HIGH ALTITUDE (ATMOSFER)

HIGH MANEUVER

HIGH ALTITUDE HIGH

MANEUVER TAKE OFF LANDING

COMMUNICATION

LONG DURATION

EMERGENCY ESCAPE

HYPOXIA DYSBARISM

UNFAMILIAR MOVEMENT

ACCELERATION

NIGHT VISION

FATIQUE

RESP SYSTEMNEURO SYSTEM

BODY CAVITY

VESTIBULAR SYSTEM

SPATIAL DISORIENTATION

G FORCE

VISUAL SYSTEM

OXYGEN SYSTEM

CABIN PRESSURE

DENITROGENISATION HYPERBARIC TH/

VISUAL SYSTEM

CARDIAC SYSTEM

AGSM,AGS, PALE, PPB

PHYSICAL FITNEES

NUTRITION

BODY & HEAD POSITION

ENT SYSTEM+

+

+

MACHINE (AIRCRAFT PERFORMANCE)

AERODYNAMICS

MEDIA (METEOROLOGY)

HUMAN (PHYSIOLOGY , RELATIF CONSTANT)

JET LAG

+

PSIKOLOGI

TEMPERATURE

MOTIVATION

SOCIAL BEHAVIOUR

LEADERSHIP

ENVIRONMENT STRESS

MENTAL FATIQUE

INTELEGENSIA /IQ &TALENT

FEAR OF FLYING

PSIKOPATOLOGY / PSYCHIATRIC

CLINICAL PATOLOGY

BODY TEMP CONTROL

ERGONOMI

TEHNOLOGI

Definisi Dysbarism

Berbagai perubahan fisiologis akibat

pengembangan gas dalam tubuh yang

timbul akibat turunnya tekanan barometer,

di luar dari efek hipoksia

Mekanisme Ekspansi Gas

Pada waktu tekanan barometer turun, tekanan udara didalam tubuh tetap- Gas-gas didalam tubuh mengembang agar tercapai keseimbangan- Hukum Boyle ( P1xV2 = P2xV2 )

Bila terhambat- Gas tidak dapat keluar- Tekanan dalam rongga meningkat- Sakit

Faktor yangg mempengaruhi terjadinya Dysbarism :

A. Umum :

1. Ketinggian

2. Kecepatan Kenaikan

3. Lamanya terpapar

4. Kegiatan Fisik

B. Individu :

1. Umur

2. Bentuk Tubuh

3. Kepekaan Individual

4. Kesemaptaan

Table. Comparative Volumes of Gases (Saturated with Water Vapor at 37’ C) Within the Body at Various Altitude

Barometric Pressure mm Hg

Altitude feet Relative volume of gas liters

760

523

349

226

141

87

54

47

0

10.000

20.000

30.000

40.000

50.000

60.000

63.000

1,0

1,5

2,4

4,0

7,6

17,0

102,0

Infinite

Gas Expansion at Altitude

4 x

2 x

1 x

10 x

80k

34k

18k

0

53k

Ideal Gas Equation

P1 V1 = P2V2

T1 T2

Composition of the Atmosphere

Although pressure changes with

altitude, this percentage relationship

remains constant

Although pressure changes with

altitude, this percentage relationship

remains constant

Oxygen21%

Nitrogen78%

Other1%

Sea Level

OO22 == 21%21%POPO22 == 160160mm Hgmm Hg

NN22 == 78%78%PNPN22 == 593593mm Hgmm Hg

OtherOther == 1%1% == 77 mm Hgmm Hg

TotalTotal == 100%100% == 760760 mm Hgmm Hg

Using Dalton’s Law, air entering the respiratory tract:

VVgasgas==AA (P(P1 1 - P- P22))TT

DD

MWMW

SolSolWhere D Where D

Fick’s Law

• For tissue diffusion:VVgasgas= rate of gas transfer= rate of gas transfer

A = surface areaA = surface area

T = membrane thicknessT = membrane thickness

PP1 1 - P- P22 = partial pressure = partial pressure

differencedifference

D = diffusion constantD = diffusion constant

Sol = solubilitySol = solubility

MW = molecular weightMW = molecular weight

OO22 103103

COCO22 4040

HH22OO 4747

NN22 570570

760760

VenousVenous

ArterialArterial

Inert Gas Uptake & Elimination

OO22 9595

COCO22 4040

HH22OO 4747

NN22 570570

752752

OO22 4040

COCO22 4646

HH22OO 4747

NN22 570570

703703

The “Oxygen Window”The “Oxygen Window”

