Molecular biomarkers for assessing the heat-adapted phenotype: a narrative scoping review

Heat acclimation/acclimatisation (HA) mitigates heat-related decrements in physical capacity and heat-illness risk and is a widely advocated countermeasure for individuals operating in hot environments. The efficacy of HA is typically quantified by assessing the thermo-physiological responses to a standard heat acclimation state test (i.e. physiological biomarkers), but this can be logistically challenging, time consuming, and expensive. A valid molecular biomarker of HA would enable evaluation of the heat-adapted state through the sampling and assessment of a biological medium. This narrative review examines candidate molecular biomarkers of HA, highlighting the poor sensitivity and specificity of these candidates and identifying the current lack of a single 'standout' biomarker. It concludes by considering the potential of multivariable approaches that provide information about a range of physiological systems, identifying a number of challenges that must be overcome to develop a valid molecular biomarker of the heat-adapted state, and highlighting future research opportunities.

Sex differences in response to exercise heat stress in the context of the military environment

Women can now serve in ground close combat (GCC) roles, where they may be required to operate alongside men in hot environments. However, relative to the average male soldier, female soldiers are less aerobically fit, with a smaller surface area (A _D), lower mass (m) with higher body fat and a larger A _D/m ratio. This increases cardiovascular strain, reduces heat exchange with the environment and causes a greater body temperature increase for a given heat storage, although a large A _D/m ratio can be advantageous. Physical employment standards for GCC roles might lessen the magnitude of fitness and anthropometric differences, yet even when studies control for these factors, women sweat less than men at high work rates. Therefore, the average female soldier in a GCC role is likely to be at a degree of disadvantage in many hot environments and particularly during intense physical activity in hot-arid conditions, although heat acclimation may mitigate some of this effect. Any thermoregulatory disadvantage may be exacerbated during the mid-luteal phase of the menstrual cycle, although the data are equivocal. Likewise, sex differences in behavioural thermoregulation and cognition in the heat are not well understood. Interestingly, there is often lower reported heat illness incidence in women, although the extent to which this is influenced by behavioural factors or historic differences in role allocation is unclear. Indeed, much of the extant literature lacks ecological validity and more work is required to fully understand sex differences to exercise heat stress in a GCC context.

In pursuit of the unicorn

This short review was prompted by The Physiological Society's recent online symposium on variability. It does not deal with a specific methodology, but rather with the myth that certain environmentally-induced clinical conditions can be identified, quantified, simplified and monitored with a single methodology. Although this might be possible with some clinical conditions, others resist the prevailing reductionist approach of minimizing rather than exploring variation in pathogenesis and pathology, and will not be understood fully until the variation in cause and effect are embraced. This is likely to require comprehensive methodologies and collaboration.

The influence of a menthol and ethanol soaked garment on human temperature regulation and perception during exercise and rest in warm, humid conditions

This study assessed whether donning a garment saturated with menthol and ethanol (M/E) can improve evaporative cooling and thermal perceptions versus water (W) or nothing (CON) during low intensity exercise and rest in warm, humid conditions often encountered in recreational/occupational settings. It was hypothesised there would be no difference in rectal (Tre) and skin (Tsk) temperature, infra-red thermal imagery of the chest/back, thermal comfort (TC) and rating of perceived exertion (RPE) between M/E, W and CON, but participants would feel cooler in M/E versus W or CON.

METHODS

Six volunteers (mean [SD] 22 [4] years, 72.4 [7.4] kg and 173.6 [3.7] cm) completed (separate days) three, 60-min tests in 30°C, 70%rh, in a balanced order. After 15-min of seated rest participants donned a dry (CON) or 80mL soaked (M/E, W) long sleeve shirt appropriate to their intervention. They then undertook 30-min of low intensity stepping at a rate of 12steps/min on a 22.5cm box, followed by 15-min of seated rest. Measurements included heart rate (HR), Tre, Tsk (chest/back/forearm), thermal imaging (back/chest), thermal sensation (TS), TC and RPE. Data were reported every fifth minute as they changed from baseline and the area under the curves were compared by condition using one-way repeated measures ANOVA, with an alpha level of 0.05.

RESULTS

Tre differed by condition, with the largest heat storage response observed in M/E (p<0.05). Skin temperature at the chest/back/forearm, and thermal imaging of the chest all differed by condition, with the greatest rate of heat loss observed in W and M/E respectively (p<0.01). Thermal sensation differed by condition, with the coolest sensations observed in M/E (p<0.001). No other differences were observed.

CONCLUSIONS

Both M/E and W enhanced evaporative cooling compared CON, but M/E causes cooler sensations and a heat storage response, both of which are likely mediated by menthol.

