1. 1 Colonel ret. Dr. med. Dipl.-Ing. H. Welsch former Head (1993 – 2007) of German Institute of Aviation Medicine, - Division Aviation Physiology – Königsbrück High Altitude: Physiology and Praxis, Slovenia Sep 2009 Individual Reactions to acute Hypoxia-Symptoms of Jet Fighter Pilots and High Altitude Parachutists

2. 2 Gegenüberstellende Betrachtung der subjektiven Wahrnehmung von Sauerstoffmangel-Symptomen bei Freifallspringern und Jet-Piloten Wissenschaftliche Prüfungsarbeit zum Ersten Staatsexamen für das Lehramt an Gymnasien Source: “Comparison of acute Oxygen-Deficiency-Symptoms between High Altitude Parachutists and Jet Fighter Pilots” Nina Alexandra Gleber im SoSe 2008 Referenten: 1. Prof. Dr. med. H.-V. Ulmer 2. Prof. Dr. M. Macsenaere

3. 3 Hypothesis and Aim of the Study High altitude training in a low pressure chamber is a mandatory task in NATO for each military person who takes part in high altitude air traffic. It was presumed that fast jet fighter pilots, all of them full ranked officers, might react more sensitively on hypoxia symptoms than high altitude parachutists, most of them enlisted soldiers with quite a different education in military behaviour. The aim of the study was to compare reaction times from both groups to verify or deny the hypothesis.

4. 4 Hypothesis and Aim of the Study High altitude training in a low pressure chamber is a mandatory task in NATO for each military person who takes part in high altitude air traffic. It was presumed that fast jet fighter pilots, all of them full ranked officers, might react more sensitively on hypoxia symptoms than high altitude parachutists, most of them enlisted soldiers with quite a different education in military behaviour. The aim of the study was to compare reaction times from both groups to verify or deny the hypothesis.

5. 5 Hypothesis and Aim of the Study High altitude training in a low pressure chamber is a mandatory task in NATO for each military person who takes part in high altitude air traffic. It was presumed that fast jet fighter pilots, all of them full ranked officers, might react more sensitively on hypoxia symptoms than high altitude parachutists, most of them enlisted soldiers with quite a different education in military behaviour. The aim of the study was to compare reaction times from both groups to verify or deny the hypothesis.

6. 6 Hypothesis and Aim of the Study High altitude training in a low pressure chamber is a mandatory task in NATO for each military person who takes part in high altitude air traffic. It was presumed that fast jet fighter pilots, all of them full ranked officers, might react more sensitively on hypoxia symptoms than high altitude parachutists, most of them enlisted soldiers with quite a different education in military behaviour. The aim of the study was to compare reaction times from both groups to verify or deny the hypothesis.

7. 7 Simulation Centre with Human Centrifuge and Altitude Chamber German Air Force Institute of Aviation Medicine - Division Aviation Physiology, D-01936 Königsbrück, Germany

8. 8 –Actual Training Devices and Areas: –Human Centrifuge, Altitude Chamber, Anti- G-Trainer, Spatial Disorientation Device, Night Vision Training Device, Special Physical Training Equipment, Aviation Psychology (CRM) –Actual Tasks: –Evaluation, Training, Diagnostics, Research, Development, Test facility for industry German Air Force Institute of Aviation Medicine Division Aviation Physiology

9. 9 Altitude Physiology Acceleration Physiology Sports Physiology (Back/Neck Training!) Nutrition Physiology Aviation Psychology Night Vision Training Training Devices

10. 10 Altitude Physiology Acceleration Physiology Sports Physiology (Back/Neck Training!) Nutrition Physiology Aviation Psychology Night Vision Training Altitude and Hypoxia Training

11. 11 Altitude Simulation Chamber Hypo baric + Hypoxia Training

12. 12 Altitude Simulation Chamber Königsbrück Max. Pressure Alt. 82.000 ft = 25.000m Main Chamber: –Climb-/Descend-Rate: +/- 20.000 ft/min –Temperature: +15 - +50 0 C Decompression- chamber –Climb-/ Descend-Rate: +/- 50.000 ft/min –Temperature: -50 - +10 0 C –RD: minimal 300 ms

13. 13

14. 14 Switch „100% Oxygen“ oxygen regulator with remote control

15. 15 ECG-Monitor Pulsoxymeter Multi-channel- Monitor

16. 16 Pulsoxymeter Multi-channel- Monitor

17. 17 physiological zone deadly zone incomplete compensation zone Oxygen Saturation Curve

