84rd asma annual scientific meeting german panel chicago...
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84rd AsMA Annual Scientific MeetingGerman Panel
Chicago, Illinois May, 2013
Title
Sudden Incapacitation secondary otolaryngological Events
Author: LtCol Dr. Andreas KnoefflerHead of the ENT Department
German Air Force Institute of Aviation MedicineCommander: Col Dr. Franz Grell
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
I have no financial relationships to disclose.
I will not discuss off-label use and/or investigational use in my presentation
Disclosure Information
84th Annual AsMA Scientific MeetingLtCol Dr. Andreas Knoeffler
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
Agenda:• Introduction• Literature Review• Risk Assessment following special Examinations
• Sleep Apnea• Sinus • Middle ear surgery
• Conclusion
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
Agenda:• Introduction• Literature Review• Risk Assessment following special Examinations
• Sleep Apnea• Sinus • Middle ear surgery
• Conclusion
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
• Noise• Vibrations• Changes of athmospheric pressure• Spatial disorientation• Psychic factors• Climatic factors
Factors
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
• Ears• Vestibular organ• Nose and paranasal sinuses• Oropharynx• Larynx and Pharynx• Neck
Aims of interest
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
“……Incapacitation:A medical event that resulted, or would have had the propensity to result in an inability to act as flight crew for at least 10 min….
…… Impairment:A partial incapacitation associated with symptoms that resulted, or would have had the propensity to result in a reduction of function …………..” *
* The annual incapacitation rate of commercial pilots. Evans S, Radcliffe SA Aviat Space Environ Med 2012 Jan; 83 (1): 42-9
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
“……Incapacitation:A medical event that resulted, or would have had the propensity to result in an inability to act as flight crew for at least 10 min….
…… Impairment:A partial incapacitation associated with symptoms that resulted, or would have had the propensity to result in a reduction of function …………..” *
* The annual incapacitation rate of commercial pilots. Evans S, Radcliffe SA Aviat Space Environ Med 2012 Jan; 83 (1): 42-9
Handlungsunfähigkeit
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
“……Incapacitation:A medical event that resulted, or would have had the propensity to result in an inability to act as flight crew for at least 10 min….
…… Impairment:A partial incapacitation associated with symptoms that resulted, or would have had the propensity to result in a reduction of function …………..” *
* The annual incapacitation rate of commercial pilots. Evans S, Radcliffe SA Aviat Space Environ Med 2012 Jan; 83 (1): 42-9
Beeinträchtigung
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
Agenda:• Introduction• Literature Review• Risk Assessment following special Examinations
• Sleep Apnea• Sinus • Middle ear surgery
• Conclusion
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
Name Country Year Affected Systems Results N
Evans Radcliff UK 2012
Causes of Episodes of temporary Unfitness (not SI)
720ENT 46 (6%)
Accidents (highest) 131 (18%)
In Flight Medical Events Resulting in Notification of Unfitness16
ENT 2 (12,5%)
Rosenquist L et al. Denmark 2008
Barotrauma ear 356 (37.6%)
958Barotrauma sinus 185 (19,3%)
Incapacitated 2%
Zadik et al. Israel 2007Barodontalgia 29 (100%) 27 Patients, 29
EventsBarosinusitis 5 (18,5%)
James an Green UK1967
Sudden incapacitation, Earache/-block153 (7%) 2295
1988 186 (8%) 2209
Newman GATSB
Australia2007
Medical events affecting Accidents and Incidents
98
acute Pain 5 (5,10%)
Pressure Effects 3 (3,06%)
Motion sickness 3 (3,06%)
Spatial disorientation 1 (1,02%)
Gastrointestinal Illnes (highest Score) 21 (21,43%)
Incapacitation /Unfitness following ENT problems – Review:
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
