RESEARCH ARTICLE

Asthma in Military Aviators: Safe Flying Is Possible

Dan Carter, Russell Pokroy, Bella Azaria,
Erez Barenboim, Yehuda Swhartz, and Liav Goldstein

CARTER D, POKROY R, AZARIA B, BARENBOIM E, SWHARTZ Y, GOLD- for flying fitness of asthmatic aviators in different air
STEIN L. Asthma in military aviators: safe flying is possible. Aviat services. Many waivers are outdated and do not con-
Space Environ Med 2006; 77:838 – 41.
Introduction: Asthma is considered relatively incompatible with avi- sider the new developments in asthma management.
ation. Firstly, due to the risk of sudden incapacitation, and secondly, due This study reports our experience with asthmatic avia-
to cold and dry air and other asthmogenic factors characteristic of the tors and describes our algorithm for managing the asth-
aviation environment. The medical requirements for flying fitness of matic aviator.
asthmatic aviators are inconsistent between different air services, and
many flight surgeons are unfamiliar with the recent developments in
asthma management. This study aims to describe our experience with METHODS
asthmatic aviators and to discuss the medical standards required for
We reviewed the medical charts of all asthmatic avi-
flying fitness in chronic asthma. Methods: The records of all aviators
diagnosed with asthma between January 1988 and September 2005 ators managed in our institution between 1988 and
were reviewed. Pulmonary function tests and examination by a pulmo-
2005. Diagnosis was based on the clinical presentation
nary disease specialist and flight surgeon were performed at least annu-
and on lung function tests. Adenosine or methacholine
ally. Results: Nineteen Israeli Air Force aviators with asthma were
challenge tests were performed when diagnosis was
studied. Most were treated with inhaled long-acting ␤ agonists and
clinically suspected and pulmonary function tests were
corticosteroids. Disease control was satisfactory in more then 90%, with
significant worsening in only one case. We had no cases of sudden
within or close to the normal limits. Challenge tests
incapacitation or any other safety breach. One aviator was grounded 23
were also used in order to reconfirm the diagnosis in
yr after diagnosis due to deterioration in the severity of the disease, and
selected cases. The challenge tests protocols have been
another aviator was permanently grounded 1 yr after diagnosis. Conclu-
previously described (4,11). A five-breath dosimeter
sions: Adequate asthma control is readily feasible, even in the aviation
technique using concentrations of 3.125–200 mg
ml⫺1
environment. Long-term inhaled corticosteroids are effective and have
few side effects in aviators. Our management approach to aviators with
was used with adenosine, and concentrations of 0.125–
asthma appears to be safe and effective. 12.5 mg
ml⫺1 were used for methacholine. At 2 min
Keywords: asthma, aviator, inhaled corticosteroids, beta agonists.
after each dose step, two forced expiratory volume
IP: 106.206.4.63 On: Tue,(FEV1) measurements
16 Jul 2024 03:49:26 were made in the first second
and theAssociation
Copyright: Aerospace Medical higher of two was selected. We considered a
A STHMA IS an episodic, chronic, inflammatory dis- by Ingenta
Delivered
ease of the airways. It is characterized by increased
responsiveness of the tracheobronchial tree to multiple
20% fall in FEV1 (PD20) to be indicative of bronchial
hyper-responsiveness. Once asthma was diagnosed,
treatment was started and meticulous medical fol-
stimuli (5). Asthma is rare in military aviators due to
low-up was performed until the disease was well con-
exclusion of applicants with any asthmatic tendency (2).
trolled.
The aviation environment, especially in the military, is All aviators were assessed annually by a flight sur-
hazardous for the asthmatic aviator. Hypobaric condi- geon. Detailed history was elicited with special empha-
tions increase the risk for hypoxemia. G-force, positive sis on the status of the disease and on possible compli-
pressure breathing and anti-G maneuvers can damage cations of asthma. Physical exams, lung function tests
lung tissue. Breathing of dry and cold cabin air may and pulmonary specialist consultations were per-
cause airway irritation. Exposure to dust and smoke can formed annually in stable disease, as well as on exac-
compromise the pulmonary function and trapped gases erbations. Asthma was considered controlled when the
can cause lung rupture during rapid decompression.
Physical and emotional stress may trigger broncho-
spasm. Lastly, long-term asthma therapy, such as cor- From the Israel Air Force Aeromedical Center, Tel Hashomer, Israel
ticosteroids and ␤ agonists, carries it own risks. (D. Carter, R. Pokroy, B. Azaria, Y. Swhartz); the Surgeon General
Not surprisingly, the diagnosis of asthma in an avi- Headquarters, Israeli Air Force, Tel Hashomer, Israel (E. Barenboim,
L. Goldstein); and the Pulmonary Disease Unit, Soraski Medical Cen-
ator is of great concern and calls for prompt authoriza- ter, Tel Aviv, Israel (Y. Swhartz).
tion of flying appropriateness. Military aviators who This manuscript was received for review in March 2006. It was
develop asthma are usually restricted to low-perfor- accepted for publication in May 2006.
mance platforms or are permanently grounded (12,13). Address reprint requests to: Dan Carter, M.D., Chief of the Clinical
Section, Israel Aeromedical Center, Military POB 02166, Tel
Asthmatic applicants for civilian aviation courses are Hashomer, Israel; carterd@zahav.net.il.
denied entry or deferred for aeromedical certification Reprint & Copyright © by Aerospace Medical Association, Alexan-
(7). There is poor consistency regarding the standards dria, VA.

