ITEM 35. Lungs and Chest

CHECK EACH ITEM IN APPROPRIATE COLUMN Normal Abnormal

I. Code of Federal Regulations

All Classes: 14 CFR 67.113(b)(c), 67.213(b)(c), and 67.313(b)(c)

(b) No other organic, functional, or structural disease, defect, or limitation that the Federal Air Surgeon, based on the case history and appropriate, qualified medical judgment relating to the condition involved, finds -

II. Examination Techniques (Updated 06/26/2024)

Breast examination is not required unless indicated by past medical history (PMH) or symptoms. It may be performed at the discretion of the examiner and applicant.

III. Aerospace Medical Dispositions

The following tables list the most common conditions of aeromedical significance and course of action which should be taken by the AME, as defined by any corresponding protocol and disposition in the table. Medical certificates must not be issued to an applicant with medical conditions that require deferral, or for any condition not listed in the table that may result in sudden or subtle incapacitation without consulting the AMCD or the RFS. In most cases, medical documentation must be submitted for these conditions in order to support an issuance of a medical certificate.

• ALLERGIES
• All Classes
• (Updated 02/25/2026)

For hay fever requiring antihistamines, see the Pharmaceuticals Section, Allergy - Antihistamine & Immunotherapy Medication.

For Alpha-Gal Syndrome (meat allergy), see following page.

ALPHA-GAL SYNDROME (meat allergy) All Classes

(Updated 02/25/2026)

DISEASE/CONDITION	EVALUATION DATA	DISPOSITION
A. History of mild reactions (e.g., hives, swelling, nausea)Symptoms resolved with dietary modification	If the AME can determine the condition is under control, and no symptoms that would interfere with flight or safety-related duties:	ISSUEAnnotate this information in Block 60.
B.• History of a severe reaction (e.g., angioedema, anaphylaxis, presyncope, or syncope)• Symptomatic	Submit the following for FAA review:1. A current, detailed Clinical Progress Note generated from a clinic visit with the Allergist, Gastroenterologist, or treating physician no more than 90 days before the AME exam. It must include:• A detailed summary of the history of the condition;• Current medications, dosage, and side effects (if any);• Exam findings;• Results of any testing performed;• Diagnosis;• Assessment and plan;• Prognosis; and Follow-up.2. It must specifically include the severity and frequency of the reaction(s) or symptoms as well as the likelihood of them reoccurring.3. Lab. Results of alpha-gal IgE level or any testing clinically indicated.	DEFERSubmit the information to the FAA for a possible Special IssuanceAnnotate (elements or findings) in Block 60.

ASTHMA (Reactive Airway Disease) All Classes (Updated 09/24/2025)

DISEASE/CONDITION	EVALUATION DATA	DISPOSITION
A. History of childhood asthma, resolvedORAsthma caused by a specific and avoidable trigger (e.g. exposure to pet or animal dander, specific foods etc.) managed by avoidance and use of as needed (PRN) rescue inhalerORExercise-induced bronchoconstriction (a.k.a. exercise-induced asthma), treated with as needed (PRN) rescue inhaler only	If the AME can determine the individual has no symptoms that would interfere with flight or safety related duties:	ISSUEAnnotate this information in Block 60.
B. Intermittent or mild persistent	See the CACI -Asthma Worksheet.This requires a current, detailed Clinical Progress Note and spirometry.If the pilot meets all CACI worksheet criteria and is otherwise qualified:	If the pilot meets all CACI worksheet criteria and is otherwise qualified,ISSUE With no time limitationAnnotate the correct CACI statement in Block 60 and keep the required supporting information on file.
C. Moderate or Severe persistent	Submit the following for FAA review:1. A current, detailed Clinical Progress Note generated from a clinic visit with the treating Pulmonologist no more than 90 days before the AME exam. It must include:• A detailed summary of the history of the condition;• Current medications, dosage, and side effects (if any);• Ophthalmological exam findings;• Results of any testing performed;• Diagnosis;• Assessment and plan;• Prognosis; and Follow-up.2. The Clinical Progress note must specifically include:• the disease course and severity including flare(s),• hospitalizations or intubations,• treatment history,• duration of symptoms,• how long the condition has been stable,• if any upcoming treatment change is planned or expected; and• does the condition severity limit activities.3. Pulmonary functions test (PFTs) performed within the past 90 days. PFTs must be both pre-and post-bronchodilator and include flow volume loops.4. Copies of any other testing already performed	DEFERSubmit the information to the FAA for a possible Special IssuanceAnnotate (elements or findings) in Item 60.