18. 18 Altitude Atmospheric pO ² (ft)(km) pressure (hPa) (hPa) 00 1013 213 3.000 0,914 908 191 7.000 2,134 782 164 10.000 3,048 697 146 12.000 3,658 645 135 15.000 4,572 572 120 18.000 5,486 506 106 20.000 6,096 466 98 22.000 6,706 428 90 25.0007,620377 79 25.000 7,620 377 79 30.000 9,144 302 63 36.000 10,973 228 48 40.000 12,192 188 40

19. 19 TUC: Time of Useful Consciousness

20. 20

21. 21 Objective of Training (1) Barometric Changes –ear drum, sinuses, trapped gases Pressure Breathing (>28.000 ft) –hyperventilation, breathing workload Acute Hypoxia (25.000 ft) –individual symptoms (at least 2!) Hypoxia in max. operational cabin altitude (18.000 ft): only jet fighter pilots

22. 22 Objective of Training (2) Altitude Hypoxia Exposure –primarily no diagnostic/evaluation tool! –situational awareness training: flying in high altitude instrumental cross check including oxygen equipment; “PRICE”-check Oxygen Equipment Safety Training Confidence Training

23. 23 Signs and Symptoms of Hypoxia Because there is always a risk of equipment failure at high altitude, early recognition of hypoxic symptoms is mandatory. The constellation of hypoxic symptoms and their sequence of appearance tend to be idiosyncratic to the individual. As a rule, the individual‘s symptoms do not change dramatically over time, but refresher training in a chamber does reacquaint the individual with the symptoms, as well as identify any change in symptoms.

24. 24 Signs and Symptoms of Hypoxia Because there is always a risk of equipment failure at high altitude, early recognition of hypoxic symptoms is mandatory. The constellation of hypoxic symptoms and their sequence of appearance tend to be idiosyncratic to the individual. As a rule, the individual‘s symptoms do not change dramatically over time, but refresher training in a chamber does reacquaint the individual with the symptoms, as well as identify any change in symptoms.

25. 25 Signs and Symptoms of Hypoxia Because there is always a risk of equipment failure at high altitude, early recognition of hypoxic symptoms is mandatory. The constellation of hypoxic symptoms and their sequence of appearance tend to be idiosyncratic to the individual. As a rule, the individual‘s symptoms do not change dramatically over time, but refresher training in a chamber does reacquaint the individual with the symptoms, as well as identify any change in symptoms.

26. 26 Pilots and Parachutists Aircrew (Pilots and WSO): –above 8.000 ft pressure altitude in the cockpit: additional oxygen in the breathing gas is required. Jet fighter aircraft aircrew is always equipped with oxygen breathing mask. High altitude parachutists: –HAHO: High Altitude, High Opening: Pre-breathing in the A/C, oxygen breathing in the air –HALO: High Altitude, Low Opening Pre-breathing in the A/C, normal breathing in the air

27. 27 5 000 10 000 15 000 20 000 25 000 30 000 35 000 Altitude (ft) Time (min.) 10 2030405060708090 8 000 3 000 18 000 I II III IV V VI 4 000 ft/min 10 000 ft/min 4 000 ft/min 2 000 ft/min Hypoxia training: pressure altitude 25.000 ft

28. 28 Pilots and Parachutists Aircrew (Pilots and WSO): –above 8.000 ft pressure altitude in the cockpit: additional oxygen in the breathing gas required. Jet fighter aircraft aircrew is always equipped with oxygen breathing mask. High altitude parachutists: –HAHO: High Altitude, High Opening: Pre-breathing in the A/C, oxygen breathing in the air –HALO: High Altitude, Low Opening Pre-breathing in the A/C, normal breathing in the air

29. 29 Zeit (min) Höhe (ft) 5000 10000 15000 20000 25000 30000 35000 1020 304050607080 I II III IV V VI 4000 ft/min 2000 ft/min 4000 ft/min 2000 ft/min 10000 ft/min Hypoxia training: pressure altitude 25.000 ft

30. 30 Monitoring 100% 90% 75% 60% Oxygen saturation % Heart rate 25.000 ft 18.000 ft Breathing 21% oxygen

31. 31

32. 32 Early (covert) features (signs and symptoms) of acute hypoxia* Visual function: –Light intensity perceived as reduced –Visual acuity diminished in poor illumination –Light threshold increased –Peripheral vision narrowed Psychomotor function: –Choice reaction time impaired –Eye-hand co-ordination impaired Cognitive function: –Memory impaired

33. 33 Overt features (signs and symptoms) of acute hypoxia* Personality Change: –Lack of insight –Loss of judgement –Loss of self-criticism –Euphoria –Loss of memory –Mental incoordination –Muscular incoordination –Sensory loss –Cyanosis Hyperventilation: –Dizziness –Light-headedness –Feeling of unreality –Feeling of apprehension –Neuromuscular irritability –Paraesthesia of skin Unconsciousness Death

