Comparison of hypobaric hypoxia symptoms between a recalled exposure and a current exposure

Oxygen Saturation Curve Analysis in 2298 Hypoxia Awareness Training Tests of Military Aircrew Members in a Hypobaric Chamber

We aim to provide reference values for military aircrews participating in hypoxia awareness training (HAT). We describe several parameters with potential biomedical interest based on selected segments and slopes of the changes in oxygen saturation (SatO2) during a standard HAT. A retrospective analysis of 2298 records of the SatO2 curve was performed, including 1526 military men aged 30.48 ± 6.47 years during HAT in a hypobaric chamber. HAT consisted of pre-oxygenation at 100% and an ascent to 7620 m, followed by O2 disconnection starting the phase of descent of SatO2 until reaching the time of useful consciousness (TUC), and finally reconnection to 100% O2 in the recovery phase. Using an ad hoc computational procedure, the time taken to reach several defined critical values was computed. These key parameters were the time until desaturation of 97% and 90% (hypoxia) after oxygen mask disconnection (D97/D90) and reconnection (R97/R90) phases, the time of desaturation (TUC-D97) and hypoxia (TUC-D90) during disconnection, the total time in desaturation (L97) or hypoxia (L90), and the slopes of SatO2 drop (SDSAT97 and SDSAT90) and recovery (SRSAT97). The mean of the quartiles according to TUC were compared by ANOVA. The correlations between the different parameters were studied using Pearson's test and the effect size was estimated with ω2. Potentially useful parameters for the HAT study were those with statistical significance (p < 0.05) and a large effect size. D97, D90, R97, and R90 showed significant differences with small effect sizes, while TUC-D97, TUC-D90, L97, L90, and SDSAT97 showed significant differences and large effect sizes. SDSAT97 correlated with TUC (R = 0.79), TUC-D97 (R = 0.81), and TUC-D90 (R = 0.81). In conclusion, several parameters of the SatO2 curve are useful for the study and monitoring of HAT. The SDSAT97 measured during the test can estimate the TUC and thus contribute to taking measures to characterize and protect the aircrew members.

A preventative role of nitrate for hypoxia-induced intestinal injury

BACKGROUND

Studying effective interventions for hypoxia-induced injury is crucial, particularly in high-altitude areas. Symptoms stemming from intestinal injuries have a significant impact on the health of individuals transitioning from plains to plateau regions. This research explores the effects and mechanisms of nitrate supplementation in preventing hypoxia-induced intestinal injury.

METHODS

A hypoxia survival mouse model was established using 7% O2 conditions. The intervention with 4 mM sodium nitrate (NaNO3) in drinking water commenced 7 days prior to hypoxia exposure. Weight monitoring, hematoxylin and eosin (HE) staining, transmission electron microscopy (TEM), and intestinal permeability assays were employed for physiological, histological, and functional analyses. Quantitative PCR (qPCR), Western blot, and immunofluorescence were utilized to analyze the levels of tight junction (TJ) proteins and hypoxia-inducible factor 1α (Hif 1α). RNA sequencing (RNA-seq) identified nitrate's target, and chromatin immunoprecipitation (ChIP) verified the transcriptional impact of Hif 1α on TJ proteins. Villin-cre mice infected with AAV9-FLEX-EGFP-Hif 1α were used for mechanism validation.

RESULTS

The results demonstrated that nitrate supplementation significantly alleviated small intestinal epithelial cell necrosis, intestinal permeability, disruption of TJs, and weight loss under hypoxia. Moreover, the nitrate-triggered enhancement of TJs is mediated by Hif 1α nuclear translocation and its subsequent transcriptional function. The effect of nitrate supplementation on TJs was largely attributed to the stimulation of the EGFR/PI3K/AKT/mTOR/Hif 1α signaling pathways.

CONCLUSION

Nitrate serves as a novel approach in preventing hypoxia-induced intestinal injury, acting through Hif 1α activation to promote the transcription of TJ proteins. Furthermore, our study provides new and compelling evidence for the protective effects of nitrate in hypoxic conditions, especially at high altitudes.