The annual incapacitation rate of commercial pilots. Evans S, Radcliffe SA Aviat Space Environ Med 2012 Jan; 83 (1): 42-9
Evans and Radcliff 2012
• Mandatory Occurence Reporting System (MORS) since 1976• 16145 UK/JAR Professional Pilot Licence Holders (2004)• 36 in Flight incapacitations• 4 sudden deaths in Flight• Male Pilot in the 60`s, 5 time higher risk than a male Pilot in the 40`s• Incapaciation Rate 40/16145 = 0,25%
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
The annual incapacitation rate of commercial pilots. Evans S, Radcliffe SA Aviat Space Environ Med 2012 Jan; 83 (1): 42-9
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
The annual incapacitation rate of commercial pilots. Evans S, Radcliffe SA Aviat Space Environ Med 2012 Jan; 83 (1): 42-9
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
The annual incapacitation rate of commercial pilots. Evans S, Radcliffe SA Aviat Space Environ Med 2012 Jan; 83 (1): 42-9The annual incapacitation rate of commercial pilots. Evans S, Radcliffe SA Aviat Space Environ Med 2012 Jan; 83 (1): 42-9
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
The annual incapacitation rate of commercial pilots. Evans S, Radcliffe SA Aviat Space Environ Med 2012 Jan; 83 (1): 42-9
Evans and Radcliff 2012
Following ENT Events:• Causes of temporary Unfitness 46/720 = 6%• Professional Pilot Incapacitation 1/36 = 2,8%• Causes of Unfit Episode compared to other medical events 3/16 = 19%
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
James M Green R Airline Pilot Incapaciation survey Aviat Environ Med 1991 62: 1068-72
• Questionaire 4345 Aircrew Members• 16 countries• 97 airlines
• Ranking (R) Incidence Incapacitation in flight:• R 1 bowel action 15,2%• R 5 Ear Block 8,5%• R 7 Headache 4,9%• R 10 Nosebleed 1,9%• R 14 Sneezing Attack 0,68%
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
C DeJohn et al. 2004
• Incapacitations and Impairments 1993 -1998• 39 Incapacitations and 11 Impairments aboard 47 aircrafts• Only male Pilots• In Flight Medical Event Rate 0,058/100000 flight/hrs• In flight medicial event would result in an A/C accident is 0.04%• one Impairment following Sinus and Ear Barotrauma (Diversion)• one Incapacitation F/O getting up for Aspirin second. Ear Ache - LOC
In Flight Medical Incapaciation an Impairment of U.S. Airlinbe Pilots: 1993 to 1998C A DeJohn, A M Wolbrink, J G Larcher DOT / FAA /AM-04/16
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
FILES DS, WEBB JT, PILMANIS AA. Depressurization in military aircraft: rates, rapidity, and health effects for 1055 incidents. Aviat Space Environ Med 2005; 76:523–9.
Depressurization in Military Aircraft
• 1055 incidents Rate per Million h: 10,8• 235 Tanker 6,8• 55 Bomber 30,3• 444 Fighter 13• 300 Trainer 6,4• 3 Rcon. /U2 9,5• 18 hours unknown
• 350 incidents with adverse health effects (33,2%)
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
FILES DS, WEBB JT, PILMANIS AA. Depressurization in military aircraft: rates, rapidity, and health effects for 1055 incidents. Aviat Space Environ Med 2005; 76:523–9.
Depressurization in Military Aircraft
350 Incidents involving:• Hypoxia 221 (63,1%)• DCS 83 (23,7%)• Barotrauma 71 (20,2%) Barotrauma alone 57 (16,3%)
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
• 450 Questionairs; 331 answered (73,6%) • Aircrew Israelian Air Force• Fighter (12 case/Resp. 133 ), Heli (9/112), Transporter (6/86)
• Recent dental Restoration 8 (29,6%) • Pulp necrosis / per-apical Peridontitis 5 (18,5%)• Barosinusitis 5 (18,5%)• Irreversible Pulpitis 2 (7,4%)• Faulty Amalgam Rerstauration 1 (3,7%)• Vertical Root Fracture 1 (3,7%)• Impacted Tooth 1 (3,7%)• Unknown 4 (14,8%)
ZADIK Y, ZAPNICK L, GOLDSTEIN L. In-flight barodontalgia: analysis of 29 cases in military aircrew. Aviat Space Environ Med 2007;78:593– 6.
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
Rosenkvist L, Klokker M, Katholm M Upper respiratory infections (URI) and barotraumas in commercial pilots: a retrospective survey. Aviat Space Environ Med 2008 Oct;79(10):960-3.
