Asthma for an AU CASA Class 2 Medical?

[ds34542]

Hi all,

I'm looking for advice from those have succeeded in passing a Class 2 medical with moderate asthma.

I've been flying RAAus, which has 'driving standard' medical requirements, for around 6 years. I've since started a family, and I'd like to one day have the option to take all four of us up, rather than be limited to the one passenger of RAAus.

I'm just over 40 years old now, and consider myself reasonably fit - I've run two marathons, a few halves, and most recently a tough mudder (13 mile obstacle course) last year, although these days typically just do a 3-4 mile run at a 9min mile on average. I do intensive interval training circuits most mornings, and my heart recovery rates are in the "very good" range.

Despite feeling confident with all that, I sat in a cramped doctor's office a few months ago and learnt I'd failed my flight medical with the DAME on a poor FEV1/FVC ratio. For a clear pass, CASA require an FEV1/FVC of >70%, with a normal being 80% (ie. 80% of your lung capacity exhaled in one second). I scored 66%.

So - I went to a doctor for an asthma management plan, and came away with a $5 a day habit in 'Seretide' - basically inhaled steroids and reliever. Four weeks of that, and I went for another spirometry test. 66% again.

So - I took them for another month, then went back to another doctor. I was feeling positive, as I felt breathing was no longer a limiting factor at my gym sessions. It came out at 62% in the first second - actually slightly worse than before. The improvement due to a reliever was negligible, so at least it's stable, which is also a factor; a 12% improvement implies your asthma isn't properly managed and is a serious issue.

So - it does seem that my asthma isn't going to disappear, and I'm going to have to work with what I have. The question is, does this mean I'm never going to be able to pass my Class 2?


The regulations seem a little confusing as to what is acceptable, and what is not:



The Avmed guidelines on the CASA website (http://services.casa.gov.au/avmed/guidelines/asthma.asp) give the 70% FEV1/FVC (FER in their guide) as the acceptable threshold, which I'm below
The DAME Manual (https://www.casa.gov.au/sites/g/files/net351/f/_assets/main/lib100096/foi_f13_5348.pdf) covers asthma in section 2.3.5, and states:
In the case of applicants with moderate well controlled asthma, periodic assessment by a respiratory physician may be required. CASA will notify specific requirements on a case-by-case basis.
I fall into the 'moderate' category as:
Their FEV1 or peak flow will be in the range 60-80% predicted, and peak flow variability may be greater than 15%. Treatment requirements will likely include low to moderate doses of inhaled corticosteroid, (e.g. beclomethasone 400-1000 micrograms per day or equivalent).
(I'm on 2000ug of seretide, but since it seems to have no impact on my FER compared to untreated, I can likely bring that down)
The actual CASR 67.155 (https://www.comlaw.gov.au/Details/F2015C00762/Html/Volume_2#_Toc429575752) Table 2.12 states for Class 2 medical:
Is not suffering from a safety-relevant condition of the respiratory system.

And that's all the actual regs have to say on it

So - it all sounds like a 'maybe'. I looked up the regs in the UK and US, and they seem similar - the UK requires a dedicated Brochial Reactionary test, which involves running for 6 minutes and testing FER before and after; a decline of less than 16% FER after exercise is acceptable for an unrestricted Class 2.

The FAA is similar - below 80% of predicted (my result was 78% of predicted) requires dedicated testing.



So - faced with all that - can anyone suggest what would my options be with CASA? It seems I fall into the 'moderate asthma' category by definition, but I can't find anything in writing with regards to any equivalent to the CAA Bronchial Reactivity tests that would specifically determine my suitability in the 'grey area'. CASA allude to such a test for 'moderate asthmatics', but I can't find information on what would perform that, and what their criteria would be.


It's a frustrating situation, particularly to see pilots twenty years older passing their medicals, while I'm running around a gym with twenty-year olds every morning, to be told I'm not physiologically safe to go up in the air. From what I can determine, the primary risk caused by asthma in my circumstance is hypoxia, as from memory a pilot may operate at 10,000ft indefinitely or 14,000ft for half an hour, and so must be medically fit to do so. In my entire 140 hours, I think I flew to 10,000ft once to see what was up there, and most aircraft I fly can't get to 14,000ft.


I'd be very interested in anyone else's experiences in a similar situation? Did you get referred, and get passed by a specialist? Did you get any restrictions on your licence - such as a maximum operating altitude? Did CASA flat-out deny the class 2? Or are there any tips and tricks to passing the medical (eg. Deep breathing exercises, or even practicing spirometry tests)?

Thanks!


Damian

[Radgirl]

Your FEV1 (the amount of air you can blow out in a second) has fallen in relation to your FVC (the total amount you can exhale in a total breath). This demonstrates obstructive lung problems which includes asthma, chronic bronchitis, emphysema, bronchiectasis and a number of other rarer problems

If BOTH fall your ratio may be 100% but both numbers are below normal. This is called restrictive lung disease, and can be caused by cancer, asbestosis, sarcoidosis, neurological issues etc. You dont have this!

