Flight safety risk assessment of self-medication among fighter pilots: a cross-sectional study.

BACKGROUND: Fighter pilots are a specific population in which any adverse drug reaction can unpredictably interact with aeronautical constraints and thus compromise flight safety. This issue has not been evaluated in risk assessments. AIM: To provide a semi-quantitative assessment of the risk to flight safety of self-medication in fighter pilots. METHOD: A cross-sectional survey that aimed at identifying the determinants of self-medication in fighter pilots was conducted. All medications consumed within 8 h preceding a flight were listed. A modified Failure Mode and Effects Analysis was performed, and any adverse drug reaction reported in the French marketing authorization document of a drug was considered a failure mode. The frequency of occurrence and severity were evaluated using specific scales to assign each to three risk criticality categories: acceptable, tolerable, and unacceptable. RESULTS: Between March and November 2020, the responses of 170 fighter pilots were analyzed, for an overall return rate of approximately 34%. Among them, 78 reported 140 self-medication events within 8 h preceding a flight. Thirty-nine drug trade names (48 different international nonproprietary names) were listed, from which 694 potential adverse drug reactions were identified. The risk criticality was considered unacceptable, tolerable and acceptable for 37, 325 and 332 adverse drug reactions, respectively. Thus, the risk criticality was considered unacceptable, tolerable and acceptable for 17, 17, and 5 drugs, respectively. CONCLUSION: This analysis suggests that the overall risk to flight safety of the current practice of self-medication in fighter pilots may be considered at least tolerable, or even unacceptable.

Residual Sleepiness Risk in Aircrew Members with -Obstructive Sleep Apnea Syndrome.

BACKGROUND: Obstructive sleep apnea syndrome (OSAS) is a major problem in aviation medicine because it is responsible for sleepiness and high cardiovascular risk, which could jeopardize flight safety. Residual sleepiness after the treatment is not a rare phenomenon and its management is not homogenous in aviation medicine. Thus, we decided to perform a study to describe this management and propose guidelines with the help of the literature.METHODS: This is a retrospective study including all aircrew members with a history of OSAS who visited our aeromedical center between 2011 and 2018. Residual sleepiness assessment was particularly studied.RESULTS: Our population was composed of 138 aircrew members (mean age 50.1 ± 9.6 yr, 76.8% civilians, 80.4% pilots); 65.4% of them had a severe OSAS with a mean Epworth Sleepiness Scale (ESS) at 8.5 ± 4.7 and a mean apnea hypopnea index of 36.2 ± 19.2/h. Of our population, 59.4% performed maintenance of wakefulness tests (MWT) and 10.1% had a residual excessive sleepiness. After the evaluation, 83.1% of our population was fit to fly.DISCUSSION: An evaluation of treatment efficiency is required in aircrew members with OSAS. Furthermore, it is important to have an objective proof of the absence of sleepiness. In this case, ESS is not sufficient and further evaluation is necessary. Many tests exist, but MWT are generally performed and the definition of a normal result in aeronautics is important. This evaluation should not be reserved to solo pilots only.Monin J, Rebiere E, Guiu G, Bisconte S, Perrier E, Manen O. Residual sleepiness risk in aircrew members with obstructive sleep apnea syndrome. Aerosp Med Hum Perform. 2023; 94(2):74-78.

Prevalence of sleep disorders in a large French cohort of aircrew members and risk of in-flight sleepiness.

BACKGROUND: /objectives: Sleep disorders are a critical issue for flight safety. Previous studies have shown a high prevalence of sleep disorders and excessive sleepiness in the general population and some aircrews. The objectives of this study are to measure the prevalence of excessive daytime sleepiness and sleep disorders in aircrews, and to determine the risk factors of falling asleep during a flight. METHODS: this is a monocentric study based on questionnaires, including all professional civilian and military aircrews examined in an aeromedical center between January and May 2021. The questionnaire, created for this study, included information about socio-demographic characteristics, aeronautical experience, lifestyle, sleep habits, an Epworth sleepiness scale, and screening tests for chronic insomnia, sleep apnea syndrome and restless legs syndrome. RESULTS: 749 aircrew members were included (86.2% male, 58.9% civilian, 74.1% pilot, mean age 43.4 ± 9.6 years), 45.9% of the population had at least one sleep disorder (chronic insomnia 39.5%, sleep apnea syndrome 10.5%, restless legs syndrome 4.1%), 15.5% had an excessive daytime sleepiness, and 24.6% reported in-flight sleep while on duty. Chronic insomnia, screen use before bedtime, use of sleeping pills, inadequate recovery time after a flight, female gender and civilian status were found as risk factors of in-flight sleep in the multivariate analysis. CONCLUSION: this study emphasizes the need to improve the screening and prevention of sleep disorders in this particular population.