• Questionaire 920 men / 28 women• 6 month period• Professional Pilots• 356 ≥ 1 ear barotromas (37,6%)• 185 Sinus barotrauma (19,5%)
• frontal Sinus 70-80%• maxillary Sinus 20-30%
• 169 Allergies (17,8%)• Climb (7,1%) Level (2%) Descend (90,9%)• 42,8% went to work in spite of URI
Medical events
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
Dr David G. Newman Pilot Incapacitation: Analysis of Medical Conditions Affecting Pilots Involved in Accidents and Incidents 1 January 1975 to 31 March 2006
ATSB TRANSPORT SAFETY REPORT Aviation Research and Analysis Report - B2006/0170
• Accidents• person dies or• serious injury
• Serius incidents• vehicle destroyed or• seriously damaged
• Incidents• property is destroyed or• seriuosly damaged
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
Dr David G. Newman Pilot Incapacitation: Analysis of Medical Conditions Affecting Pilots Involved in Accidents and Incidents 1 January 1975 to 31 March 2006
ATSB TRANSPORT SAFETY REPORT Aviation Research and Analysis Report - B2006/0170
1975 – 2006:Events: Medical:Accidents 8302 16 (0,19%)Serious incidents 95 1 (9,5%)Incidents 151 941 81 (0,05%)Total 160 338 98 (0,061%)
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
Dr David G. Newman Pilot Incapacitation: Analysis of Medical Conditions Affecting Pilots Involved in Accidents and Incidents 1 January 1975 to 31 March 2006
ATSB TRANSPORT SAFETY REPORT Aviation Research and Analysis Report - B2006/0170
Type of Medical event or Incapacitation(98):Gastrointesinal 21 (21,43%)Heart attack 8 (8,16%)Pressure effects 3 (3,06%)Motion sicknes 3 (3,06%)
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
Agenda:• Introduction• Literature Review• Risk Assessment following special Examinations
• Sleep Apnea• Sinus • Middle ear surgery
• Conclusion
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
0
5
10
15
20
25
30
35
40
HELI FW JET Other
A/C
OSAS vs. A/C
N
BMI
AHI
AHI = 10/h
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
Screening - Special Examaniation - Therapy - Survey
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
Therapeutic Effect* on av. AHI (n/h)
2.88
17.43
0
2
4
6
8
10
12
14
16
18
20
Pretherapeutic Posttherapeutic
Therapeutic Effect on O2-Saturation
81.3
93.3
90.1
95.2
70
75
80
85
90
95
100
AV SaO2 (%) Min SAO2(%)
Pretherapeutic Postherapeutic
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
Agenda:• Introduction• Literature Review• Risk Assessment following special Examinations
• Sleep Apnea• Sinus • Middle ear surgery
• Conclusion
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
Typical findings of the paranasal sinus: Blocked OMC
MRI - Scan CT - Scan
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
fit for flying; 71.92%
unfit for flying; 2.69%
unfit for flying untill sucessfull
treatment; 9.23%
fit for flying with slight signs;
16.15%
Results of first ENT – examination of ever first candidates Results of first ENT – examination of ever first candidates Sinus findings Sinus findings (11/ 2005 – 11/2006; N=429)(11/ 2005 – 11/2006; N=429)
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
Results after treatment N = 28
sucessfullsurgical treatment (FESS)
50%
sucessfullnon-surgical
treatment 32%
remaining unfit for flying
18%
Results of first ENT – examination of ever first candidates Results of first ENT – examination of ever first candidates Sinus findings Sinus findings (11/ 2005 – 11/2006; N=429)(11/ 2005 – 11/2006; N=429)
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
Agenda:• Introduction• Literature Review• Risk Assessment following special Examinations
• Sleep Apnea• Sinus • Middle ear surgery
• Conclusion
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
Electronystagmography
Tympanometry
ENG - Tympanometry
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
Agenda:• Introduction• Literature Review• Risk Assessment following special Examinations
• Sleep Apnea• Sinus • Middle ear surgery
• Conclusion
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
Sudden incapacitations causes by ENT problems in flight are rare (2-8,5%) Male pilots in the 60’s have a 5x higher risk than male pilots in the 40’s ENT events compared to other incapacitating medical events ~ 19%. In flight medical events leading to an a/c accident ~ 0,04% Special risk assessment preventing SI in ENT
Risk assessment sleep apnea:Screening-examination-therapy-survey
Risk assessment sinus:Imaging-endoscopy-hypobaric chamber
Risk assessment ear/middle ear:Otoscopy-tympanometry
AsMA Annual Meeting 2013, Chicago
Sudden Incapacitationsecondary Otolaryngological Events
- German Panel -
LtCol Dr. Andreas KnöfflerGerman Air Force Institute of Aviation MedicineENT DepartmentPB 1264/KFM82242 FürstenfeldbruckTel.: 08141 5360 2015Fax: 08141 5360 2989E-Mail: [email protected]
Thank you for your attention !