**4.2 The NASA flight surgeon and NASA space person companions**

Airway management procedures had been investigated in a previous study which described using them in inadequate conditions pertaining to space flight. Actually, the optimal way for patient care aboard on space station require that caregiver and patient to be restrained. The Medical Operation Support Team (MOST), 2007 and others previously assessed how to secure airways in microgravity experiments using different techniques for establishing airways in substandard positions by caregiving non-physician – they had accomplished direct laryngoscopy and inserted a cuffed endotracheal tube [24]. As researches are advancing in this field, NASA doctors and companions would be able to provide proper airway management during space trips.

There have been several important studies on airway management in microgravity, with the assumption that a laryngeal airway mask (LMA) had been used. Intubating Laryngeal Mask Airway effectively used which is a supraglottic airway device. Either approach is adequate to perform in substandard situations within a microgravity situation. [23, 25] The challenge to the advanced airway management during space journey is the presence of expertise to be one of the medical onboard team, occasionally the crew physician may had been diseased or incapacitated.

#### **4.3 NASA studies on airway management in microgravity**

In studies investigating the efficacy of airway management during air transport. Air medical transport teams are periodically confronted with the responsibility of conducting airways in unexpected and difficult circumstances, meanwhile they should be essentially trained to do the task in a limited field with less resources during their duty in the aircraft.

Unexpected abrupt patient deterioration prominently considered as the prevailing reason for Airway management during aviation. Intubation process achievement was not related to the category of aircraft. The total intubation successfulness rate for advanced airway handling procedures, was 96%. The successful Airway management procedures during flights was conducted with a high achievement percentage in a variety of venues and for a variety of patient status and conditions. Air medical transport teams achievement rates were proportionate to other emergency medical staff [26]. Anatomically the epiglottis lies at the base of tongue and provides an essential reference point for direct laryngoscopy. The epiglottis fulfills the function of gate that covers the glottis, the vallecula is the concavity between the base of the tongue and the epiglottis, shown as reference point where a curved laryngoscope blade is placed. The pressure exerted by the blade tip against the vallecula elevates the epiglottis and this elevation is affected by gravity. In 1978, LeJeune hypothesized that tracheal intubation using laryngoscopy would be difficult in microgravity, since the force exerted by the laryngoscope causes the head and neck move out of the field of vision by lever effect exerted on the head and generated through the laryngoscope blade by hand generating a lack of stability, resulting in the difficulty to insert the tracheal tube [27].

In 2000, a group tried using a deep pool to simulate microgravity and found that the success rate for anesthesiologists in the free-floating condition was 15%, increasing to 92% if the mannequin was tied to a surface [22].

On the ground with the help of gravity, an adequate positioning of the patient is facilitated to achieve alignment of the laryngeal, pharyngeal and oral axes, which is known as sniffing position. This sniffing position allows visualization of the vocal cords and supraglottic structures that allows the introduction of a endotracheal tube (as shown in **Figure 1**).

The need to intubate personnel in the space can arise from traumatic injuries or some other medical condition leading to deterioration of consciousness or respiratory failure and this possibility increases with longer stays in the space that arises with further incursions, and for this it is necessary to evaluate and try to determine probable complications which involves Airway management in non-terrestrial conditions with microgravity or zero gravity, with the complication extra conferred by not having a doctor trained in advanced Airway management and unavailability of an ideal area with the enough space to maneuver comfortably [23].

Intubation and suction techniques used for Airway management in terrestrial conditions are inefficient and of little use in the environment of a space station; so, it is necessary to have special equipment that facilitates endotracheal intubation. In an environment of minimal gravity or zero gravity the main problem will be the proper positioning of the patient to achieve proper alignment and approach of the airway, since without the help of terrestrial gravity the patient's body and personnel attempting Airway management lack adequate support, hence the need for creating a fixation device is paramount. The need to make these attachments has made are tested in simulators that create environments with minimal gravity or zero gravity [24].