34. 34 Results: Pressure Altitude 25.000 ft Questions and Answers 1.Statistic Data of Trainees 2.First Hypoxia Symptoms (Time and SaO 2 ) 3.Duration of Breathing 21% Oxygen until Re-connection to 100% Oxygen Breathing Gas (Time and SaO 2 ) 4.Time between first Hypoxia Symptom and Re-connection to 100% Oxygen

35. 35 Results Pressure Altitude 25.000 ft 1.Statistic Data of Trainees 2.First Hypoxia Symptoms (Time and SaO 2 ) 3.Duration of Breathing 21% Oxygen until Re-connection to 100% Oxygen Breathing Gas (Time and SaO 2 ) 4.Time between first Hypoxia Symptom and Re-connection to 100% Oxygen

36. 36 Biographic Data of Trainees Jan 2005 – Nov 2006 PilotsParachutistsΣ Trainees265250515 age21 - 5719 - 5219 - 57 medium age35,130,332,8 smoker58 (22%) 79 (32%) 137 (27%) non-smoker207 (78%) 171 (68%) 378 (73%)

37. 37 Results Pressure Altitude 25.000 ft 1.Statistic Data of Trainees 2.First Hypoxia Symptoms (Time and SaO 2 ) 3.Duration of Breathing 21% Oxygen until Re-connection to 100% Oxygen Breathing Gas (Time and SaO 2 ) 4.Time between first Hypoxia Symptom and Re-connection to 100% Oxygen

38. 38 First Hypoxia Symptoms unknown12 (5%) 9 (4%) 21 (4%) 32 - 60 s4 (1%) 13 (5%) 17 (3%) 61 – 75 s16 (6%) 28 (11%) 44 (9%) 76 – 90 s52 (20%) 47 (19%) 99 (19%) 91 – 105 s46 (17%) 40 (16%) 86 (17%) 106 – 120 s47 (18%) 42 (17%) 89 (17%) 121 – 135 s43 (16%) 28 (11%) 71 (14%) 136 - 240 s45 (17%) 43 (18%) 88 (17%) TimePilotsParachutistsΣ

39. 39 First Hypoxia Symptoms SaO 2 unknown12 (5%) 9 (4%) 21 (4%) 99%20 (8%) 37 (15%) 57 (11%) 90 – 99% 84 (32%) 76 (30%) 160 (31%) 80 – 89% 40 (15%) 27 ( 11%) 67 (13%) 75 – 79%25 (9%) 30 (12%) 55 (11%) 70– 74% 38 (14%) 25 (10%) 63 (12%) 65 – 69% 33 (12%) 34 (14%) 67 (13%) 60 – 64%13 (5%) 12 (5%) 25 (5%) SaO 2 PilotsParachutistsΣ

40. 40 Results Pressure Altitude 25.000 ft 1.Statistic Data of Trainees 2.First Hypoxia Symptoms (Time and SaO 2 ) 3.Duration of Breathing 21% Oxygen until Re-connection to 100% Oxygen Breathing Gas (Time and SaO 2 ) 4.Time between first Hypoxia Symptom and Re-connection to 100% Oxygen

41. 41 Time: Re-Connection to 100% Oxygen Breathing Gas unknown0 (0%) 72 - 100 s19 (7%) 14 (6%) 33 (6%) 101 – 120 s45 (17%) 21 (8%) 66 (13%) 121 – 150 s110 (42%) 79 (32%) 189 (37%) 151 – 180 s62 (23%) 86 (34%) 148 (29%) 181 – 210 s22 (8%) 37 (15%) 59 (11%) 211 – 240 s6 (2%) 8 (3%) 14 (3%) 241 - 322 s1 (0%) 5 (2%) 6 (1%) TimePilotsParachutistsΣ

42. 42 Oxygen Saturation when re-connected to 100% Oxygen breathing gas 0 20 40 60 80 100 120 Oxygen Saturation (%) Number of Trainees Pilots Parachutists 99% 95% 90% 85% 80% 75% 70% 65% 60%

43. 43 SaO 2 : Re-Connection to 100% Oxygen Breathing Gas unknown 0 (0%) 6 (2%) 6 (1%) 99%2 (1%) 1 (0%) 3 (1%) 90 – 99%15 (6%) 14 (6%) 29 (6%) 80 – 89% 27 (10%) 18 ( 7%) 45 (9%) 75 – 79% 64 (24%) 20 (8%) 84 (16%) 70– 74% 99 (37%) 93 (37%) 192 (37%) 65 – 69%56 (21%) 95 (38%) 151 (29%) 60 – 64%2 (1%) 3 (1%) 5 (1%) SaO 2 PilotsParachutistsΣ Most of these trainees are forced by the instructor to re- connect themselves to 100% oxygen breathing gas, when reached the 70% SaO 2 -level. The „after-drop“ explains the values between 60 – 70% SaO 2.