““Inherent Unsaturation”Inherent Unsaturation”

NN22 570570

570 mmHg570 mmHg

92 mmHg92 mmHg

At 25,000 feet breathing O2

OO22 103103

COCO22 4040

HH22OO 4747

NN22 9292

282282

OO22 9595

COCO22 4040

HH22OO 4747

NN22 9292

274274

OO22 4040

COCO22 4646

HH22OO 4747

NN22 570570

703703VenousVenous

ArterialArterial

NN22 570570

92 mmHg92 mmHg

Now introduce a bubble...

OO22 103103

COCO22 4040

HH22OO 4747

NN22 9292

282282

OO22 4040

COCO22 4646

HH22OO 4747

NN22 570570

703703

OO22 4040

COCO22 4646

HH22OO 4747

NN22 149149

282282 VenousVenous

ArterialArterial

Altitude (feet) 60 mins 120 mins

18,000 10% 30%

21,000 25% 40%

Incidence of venous gas emboli by altitude and duration of exposure.No preoxygenation. Breathing gas: 100% oxygen.

Estimated DCI risks in resting subjects with no preoxygenation(based on Pilmanis, 1996)

Altitude (ft) Estimated DCI risk(%) at 1 hour

Estimated DCI risk(%) at 2 hours

Estimated DCI risk(%) at 3 hours

18,000 <5 <5 0*

20,000 <5 <5 5*

22,500 10 40 50

25,000 25 65 85

*with 15 minutes preoxygenation

Persentase Penyakit Dekompresi

• Joint pain: 60 %, usually knee, shoulders, elbows

• Neuro: 34%, motor, sensory, visual, cerebellar

• Both: 23%• Chokes: 8%• Collapse is rare. (1 in 140

cases, 136,000 exposures)• 40-54% present on return to

MSL

Faktor lain yang berpengaruh

No effects• Gender• Menstrual cycle• Microgravity

Possible risks• Increasing age

– >40-ish

• ?Body weight (fat!)• Recent illness/injury• Cold• Alcohol• Rate of climb??• Hypoxia??

EFEK PERUBAHAN TEKANAN

1. NYERI TELINGA TENGAH

2. NYERI SINUS PARANASAL

3. NYERI TAMBALAN GIGI

4. NYERI SALURAN PENCERNAAN

5. NYERI SENDI

6. NYERI KEPALA

7. NYERI DADA

8. NYERI KULIT

DYSBARISM (Penyakit

dekompresi) yaitu :

- Trapped Gas Problem

- Evolved Gas Problem

TRAPPED GAS adalah Kelainan yang timbul pada rongga-rongga tubuh akibat perubahan tekanan udara, makin tinggi altitude, tekanan gas semakin menurun. Terperangkapnya Gas di dalam tubuh dan akan mengembang

Dengan Gejala :

NYERI TELINGA TENGAH

NYERI SINUS PARANASAL

NYERI TAMBALAN GIGI

NYERI SALURAN PENCERNAAN dll

Trapped Gas Problem

Semi Closed Cavity a. Ruang Telinga Tengah b. Sinus Paranasal c. Paru-paru

Closed Cavity a. Saluran Cerna b. Gigi

Semi Closeda. Ruang Telinga Tengah

- Saat di ketinggian, tekanan barometer menurun, udara di telinga tengah akan mengembang, dilepaskan ke rongga hidung melalui tuba eustachii

- Udara mengembang, tekanan telinga tengah meningkat, selaput tympani terdorong keluar, s/d tekanan kurang lebih 15 mmHg, gelembung udara yang berusaha keluar dari tuba, tercapai keseimbangan, selaput tympani kembali ke posisi semula.

gejala : - rasa penuh pada telinga - waktu udara keluar ada bunyi `klik`

Gas Expansion in

the Ear - Climb

Gas Expansion in

the Ear - Descent

760 mmHg

O2

Problems with 100% oxygen: Oxygen ear

• Also:– Oxygen sinus– Oxygen lung– Airway irritation– Mission endurance– Fire hazard