Self-Medication Among Military Fighter Aircrews.

BACKGROUND: The practice of self-medication among military fighter aircrew could compromise flight safety because of the adverse effects that can occur in flight. However, data on this subject is scarce. The aim of this study was to identify the determinants of the practice in this population.METHODS: A cross-sectional study was carried out among the French Air Force fighter aircrew based on an anonymous questionnaire distributed electronically. The questions included personal characteristics, opinions, and relations with the healthcare domain as well as the use of self-medication in general and before a flight.RESULTS: Between March and November 2020, 170 questionnaires were reviewed for an overall return rate of approximately 34%. Our data showed an absolute self-medication rate of 97.6%, but the frequency of its use was rare or nonexistent in 53.5% of cases. Factors associated with a more frequent use of self-medication were the function of pilot, age under 35, having a regular prescription, lacking intentionality toward getting enough sleep, having confidence in the medical profession, and some specific clinical situations. The consumption of 97 medications was recorded and 49 before a flight.DISCUSSION: Despite the limitations due to the design of this survey, results suggest that the use of self-medication in fighter aircrews is a reality, but that the frequency of its use is less common. This practice is probably the result of a complex interaction between many personal factors. However, its impact on flight safety remains uncertain.du Baret de Limé M, Monin J, Leschiera J, Duquet J, Manen O, Chiniard T. Self-medication among military fighter aircrews. Aerosp Med Hum Perform. 2022; 93(7):571-580.

Travel health study in commercial aircrew members.

BACKGROUND: Aircrew members of airlines are exposed to travel risks. The objectives of our study are to assess the experience of aircrews about these risks and their knowledge about prevention means. METHODS: We conducted an observational qualitative study in commercial aircrews at the aeromedical center of Percy Military Hospital between November 2018 and June 2019. RESULTS: 200 aircrews answered the questionnaire, 54% of which were pilots, 91% work on long and/or medium-haul flights, 82.5% of airmen are concerned by their immunization status. Vaccination rate varied according to the vaccine. Two third of airmen usually go to malaria-endemic countries, 12% of respondents use antimalarial treatment in such infected countries, while 93.5% protect themselves against mosquito bites mainly with insect repellent. In case of a fever after a stay in a malaria-endemic country, only 51.5% of respondents immediately think about acute malaria. Aircrews are very motivated by their job but 58% of them feel tired probably linked to quality of sleep and effects of jet-lag, with a statistically significant difference between pilots and cabin crews (43% vs 75% [p < 0.01]). CONCLUSION: Aircrew members know a lot about travel issues. Malaria remains a major concern for aircrews, but it is necessary to maintain information about this topic throughout their career and to provide them with repellents, what many airlines actually do. Fatigue management is also important for airmen, so as they use different technics to accelerate recovery. Some airlines try to help them with a guide for aircrew fatigue management. This particular population involved in flight safety has few risky behaviors; nevertheless, alcohol misuse and drug use are screened during medical examinations and by airlines.

An introduction to aviation cardiology.

The management of cardiovascular disease (CVD) has evolved significantly in the last 20 years; however, the last major publication to address a consensus on the management of CVD in aircrew was published in 1999, following the second European Society of Cardiology conference of aviation cardiology experts. This article outlines an introduction to aviation cardiology and focuses on the broad aviation medicine considerations that are required to manage aircrew appropriately and optimally (both pilots and non-pilot aviation professionals). This and the other articles in this series are born out of a 3 year collaborative working group between international military aviation cardiologists and aviation medicine specialists, many of whom also work with and advise civil aviation authorities, as part of a North Atlantic Treaty Organization (NATO) led initiative to address the occupational ramifications of CVD in aircrew (HFM-251). This article describes the types of aircrew employed in the civil and military aviation profession in the 21st century; the types of aircraft and aviation environment that must be understood when managing aircrew with CVD; the regulatory bodies involved in aircrew licensing and the risk assessment processes that are used in aviation medicine to determine the suitability of aircrew to fly with medical (and specifically cardiovascular) disease; and the ethical, occupational and clinical tensions that exist when managing patients with CVD who are also professional aircrew.

Assessing aeromedical risk: a three-dimensional risk matrix approach.

