aviation hypoxia, cognition and human...
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Aviation hypoxia, cognition and human performance
Dr Thomas Smith MBBS DPhil FRCA
Academic Clinical Lecturer in Anaesthetics, University of Oxford, UKFellow of University College, Oxford, UK
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Disclosure Information84th Annual AsMA Scientific Meeting
Dr Thomas Smith
I have no financial relationships to disclose
I will not discuss off-label use and/or investigational use in my presentation
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“Anoxaemia not only stops the machine, it wrecks the machinery”
- J.S. Haldane
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Does aviation hypoxia impair cognition and performance?
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Does aviation hypoxia impair cognition and performance?
Could aviation hypoxia negatively impact CRM?
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Does aviation hypoxia impair cognition and performance?
Could aviation hypoxia negatively impact CRM?
We don’t know
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Time of useful consciousness
20,000 ft 30+ minutes
25,000 ft 3-5 minutes
30,000 ft 1-2 minutes
35,000 ft 30-60 seconds
40,000 ft 15-20 seconds
45,000 ft 10 seconds
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Commercial airline cabin
5,000 – 8,000 ft
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Commercial airline cabin
5,000 – 8,000 ft
Denver
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Commercial airline cabin
5,000 – 8,000 ft
Denver Mexico City
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Physiological effects of aviation hypoxia
↑ ventilation (ventilatory acclimatisation to hypoxia)
Fatemian M et al. Pflugers Arch - Eur J Physiol 2001
↑ erythropoietin secretion
Gunga HC et al. Lancet 1996
↑ pulmonary artery pressure (hypoxic pulmonary vascostriction)
Smith TG et al. Aviat Space Environ Med 2012
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How hypoxic are commercial aircrew?
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How hypoxic are commercial aircrew?
38 pilots on 21 flights
Peak cabin altitude range 6,000-8,550 ft
Cottrell JJ. Aviat Space Environ Med 1995
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How hypoxic are commercial aircrew?
38 pilots on 21 flights
Peak cabin altitude range 6,000-8,550 ft
Mean nadir SpO2 89%
Cottrell JJ. Aviat Space Environ Med 1995
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How hypoxic are commercial aircrew?
38 pilots on 21 flights
Peak cabin altitude range 6,000-8,550 ft
Mean nadir SpO2 89%
Range nadir SpO2 93-80%
Cottrell JJ. Aviat Space Environ Med 1995
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How hypoxic are commercial aircrew?
38 pilots on 21 flights
Peak cabin altitude range 6,000-8,550 ft
Mean nadir SpO2 89%
Range nadir SpO2 93-80%
Half desaturated below SpO2 90%
Cottrell JJ. Aviat Space Environ Med 1995
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How hypoxic are commercial aircrew?
38 pilots on 21 flights
Peak cabin altitude range 6,000-8,550 ft
Mean nadir SpO2 89%
Range nadir SpO2 93-80%
Half desaturated below SpO2 90%
Cottrell JJ. Aviat Space Environ Med 1995
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What about cerebral oxygenation?
Weatherall A et al. Acta Anaesthesiol Scand 2012
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What about cerebral oxygenation?
volunteers ascending to altitude
Sea level: 69%
2,400 m: 68%
Wolff CB et al. Adv Exp Med Biol 2007
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What about cerebral oxygenation?
17 paediatric helicopter transport patients
Sea level: 69%
> 5,000 ft: 66%
Stroud MH et al. Pediatr Emerg Care 2012
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What about cerebral blood flow and autoregulation?
13 volunteers breathing 15% oxygen for 5 hours
Nishimura N et al. J Appl Physiol 2010
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What about cerebral blood flow and autoregulation?
13 volunteers breathing 15% oxygen for 5 hours
Fall in cerebral blood flow velocity (accompanying the ↓ CO2)
Nishimura N et al. J Appl Physiol 2010
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What about cerebral blood flow and autoregulation?
13 volunteers breathing 15% oxygen for 5 hours
Fall in cerebral blood flow velocity (accompanying the ↓ CO2)
Impaired dynamic cerebral autoregulation
Nishimura N et al. J Appl Physiol 2010
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Does aviation hypoxia impair neuro-cognitive performance?
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Does aviation hypoxia impair neuro-cognitive performance?
Several studies have examined psychomotor and cognitive tasks at 5,000-8,000 ft
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Does aviation hypoxia impair neuro-cognitive performance?
Several studies have examined psychomotor and cognitive tasks at 5,000-8,000 ft
Early work in the 1960s established that the ability to respond to novels tasks is affected by mild hypoxia
Denison DM et al. Aerosp Med 1966
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Does aviation hypoxia impair neuro-cognitive performance?