CACI - Asthma Worksheet

(Updated 09/24/2025) To determine the applicant’s eligibility for certification, the AME must review a current, detailed Clinical Progress Note generated from a clinic visit with the treating physician or specialist no more than 90 days prior to the AME exam. If the applicant meets ALL the acceptable certification criteria listed below, the AME can issue. Applicants for first- or second- class must provide this information annually; applicants for third-class must provide the information with each required exam.

AME MUST NOTE in Block 60 one of the following:

[ ] CACI qualified asthma. (Documents do not need to be submitted to the FAA.)

[ ] Has current OR previous SI/AASI but now CACI qualified asthma.

[ ] NOT CACI qualified asthma. I have deferred. (Submit supporting documents.)

• PECTUS EXCAVATUM
• All Classes
• (Updated 08/28/2024)

DISEASE/CONDITION	EVALUATION DATA	DISPOSITION
A. Asymptomatic;Mild;ORSurgically corrected	If the AME can determine the condition has fully resolved without sequelae with no symptoms or current problems that would interfere with flight duties:	ISSUE Annotate this information in Block 60.If any underlying cause is found, see that section.
B. SymptomaticORAffects cardiac or pulmonary function	Submit the following for FAA review:1. The most recent, detailed Clinical Progress Note generated from a clinic visit with the treating physician. It must include:• A detailed summary of the history of the condition;• Current medications, dosage, and side effects (if any);• Physical exam findings;• Results of any testing performed;• Diagnosis;• Assessment and plan;• Prognosis; and• Follow-up.2. Copies of any testing already performed such as pulmonary function tests, cardiac echo, cardiac MRI, stress testing, etc.If the AME has concerns with the applicant’s ability to operate the aircraft during routine or emergency procedures, explain in Block 60.	DEFERSubmit the information to the FAA for a possible Special IssuanceAnnotate (elements or findings) in Block 60.

Chronic Obstructive Pulmonary Disease (COPD); Emphysema; Chronic Bronchitis All Classes

(Updated 08/26/2026)

DISEASE/CONDITION	EVALUATION DATA	DISPOSITION
A. GOLD stage 1A or 2A on multi-dimensional assessment of COPDAND• Oxygen saturation (SpO2) is 96% or higher at rest, on room air (without supplemental oxygen)• Postbronchodilator FEV1 is 61% or higher• 6-minute walk test findings: o 1-3% drop in SpO2 from baseline AND o Walked 400 meters or more• Treated with 3 or fewer medications (excluding a rescue inhaler)• NOT taking daily oral steroidALL OTHERS, see Row B	Submit the following:1. The COPD Status Summary (to expedite case processing);2. A current, detailed Clinical Progress Note from the treating physician or a board-certified Pulmonologist no more than 90 days before the AME exam;3. The progress note must specifically include:• History of the condition (how it was diagnosed, past and current treatments);• Current disease severity utilizing GOLD multi-dimensional assessment;• History of acute exacerbations or other complications;• Medication list noting presence or absence of side effects and dates used;• Physical exam findings;• Treatment plan; and• Prognosis;4. Pulmonary Function Test (PFT) performed no more than 90 days before the AME exam. PFT must be both preand post-bronchodilator and include flow volume loops;5. Current 6-minute walk test;6. Labs to include CBC within the past 90 days and any other tests deemed indicated or already performed; and7. Results of any tests/ imaging already performed	DEFERSubmit the information to the FAA for a possible Special IssuanceAnnotate (elements or findings) in Item 60.
B. All others (or any of the following)Any GOLD stage other than 1A or 2A on multidimensional assessment of COPDOR• Oxygen saturation (SpO2) is 95% or less at rest, on room air (without supplemental oxygen) OR• Postbronchodilator FEV1 is 60% predicted or less OR• 6-minute walk test findings: o Greater than 3% drop in SpO2 from baseline OR o Walked less than 400 meters OR• Treated with 4 or more medications, (excluding a rescue inhaler) OR• Daily oral steroid use	Submit the following:ALL items in Row AHowever:• The evaluation, and current, detailed Clinical Progress Note must be from a board-certified PULMONOLOGIST• Pulmonary Function Test (PFT) must include DLCO, both pre- and postbronchodilator, and include flow volume loops	DEFERSubmit the information to the FAA for a possible Special IssuanceAnnotate (elements or findings) inItem 60.