Physiological cost and thermal envelope: a novel approach to cycle garment evaluation during a representative protocol

This study aimed to examine thermoregulation in different clothing assemblies during a representative cycling exercise protocol. Six men undertook cycling exercise simulating representative thermal exchange challenges while wearing low (LOW), intermediate (INT1 and INT2), or high (HI) amounts of clothing. Exercise was conducted at 14.5 °C, 46.8% relative humidity and included a "flat" [45 min at 35% peak power output (PPO), wind speed 8.3 m/s], "uphill" (30 min at 55% PPO, wind speed 3.6 m/s), and "downhill" (20 min at 50 W, wind speed 16.7 m/s) stage. Rectal temperature changed with the exercise stage and was independent of clothing assembly. In contrast, an "envelope" was evident for mean body temperature, resulting from differences in mean skin temperature between the LOW and HI conditions. The elevated mean body temperature in HI was associated with increased physiological "cost," in the form of increased sweat production and heart rate. Physiological cost provides a better index of clothing performance than deep body temperature in the "thermoregulatory zone," as a consequence sports clothing should attempt to optimize the balance between comfort and reduced physiological cost.

Moderate hypoxia does not affect the zone of thermal comfort in humans

The zone of thermal comfort was determined during normoxia and hypoxia in 15 healthy normothermic young subjects. Subjects dressed only in shorts/shorts and bikini top donned a water-perfused suit and assumed a supine position on a bench. The ambient temperature was maintained at a mean (SD) of 25.7 (0.3) degrees C. The thermal comfort zone was determined by increasing the temperature of the water perfusing the suit from cool to warm. During the heating process, subjects were instructed to report when their perception of the thermal stimulus provided by the suit changed from unpleasant to pleasant, and again from pleasant to unpleasant. The boundaries of the thermal comfort zone were assumed to be the temperatures of the water perfusing the suit at the time the subjects reported a change in the affective component of their thermal perception. In normoxia, subjects inspired room air and in hypoxia a gas mixture containing 10% O(2) in N(2). Tympanic temperature was similar in the normoxia and hypoxia conditions (P>0.05). The average (SD) lower and upper limits of the thermal comfort zone were 30.5 (1.5) and 34.7 (3.3) degrees C, respectively, during normoxia, and 30.5 (1.7) and 35.1 (3.4) degrees C, respectively, during hypoxia. No significant differences were observed between the normoxia and hypoxia conditions (P>0.05). Also, no gender-related differences were observed in the characteristics of the thermal comfort zone. The results of the present study indicate that acute hypoxic exposure simulated in the present study does not affect the zone of thermal comfort in humans.

Hypoxia increases the cutaneous threshold for the sensation of cold

Cutaneous temperature sensitivity was tested in 13 male subjects prior to, during and after they breathed either a hypocapnic hypoxic (HH), or a normocapnic hypoxic (NH) breathing mixture containing 10% oxygen in nitrogen. Normocapnia was maintained by adding carbon dioxide to the inspired gas mixture. Cutaneous thresholds for thermal sensation were determined by a thermosensitivity testing device positioned on the plantar side of the first two toes on one leg. Heart rate, haemoglobin saturation, skin temperature at four sites (arm, chest, thigh, calf) and adapting temperature of the skin (T(ad); degrees centigrade), i.e. the temperature of the toe skin preceding a thermosensitivity test, were measured at minute intervals. Tympanic temperature (T(ty); degrees centigrade) was measured prior to the initial normoxic thermosensitivity test, during the hypoxic exposure and after the completion of the final normoxic thermosensitivity test. End-tidal carbon dioxide fraction and minute inspiratory volume were measured continuously during the hypoxic exposure. Ambient temperature, T(ty), T(ad) and mean skin temperature remained similar in both experimental conditions. Cutaneous sensitivity to cold decreased during both HH (P<0.001) and NH conditions (P<0.001) as compared with the tests undertaken pre- and post-hypoxia. No similar effect was observed for cutaneous sensitivity to warmth. The results of the present study suggest that sensitivity to cold decreases during the hypoxic exposure due to the effects associated with hypoxia rather than hypocapnia. Such alteration in thermal perception may affect the individual's perception of thermal comfort and consequently attenuate thermoregulatory behaviour during cold exposure at altitude.

