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The effect of repeated altitude exposures on the incidence of decompression sickness

INTRODUCTION: Repeated altitude exposures in a single day occur during special operations parachute training, hypobaric chamber training, unpressurized flight, and extravehicular space activity. Inconsistent and contradictory information exists regarding the risk of decompression sickness (DCS) during such hypobaric exposures. HYPOTHESIS: We hypothesized that four short exposures to altitude with and without ground intervals would result in a lower incidence of DCS than a single exposure of equal duration. METHODS: The 32 subjects were exposed to 3 different hypobaric exposures--condition A: 2 h continuous exposure (control); condition B: four 30-min exposures with descent/ascent but no ground interval between the exposures; condition C: four 30-min exposures with descent/ascent and 60 min of ground interval breathing air between exposures. All exposures were to 25,000 ft with 100% oxygen breathing. Subjects were observed for symptoms of DCS, and precordial monitoring of venous gas emboli (VGE) was accomplished with a SONOS 1000 echo-imaging system. RESULTS: DCS occurred in 19 subjects during A (mean onset 70+/-29 min), 7 subjects in B (60+/-34 min), and 2 subjects in C (40+/-18 min). There was a significant difference in DCS incidence between B and A (p = 0.0015) and C and A (p = 0.0002), but no significant difference between B and C. There were 28 cases of VGE in A (mean onset 30+/-23 min), 21 in B (41+/-35 min), and 21 in C (41+/-32 min) with a significant onset curve difference between B and A and between C and A, but not between B and C. Exposure A resulted in four cases of serious respiratory/neurological symptoms, while B had one and C had none. All symptoms resolved during recompression to ground level. CONCLUSION: Data indicate that repeated simulated altitude exposures to 25,000 ft significantly reduce DCS and VGE incidence compared with a single continuous altitude exposure.

Non-NASA Center↗

Suited Ground Vacuum Chamber Testing Decompression Sickness Tiger Team Report

Suited vacuum chamber testing is critical to flight crew training, sustaining engineering, and development engineering. Most suited vacuum chamber testing at NASA’s Johnson Space Center (JSC) involves crewmembers or human test subjects working at a hypobaric pressure of 4.3 psia, which requires that an oxygen prebreathe be performed prior to decompression to reduce the risk of decompression sickness (DCS). Since 1986, NASA’s policy has been to require a 4-hour resting prebreathe for hypobaric chamber exposures of 4.2 psia lasting greater than 30 minutes. There have been no reports of Type II (i.e., serious, potentially life-threatening) DCS at NASA while using this prebreathe protocol. Several chamber runs, believed to be approximately 5% of all runs, are believed to have been terminated due to Type I DCS symptoms that were performance impairing; however, detailed records of DCS symptoms during suited vacuum chamber runs are not available. The adequacy of the 4-hour prebreathe protocol, as well as the processes by which prebreathe protocols and policies are established, became the subject of significant discussion in April 2018 when medical planning was initiated for chamber runs that were scheduled to occur later in 2018 that would last 8 hours or more with high metabolic rates.

Abercromby, Andrew F. J.↗

Assessing the Influence of Decompression Sickness on Medical Risk for Artemis

As NASA begins to shift its focus from LEO missions to the Moon and beyond, our understanding of the risk associated with human spaceflight is challenged by mission profiles and objectives far different from preceding missions. For Artemis, one of these aspects is surface Extra Vehicular Activity (EVA) tempo, in which the crew will perform 3 to 4 surface EVA’s in quick succession. The crew health and performance risk associated with EVA Decompression Sickness (DCS) and its associated countermeasures, is an important consideration for Artemis missions given this new and unprecedented EVA frequency. Successfully completing Artemis mission objectives relies heavily on the crew being able to perform and complete these EVAs. This analysis quantifies how medical risk changes when accounting for the expected increase in DCS risk due to the increase in EVA frequency. If there is an occurrence of DCS during a mission, appropriate downtime needs to be accounted for. Treatment for DCS requires crewmember to stop the current EVA and return to the habitat. This impacts the current EVA the crew is performing, could potentially delay the next EVA, and increases the chance of the crewmember being unable to perform future EVAs. Capturing the downtime and impact of that downtime based on the number of DCS occurrences allows us to better understand how the risk associated with DCS affects the overall medical risk and completion of missions that have more frequent EVA tempo. There are preventative strategies and mitigation countermeasures to decrease the chance of DCS occurring such as different prebreathe protocols, variable suit pressure, and vehicle pressure settings. Modeling the medical risk with and without different DCS countermeasures enables quantitative comparisons of risk reduction associated with each DCS countermeasure. We present results on how these countermeasures affect medical risks and quantify changes in the medical kit contents with respect to the countermeasures implemented within Artemis-class missions.