Several studies have examined psychomotor and cognitive tasks at 5,000-8,000 ft
Early work in the 1960s established that the ability to respond to novels tasks is affected by mild hypoxia
Denison DM et al. Aerosp Med 1966
Some subsequent studies have replicated these findings, others have not
Paul MA et al. Aviat Space Environ Med 1994
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One suggested hierarchy of hypoxic thresholds:
Threshold Affected functions
5,000 ft Light sensitivity of the dark-adapted eye
8,000 ft Short- and long-term memory
10,000 ft Complex hand-eye co-ordinationPerformance on previously learnt coding and conceptual reasoning tasks
12,000 ft Performance on pursuit motor tasksChoice reaction time on well learned tasks
15,000 ft Fine hand tremor reduces ability to make precise adjustments
16,000 ft Simple reaction time increased
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One suggested hierarchy of hypoxic thresholds:
Threshold Affected functions
5,000 ft Light sensitivity of the dark-adapted eye
8,000 ft Short- and long-term memory
10,000 ft Complex hand-eye co-ordinationPerformance on previously learnt coding and conceptual reasoning tasks
12,000 ft Performance on pursuit motor tasksChoice reaction time on well learned tasks
15,000 ft Fine hand tremor reduces ability to make precise adjustments
16,000 ft Simple reaction time increased
But the literature is conflicting for altitudes up to 10,000 ft
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A good review of the subject covering 8,000-15,000 ft:
Petrassi FA, Hodkinson PD, Walters PL, Gaydos SJ.
Hypoxic hypoxia at moderate altitudes: review of the state of the
science. Aviat Space Environ Med 2012; 83(10): 975-84.
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A good review of the subject covering 8,000-15,000 ft:
Petrassi FA, Hodkinson PD, Walters PL, Gaydos SJ.
Hypoxic hypoxia at moderate altitudes: review of the state of the
science. Aviat Space Environ Med 2012; 83(10): 975-84.
“Undoubtedly, most readers are familiar with Reason’s Swiss
cheese model of human error, and it is with ease that one can
imagine hypoxic hypoxia opening new holes (or enlarging
existing ones) with respect to HFACS accident preconditions.”
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Hypoxia symptoms ≤ 8,000 ft in helicopter aircrew
53 aircrew surveys
Smith A. Aviat Space Environ Med 2005
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Hypoxia symptoms ≤ 8,000 ft in helicopter aircrew
53 aircrew surveys
76% had experienced symptoms of hypoxia
- difficulty with calculations
- light-headedness
- delayed reaction time
- mental confusion
Smith A. Aviat Space Environ Med 2005
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Hypoxia symptoms ≤ 8,000 ft in helicopter aircrew
53 aircrew surveys
76% had experienced symptoms of hypoxia
- difficulty with calculations
- light-headedness
- delayed reaction time
- mental confusion
Symptoms as low as 6,500 ft
Smith A. Aviat Space Environ Med 2005
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Abridged narratives from aircrew
A loadmaster took 35 min to complete the takeoff and landing data
(TOLD) card at an altitude of ~ 7,500 ft (2,286 m).
(Note: a TOLD card would normally take ~ 5 min to complete.)
Smith A. Aviat Space Environ Med 2005
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Abridged narratives from aircrew
During an approach to a confined landing zone at 8,000 ft (2,438 m), an
experienced loadmaster instructor stopped calling ground clearance
distances. He did not respond appropriately to prompting from the
other loadmaster and was unable to participate in the landing
procedure.
Smith A. Aviat Space Environ Med 2005
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Abridged narratives from aircrew
When approaching a landing zone at 8,000 ft (2,438 m), a loadmaster
was unable to complete the TOLD card and became "unable to
complete [his] flying duties," requiring the aircraft to complete the
mission with a single effective loadmaster.
Smith A. Aviat Space Environ Med 2005
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Abridged narratives from aircrew
While cruising at 8,000 ft (2438 m), the co-pilot had to take control of
the aircraft when he noticed the handling pilot had become "euphoric"
and wanted to keep climbing. The affected pilot recovered when the
aircraft descended to a lower altitude.
Smith A. Aviat Space Environ Med 2005
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Conclusions
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Conclusions
Aircraft cabin hypoxia (5,000-8,000 ft) probably impairs aspects of
human performance and may consequently degrade CRM for aircrew
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Conclusions
Aircraft cabin hypoxia (5,000-8,000 ft) probably impairs aspects of
human performance and may consequently degrade CRM for aircrew
This applies to aeromedical crew too!