Motion sickness potentiates core cooling during immersion in humans

1. The present study tested the hypothesis that motion sickness affects thermoregulatory responses to cooling in humans. 2. Ten healthy male volunteers underwent three separate head-out immersions in 28 degrees C water after different preparatory procedures. In the 'control' procedure immersion was preceded by a rest period. In the 'motion sickness' procedure immersion was preceded by provocation of motion sickness in a human centrifuge. This comprised rapid and repeated alterations of the gravitational (G-) stress in the head-to-foot direction, plus a standardized regimen of head movements at increased G-stress. In the 'G-control' procedure, the subjects were exposed to similar G-stress, but without the motion sickness provocation. 3. During immersion mean skin temperature, rectal temperature, the difference in temperature between the forearm and 3rd digit of the right hand (DeltaT(forearm-fingertip)), oxygen uptake and heart rate were recorded. Subjects provided ratings of temperature perception, thermal comfort and level of motion sickness discomfort at regular intervals. 4. No differences were observed in any of the variables between control and G-control procedures. In the motion sickness procedure, the DeltaT(forearm-fingertip) response was significantly attenuated, indicating a blunted vasoconstrictor response, and rectal temperature decreased at a faster rate. No other differences were observed. 5. Motion sickness attenuates the vasoconstrictor response to skin and core cooling, thereby enhancing heat loss and the magnitude of the fall in deep body temperature. Motion sickness may predispose individuals to hypothermia, and have significant implications for survival time in maritime accidents.

Assessment of physical fitness for occupations encompassing load-carriage tasks

There is increasing anecdotal evidence that simple occupational tests of aerobic fitness impose a systematic bias against heavier personnel when predicting fitness for load-carrying tasks. This study tested the hypothesis that simple field tests of aerobic fitness are not good predictors of load-carrying performance and that personnel with greater body mass are more able to perform occupationally relevant load-carrying tasks. Twelve healthy male volunteers ran on a level treadmill at 9.5 km/h for 4 min, with (T18) and without (T0) an external backpack load of 18 kg. During each exercise period, steady-state oxygen uptake (VO(2)) was assessed. On a subsequent occasion (at least 7 days later), 11 of the subjects ran to exhaustion at 9.5 km/h whilst carrying the 18 kg external load (ETT18). There was a strong inverse linear relationship between relative VO(2) and body mass (r = -0.87, P < 0.01) and between VO(2) and lean body mass (r = -0.74, P < 0.01) during the T18 trials. Furthermore, there was a moderately strong relationship between exercise time (ETT18) and body mass (r = 0.69, P < 0.05) and between exercise time and lean body mass (r = 0.71, P < 0.05). There was no relationship between exercise tolerance time and VO(2) (r = 0.12). The results show that fitness tests that determine aerobic power in units relative to body mass (e.g. timed distance run) incur a systematic bias against heavier personnel. Such tests are therefore inappropriate when predicting the ability of personnel to work in occupations that encompass load-carrying tasks.

Thermal status of saturation divers during operational dives in the North Sea

The principal aim of the present study was to monitor the core temperature (Tc) of a population of saturation divers conducting routine deep dives at different locations in the United Kingdom sector of the North Sea and to assess whether current dive procedures are adequate in preventing deleterious decreases in Tc. A total of 30 divers, with an average (SD) of 19.3 (6.6) yr of experience as saturation divers, participated in the study. The survey included 59 dives conducted at six locations (Scott Field, Norfra Pipeline, Hudson Field, Pierce Field, Forties Field, and Bruce Field) from four Diver Support Vessels (Rockwater 1, Semi 2, Bar Protector, and Discovery). The depth of the dives monitored ranged from 54 to 160 meters of seawater (msw), and the duration of the dives from 31 min to 7 h 30 min. before each dive, divers were requested to ingest a radio pill and strap a data logger to their abdomen. Upon returning to the chamber within the Diver Support Vessel following a dive, they provided subjective ratings of thermal perception (7 point scale) and thermal comfort (4 point scale) for the period just before, during, and immediately after the dive. In 55 dives, Tc of saturation divers working at depths to 160 msw for up to 6 h with water temperatures ranging from 4 degrees to 6 degrees C increased above the pre-dive core temperature of 37.4 degrees (0.620+/-0.6 degrees C). In four dives there was a decrease in Tc: 2 divers had a 0.2 degrees C fall in Tc, and 2 bellmen had a decrease of 0.4 degrees and 1.0 degrees C. The subjective responses of divers indicated that they were thermally neutral (neither warm nor cold) and comfortable before and immediately after the dives. The current practice of providing thermal protection with hot water suits to saturation divers working in the North Sea is adequate for preventing the risk of hypothermia and maintaining thermal comfort.