Early aeromedical risk i was based on aeromedical standards designed to eliminate individuals ii from air operations with any identifiable medical risk, and led to frequent medical disqualification. The concept of considering aeromedical risk as part of the spectrum of risks that could lead to aircraft accidents (including mechanical risks and human factors) was first proposed in the 1980s and led to the development of the 1% rule which defines the maximum acceptable risk for an incapacitating medical event as 1% per year (or 1 in 100 person-years) to align with acceptable overall risk in aviation operations. Risk management has subsequently evolved as a formal discipline, incorporating risk assessment as an integral part of the process. Risk assessment is often visualised as a risk matrix, with the level of risk, urgency or action required defined for each cell, and colour-coded as red, amber or green depending on the overall combination of risk and consequence. This manuscript describes an approach to aeromedical risk management which incorporates risk matrices and how they can be used in aeromedical decision-making, while highlighting some of their shortcomings.

Management of established coronary artery disease in aircrew without myocardial infarction or revascularisation.

This paper is part of a series of expert consensus documents covering all aspects of aviation cardiology. In this manuscript, we focus on the broad aviation medicine considerations that are required to optimally manage aircrew with established coronary artery disease in those without myocardial infarction or revascularisation (both pilots and non-pilot aviation professionals). We present expert consensus opinion and associated recommendations. It is recommended that in aircrew with non-obstructive coronary artery disease or obstructive coronary artery disease not deemed haemodynamically significant, nor meeting the criteria for excessive burden (based on plaque morphology and aggregate stenosis), a return to flying duties may be possible, although with restrictions. It is recommended that aircrew with haemodynamically significant coronary artery disease (defined by a decrease in fractional flow reserve) or a total burden of disease that exceeds an aggregated stenosis of 120% are grounded. With aggressive cardiac risk factor modification and, at a minimum, annual follow-up with routine non-invasive cardiac evaluation, the majority of aircrew with coronary artery disease can safely return to flight duties.

The challenge of asymptomatic coronary artery disease in aircrew; detecting plaque before the accident.

Coronary events remain a major cause of sudden incapacitation, including death, in both the general population and among aviation personnel, and are an ongoing threat to flight safety and operations. The presentation is often unheralded, especially in younger adults, and is often due to rupture of a previously non-obstructive coronary atheromatous plaque. The challenge for aeromedical practitioners is to identify individuals at increased risk for such events. This paper presents the NATO Cardiology Working Group (HFM 251) consensus approach for screening and investigation of aircrew for asymptomatic coronary disease.A three-phased approach to coronary artery disease (CAD) risk assessment is recommended, beginning with initial risk-stratification using a population-appropriate risk calculator and resting ECG. For aircrew identified as being at increased risk, enhanced screening is recommended by means of Coronary Artery Calcium Score alone or combined with a CT coronary angiography investigation. Additional screening may include exercise testing, and vascular ultrasound imaging. Aircrew identified as being at high risk based on enhanced screening require secondary investigations, which may include functional ischaemia, and potentially invasive coronary angiography. Functional stress testing as a stand-alone investigation for significant CAD is not recommended in aircrew. Aircrew identified with coronary disease require further clinical and aeromedical evaluation before being reconsidered for flying status.

Management of established coronary artery disease in aircrew with previous myocardial infarction or revascularisation.

This manuscript focuses on the broad aviation medicine considerations that are required to optimally manage aircrew with established coronary artery disease (CAD) without myocardial infarction (MI) or revascularisation (both pilots and non-pilot aviation professionals). It presents expert consensus opinion and associated recommendations and is part of a series of expert consensus documents covering all aspects of aviation cardiology.Aircrew may present with MI (both ST elevation MI (STEMI) and non-ST elevation MI (NSTEMI)) as the initial presenting symptom of obstructive CAD requiring revascularisation. Management of these individuals should be conducted according to published guidelines, ideally with consultation between the cardiologist, surgeon and aviation medical examiner. Return to restricted flight duties is possible in the majority of aircrew; however, they must have normal cardiac function, acceptable residual disease burden and no residual ischaemia. They must also be treated with aggressive cardiac risk factor modification. Aircrew should be restricted to dual pilot operations in non-high-performance aircraft, with return to flying no sooner than 6 months after the event. At minimum, annual follow-up with routine non-invasive cardiac evaluation is recommended.

Management of cardiac conduction abnormalities and arrhythmia in aircrew.