838 Aviation, Space, and Environmental Medicine • Vol. 77, No. 8 • August 2006
ASTHMA & FLYING—CARTER ET AL.
TABLE I. AVIATORS WITH ASTHMA.

GINA ICS/ Flight years Recent

Age at severity at Duration Flying after pulmonary
Case Platform/Duty diagnosis diagnosis (years) state diagnosis function test
1 HP/P 22 Moderate Yes/13 Waivered 13 Normal
2 HP/P 26 Mild Yes/1 Waivered 2 Normal
3 HP/P 23 Moderate Yes/1 Waivered 9 Normal
4 HP/WSO 27 Intermediate No Waivered 9 Normal
5 HP/P 24 Moderate Yes/5 Waivered 6 Normal
6 HP/P 22 Moderate No Waivered 7 Normal
7 HP/WSO 22 Moderate Yes/1 Grounded 1 Mild obstruction
8 HP/P 42 Severe Yes/23 Grounded 23 Mild obstruction
9 HP/P 27 Moderate Yes/2 Waivered 7 Normal
10 HP/P 24 Moderate Yes/3 Waivered 18 Normal
11 HP/P 25 Intermediate No Waivered 12 Normal
12 HP/P 21 Intermediate No Waivered 4 Normal
13 HP/P 23 Mild Yes/2 Waivered 11 Normal
14 RW/P 22 Moderate Yes/13 Waivered 13 Normal
15 RW/P 35 Moderate Yes*/10 Waivered 12 Mild obstruction
16 RW/P 21 Moderate No Waivered 10 Normal
17 Trans/P 43 Moderate Yes/1 Waivered 6 Normal
18 Trans/P 21 Mild No Waivered 9 Normal
19 Trans/P 26 Mild Yes/1 Waivered 11 Normal

GINA ⫽ Global Initiative for Asthma classification (6); HP ⫽ High performance; ICS ⫽ inhaled corticosteroids; P ⫽ pilot; RW ⫽ Rotary wing;
Trans ⫽ Transport; WSO ⫽ Weapon system operator.
* Also treated with antileukotriene.