Permanence of the habituation of the initial responses to cold-water immersion in humans

Sudden immersion in cold water initiates an inspiratory gasp response followed by uncontrollable hyperventilation and tachycardia. It is known that this response, termed the "cold shock" response, can be attenuated following repeated immersion. In the present investigation we examined how long this habituation lasts. Twelve healthy male volunteers participated in the experiment, they were divided into a control (C) group (n = 4), and a habituation (H) group (n = 8). In October, each subject undertook two 3-min head-out seated immersions into stirred water at 10 degrees C wearing swimming trunks. These immersions took place at the same time of day, with 4 days separating the two immersions. In the intervening period, the C group were not exposed to cold water, while the H group undertook six, 3-min head-out immersions in water at 15 degrees C. Two months (December), 4 months (February), 7 months (May) and 14 months (January) after their first immersion, all subjects undertook another 3-min head-out immersion in water at 10 degrees C. The H group showed a reduction in respiratory frequency (47 to 24 breaths x min(-1)), inspiratory minute volume (72.2 to 31.3 1 x min(-1)) and heart rate (128 to 109 beats x min(-1)) during the first 30 s of immersion on day 5 compared to day 1. Seven months later these responses were still significantly reduced compared to day 1. After 14 months, heart rate remained attenuated but respiratory frequency and inspiratory minute volume had returned towards pre-habituation levels. The responses of the C group during the first 30 s of immersion were not altered. Both groups showed an attenuation in the responses during the remaining 150 s of immersion following repeated immersions. It is concluded that repeated immersions in cold water result in a longlasting (7-14 months) reduction in the magnitude of the cold shock response. Less frequent immersions produced a decrease in the duration, but not the magnitude of the response.

Habituation of the initial responses to cold water immersion in humans: a central or peripheral mechanism?

1. The initial respiratory and cardiac responses to cold water immersion are thought to be responsible for a significant number of open water deaths each year. Previous research has demonstrated that the magnitude of these responses can be reduced by repeated immersions in cold waterwhether the site of habituation is central or peripheral. 2. Two groups of subjects undertook two 3 min head-out immersions in stirred water at 10 C of the right-hand side of the body (R). Between these two immersions (3 whole days) the control group (n = 7) were not exposed to cold water, but the habituation group (n = 8) undertook a further six 3 min head-out immersions in stirred water at 10 C of the left-hand side of the body (L). 3. Repeated L immersions reduced (P < 0.01) the heart rate, respiratory frequency and volume responses. During the second R immersion a reduction (P < 0.05) in the magnitude of the responses evoked was seen in the habituation group but not in the control group, despite both groups having identical skin temperature profiles. 4. It is concluded that the mechanisms involved in producing habituation of the initial responses are located more centrally than the peripheral receptors.

Temperature dependence of habituation of the initial responses to cold-water immersion

The initial responses to cold-water immersion, evoked by stimulation of peripheral cold receptors, include tachycardia, a reflex inspiratory gasp and uncontrollable hyperventilation. When immersed naked, the maximum responses are initiated in water at 10 degrees C, with smaller responses being observed following immersion in water at 15 degrees C. Habituation of the initial responses can be achieved following repeated immersions, but the specificity of this response with regard to water temperature is not known. Thirteen healthy male volunteers were divided into a control (C) group (n = 5) and a habituation (H) group (n = 8). Each subject undertook two 3-min head-out immersions in water at 10 degrees C wearing swimming trunks. These immersions took place at a corresponding time of day with 4 days separating the two immersions. In the intervening period the C group were not exposed to cold water, while the H group undertook another six, 3-min, head-out immersions in water at 15 degrees C. Respiratory rate (fR), inspiratory minute volume (VI) and heart rate (fH) were measured continuously throughout each immersion. Following repeated immersions in water at 15 degrees C, the fR, VI and fH responses of the H group over the first 30 s of immersion were reduced (P < 0.01) from 33.3 breaths x min(-1), 50.5 l x min(-1) and 114 beats x min(-1) respectively, to 19.8 breaths x min(-1) 26.41 x min(-1) and 98 beats x min(-1), respectively. In water at 10 degrees C these responses were reduced (P < 0.01) from 47.3 breaths x min(-1), 67.61 x min(-1) and 128 beats x min(-1) to 24.0 breaths x min(-1), 29.5 l x min(-1) and 109 beats x min(-1), respectively over a corresponding period of immersion. Similar reductions were observed during the last 2.5 min of immersions. The initial responses of the C group were unchanged. It is concluded that habituation of the cold shock response can be achieved by immersion in warmer water than that for which protection is required. This suggests that repeated submaximal stimulation of the cutaneous cold receptors is sufficient to attenuate the responses to more maximal stimulation.