• Also:– Oxygen sinus– Oxygen lung– Airway irritation– Mission endurance– Fire hazard

SQUEEZE During Descent

REVERSE Squeeze During Ascent

Otic Barotrauma

Grade 0 = Symptoms without signs

Grade 1 = Injection of TM

Grade 2 = Injection plus mild haemorrhage of TM

Grade 3 = Gross haemorrhage within TM

Grade 4 = Free blood in middle ear, bulging of TM

Grade 5 = Perforation of TM

b. Ruang Sinus

Perubahan tekanan tiba-tiba, selisih tekanan antara sinus dan udara luar, rasa sakit hebat

Gejala : - Nyeri kening

- Nyeri di pipi

- Nyeri dipelipis

frontal sinusfrontal sinus

maxillarmaxillary sinusy sinus

sphenoidal sphenoidal sinussinus

Cavities Containing Gas: Sinuses

The Upper Respiratory TractThe Upper Respiratory Tract

Frontal sinusFrontal sinus

Sphenoidal sinusSphenoidal sinus

TurbinatesTurbinates

Eustachian tubeEustachian tube

Soft palateSoft palate

TongueTongue

Oral cavityOral cavity

Nasal CavityNasal Cavity

• Only a problem if epiglottis closed

• Pneumothorax• Arterial Gas Embolism• Pneumomediastinum• Subcutaneous

emphysema

c. Udara di saluran nafas dan Paru-paruc. Udara di saluran nafas dan Paru-paru

Closed

a. Rongga Abdomen

- Sumber gas a.l. proses menelan, hasil pencernaan, fermentasi, pembusukan sisa makanan

- Semakin tinggi, gas semakin mengembang, rasa tidak enak

- Pengurangan gas dapat dengan sendawa dan flatus

• Biasanya terdapat

500mls gas

• Berhubungan dengan

udara luar melalui

oesophagus

• Tidak selalu

menimbulkan masalah

• Rapat sekali tidak beraturan

• Diameter kecil

• Terdapat katup setiap ujung

• Expansi gas dapat terjadi :

– Sakit pada saat naik

– Pingsan

• Stand, stretch, massage

Gejala pada ColonGejala pada Colon

• Berhubungan

bebas dengan

udara luar

(Flatus)

• Kadang terasa

tidak nyaman

b. Gigi

Penyebab : penambalan gigi tidak sempuna, bahan penambal gigi tidak tepat atau kurang baik

Gejala : nyeri pada gigi

Gejala pada gigi :

• “Aerodontalgia”

• Pain on ascent

• Cavities/caries

• Fillings

• Gingivitis

• Mimics sinus pain

PENCEGAHAN

- TIDAK TERBANG SAAT SEDANG FLU

- TAMBALAN GIGI YANG TIDAK

SEMPURNA HARUS DI PERBAIKI

- SEBELUM TERBANG TIDAK MAKAN

MAKANAN YANG MENIMBULKAN GAS

PENCERNAAN

Evolved Gas Problem

Definisi :

Keadaan pengembangan gas dan

berkumpulnya gas yang dialami dalam

penerbangan merupakan hasil

langsung dari penurunan tekanan

atmosfer

Gas-gas yang terlarut dalam cairan tubuh

( pada sea level ), menjadi gas lagi dalam

bentuk gelembung udara ( pada

ketinggian )

Gas utama yang membentuk gelembung

udara yaitu Nitrogen, tidak terkompensasi

tubuh, menjadi gelembung udara atau

aeroembolism

Termasuk Evolved Gas Problem yang sering tejadi :

- Bends

- Chokes

- Skin

- CNS (Gejala neurologis)

Manifestasi Klinis :

a.Tipe I ( Minor) :

1. Kelainan Kulit

2. Nyeri pada Sendi (Bends)

b. Tipe II ( Mayor ) :

1. Gangguan Paru ( Chokes )

2. Kelainan Syaraf

3. Kolaps Vasomotor

4. Bintik pada Kulit dg/tanpa Cyanosis

BENDS

• Terjadi akibat terbentuk/terkumpul gas

dalam tubuh yang berada pada

persendian-persendian

• Gejala :

Rasa sakit pada persendian

45.000 Ft

25.000 Ft

• “The Bends”