Cardiovascular diseases i are the most common cause of loss of flying licence globally, and cardiac arrhythmia is the main disqualifier in a substantial proportion of aircrew. Aircrew ii often operate within a demanding physiological environment, that potentially includes exposure to sustained acceleration (usually resulting in a positive gravitational force, from head to feet (+Gz)) in high performance aircraft. Aeromedical assessment is complicated further when trying to discriminate between benign and potentially significant rhythm abnormalities in aircrew, many of whom are young and fit, have a resultant high vagal tone, and among whom underlying cardiac disease has a low prevalence. In cases where a significant underlying aetiology is plausible, extensive investigation is often required and where appropriate should include review by an electrophysiologist. The decision regarding restriction of flying activity will be dependent on several factors including the underlying arrhythmia, associated pathology, risk of incapacitation and/or distraction, the type of aircraft operated, and the specific flight or mission criticality of the role performed by the individual aircrew.

Heart muscle disease management in aircrew.

This manuscript focuses on the broad aviation medicine considerations that are required to optimally manage aircrew with suspected or confirmed heart muscle disease (both pilots and non-pilot aviation professionals). ECG abnormalities on aircrew periodic medical examination or presentation of a family member with a confirmed cardiomyopathy are the most common reason for investigation of heart muscle disease in aircrew. Holter monitoring and imaging, including cardiac MRI is recommended to confirm or exclude the presence of heart muscle disease and, if confirmed, management should be led by a subspecialist. Confirmed heart muscle disease often requires restriction toflying duties due to concerns regarding arrhythmia. Pericarditis and myocarditis usually require temporary restriction and return to flying duties is usually dependent on a lack of recurrent symptoms and acceptable imaging and electrophysiological investigations.

Contemporaneous management of valvular heart disease and aortopathy in aircrew.

Valvular heart disease (VHD) is highly relevant in the aircrew population as it may limit appropriate augmentation of cardiac output in high-performance flying and predispose to arrhythmia. Aircrew with VHD require careful long-term follow-up to ensure that they can fly if it is safe and appropriate for them to do so. Anything greater than mild stenotic valve disease and/or moderate or greater regurgitation is usually associated with flight restrictions. Associated features of arrhythmia, systolic dysfunction, thromboembolism and chamber dilatation indicate additional risk and will usually require more stringent restrictions. The use of appropriate cardiac imaging, along with routine ambulatory cardiac monitoring, is mandatory in aircrew with VHD.Aortopathy in aircrew may be found in isolation or, more commonly, associated with bicuspid aortic valve disease. Progression rates are unpredictable, but as the diameter of the vessel increases, the associated risk of dissection also increases. Restrictions on aircrew duties, particularly in the context of high-performance or solo flying, are usually required in those with progressive dilation of the aorta.

Congenital heart disease in aircrew.

This article focuses i on the broad aviation medicine considerations that are required to optimally manage aircrew ii with suspected or confirmed congenital heart disease (both pilots and non-pilot aviation professionals). It presents expert consensus opinion and associated recommendations and is part of a series of expert consensus documents covering all aspects of aviation cardiology. This expert opinion was born out of a 3 year collaborative working group between international military aviation cardiologists and aviation medicine specialists, as part of a North Atlantic Treaty Organization (NATO) led initiative to address the occupational ramifications of cardiovascular disease in aircrew (HFM-251) many of whom also work with and advise civil aviation authorities.

Non-coronary cardiac surgery and percutaneous cardiology procedures in aircrew.

This manuscript focuses on the broad aviation medicine considerations that are required to optimally manage aircrew following non-coronary surgery or percutaneous cardiology interventions (both pilots and non-pilot aviation professionals). Aircrew may have pathology identified earlier than non-aircrew due to occupational cardiovascular screening and while aircrew should be treated using international guidelines, if several interventional approaches exist, surgeons/interventional cardiologists should consider which alternative is most appropriate for the aircrew role being undertaken; liaison with the aircrew medical examiner is strongly recommended prior to intervention to fully understand this. This is especially important in aircrew of high-performance aircraft or in aircrew who undertake aerobatics. Many postoperative aircrew can return to restricted flying duties, although aircrew should normally not return to flying for a minimum period of 6 months to allow for appropriate postoperative recuperation and assessment of cardiac function and electrophysiology.

Epidemiology of Airmen Treated with Immunosuppressive Drugs and Vaccination Concerns.