An examination of two emergency breathing aids for use during helicopter underwater escape

BACKGROUND

There is a paucity of published work in which the performance of Emergency Underwater Breathing Aids (EUBA) has been examined in the wide range of scenarios in which helicopter underwater escape may be necessary. In the present investigation two EUBA were examined: the Air Pocket (AP) rebreather and the Short Term Air Supply System (STASS) mini SCUBA set.

METHOD

Young, healthy male subjects undertook simple simulated helicopter underwater escapes in water at 15 degrees C and/or 5 degrees C. During the immersions the subjects attempted to remain submerged for 60 s while traversing back and forth along a ladder secured at a depth of 1.25 m. At each temperature the subjects used AP and STASS twice. The subjects were dressed in the Royal Navy winter sea helicopter aircrew equipment assembly and an aircrew helmet.

RESULTS

Both AP and STASS significantly extended the underwater survival time of individuals when compared to their maximum breath-hold time (BHT). It is clear from the measurements made of gas concentrations in AP; the volume of air used from STASS; and subjective responses, that the 60-s submersions were achieved more easily with STASS than AP.

CONCLUSION

It is concluded that in conditions similar to those of the present experiment STASS will give a longer underwater duration than AP, but this benefit must be offset against the possible risk of pulmonary barotrauma associated with the use of STASS, as well as increased training and maintenance costs. Irrespective of the EUBA which is provided, in-water training, preferably including exposure to cold water, will significantly improve the ability of an individual to use it.

Substrate utilisation during exercise and shivering

It is generally assumed that exercise and shivering are analogous processes with regard to substrate utilisation and that, as a consequence, exercise can be used as a model for shivering. In the present study, substrate utilisation during exercise and shivering at the same oxygen consumption (VO2) were compared. Following an overnight fast, eight male subjects undertook a 2-h immersion in cold water, designed to evoke three different intensities of shivering. At least 1 week later they undertook a 2-h period of bicycle ergometry during which the exercise intensity was varied to match the VO2 recorded during shivering. During both activities hepatic glucose output (HGO), the rate of glucose utilisation (Rd), blood glucose, plasma insulin, free fatty acid (FFA) and beta-hydroxybutyrate (B-HBA) concentrations were measured. The VO2 measured during the different levels of shivering averaged 0.49 l.min-1 (level 1: low), 0.6 l.min-1 (level 2: low-moderate), and 0.9 l.min-1 (level 3: moderate), and corresponded closely to the levels measured during exercise. HGO and Rd were greater (P < 0.05) during exercise than during shivering at the same VO2 (9.5% and 14.7%, respectively). The average (SD). HGO during level 3 exercise was 3.0 (0.91) mg.kg-1.min-1 compared to 2.76 (1.0) mg.kg-1.min-1 during shivering. The values for Rd were 3.06 (0.98) mg.kg-1.min-1 during level 3 exercise and 2.68 (0.82) mg.kg-1.min-1 during shivering. Blood glucose levels did not differ between conditions averaging 5.4 (0.3) mmol.l-1 over all levels of shivering and 5.2 (0.3) mmol.l-1 during exercise. Plasma FFA and B-HBA were higher (P < 0.01) during shivering than during corresponding exercise (12.3% and 33.3%, respectively). FFA averaged 0.61 (0.2) mmol.l-1 over all levels of shivering and 0.47 (0.16) mmol.l-1 during exercise. The figures for L-HBA were 0.44 (0.13) mmol. l-1 during all levels of shivering and 0.32 (0.1) mmol.l-1 during exercise. Plasma insulin was higher (P < 0.05) during level 2 and 3 shivering compared to corresponding exercise; at these levels the average value for plasma insulin was 95.9 (21.9) pmol.l-1 during shivering and 80.6 (16.1) pmol.l-1 during exercise. On the basis of the present findings it is concluded that, with regard to substrate utilisation, shivering and exercise of up to 2 h duration should not be regarded as analogous processes.

The effect of blood alcohol on the initial responses to cold water immersion in humans

Many drowning victims have alcohol in their blood, but it is not clear whether there is a causal relationship. This study examined the effect of moderate alcohol consumption on the initial responses to cold water immersion. Sixteen subjects wearing swimming costumes undertook two, 3-min head-out seated immersions in water at 15 degrees C. One hour before immersion, subjects drank either 3.7 ml.kg body water-1 of 40% v:v alcohol as vodka, or an equivalent volume of water (control) mixed with squash. On immersion, the average blood alcohol concentration was 23 mmol.l-1 (105 mg.100 ml-1) after alcohol consumption and zero in the control condition. Respiratory frequency in the first 20 s of immersion was found to be reduced (P < 0.05) by 10% (a total of 2-3 breaths) after alcohol consumption compared to the control immersion. Tidal volume, heart rate, rectal temperature and skin temperatures did not differ significantly between immersions. It is concluded that moderate alcohol consumption does not attenuate the initial "cold shock" responses to a practically significant extent and is thus unlikely to reduce the risk of drowning on immersion in cold water.

