • The specialist report and sleep study confirm moderately severe Obstructive Sleep Apnoea. Having explained the risks of the condition and the need for appropriate management.
    • • What are the aeromedical and deployment implications of the different treatments available for OSA?
    • • Which one do you think is the most appropriate?
    • You review WOFF Albert after he commences CPAP and he reports marked improvement in his symptoms. His specialist reports a good response to therapy and good compliance.
    • • What MECR procedure is now required?
    • • What is the likely aeromedical disposition of this member?
  36. Hypobaric collapse
    • • A 43 yr old loadmaster on C-130H aircraft has just collapsed during a rapid decompression in a hypobaric chamber. He is brought to your medical centre.
    • • His symptoms and signs included chest discomfort, light headedness, shortness of breath, sensory loss below the waist and blurred vision. He could not sit upright, and was sweating.
    • • Examination: right homonymous hemianopia, poor serial 7s, mild disorientation in T/P/P.
    • • What do you think might be going on?
    • • What would you like to know?
    • • The CXR reveals the source of the problem and you diagnose cerebral arterial gas embolism resulting from the 4cm intraparenchymal pulmonary cyst.
    • • Four hyperbaric treatments over 4 days results in complete resolution of neurological signs.
    • • What is the impact of the condition and its prognosis on the operating environment of this aircrew member?
    • • What is the impact of his working environment on the condition?
    • • Your aeromedical assessment of his operating environment raises concerns about his ability to tolerate future exposure to pressure change both operationally and in chamber training required for his mustering.
    • • What further information investigations or reports do you need to assess his ongoing aeromedical disposition?
    • • Chest CT better defines the single partially fluid filled cyst in the upper lobe of the left lung, with no pneumothorax or pneumomediastinum.
    • • The past history you requested reveals normal previous chest x-rays and spirometry, and a previous echocardiogram found trivial mitral valve prolapse but no evidence of ASD or VSD.
    • Your referral to a cardiothoracic surgeon results in a recommendation to surgically resect the cyst.
    • • What are the aeromedical implications of this course of action?
    • • What further assessments and reports will be required post-operatively?
    • • A left posterolateral thoractotomy results in successful left upper lobe segmentectomy with good recovery.
    • • Pathology reveals a large subpleural cyst partially lined with bronchial cells and fibrous tissue, with smaller satellite cysts. Probable bronchogenic origin.
    • • Neurology, neuropsychology and ophthalmology reports that you organised show full functional recovery. Respiratory function tests post-op are normal.
    • • What is the prognosis of this condition and how will it affect his ongoing fitness?
    • • What MECR process would you now recommend, and what is the likely disposition?

Card Set Information

Author:
david_hughm
ID:
328613
Filename:
Topic 3.5 Resp Med & Cases AVMO 0019 STUDY CARD 18022017
Updated:
2017-02-18 15:18:03
Tags:
AVMO 2017
Folders:

Description:
Resp Med & Cases AVMO 0019 STUDY CARD
Show Answers:

Home > Flashcards > Print Preview