– Large joint pain, minor niggle to severe

pain

– Relatively common

– Better with pressure, worse with use

– Migratory polyarthralgia/myalgia

– ? Due to compressive effects,

inflammatory mediators or referred CNS

pain

Chokes

• Terjadi akibat terkumpul/terbentuk gas dalam tubuh yang berada pada daerah dada atau pada Paru-paru

• Gejala :

Rasa sakit pada dada sampai punggung disertai rasa sesak nafas

103103

570570

40404747

Alveolar airAlveolar air

Carbon dioxide

Water vapour

Oxygen

Nitrogen

160160

593593

Atmospheric airAtmospheric air

Oxygen

Nitrogen

00

760760

Other Other 77

Partial pressures in mmHg at sea level

Partial pressures in mmHg at sea level

10,000 ft10,000 ft

523 mm Hg523 mm Hg

5555O2

381381N2

4040

4747

CO2

H2O

Sea levelSea level

760 mm Hg760 mm Hg

103103O2

570570N2

4040

4747

CO2

H2O

Alveolar Gases

10,000 ft10,000 ft

523 mm Hg523 mm Hg

5555O2

381381N2

4040

4747

CO2

H2O

Sea levelSea level

760 mm Hg760 mm Hg

103103O2

570570N2

4040

4747

CO2

H2O

18,000 ft18,000 ft

380 mm Hg380 mm HgAirAir

3939O2

264264N2

3030

4747

CO2

H2O

Alveolar GasesAlveolar Gases

18,000 ft18,000 ft

380 mm Hg380 mm HgAirAir

3939O2

264264N2

3030

4747

CO2

H2O

18,000 ft18,000 ft

380 mm Hg380 mm HgAirmixAirmix

190190

4040

4747

N2

CO2

H2O

103103O2

Alveolar GasesAlveolar Gases

18,000 ft18,000 ft

380 mm Hg380 mm HgAirAir

3939O2

264264N2

3030

4747

CO2

H2O

33,700 ft33,700 ft

190 mm Hg190 mm Hg100%O100%O22

4040

4747

CO2

H2O

103103O2

18,000 ft18,000 ft

380 mm Hg380 mm HgAirmixAirmix

190190

4040

4747

N2

CO2

H2O

103103O2

Alveolar GasesAlveolar Gases

33,700 ft33,700 ft

190 mm Hg190 mm Hg100%O100%O22

4040

4747

CO2

H2O

103103O2

40,000 ft40,000 ft

142 mm Hg142 mm Hg100%O100%O22

4040

4747

CO2

H2O

5555O2

18,000 ft18,000 ft

380 mm Hg380 mm HgAirmixAirmix

190190

4040

4747

N2

CO2

H2O

103103O2

18,000 ft18,000 ft

380 mm Hg380 mm HgAirAir

3939O2

264264N2

3030

4747

CO2

H2O

Alveolar GasesAlveolar Gases

10,000 ft10,000 ft

523 mm Hg523 mm Hg

5555O2

381381N2

4040

4747

CO2

H2O

Alveolar Gases: Pressure Alveolar Gases: Pressure BreathingBreathing40,000 ft40,000 ft

142 mm Hg142 mm Hg100%O100%O22

4040

4747

CO2

H2O

5555O2

45,000 ft45,000 ft

112 mm Hg112 mm Hg+30mmHg 100%O+30mmHg 100%O22

4040

4747

CO2

H2O

5555O2

45,000 ft45,000 ft

112 mm Hg112 mm Hg100%O100%O22

3030

4747

CO2

H2O

3535O2

45,000 ft45,000 ft

112 mm Hg112 mm Hg+78 mmHg 100%O+78 mmHg 100%O22

4040

4747

CO2

H2O

103103O2

• Bermasalah bila epiglottis tertutup

• Pneumothorax

• Arterial Gas Embolism

• Pneumomediastinum

• Subcutaneous emphysema

Gejala pada paru-paru :Gejala pada paru-paru :

• “The Chokes”

– Lungs act as “bubble filters”, but can be

overwhelmed

– Increase in pulmonary venous pressure

– Pain, chest tightness, cough

– Rare / Jarang

– Beware associated pulmonary barotrauma

Skin (Creeps)

• Terjadi akibat terkumpul/terbentuk gas

dalam tubuh yang berada pada kulit

• Gejala :