Personal Hypoxia Symptoms Vary Widely Within Individuals

INTRODUCTION: Exposure to high ambient altitudes above 10,000 ft (3048 m) over sea level during aviation can present the risk of hypobaric hypoxia. Hypoxia can impair sensory and cognitive functions, degrading performance and leading to mishaps. Military aircrew undergo regular hypoxia familiarization training to recognize their symptoms and understand the consequences of hypoxia. However, over the years, aviators have come to believe that individuals have a "personal hypoxia signature." The idea is that intraindividual variability in symptom experience during repeated exposure is low. In other words, individuals will experience the same symptoms during hypoxia from day to day, year to year.METHODS: We critically reviewed the existing literature on this hypothesis. Most studies that claim to support the notion of a signature only examine group-level data, which do not inform individual-level consistency. Other studies use inappropriate statistical methods, while still others do not control for accuracy of recall over the period of years. To combat these shortcomings, we present a dataset of 91 individuals who completed nearly identical mask-off, normobaric hypoxia exposures days apart.RESULTS: We found that for every symptom on the Hypoxia Symptom Questionnaire, at least half of the subjects reported the symptom inconsistently across repeated exposure. This means that, at best, 50% of subjects did not report the same symptom across exposures.DISCUSSION: These data provide compelling evidence against the existence of hypoxia signatures. We urge that hypoxia familiarization training incorporate these findings and encourage individuals to expect a wide range of hypoxia symptoms upon repeated exposure.Cox BD, McHail DG, Blacker KJ. Personal hypoxia symptoms vary widely within individuals. Aerosp Med Hum Perform. 2024; 95(1):54-58.

Recurrent unilateral pupillary dilation and transient visual blurring: A clinical challenge during hypoxia exposure in a male fighter pilot

Hypoxia is an operational concern in military aviation, and fighter pilots should undertake altitude hypoxia training. Anisocoria is a significant clinical dilemma and may remain a diagnostic challenge for specialists. We present a case of atraumatic unilateral mydriasis during hypobaric chamber training. Our diagnostic dilemma is novel and unique because the authors reported no similar presentation yet, it occurred in a fighter pilot whose occupational future depends on having normal vision, and second, the presence of hypoxia seems to trigger symptoms.

Striving for humane deaths for laboratory mice: hypobaric hypoxia provides a potential alternative to carbon dioxide exposure

Killing is often an unavoidable and necessary procedure for laboratory mice involved in scientific research, and providing a humane death is vital for public acceptance. Exposure to carbon dioxide (CO2) gas is the most widely used methodology despite well proven welfare concerns. Consequently, the continued use of CO2 and its globally permitted status in legislation and guidelines presents an ethical dilemma for users. We investigated whether killing with hypobaric hypoxia via gradual decompression was associated with better welfare outcomes for killing laboratory mice. We compared the spontaneous behaviour of mice exposed to CO2, decompression or sham conditions, and used analgesic or anxiolytic interventions to determine their relative welfare impact. Gradual decompression resulted in longer times to unconsciousness and death and the pharmacological interventions support the notion of a minimally negative animal experience, while providing further evidence for pain and anxiety associated with exposure to CO2. Decompression resulted in moderate ear haemorrhage, but our welfare assessment suggests this may happen when mice are unconscious. Hence, gradual decompression could be the basis of significant refinement for killing laboratory mice. Future work should corroborate behaviour with neurobiological markers of loss of consciousness to verify the conscious phase of concern for animal welfare.

Characterizing candidate decompression rates for hypobaric hypoxic stunning of pigs. Part 2: Pathological consequences