The effect of water leakage on the results obtained from human and thermal manikin tests of immersion protective clothing

The effect of both the volume and location of water leakage on the protection provided by an uninsulated immersion suit was investigated using human subjects and, in corresponding experiments, an immersion thermal manikin. Three volumes of "leakage" to the torso (200, 500 and 1000 ml) were examined, as were two conditions in which no leakage was simulated and one condition in which a 500-ml leak to the limbs was simulated. All leakages were introduced in a standardised way before immersion. The measurements of clothing insulation obtained, both from the manikin and the humans, were in general agreement. The human experimentation provided some support for a 200-ml limit to water leakage in tests of immersion suits. Rectal and aural temperatures remained significantly (P < 0.05) higher when a 500-ml leak was applied to the limbs rather than the torso; this was primarily due to greater heat flow through and from the torso (back) during the immersions with torso wetting. The physiological responses and anthropometric characteristics which determine this response are not present in manikins; the implications of this for the application and design of immersion thermal manikins, as well as the protection of those at risk of immersion in cold water, are discussed. It is concluded that using immersion thermal manikins to provide a single overall measure of clothing insulation will not necessarily distinguish between suits which provide quite different levels of protection for humans.

An evaluation of hand immersion for rewarming individuals cooled by immersion in cold water

The hypothesis that hypothermic individuals can be actively rewarmed in the field by immersion of the extremities in hot water was investigated. Three techniques for rewarming subjects with lowered deep body temperatures were compared: a) whole body immersion to the neck in water at 40 degrees C; b) immersion of two hands plus forearms only in water at 42 degrees C; and c) passive rewarming. The suggestion that the fall in deep body temperature resulting from immersion to the neck in water at 15 degrees C could be arrested by immersing both arms in water at 42 degrees C was also investigated. Results indicated that immersion to the neck in hot water was clearly the most effective rewarming technique. No significant difference (p > 0.05) was observed in the deep body temperature response during passive rewarming or during immersion of both hands and forearms in water at 42 degrees C. In the later condition some increase in peripheral blood flow to the hands may have occurred and resulted in a heat input of approximately 12 W, but any benefit from this was negated by an associated significant decrease (p > 0.05) in intrinsic heat production. Immersing the arms in hot water during immersion to the neck in cold water appeared to accelerate rather than decelerate the rate of fall of deep body temperature. We concluded that hand rewarming, although theoretically attractive, is ineffective in practice and could be detrimental in some circumstances, by suppressing intrinsic heat production or precipitating rewarming collapse.

A simple emergency underwater breathing aid for helicopter escape

Experiments were undertaken to determine whether a simple rebreathing system, termed "Air Pocket" (AP), could, when integrated into an immersion dry suit, extend the underwater survival time of individuals when compared with their maximum breath hold time (BHTmax). Eight naive healthy male subjects undertook a series of resting submersions and simulated simple helicopter underwater escapes in water 25 degrees C and 10 degrees C. During the submersions the subjects breath-held maximally and then rebreathed using an otherwise empty AP. the BHTmax times of subjects and the total time they could remain underwater (RBT) were recorded. The results showed that the ability to rebreathe following a BHTmax extended the time all subjects could remain submerged, resting or exercising, in cold water by a factor of at least two. The average BHTmax during simulated helicopter underwater escapes in the cold water was 17.2 s. It is concluded that the ability of subjects to rebreathe immediately following maximum breath holding extends the time they can remain submerged in cold water to as much as 60 s. Further, if used unprimed, a simple rebreathing system will not introduce any additional dangers such as a pulmonary over-pressure accident.

Supraventricular arrhythmias following breath-hold submersions in cold water

Twelve subjects undertook one submersion into water at 5 degrees C and two at 10 degrees C wearing either a wet or dry suit. During the submersions the subjects held their breath for as long as they could and then breathed through respiratory tubing for a further 10 s before being removed from the water. Bradycardia (heart rate < 60 beats/min) was observed during breath holding in 10 subjects in 28 of the 36 submersions. Ectopic arrhythmias were observed in 11 subjects in 29 of the 36 submersions, a much higher frequency than previously reported. These ectopic arrhythmias included premature atrial and junctional complexes, runs of supraventricular tachycardia, and premature ventricular complexes. They occurred predominantly in the 10-s period of submersion after the cessation of breath holding. The possible etiology of these arrhythmias and their significance are discussed and it is concluded that after breath-hold termination during cold-water submersion there is a short time during which the heart may be particularly susceptible to supraventricular ectopic arrhythmias.