Chronic Obstructive Pulmonary Disease (COPD) Status Summary (Updated 06/28/2023) Name: _______________________________ Birthdate: ______________________ Applicant ID: __________________________ PI#: ___________________________

Please have your Pulmonologist or the physician who manages your COPD provide the requested information in the space provided. Submit this summary and a current, detailed Clinical Progress Note addressing each item. Attach a copy of Pulmonary Function Test (#3) and the 6-minute Walk Test results (#4) and submit to your AME or mail to the FAA:

• Federal Aviation Administration
• Civil Aerospace Medical Institute, Building 13

Aerospace Medical Certification Division, AAM-300, PO Box 25082 Oklahoma City, OK 73125-9867

For stage criteria, see the Global

Initiative for Chronic Lung Disease

(GOLD) pocket guide app.

Is the Post-bronchodilator FEV1 greater than 60% predicted:

Do the results verify:

5. Medications.

________________________________________________ __________________ Treating Physician Signature (Circle: Pulmonologist; PCP; Other) Date of Evaluation

________________________________________________ __________________ Name or Office Stamp Phone Number

• YES NO
• YES NO
• YES NO

Attach test results.

YES NO

Attach test results.

YES NO

• DISEASE OF THE LUNGS, PLEURA, OR MEDIASTINUM
• All Classes
• (Updated 9/24/2025)

• CYSTIC FIBROSIS
• All Classes
• (Updated 09/30/2026)

DISEASE/CONDITION	EVALUATION DATA	DISPOSITION
A. Cystic Fibrosis	Submit the following for FAA review:1. A current, detailed Clinical Progress Note generated from a clinic visit with a board-certified Pulmonologist associated with an accredited Cystic Fibrosis Care Center no more than 90 days before the AME exam.It should include a summary of the history of the condition or diagnosis; current medications, dosages, and side effects (if any); clinical exam findings; results of any testing performed; diagnosis; assessment and plan (prognosis); and follow-up.2. It must specifically include:a. Summary of multi-disciplinary care b. Current functional status and symptoms c. All medications and any side effects d. Physical exam findings e. Treatment plan3. Pulmonary Function Test (PFTs) with DLCO performed within the past 90 days.4. Current 6-Minute Walk Test (6MWT) performed no more than 90 days prior to the AME exam.5. Current lab performed no more than 90 days prior to the AME exam.a. CBC - complete blood count b. CMP - comprehensive metabolic panel c. OGTT - oral glucose tolerance test (not a hemoglobin A1c)6. Reports from all other studies (lab, imaging) already performed for this condition.	DEFERSubmit the information to the FAA for a possible Special Issuance.Annotate (elements or findings) in Item 60.