Pigs are commonly stunned pre-slaughter by exposure to carbon dioxide (CO2), but this approach is associated with significant welfare concerns. Hypobaric hypoxia, achieved with gradual decompression (also known as Low Atmospheric Pressure Stunning or LAPS) may be an alternative, allowing the retention of welfare friendly handling approaches and group stunning. Although validated in poultry, the feasibility and welfare consequences of gradual decompression for pigs are unknown. Here, we characterize pathological changes in 60 pigs resulting from exposure to a range of candidate decompression curves (ranging from 40 to 100 ms-1 ascent equivalent, with two cycle durations 480 and 720 s). To protect welfare, we worked on unconscious, terminally anesthetized pigs which were subject to detailed post-mortem examinations by a specialized porcine veterinary pathologist. All pigs were killed as a result of exposure to decompression, irrespective of cycle rate or length. Pigs showed no external injuries during ante-mortem inspections. Exposing pigs to decompression and the unavoidable subsequent recompression resulted in generalized congestion of the carcass, organs and body cavities including the ears, oral cavity, conjunctivae and sclera, mucosa of other external orifices (anus and vulva), nasal planum, nasal cavities including nasal conchae, frontal sinuses, cranium, meninges, brain, larynx, trachea, lungs, heart, parietal pleura of the thoracic cavity, peritoneum of the abdominal cavity, stomach, small intestine, caecum, colon, liver, spleen and kidneys and representative joint cavities in the limbs (stifles and elbows). Various severities of hemorrhage were observed in the conjunctivae and sclera, mucosa of other external orifices (anus and vulva), nasal cavities including nasal conchae, frontal sinuses, cranium, meninges, brain, larynx, tracheal lumen, lungs, parietal pleura of the thoracic cavity, liver, spleen and kidneys and representative joint cavities in the limbs (stifles and elbows). In general, faster decompression rates produced higher scores, but in the conjunctivae, sclera and kidneys, faster decompression rates were associated with marginally lower congestion scores. There was considerable individual variation in pathological scores across all body regions. The congestion and hemorrhage observed could translate into welfare harms in conscious pigs undergoing this type of stunning, depending when in the cycle the damage is occurring, but no welfare related conclusions can be drawn from the responses of unconscious pigs. Since recompression is always required, its effects cannot be separated from decompression, however cessation of cardiac activity several minutes before recompression should have eliminated any haemodynamic effects relating to cardiac function and blood pressure. This study represents the first systematic attempt to identify candidate rate profiles to underpin future explorations of decompression as a stunning method for pigs. These pathological findings also inform discussions about the likely carcass quality implications of this novel stunning method.

Effects of Acute Hypoxia on Early Visual and Auditory Evoked Potentials

Reduced levels of environmental oxygen lead to hypoxic hypoxia and are a primary threat in tactical aviation. The visual system is particularly vulnerable to hypoxia, and its impairment can severely impact performance. The auditory system is relatively spared by hypoxia, although which stages of auditory processing are most impacted by hypoxia remains unclear. Previous work has used electroencephalography (EEG) to assess neural markers of cognitive processing for visual and auditory stimuli and found that these markers were sensitive to a normobaric hypoxic exposure. In the current study, we assessed whether early sensory evoked potentials, that precede cognitive activity, are also impaired by normobaric hypoxia. In a within-subjects design, we compared visual (P100) and auditory evoked potentials (sensory gating for the P50, N100, and P200) in 34 healthy adults during normoxic (21% O2) and two separate hypoxic (9.7% O2) exposures. Self-reported symptoms of hypoxia were also assessed using the Hypoxia Symptom Questionnaire (HSQ). We found that P100 mean amplitude was not reduced under hypoxic compared to normoxic conditions, suggesting no statistically significant impairment of early visual processing. The sensory gating ratio for auditory stimuli was intact for paired responses of the P50 and N100. However, the P200 sensory gating ratio was attenuated under hypoxic compared to normoxic conditions, suggesting disruption of the auditory system specific to the level of allocating attention that follows basic auditory processing. Exploratory analyses of HSQ scores identified a robust effect of hypoxia. However, consistency of symptoms reported between the two hypoxia exposures exhibited high intra-individual variability, which may have implications for the theory that individuals have a consistent hypoxia signature or reliable constellation of responses to hypoxia. These findings suggest that early sensory processing is not impaired during hypoxia, but for the auditory system there is impairment at the level of attentional processing. Given the previous findings of impaired visual performance under hypoxia, these results suggest that this impairment does not stem from early visual processing deficits in visual cortex. Together these findings help focus the search on when and where hypoxia-induced deficits occur and may guide the development of countermeasures for hypoxia in tactical aviation.

Determining Candidate Hypobaric Hypoxia Profiles for Humane Killing of Laboratory Mice

Millions of mice are used annually in scientific research and must be humanely killed. Despite significant welfare concerns, carbon dioxide exposure remains the most common killing method, primarily because there is no practical and humane alternative. We explored whether hypobaric hypoxia via gradual decompression could induce a non-recovery state in anesthetized male C57BL/6 and Balb/c laboratory mice. We aimed to determine if this was possible in a feasible timescale with minimal pathological consequences, as a proof-of-principle step. Systematic evaluation of two decompression rates (75, 150 ms−1) and three profile shapes (accelerated, linear, gradual) in a factorial design revealed that hypobaric hypoxia effectively induced a non-recovery state in anesthetized laboratory mice, irrespective of decompression rate and shape. Mice took longer to reach a non-recovery state with the 75 ms−1 decompression rate (75 ms−1: 257 ± 8.96 vs. 150 ms−1: 214 ± 7.26 s), with longer latencies in gradual and linear shaped profiles. Accelerated shaped profiles were least susceptible to meaningful refinement via rate. The only pathological changes of concern were moderate middle ear congestion and hemorrhage. These findings suggest that hypobaric hypoxia has potential, and subsequent work will evaluate the welfare consequences of gradual decompression in conscious mice, to identify decompression profiles that minimize welfare harms associated with ear barotrauma.