Rasa sakit pada kulit

Bila ditekan akan terasa gelembung

udara

• The Creeps”

– Inflammatory reaction

– Subcutaneous bubbles

– Rashes, marbling, itchiness, crawling, etc

– Also relatively common

CNS (Gejala neurologis)

• Terjadi akibat terkumpul/terbentuk gas

dalam tubuh yang berada pada

pembuluh darah di otak

• Gejala :

Rasa sakit di kepala gejala

neurologis

• “The Staggers”

– Lipid rich tissue - predilection for white

matter

– permeability changes

– Motor, sensory, visual, cognitive, mood

changes, vestibulocochlear, peripheral

neuropathies, seizures

– Diverse neurocognitive symptoms/signs

• Spinal cord DCI

– Divers, not aviators

– Venous congestion

– Paraplegia

– Quadriplegia

• Cerebral arterial gas embolism (CAGE)

– Rare in aviators, exact incidence unknown

– Breath holding, pulmonary disease, gas

trapping

– Assoc pulmonary barotrauma

– Sudden collapse, recovery, deterioration

• Joint pain: 60 %, usually knee, shoulders, elbows

• Neuro: 34%, motor, sensory, visual, cerebellar

• Both: 23%

• Chokes: 8%

• Collapse is rare. (1 in 140 cases, 136,000 exposures)

• 40-54% present on return to MSL

PENCEGAHAN PENYAKIT DEKOMPRESI

1. Denitrogenisasi2. Memperpendek durasi

penerbangan 3. Menurunkan ketinggian

penerbangan4. Mempertahankan berat badan

yang ideal5. Mempertahankan tingkat

kesamaptaan jasmani tetap baik

Denitrogenation

• 100% oxygen

• The longer the better, but diminishing returns

• Enhanced by exercise

• 30 mins eliminates approx. 30%

• Aircrew MUST prebreathe before flight above 18,000 ft

Aircrew Immediate Actions

• Descend ASAP

• Use 100% oxygen

• Keep warm

• Minimise activity

• Declare emergency

• Report to Medical

Pencegahan Penyakit Decompressi

• Limit altitude

• Denitrogenation

• Minimise time of exposure

Pengobatan pada penyakit Dekompresi

1. Berikan Oksigen 100 % dengan Masker

2. Segera mendarat 3. Letakkan penderita dalam

posisi terlentang4. Pengobatan Supportif

Management Overview

• HPD 130 (July 1998)• History and examination• Tests• Patient positioning• Oxygen• Fluids• Recompression• Pharmacological adjuncts

Oxygen Therapy

• 100% oxygen is mandatory• Aviators mask ideal (but often impractical), must

be good seal• Continues denitrogenation• For pain only DCI which resolves,

– 2 hrs ground level oxygen and observe– therapeutic “recompression”– 96 % successful in preventing recurrence

IV Fluids

• Oral vs intravenous• Prevents sludging from increased viscosity• Isotonic crystalloids - aggressive• 1000 mls in first hour, then 250mls/hr• Avoid hypotonic solutions, and dextrose• Urine output 1-2 mls/kg/hr

Recompression

• Reduce the size of bubbles

• Increase diffusion gradient out of bubbles

• Relieve ischaemia and hypoxia

• Restore normal tissue function

Recompression

• Symptoms that clear on descent with normal neuro exam -– 100% oxygen for 2 hrs– aggressive hydration– observe 24 hrs and re-evaluate– recompression may not be required– unfit to fly 72 hours

Recompression

• Symptoms that persist at ground level or recur - – 100% oxygen– IV fluids– hyperbaric therapy

Recompression

• Severe DCI - – 100% oxygen, IV fluids, urgent HBO

• Any recurrence - – 100% oxygen– HBO

DCI & Collapse

• Manage as with all unconscious patients

• AIRWAY (& c-spine)

• BREATHING

• CIRCULATION

• DISABILITY

Pengobatan tambahan

• Corticosteroids

• Anti-inflammatories

• Anticoagulants

• Lignocaine infusion - promising initial studies in neurological and refractory DCI

• Not much of proven benefit yet

In all cases the nearest hyperbaric facility must be

consulted

Evacuation

• Road

• Beware of terrain!

• Sea level cabin

• Portable chamber