• PULMONARY FIBROSIS
• All Classes
• (Updated 09/24/2025)

DISEASE/CONDITION	EVALUATION DATA	DISPOSITION
A. Idiopathic Pulmonary Fibrosis	Submit the following for FAA review:1. A current, detailed Clinical Progress Note generated from a clinic visit with a boardcertified Pulmonologist no more than 90 days prior to the AME exam. It must include:• A detailed summary of the history of the condition;• Current medications, dosage, and side effects (if any);• Physical exam findings;• Results of any testing performed;• Diagnosis; assessment and plan;• Prognosis; and follow-up.2. The Clinical Progress Note must specifically include:• Current disease severity,• GAP score,• History of acute exacerbations or other complications3. Pulmonary Function Test (PFTs) with DLCO performed within the past 90 days4. Current 6-Minute Walk Test (6MWT) per FAA protocol5. Results of tests/ imaging already performed (such as High-Resolution CT or arterial blood gas).	DEFERSubmit the information to the FAA for a possible Special Issuance.Annotate (elements or findings) in Item 60.
B. Secondary Pulmonary FibrosisDue to a known cause (See corresponding page)	Submit the following for FAA review:• All Evaluation Data in Row A and• Any information required for the underlying condition.	DEFERSubmit the information to the FAA for a possible Special Issuance.Annotate (elements or findings) in Item 60.

PULMONARY HYPERTENSION (Pulmonary HTN)

All Classes

(Updated 09/30/2026)

DISEASE/CONDITION	EVALUATION DATA	DISPOSITION
A.WHO Group 1:Pulmonary Arterial Hypertension (PAH)	Submit the following for FAA review:1. A current, detailed Clinical Progress Note generated from a clinic visit with their treating pulmonologist no more than 90 days before the AME exam.It should include a summary of the history of the condition or diagnosis; current medications, dosages, and side effects (if any); clinical exam findings; results of any testing performed; diagnosis; assessment and plan (prognosis); and follow-up.2. It must specifically include a discussion of WHO Functional Class and changes over time.3. Pulmonary Function Test (PFTs) with DLCO performed within the past 90 days.4. Chest Computed Tomography (CT) from the most recent test.5. Echocardiogram (Echo) with bubble study. Report from a 2-D and Doppler flow study performed no more than 90 days prior to the AME exam.6. 24-hour cardiac monitor performed no more than 90 days prior to the AME exam. ≥ 24-hour cardiac monitor (such as a Holter, Zio Patch, etc.). It should have atrial and ventricular ectopic counts; hourly tabular data to include the longest pause duration and counts of all pauses > 2.0 or 2.5 seconds; heart rate (max, min, and average); other histograms and frequency graphs; and percentage of atrial fibrillation/flutter.7. Current 6-Minute Walk Test (6MWT) per FAA protocol OR an Exercise stress test (EST) performed no more than 90 days prior to the AME exam.	DEFERSubmit the information to the FAA for a possible Special Issuance
	8. Reports from all other studies performed for PAH (ex. Right heart catheterization).9. All other relevant testing related to PAH (lab work, rheumatology or hematology notes, biopsy results if performed, sleep study).
B. WHO Group 2:Pulmonary Hypertension (PH)Due to Left-sided heart disease	Submit the following for FAA review:1. A current, detailed Clinical Progress Note generated from a clinic visit with their treating cardiologist no more than 90 days before the AME exam.It should include a summary of the history of the condition or diagnosis; current medications, dosages, and side effects (if any); clinical exam findings; results of any testing performed; diagnosis; assessment and plan (prognosis); and follow-up.2. Echocardiogram (Echo) with bubble study. Report from a 2-D and Doppler flow study performed no more than 90 days prior to the AME exam.3. 24-hour cardiac monitor performed no more than 90 days prior to the AME exam. ≥ 24-hour cardiac monitor (such as a Holter, Zio Patch, etc.). It should have atrial and ventricular ectopic counts; hourly tabular data to include the longest pause duration and counts of all pauses > 2.0 or 2.5 seconds; heart rate (max, min, and average); other histograms and frequency graphs; and percentage of atrial fibrillation/flutter.	DEFERSubmit the information to the FAA for a possible Special Issuance
	4. Exercise stress test (EST) performed no more than 90 days prior to the AME exam.5. Reports from all other studies performed for PAH (ex. heart catheterization).6. All other relevant testing related to PAH (lab work, rheumatology or hematology notes, biopsy results if performed, sleep study).7. Any other documentation as required for Left Heart Disease (e.g. CHD protocol).
C. WHO Groups 3-5Pulmonary HTN due to:Group 3: lung diseaseGroup 4: pulmonary embolism such as CTEPHGroup 5: blood, inflammatory, kidney disease or rare disorders	Submit the following for FAA review:• All items in Row A AND(additional items based on group)Group 3:• All additional requirements based on lung disease (i.e. OSA, COPD, ILD, etc.Group 4• Pulmonary Embolism Requirements• Hypercoagulable evaluationGroup 5• A current, detailed Clinical Progress Note generated from a clinic visit with their treating hematologist or rheumatologist or other boardcertified specialist discussing the underlying disorder no more than 90 days before the AME exam.• Any additional lab work and imaging performed for the underlying condition.	DEFERSubmit the information to the FAA for a possible Special Issuance