Clara Gasiewski↗

The Mars Project: Avoiding Decompression Sickness on a Distant Planet

A cost-effective approach for Mars exploration is to use available resources, such as water and atmospheric gases. Nitrogen (N2) and argon (Ar) are available and could form the inert gas component of a habitat atmosphere at 8.0, 9.0, or 10.0 pounds per square inch (psia). The habitat and space suit are designed as an integrated system: a comfortable living environment about 85% of the time and a safe working environment about 15% of the time. A goal is to provide a system that permits unrestricted exploration of Mars, but the risk of decompression sickness (DCS) during the extravehicular activity in a 3.75-psia suit, after exposure to any of the three habitat conditions, may limit unrestricted exploration. I evaluate here the risk of DCS since a significant proportion of a trinary breathing gas in the habitat might contain Ar. I draw on past experience and published information to extrapolate into untested, multivariable conditions to evaluate risk. A rigorous assessment of risk as a probability of DCS for each habitat condition is not yet possible. Based on many assumptions about Ar in hypobaric decompressions, I conclude that the presence of Ar significantly increases the risk of DCS. The risk is significant even with the best habitat option: 2.56 psia oxygen, 3.41 psia N2, and 2.20 psia Ar. Several hours of prebreathing 100% 02, a higher suit pressure, or a combination of other important variables such as limited exposure time on the surface or exercise during prebreathe would be necessary to reduce the risk of DCS to an acceptable level. The acceptable level for DCS risk on Mars has not yet been determined. Mars is a great distance from Earth and therefore from primary medical care. The acceptable risk would necessarily be defined by the capability to treat DCS in the Rover vehicle, in the habitat, or both.

Conkin, Johnny↗

Relationship of Exercise, Age, and Gender on Decompression Sickness and Venous Gas Emboli During 2-Hour Oxygen Prebreathe Prior to Hypobaric Exposure

We evaluated four 2-hour oxygen prebreathe protocols combining adynamia (non-walking) and 4 different amounts of exercise for potential use with extravehicular activity (EVA) on the International Space Station. Phase I: upper and lower body exercises using dual-cycle ergometry (75% VO2 max for 10 min). Phase 11: same ergometry plus 24 min of light exercise that simulated space suit preparations. Phase III: same 24 min of light exercise but no ergometry, and Phase IV: 56 min of light exercise without ergometry. After 80 min on 100% O2, the subjects breathed 26.5% O2 - 73.5% N2 for 30 min at 10.2 psi. All subjects performed a series of upper body exercises from a recumbent position for 4 hrs at 4.3 psi to simulate EVA work. Venous gas emboli (VGE) were monitored every 12 min using precordial Doppler ultrasound. The 39 female and 126 male exposures were analyzed for correlations between decompression sickness (DCS) or VGE, and risk variables. The duration and quantity of exercise during prebreathe inversely relates to DCS and VGE incidence. The type and distribution of the 19 cases of DCS were similar to historical cases. There was no correlation of age, gender, body mass index, or fitness level with greater incidence of DCS or all VGE. However there were more Grade IV VGE in males > 40 years (10 of 19) than in those =< 40 years (3 of 107), with p<0.01 from Fisher's Exact Chi square The latency time for VGE was longer (103 min +/- 56 SD, n = 15 versus 53 min +/- 31, n =13) when the ergometry occurred about 15 min into the prebreathe than when performed at the start of the prebreathe, but the order of the ergometry did not influence the overall DCS and VGE incidence. An increasing amount of exercise during prebreathes reduced the risk of DCS during subsequent exposures to 4.3 psi. Age, gender, or fitness level did not correlate with the incidence of DCS or VGE (combination of Grades I-IV). However males greater than 40 years had a higher incidence of Grade IV VGE.

Conkin, J.↗

Exercise with prebreathe appears to increase protection from decompression sickness: Preliminary findings

Extravehicular activity (EVA) from the Space Shuttle involves one hour of prebreath with 100% oxygen, decompression of the entire Shuttle to 10.2 psia for at least 12 hours, and another prebreath for 40 minutes before decompression to the 4.3 psia suit pressure. We are investigating the use of a one-hour prebreathe with 100% oxygen beginning with a ten-minute strenuous exercise period as an alternative for the staged decompression schedule described above. The 10-minute exercise consists of dual-cycle ergometry performed at 75% of the subject's peak oxygen uptake to increase denitrogenation efficiency by increasing ventilation and perfusion. The control exposures were preceded by a one-hour prebreathe with 100% oxygen while resting in a supine position. The twenty-two male subjects were exposed to 4.3 psia for 4 hours while performing light to moderate exercise. Preliminary results from 22 of the planned 26 subjects indicate 76% DCS following supine, resting prebreathe and 38% following prebreathe with exercise. The staged decompression schedule has been shown to result in 23% DCS which is not significantly different from the exercise-enhanced prebreathe results. Prebreathe including exercise appears to be comparable to the protection afforded by the more lengthy staged decompression schedule. Completion of the study later this year will enable planned statistical analysis of the results.

Webb, James T.↗