44. 44 Oxygen Saturation when re-connected to 100% Oxygen 207 (78%) of 265 pilots are re-connected before their oxygen-saturation dropped beneath 70%. Only 146 (60%) of 244 parachutists are re- connected before their oxygen-saturation dropped beneath 70%.

45. 45 Results Pressure Altitude 25.000 ft 1.Statistic Data of Trainees 2.First Hypoxia Symptoms (Time and SaO 2 ) 3.Duration of Breathing 21% Oxygen until Re-connection to 100% Oxygen Breathing Gas (Time and SaO 2 ) 4.Time between first Hypoxia Symptom and Re-connection to 100% Oxygen

46. 46 Time between First Symptom and Re-Connection to 100% Oxygen Breathing Gas 0s10 (4%) 6 (2%) 16 (3%) 1 - 15 s47 (18%) 21 (8%) 68 (13%) 16 – 30 s76 (29%) 51 (20%) 127 (25%) 31 – 45 s65 (25%) 48 (19%) 113 (22%) 46 – 60 s31 (12%) 42 (17%) 73 (14%) 61 – 120 s22 (8%) 64 (26%) 86 (17%) 121 – 248 s 2 (1%) 9 (4%) 11 (2%) unknown12 (4%) 9 (4%) 21 (4%) TimeJet-PilotsParachutistsΣ 72% 62%

47. 47 265 Pilots 250 Parachutists

48. 48 Duration of Hypoxia between first Symptom and Re-Connection to 100% Oxygen 229 (91%) of 253 pilots are re-connected within the first minute (60 seconds) after recognition of their first hypoxia-symptom. Only 168 (70%) of 241 parachutists are re- connected within the first minute (60 seconds) after recognition of their first hypoxia-symptom.

49. 49 Results – Smoker/Non-Smoker

50. 50 Results – Smoker/Non-Smoker MORE OR LESS: NO DIFFERENCE!

51. 51 Summary Pilots - Parachutists No Differences in Type of Hypoxia Symptoms No Differences in Recognition of first Hypoxia Symptoms in Time and SaO 2 Pilots Re-connect themselves earlier than Parachutists (Time and SaO 2 ) to 100% Breathing Gas Parachutists wait much longer after first Experience of Hypoxia Symptoms until Re-connection to 100% Breathing Gas There is no Difference between Smokers and Non- Smokers.

52. 52 Summary Pilots - Parachutists No Differences in Type of Hypoxia Symptoms No Differences in Recognition of first Hypoxia Symptoms in Time and SaO 2 Pilots Re-connect themselves earlier than Parachutists (Time and SaO 2 ) to 100% Breathing Gas Parachutists wait much longer after first Experience of Hypoxia Symptoms until Re-connection to 100% Breathing Gas There is no Difference between Smokers and Non- Smokers.

53. 53 Summary Pilots - Parachutists No Differences in Type of Hypoxia Symptoms No Differences in Recognition of first Hypoxia Symptoms in Time and SaO 2 Pilots Re-connect themselves earlier than Parachutists (Time and SaO 2 ) to 100% Breathing Gas Parachutists wait much longer after first Experience of Hypoxia Symptoms until Re-connection to 100% Breathing Gas There is no Difference between Smokers and Non- Smokers.

54. 54 Summary Pilots - Parachutists No Differences in Type of Hypoxia Symptoms No Differences in Recognition of first Hypoxia Symptoms in Time and SaO 2 Pilots Re-connect themselves earlier than Parachutists (Time and SaO 2 ) to 100% Breathing Gas Parachutists wait much longer after first Experience of Hypoxia Symptoms until Re-connection to 100% Breathing Gas There is no Difference between Smokers and Non- Smokers.

55. 55 Summary Pilots - Parachutists No Differences in Type of Hypoxia Symptoms No Differences in Recognition of first Hypoxia Symptoms in Time and SaO 2 Pilots Re-connect earlier than Parachutists (Time and SaO 2 ) to 100% Oxygen Breathing Gas Parachutists wait much longer after first Experience of Hypoxia Symptoms until Re-connection to 100% Oxygen Breathing Gas There is no Difference between Smokers and Non- Smokers.

56. 56 Thank You for Patience and Listening! Questions?

57. 57 Incidence of Decompression Sickness (DCS) and Venous Gas Emboli (VGE) staying in high altitude; without pre-breathing (Andrew A. Pilmanis, Ph.D.) 0 10 20 30 40 50 60 70 80 90 100 1113151719212325 Höhe, ft X 1000 % Vorkommen VGE DCS