Note: If primary (essential) or secondary hypertension (HTN / high blood pressure), see that page.

• PULMONARY (LUNG NODULE)
• All Classes
• (Updated 9/30/2026)

DISEASE/CONDITION	EVALUATION DATA	DISPOSITION
A. Incidental findingANDNo indication in clinical record or exam of an associated aeromedically relevant condition.	If the AME can determine there are no symptoms or current problems that would interfere with flight duties and no ongoing treatment or surveillance needed:	ISSUESummarize findings in Item 60.
B. If associated with another aeromedically relevant conditionORSuspicious of lung cancerSee that page	See that page

• PLEURA AND PLEURAL CAVITY
• All Classes
• (Updated 9/24/2025)

*A history of a single episode of spontaneous pneumothorax is considered disqualifying for airman medical certification until there is x-ray evidence of resolution and until it can be determined that no condition that would be likely to cause recurrence is present (i.e., residual blebs). On the other hand, an individual who has sustained a repeat pneumothorax normally is not eligible for certification until surgical interventions are carried out to correct the underlying problem. A person who has such a history is usually able to resume airmen duties 3 months after the surgery. No special limitations on flying at altitude are applied.

• SARCOID (Sarcoidosis, Neurosarcoidosis, Cardiac Sarcoid)
• All Classes
• (Updated 08/26/2026)

DISEASE/CONDITION	EVALUATION DATA	DISPOSITION
A. Pulmonary Stage 1(bilateral hilar lymphadenopathy alone)	The AME should review a completed and signed Sarcoid or Sarcoidosis Status Summary from the pulmonologist OR a detailed clinical progress note which addresses all itemsIf all items fall into the “YES” column, the individual meets vision standards, and the AME has no concerns:	ISSUEAnnotate Block 60 and submit the evaluation to the FAA for retention in the file.
B. Pulmonary Stage 2 or greaterOROther organ involvement such as• skin,• eye,• liver,• bone marrow,• spleen,• kidney,• musculoskeletal.ORSarcoid with hypercalcemiaAll items marked with a ^ must be performed no more than 90 days prior to the AME exam.	Submit the following for FAA review:1. Detailed clinical progress note^ (within the past 90 days) from a board-certified Pulmonologist, Rheumatologist or Internist, to include systems affected and physical exam emphasizing lung, heart, liver, spleen, and skin. Include a thorough neurological examination. Identify the current stage of pulmonary sarcoidosis, if present.2. Labs^• Complete Blood Count (CBC),• Complete Metabolic Panel (CMP),• Serum Calcium, and• Urinalysis.3. Chest X-ray report^ and most recent chest CT report (if performed)4. Pathology reports from all biopsies to confirm sarcoidosis diagnosis5. Tuberculosis (TB) testing if pulmonary sarcoidosis present.6. Pulmonary Function Test (PFT) to include flow volume loops, spirometry, lung volumes, and DLCO^.7. 6-minute walk test^8. Eye evaluation by an ophthalmologist^9. 12-lead ECG^10. Cardiac monitoring study of at least 24 hours, such as Holter monitor^11. Most recent brain MRI with contrast	DEFER Submit the information to the FAA for a possible Special IssuanceAnnotate (elements or findings) in Block 60.
C. Cardiac sarcoidosisOrNervous system involvement (Neurosarcoidosis)	Submit the following for FAA review:1. All items in Row B 2. Include any information that supports disease stability. 3. Items specified for cardiac or neurological sarcoidosis below.Cardiac sarcoidosisalso submit:• Detailed clinical progress note from a boardcertified Cardiologist (within the past 90 days)• Report from the most recent echocardiogram• Report from the most recent Cardiac MRI• Cardiac monitoring study (event monitor) of at least 30 daysNeurologic sarcoidosis is present also submit:• Neurological Evaluation per FAA specifications (within past 90 days)• Brain MRI with contrast since initial diagnosis or most recent brain MRI if new symptoms have developed since last evaluation• All neuroimaging on CD in DICOM format• Lumbar puncture results (if performed)	DEFER Submit the information to the FAA for a possible Special IssuanceAnnotate (elements or findings) in Block 60.