Analysis of Altitude Hypoxia Training and In-Flight Hypoxia Events among the Helicopter Aircrews

All aircrews are required to undertake the altitude hypoxia training and be familiarized with the hypobaric effect on their physiological regulation. Due to the characteristics of the helicopter aircrafts, few researches have reported in-flight hypoxia events among the helicopter aircrews. The main goal of this study was designed to compare the hypoxia symptoms of helicopter aircrews between the altitude hypoxia training and during flight. We developed a questionnaire to collect the details of chamber flights and in-flight hypoxia events in 2019. All data were managed by the SPSS software and two-tailed 0.05 alpha level was considered as a significant level. Of the 213 study participants, there were eight (3.8%) cases that experienced hypoxia symptoms during the flight. The top five symptoms that appeared both in the last and current altitude hypoxia trainings were visual impairment (20.7%), difficulty concentrating (12.7%), tiredness (12.2%), cognitive impairment (8.0%), and air hunger (5.2%). Meanwhile, the frequency of those symptoms above was not significantly different from the last or current training compared with those in-flight hypoxia events. The survey unveiled a series of consistency correlations of hypoxia symptoms between the chamber flights and in-flight environment for the helicopter aircrew group.

Hypoxic Hypoxia and Brain Function in Military Aviation: Basic Physiology and Applied Perspectives

Acute hypobaric hypoxia (HH) is a major physiological threat during high-altitude flight and operations. In military aviation, although hypoxia-related fatalities are rare, incidences are common and are likely underreported. Hypoxia is a reduction in oxygen availability, which can impair brain function and performance of operational and safety-critical tasks. HH occurs at high altitude, due to the reduction in atmospheric oxygen pressure. This physiological state is also partially simulated in normobaric environments for training and research, by reducing the fraction of inspired oxygen to achieve comparable tissue oxygen saturation [normobaric hypoxia (NH)]. Hypoxia can occur in susceptible individuals below 10,000 ft (3,048 m) in unpressurised aircrafts and at higher altitudes in pressurised environments when life support systems malfunction or due to improper equipment use. Between 10,000 ft and 15,000 ft (4,572 m), brain function is mildly impaired and hypoxic symptoms are common, although both are often difficult to accurately quantify, which may partly be due to the effects of hypocapnia. Above 15,000 ft, brain function exponentially deteriorates with increasing altitude until loss of consciousness. The period of effective and safe performance of operational tasks following exposure to hypoxia is termed the time-of-useful-consciousness (TUC). Recovery of brain function following hypoxia may also lag beyond arterial reoxygenation and could be exacerbated by repeated hypoxic exposures or hyperoxic recovery. This review provides an overview of the basic physiology and implications of hypoxia for military aviation and discusses the utility of hypoxia recognition training.

Contributions of Hypoxia-Awareness Training to the Familiarization of Personal Symptoms for Occupational Safety in the Flight Environment

Hypoxia remains a flight-safety issue in terms of aviation medicine. Hypoxia-awareness training has been used to help aircrew members recognize personal hypoxia symptoms. There is still no study, as yet, to establish the association of within-subject data between inflight hypoxia events and the altitude chamber. The main purpose of our study was to use paired subjects' data on inflight hypoxia symptoms compared with those experienced during training. A questionnaire was developed to obtain information on military aircrew members in 2018. Among 341 subjects, 46 (13.49%) suffered from inflight hypoxia. The majority of the subjects detected ongoing inflight hypoxia on the basis of their previous experience with personal hypoxia symptoms or sensations in previous chamber flights. Of the top five hypoxia symptoms, the data revealed that hot flashes, poor concentration, and impaired cognitive function appeared both during the inflight events and during the hypoxia-awareness training. The occurrence rate of hypoxia symptoms was found to not be significantly different between the in-flight events and the past chamber flights through an analysis of within-subject data. Because the individual memory had faded away over time, fresher hypoxia awareness training is still mandatory and valuable to recall personal hypoxia experience for military aircrew members.