aviator was symptomless, lung function tests were nor- • Severe Persistent Asthma
mal (FEV1 ⬎ 80% predicted; or peak expiratory force,
80% of personal best), and no airway hyper-responsive- Symptoms daily
ness was demonstrated on challenge testing. Frequent exacerbations
The determination of asthma severity was based on Frequent nocturnal asthma symptoms
the Global Initiative for Asthma (GINA) classification, Limitations of physical activities
as summarized below (6). Flight safety data for each FEV1 ⬍ 60% predicted or PEF ⬍ 60% of personal
aviator, consisting of accidents or near accidents, was best
obtained from the Israeli Air Force safety center. PEF or FEV1 variability ⬎ 30%

Global Initiative for Asthma (GINA): Classification RESULTS

of Asthma Severity IP: 106.206.4.63 On: Tue, 16 Jul 2024 03:49:26
ThereAssociation
Copyright: Aerospace Medical were 19 Israeli Air Force aviators with asthma
• Intermittent Asthma Delivered by Ingenta all were included in this study. Of these, 18
detected;
Symptoms less then once a week were men, and all were Caucasian. The median age at
Brief exacerbations diagnosis was 24 yr (range, 21– 43). None had history of
Nocturnal symptoms not more then twice a month childhood asthma. Only one had a family history of
FEV1 ⬎ 80% predicted or ⬎ 80% of personal best asthma. Seven had other allergic complaints, usually
PEF or FEV1 variability ⬍ 20% mild allergic rhinitis. Of the 19, 17 were pilots, includ-
ing 11 high-performance operators, 3 rotary wing oper-
• Mild Persistent Asthma ators and 3 transport craft aviators; 2 were weapon
system operators (WSO), flying on high-performance
Symptoms more then once a week but less then once platforms.
a day Of the 19 aviators, 3 had intermediate persistent
Exacerbations may affect activity and sleep asthma, 4 had mild persistent asthma, 11 had moderate
Nocturnal symptoms more then twice a month persistent asthma, and 1 had severe disease. Of the 19
FEV1 ⬎ 80% predicted or ⬎ 80% of personal best aviators, 18 continued active duty, flying a combined
PEF or FEV1 variability 20 –30% 182 (median of 9, mean of 9.6) years after asthma diag-
• Moderate Persistent Asthma nosis. No sudden incapacitation or other flight safety-
jeopardizing event related to asthma occurred in any
Symptoms daily aviator during these flight years. Table I summarizes
Exacerbations may affect activity and sleep the aviation medical data of the 19 aviators.
Nocturnal symptoms more then once a week Combination therapy of ␤ agonists, usually long-
Daily use of short acting ␤2-agonists acting, and inhaled corticosteroids (ICS) was started on
FEV1 60 – 80% predicted or PEF 60 – 80% of personal diagnosis or during the first exacerbation. We at-
best tempted to withdraw the ␤ agonist therapy as soon as
PEF or FEV1 variability ⬎ 30% possible, once asthma symptoms resolved and pulmo-

Aviation, Space, and Environmental Medicine • Vol. 77, No. 8 • August 2006 839
ASTHMA & FLYING—CARTER ET AL.

nary function test normalized. As shown in Tables I

and II, inhaled corticosteroids were the mainstay of our
treatment. These were used in almost all aviators with a
GINA classification of mild persistent or worse. The one
aviator with severe disease was treated with inhaled
and systemic steroids, and was permanently grounded.
Inhaled corticosteroids were continued for at least 12
mo. Antileukotriene agents were used in one aviator.
Disease control compatible with unrestricted flying
was achieved in 90% of the aviators. With the exception
of Case 8, no disease deterioration occurred. Case 8
deteriorated from moderate persistent to severe disease
during the final 3 yr of 23 yr of jet aviation, and subse-
quently was permanently grounded. The only other
case of permanent disqualification was Case 7, a 22-yr-
old high-performance WSO with moderate disease and
frequent complaints.