In your case there has been an assumption you have asthma. You dont say if you are symptomatic - I would expect this number to be associated with wheezing episodes, or breathlessness on exercise.

I would start you on a blue puffer and monitor it. Your FVC wont change so you just need to measure FEV1 also called peak flow using one of those toilet roll like machines - a few dollars from your drug store. If you have asthma it MUST be variable (go up and down) and should improve after a blue puffer so we measure peak flow before and after.

If your symptoms are still a problem we add the brown puffer or steroids which is prophylactic. You take it regularly to stop the problem, as opposed to the blue puffer you take to reverse the problem at the time.

I appreciate your doctor is trying to get you through your medical so good on him for going to the brown puffer, but unless your 66% represents reversibility from 80% something isnt quite right. I am afraid you may indeed have moderate asthma deteriorating to 66% and the risk is not hypoxia but an asthma attack when flying which incapacitates you. Flying without a safety pilot would be unsafe. BUT if you have no or few symptoms, no improvement on steroids I think you need to see a chest physician, have more complex pulmonary function tests than your GP can do, and consider other causes. I dont want to give you an overoptimistic outlook, but just sticking to puffers without consultant review wont work

As always please update us not only for other sufferers but so us quacks can get feedback - this telemedicine is hugely satisfying for Gingernut and others but we need to know how we are doing :ok:

[ds34542]

Hi Radgirl,

Sorry - :ugh:I seem to have forgotten to add: I'm a diagnosed asthmatic - had it much of my childhood and teens with memories of peak flows of 350-450 (I'm 6'5") on Becotide and Ventolin. It died away in my early twenties, and the last serious attack was 20 years ago. My peak flow is 550-590 these days (predicted is 650).

Before my current sedetide prescription, I would take a couple of ventolin puffs at some point on a 4-mile run, on half my runs. With Seretide, Ventolin gives no measurable benefit, so it is 'controlled' in that respect, but not in the respect of getting >0.7FER.

...unless your 66% represents reversibility from 80% something isnt quite right. I am afraid you may indeed have moderate asthma deteriorating to 66% and the risk is not hypoxia but an asthma attack when flying which incapacitates you.

Sorry - I don't quite understand "66% represents reversibility from 80%". Just to confirm - my FER is 66% of FVC exhaled in 1 second, or 83% of predicted. (ie. (66% measured FER / 80% predicted FER) x 100 = 83% of predicted). The required >0.7FER would be 87.5% of predicted.

With regards to the risk of asthma attack leading to incapacitation - I do intense exercise every morning on just my regular medication, and my last attack was twenty years ago, so I would argue that based on previous history I'm unlikely to be incapacitated in-flight. But my quandary is, who do I argue that case to? Do I get a DAME referral to a chest physician and take back their report for consideration, or are there aviation-qualified chest physicians who handle those referrals?

And what would be their likely response: are they likely to consider my fitness and take the same view, or do they take a very conservative view and simply deny anyone who 'nearly but not quite' makes the numbers?

Thanks!


Damian

[Radgirl]

Thanks for clearing up my concerns that something wasn't quite right. I am afraid it doesn't look good. You are diagnosed as an asthmatic with a recognised history and measurements below the limits. There are a couple of newer drugs but they would be unlikely to make a big difference in your case although worth discussing with your doctor.

I am afraid there have been a number of threads in the past about asthma. The regulators do take it seriously and despite your history of only moderate limitations there is a risk of an exacerbation. You could discuss it with a DAME

[ds34542]

Thanks Radgirl.

I'll keep looking into it, and maybe get a referral to a respiratory specialist for aviation, if I can find one.

I do see plenty of discussions about UK pilots running around Gatwick House in order to test post-exercise reactivity, so I assume there are more tests that can be done which the standard CASA test criteria don't touch upon.

[Blenk]

CASA allude to such a test for 'moderate asthmatics', but I can't find information on what would perform that, and what their criteria would be.

I know that is is a long shot, and you may have gone down this path already, but have you contacted CASA to see what their take on it is? Under their Aviation Medicine section on the website there are multiple email addressess (see How to provide feedback (http://services.casa.gov.au/avmed/contact.asp)) - might be worth seeing if you can get in touch with someone that can guide you in the right direction? With the test results you have already they might be able to consider what (if any) further tests would be required, what restrictions you might expect to have in you licence/medical, or, worst case, give you the bad news that they see no way to make it work (hopefully not!).

While they don't have a reputation for being über helpful at times, when a question came up about my (mild) asthma during a Class 2 medical a few years ago CASA were very forthcomming, perscriptive with what they wanted to see and there was no second guessing the system.