SARCOID or SARCOIDOSIS STATUS SUMMARY

(Updated 09/24/2025) Name ________________________________ Birthdate ______________________

Applicant ID# __________________________ PI#___________________________

Please have the pulmonologist or physician who treats your Sarcoid/Sarcoidosis complete, sign, and date this sheet or submit a current, detailed Clinical Progress Note that addresses ALL items below.

*If any YES answers, please attach narrative, tests, etc.

Treating Provider Signature Date

_______________________________________________ _______________________ Name or Office Stamp Phone Number

Note: If you are diagnosed with Pulmonary stage 2 or above, or if any other organs are affected, please consult the disposition table to find the list of additional required documents.

AME Actions:

• BRONCHIECTASIS
• All Classes
• (Updated 08/27/2025)

DISEASE/CONDITION	EVALUATION DATA	DISPOSITION
A. All stages/severity, symptomatic or asymptomaticIf the cause of bronchiectasis is cystic fibrosis, see that section.	Submit the following for FAA review:1. A current, detailed Clinical Progress Note generated from a clinic visit with a boardcertified Pulmonologist no more than 90 days prior to the AME exam. It must include:• A detailed summary of the history of the condition;• Current medications, dosage, and side effects (if any);• Physical exam findings;• Results of any testing performed;• Diagnosis; assessment and plan;• Prognosis; and follow-up.2. The Clinical Progress Note must specifically include:• current disease severity;• history of acute exacerbations or other complications; and• dates medication used3. Spirometry within the past 90 days.4. A 6-minute walk test performed within the past 90 days.5. Lab.• Complete Blood Count (CBC) performed within the past 90 days.• Copies of other labs already performed or clinically indicated (such as alpha-1 antitrypsin).6. Results of tests/ imaging already performed (such as Chest X-ray and/or High-Resolution CT (computed tomography).	DEFERSubmit the information to the FAA for a possible Special Issuance.Annotate (elements or findings) in Item 60.

SLEEP APNEA

(Updated 05/27/2026)

• RESTLESS LEG SYNDROME (RLS)
• All Classes
• (Updated 01/25/2023)

DISEASE/CONDITION	EVALUATION DATA	DISPOSITION
Restless Leg Syndrome (RLS)	Submit the following for FAA review:1. A current, detailed Clinical Progress Note from a clinic visit with the treating physician no more than 90 days before the AME exam. It should include a detailed summary of the history of the condition, current medications, dosage, and side effects (if any); physical exam findings; results of any testing performed; diagnosis; assessment and plan (prognosis), and follow-up.2. It must specifically include:• Etiology and presence or absence of excessive daytime sleepiness (EDS), disruptive sleep, and presenting symptoms (if any); and• Current medication list. Specifically annotate medication used to treat RLS or sleep disorder(s) (name, dose, frequency, and side effects, if any).3. Lab performed no more than 90 days before the AME exam to include:• Complete blood count (CBC); and• Ferritin level4. Sleep study (polysomnography)results if already performed.Note: The FAA may request a sleep study for certification determination in some cases.	DEFER Submit the information to the FAA for a possible Special Issuance.