DISCUSSION
Diagnosis of asthma in trained military aviators usu-
ally ends with restriction to special missions or perma-
nent grounding (12,13). The reasons for these restric-
tions are numerous and include the dangers of sudden
incapacitation due to acute bronchospasm, side effects
of medications, lung rupture due to rapid decompres- Fig. 1. Algorithm for management of the asthmatic military aviator.
sion and acceleration atelectasis, or performance degra- ¶
Therapy consisting of combination of inhaled steroids and ␤ agonists;
¶¶
dation due to hypoxia (1). In the course of 182 flight- operating on dual seated⶿ multicrew platform for 1 yr; *lung function,
peak flow variability and bronchial challenge testing; **continuation of
years of 18 aviators (1 WSO was permanently grounded pulmonary evaluation and therapy, with transfer to low-performance
1 yr after diagnosis), only 1 had disease worsening, and platform.
no breach of safety standards occurred. Although most
of the aviators were treated with ICS for long periods,
no systemic side effects were seen. disease is well controlled by ICS for at least 1 yr. Airway
Our study group responded well to temporary flight hyper-responsiveness and lung function tests usually
restriction and therapy. Other studies showed that normalize during this period. Cargo aircraft aviation
good asthma control, defined by stabilizing the FEV1, carries the hazards of cold and dry compressed air, and
was usually achieved within 3 mo of ICS therapy (10). long-distance flights, but not of high G forces. Although
Combination therapy, using inhaled long-acting ␤
IP: 106.206.4.63 On: Tue,helicopter
ago- 16 Jul 2024 aviation
03:49:26exposes the aviator to dusty condi-
nists such as salmeterol and ICS, Copyright: reduced the tions, it is not
time Medical Association
Aerospace as physically demanding as fighter jet
duration necessary for disease control (3,9). Our expe- aviation
Delivered by Ingenta and usually does not require the use of com-
rience, as well as that of Redek et al. (8), was that airway pressed air. Regarding the Israel Airforce, both cargo
hypersensitivity usually normalized within 12 mo of aircraft and helicopters are operated by two or more
ICS therapy. Almost all of our aviators responded aviators. Therefore, we allow resumption of aviation on
within shorter periods than the afore-mentioned stud- low-performance multiple crew platforms after 3 mo of
ies, probably because of their relatively mild asthma therapy in asymptomatic aviators, even if there is a
and their high compliance to therapy. mild obstructive pattern on pulmonary function tests.
Each flight platform has specific aeromedical con- Regarding all platforms, ICS therapy is continued for at
cerns. High-performance platforms expose the aviator least 1 yr.
to high G forces, and cold and dry compressed air. We Based on our experience, we constructed an algo-
believe that once asthma is diagnosed in a jet aviator, rithm for management of the asthmatic aviator (Fig. 1).
resuming unrestricted aviation is possible only if the After an asthmatic attack, we ground all aviators for 3
mo. During this time, we treat with ICS and long-acting
␤ agonists. We educate aviators to be aware of mild
TABLE II. INHALED CORTICOSTEROID TREATMENT BY GINA asthma symptoms, and to promptly present to their
SEVERITY GROUPS. flight surgeons if any symptoms appear. If the aviator
remains symptomatic after these 3 mo, we continue
Aviators treated with
GINA severity at diagnosis inhaled steroids, N (%) grounding and medical treatment. If the aviator is
symptom free, lung functions tests are performed.
Intermediate persistent, N ⫽ 3 0 Moderate and severe obstructive patterns require con-
Mild persistent, N ⫽ 4 3 (75)
Moderate persistent, N ⫽ 11 9 (82) tinued grounding and therapy. Aviators with mild ob-
Severe persistent, N ⫽ 1 1 (100) structive lung function tests (FEV1 ⬎ 80% or ⬎ 80% of
personal best, PEF of FEV1 variability 20 –30%) may
GINA - Global Initiative for Asthma classification (6). resume low-performance aviation (rotary wing and

840 Aviation, Space, and Environmental Medicine • Vol. 77, No. 8 • August 2006
ASTHMA & FLYING—CARTER ET AL.

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