The effects of warming by active and passive means on the subsequent responses to cold water immersion

Two experiments were undertaken to investigate the effects of warming the body upon the responses during a subsequent cold water immersion (CWI). In both experiments the subjects, wearing swimming costumes, undertook two 45-min CWIs in water at 15 degrees C. In experiment 1, 12 subjects exercised on a cycle ergometer until their rectal temperatures (Tre) rose by an average of 0.73 degree C. They were then immediately immersed in the cold water. Before their other CWI they rested seated on a cycle ergometer (control condition). In experiment 2, 16 different subjects were immersed in a hot bath (40 degrees C) until their Tre rose by an average of 0.9 degrees; they were then immediately immersed in the cold water. Before their other CWI they were immersed in thermoneutral water (35 degrees C; control condition). Heart rate in both experiments and respiratory frequency in experiment 1 were significantly (P < 0.05) higher during the first 30 s of CWI following active warming. In experiment 1, the rate of fall of Tre during the final 15 min of CWI was significantly (P < 0.01) faster when CWI followed active warming (2.46 degrees C.h-1) compared with the control condition (1.68 degrees C.h-1). However, this rate was observed when absolute Tre was still above that seen in the control CWIs. It is possible, therefore, that if longer CWIs had been undertaken, the two temperature curves may have converged and thereafter fallen at similar rates; this was the case with the aural temperature (Tau) seen in experiment 1 and the Tau and Tre in experiment 2. It is concluded that pre-warming is neither beneficial nor detrimental to survival prospects during a subsequent CWI.

The relationship between maximum breath hold time in air and the ventilatory responses to immersion in cold water

Eight subjects performed maximum breath holds in air and naked head-out immersions of 2 min duration in stirred water at 5, 10 and 15 degrees C. Analysis of the respiratory data collected in air and on immersion revealed a significant (P less than 0.05) inverse relationship between the maximum breath hold time (tbh,max) of subjects in air and their frequency of breathing and inspiratory volumes on immersion. No such relationship was identified between tbh,max in air and tidal volumes on immersion. It is concluded that the tbh,max of individuals in air may provide an indication of the magnitude of some of their respiratory responses to immersion. This information may be of use when personnel are being selected for activities with a high risk of immersion in cold water.

Human initial responses to immersion in cold water at three temperatures and after hyperventilation

The present investigation was designed to examine the influence of water temperature and prior hyperventilation on some of the potentially hazardous responses evoked by immersion in cold water. Eight naked subjects performed headout immersions of 2-min duration into stirred water at 5, 10, and 15 degrees C and at 10 degrees C after 1 min of voluntary hyperventilation. Analysis of the respiratory and cardiac data collected during consecutive 10-s periods showed that, at the 0.18-m/s rate of immersion employed, differences between the variables recorded on immersion in water at 5 and 10 degrees C were due to the duration of the responses evoked rather than their magnitude during the first 20 s. The exception to this was the tidal volume of subjects, which was higher on immersion in water at 15 degrees C than at 5 or 10 degrees C. The results suggested that the respiratory drive evoked during the first seconds of immersion was more closely reflected in the rate rather than the depth of breathing at this time. Hyperventilation before immersion in water at 10 degrees C did not attenuate the respiratory responses seen on immersion. It is concluded that, during the first critical seconds of immersion, the initial responses evoked by immersion in water at 10 degrees C can represent as great a threat as those in water at 5 degrees C; also, in water at 10 degrees C, the respiratory component of this threat is not influenced by the biochemical alterations associated with prior hyperventilation.

Laboratory-based evaluation of the protection provided against cold water by two helicopter passenger suits

The thermal protection provided by two helicopter passenger immersion suits was evaluated. Suit A was a standard 'dry' suit and suit B was a 'dry' suit with inherent insulation provided by inflation of the outer shell of the suit. During four hour immersions in water at 4 degrees C with simulated rain, wind and waves, suit B provided significantly (p less than 0.01) better protection against the long-term effects of immersion than suit A. The skin and core temperature of subjects fell at slower rates over the immersion period when they wore suit B, they shivered less, had lower heart rates and were more comfortable in this suit. The problems of testing and selecting appropriate immersion suits are discussed and it is concluded that tests of immersion suits should be as realistic as possible and, when this is so, 'dry' suits with inherent insulation which is unaffected by leakage are likely to perform better in cold water than those without such insulation.