BACKGROUND: Immunosuppressive treatments are increasingly prescribed in a variety of diseases. This issue concerns airmen. METHODS: To assess the problem, we conducted an observational retrospective study in the aircrew population examined in 2014 at the Aeromedical Center of Percy Military Hospital. RESULTS: Airmen treated with immunosuppressive drugs accounted for 0.5% of the total population (N = 13,326). Rheumatic and digestive diseases were the main etiologies, respectively 43% and 35% of cases. One-third of airmen took such medications during at least 3 yr and three-quarters of airmen were declared fit to fly, with some limitations. DISCUSSION: Due to their working conditions, airmen are exposed to a real infectious risk, which is, however, difficult to evaluate. The risk is obviously increased by immunosuppressive drugs and may affect flight safety. Aeromedical evaluation should consider this problem. Vaccination plays a central role in the prevention of infectious risk. Based on French recommendations, we propose a vaccination schedule for these particular patients.Guiu G, Monin J, Hamm-Hornez A-P, Manen O, Perrier E. Epidemiology of airmen treated with immunosuppressive drugs and vaccination concerns. Aerosp Med Hum Perform. 2018; 89(4):377-382.

Progression of early repolarization patterns at a four year follow-up in a female flight crew population: Implications for aviation medicine.

BACKGROUND: To assess the prevalence, the appearance, and the distribution, as well as the fluctuation over time of early repolarization patterns after four years in a female population derived from the French aviation sector. METHODS: This was a retrospective longitudinal study from 1998 to 2010 of a population of female employees who received a full clinical examination and an electrocardiogram (ECG) upon their recruitment and after a period of four years. RESULTS: A total of 306 women were included (average of 25.87 ± 3.3 years of age). The prevalence of early repolarization was 9.2%. The most common appearance was J-point slurring for 64.3% (i.e. 20/28 subjects) that occurred in the inferior leads for 28.6% (i.e. 8/28 subjects). After four years, the prevalence was 7.5%, with a regression of this aspect in five of the subjects. There were no changes in the ECG in terms of the distribution and the appearance among the 23 subjects for whom the aspect persisted. Over the course of this four year period all of the subjects remained asymptomatic. CONCLUSIONS: Early repolarization in this largely physically inactive female population was common, and it fluctuated over time. At present, no particular restrictions can be placed on asymptomatic flight crew who exhibit this feature in the absence of a prior medical history for heart disease.

Prevalence of Intraventricular Conduction Disturbances in a Large French Population.

BACKGROUND: Recommendations for the interpretation of electrocardiogram have been published in 2009. The aim of this study was to define the prevalence of intraventricular conduction disturbances (ICoDs) in a large population, using these recommendations. METHODS: From 01/31/1996 to 09/22/2010, an electrocardiogram was performed at each visit for all aircrew members examined for fitness assessment in an aeromedical center. The prevalence of left bundle branch block (LBBB), right bundle branch block (RBBB), incomplete LBBB, incomplete RBBB, nonspecific intraventricular disturbance (NIVCD), left anterior fascicular block (LAFB), and left posterior fascicular block (LPFB) was measured and compared by age and gender. RESULTS: The global prevalence of ICoD was 3.09% in our population of 69,186 patients. The most frequent types of ventricular blocks were IRBBB (1.25%) and LAFB (1.10%), whereas RBBB (0.46%), LBBB (0.08%), ILBBB (0.03%), NIVCD (0.05%), and LPFB (0.13%) were rare findings. ICoDs are more frequent for males and older age groups (P < 0.001). DISCUSSION: Our results are comparable to studies concerning low cardiovascular risks populations. The association between ICoD and cardiovascular diseases needs to be studied in this population.

Limitations of stroke volume estimation by non-invasive blood pressure monitoring in hypergravity.

BACKGROUND: Altitude and gravity changes during aeromedical evacuations induce exacerbated cardiovascular responses in unstable patients. Non-invasive cardiac output monitoring is difficult to perform in this environment with limited access to the patient. We evaluated the feasibility and accuracy of stroke volume estimation by finger photoplethysmography (SVp) in hypergravity. METHODS: Finger arterial blood pressure (ABP) waveforms were recorded continuously in ten healthy subjects before, during and after exposure to +Gz accelerations in a human centrifuge. The protocol consisted of a 2-min and 8-min exposure up to +4 Gz. SVp was computed from ABP using Liljestrand, systolic area, and Windkessel algorithms, and compared with reference values measured by echocardiography (SVe) before and after the centrifuge runs. RESULTS: The ABP signal could be used in 83.3% of cases. After calibration with echocardiography, SVp changes did not differ from SVe and values were linearly correlated (p<0.001). The three algorithms gave comparable SVp. Reproducibility between SVp and SVe was the best with the systolic area algorithm (limits of agreement -20.5 and +38.3 ml). CONCLUSIONS: Non-invasive ABP photoplethysmographic monitoring is an interesting technique to estimate relative stroke volume changes in moderate and sustained hypergravity. This method may aid physicians for aeronautic patient monitoring.