The initial responses to cold-water immersion in man

This review is summarized in Fig. 1. It is concluded that the cold-shock response can result in the death or serious incapacitation of an individual long before general hypothermia develops. As such, this response is probably responsible for the majority of annual open-water immersion deaths.

Protection provided against the initial responses to cold immersion by a partial coverage wet suit

The protection provided against the initial responses to cold water immersion by a partial coverage wet suit was assessed. Eighteen subjects performed three 2-min immersions into water at 5 degrees C. During each immersion, the subjects wore either: a) cotton overall, b) trunk and arms "wet" immersion suit, or c) "dry" immersion suit. Results showed that the dry suit provided significantly (p less than 0.05) greater protection against the initial cardiac and ventilatory responses to immersion than either the wet suit or cotton overall assemblies. The responses recorded in the wet suit were similar to, and in some cases did not differ from, the cotton overall. We conclude that immersion suit design and tests should consider all of the responses associated with accidental cold water immersion and not just those resulting in a fall in core temperature.

The effects of cold immersion and hand protection on grip strength

The maximal voluntary grip strength (MVGS) of male volunteers was examined following a series of five intermittent 2 min cold water (5 degrees C) immersions of the unprotected hand or forearm. MVGS changes due to wearing a protective glove were also investigated. The surface electrical activity over the hand flexor muscles was recorded, as was the skin temperature of the hand and forearm. MVGS decreased significantly (p less than 0.01) following hand immersions (16%) and forearm immersion (13%). The majority of these reductions occurred during the first 2-min period of immersion. The effect of wearing a glove after unprotected hand cooling also produced significant (p less than 0.01) MVGS reductions which averaged 14%. These reductions were in addition to those caused by hand cooling. We conclude that both hand and forearm protection are important for the maintenance of hand-grip strength following cold water immersion.

Human adaptation to repeated cold immersions

1. The present investigation was designed to examine human adaptation to intermittent severe cold exposure and to assess the effect of exercise on any adaptation obtained. 2. Sixteen subjects were divided into two equal groups. Each subject performed ten head-out immersions; two into thermoneutral water which was then cooled until they shivered vigorously, and eight into water at 15 degrees C for 40 min. During the majority of the 15 degrees C immersions, one group (dynamic group) exercised whilst the other (static group) rested. 3. Results showed that both groups responded to repeated cold immersions with a reduction in their initial responses to cold. The time course of these reductions varied, however, between responses. 4. Only the static group developed a reduced metabolic response to prolonged resting immersion. 5. It is concluded that repeated resting exposure to cold was the more effective way of producing an adaptation. The performance of exercise during repeated exposure to cold prevented the development of an adaptive reduction in the metabolic response to cold during a subsequent resting immersion. In addition, many of the adaptations obtained during repeated resting exposure were overridden or masked during a subsequent exercising immersion.

The influence of regional insulation on the initial responses to cold immersion

Twelve healthy male subjects performed three 10-min head-out immersions in water at 10 degrees C. The responses of the subjects to immersion were recorded under three conditions: a) Control condition (CC)--torso and limbs exposed; b) Torso protected/limbs exposed condition (TPC); and c) Limbs protected/torso exposed condition (LPC). Results showed that the LPC significantly reduced the heart rate (p less than 0.01), minute ventilation (p less than 0.05), and respiratory frequency (p less than 0.05) during the first minute of immersion compared to the CC. Subjects also found the LPC the most comfortable. The TPC significantly reduced minute ventilation (p less than 0.01) and respiratory frequency (p less than 0.01) on immersion compared to the CC, but did not significantly lower the heart rate response. A comparison of the LPC and TPC revealed no significant difference in minute ventilation and respiratory frequency recorded on immersion. The LPC however, produced significantly lower heart rates on immersion (p less than 0.05) than the TPC. It was concluded that the limbs may be more important than the torso for the initiation of cardiac response to cold water immersion.

Human thermal responses during leg-only exercise in cold water

1. Exercise during immersion in cold water has been reported by several authors to accelerate the rate of fall of core temperature when compared with rates seen during static immersion. The nature of the exercise performed, however, has always been whole-body in nature. 2. In the present investigation fifteen subjects performed leg exercise throughout a 40 min head-out immersion in water at 15 degrees C. The responses obtained were compared with those seen when the subjects performed an identical static immersion. 3. Aural and rectal temperatures were found to fall by greater amounts during static immersion. 4. It is concluded that 'the type of exercise performed' should be included in the list of factors which affect core temperature during cold water immersion.