Assessment of respiratory failure or the need for airway management can be evaluated by assessment that includes observation of the ventilatory pattern, pulse oximetry and vital signs; after which and if required, the patient must being moved

#### **Figure 1.**

*Simulation of microgravity environment and intubation in restrained mannequin with a demonstration of sniffing position.*

**223**

*Airway Management in Aviation, Space, and Microgravity*

to a special area for medical or surgical procedure that indicate airway management, which could be affected in microgravity environments [28]. So it is necessary to provide a mean of fixation of the patient and the person who will secure the airway so that positioning would be easier also decreasing the possibility of complications that might happens during laryngoscopy using a restraint system [24].

A study published in 2005, which simulated a least gravity environment within a deep pool, in which the ability to manage the airway by expert staff and non-expert staff with and without devices holding and optimizing the alignment position; it was found that the success rate for the airway approach was equally rare for inexperienced staff and expert personnel in the free floating condition with the head of the mannequin caught between the knees, and in the fixation condition using a stability device while the dummy tied to a surface, this opens the discussion about using devices to restrain the patient either mandatory or using simple techniques is

So the use of other alternative methods is required to overcome this difficulty like the practice for tracheal intubation as a single hand in free floating attitude or using a device that facilitate intubation indirectly, such as laryngeal masks would be

Studying all the difficulties which is possible to happen in space flights is challenging due to the difficulty of creating a simulated environment, and the research in this field have great limitations. This research field needs an interest to develop the necessary devices, and train flight personnel under these circumstances and manufacture airway approach instruments that makes their approach easier [23]. Moreover, the accessibility of telecare, use of telecommunication and information technologies in order to provide clinical health care assistance at a distance will be unavailable. Managing critical conditions may necessitate some measures, that needs the help of anesthesia provider, but the flight staff might be deficient or unskilled. So, proper training and skills of airway management are essential to perform this procedure during microgravity or aviation circumstances whilst they

A very important point to raise regarding medical care during aviation is the supportive care and medical resuscitation. A structured protocol needs to be in place to guide medical practice during management of emergency situation in space missions, the development of such protocols must take into account the limited

It is expected that, the increasing demand for a trained personal in space missions will affect the training structure of medical schools and hospitals, and space companies will support this kind of training. In aviation at least one crew member needs to be trained to deal with medical emergencies and the physicians should be skilled and competent in all basic lifesaving procedures. A focus on psychomotor skills and telemedicine is expected as telemedicine in the shape of the future and psychomotor skills is affected by microgravity. The special skills actually required for performance of surgery can be acquired, augmented, or practiced by using simulators and a hybrid technology that has been termed "cybersurgery" Training

availability restorative care, pain control and psychological adjuncts.

*DOI: http://dx.doi.org/10.5772/intechopen.96603*

quite sufficient [25].

alternatively possibly useful [22].

are in outer space journey.

**5. Future consideration**

**5.1 End of life guidelines**

**5.2 Health care providers**

#### *Airway Management in Aviation, Space, and Microgravity DOI: http://dx.doi.org/10.5772/intechopen.96603*

*Special Considerations in Human Airway Management*

(as shown in **Figure 1**).

zero gravity [24].

increasing to 92% if the mannequin was tied to a surface [22].

of an ideal area with the enough space to maneuver comfortably [23].

In 2000, a group tried using a deep pool to simulate microgravity and found that the success rate for anesthesiologists in the free-floating condition was 15%,

On the ground with the help of gravity, an adequate positioning of the patient is facilitated to achieve alignment of the laryngeal, pharyngeal and oral axes, which is known as sniffing position. This sniffing position allows visualization of the vocal cords and supraglottic structures that allows the introduction of a endotracheal tube

The need to intubate personnel in the space can arise from traumatic injuries or some other medical condition leading to deterioration of consciousness or respiratory failure and this possibility increases with longer stays in the space that arises with further incursions, and for this it is necessary to evaluate and try to determine probable complications which involves Airway management in non-terrestrial conditions with microgravity or zero gravity, with the complication extra conferred by not having a doctor trained in advanced Airway management and unavailability

Intubation and suction techniques used for Airway management in terrestrial conditions are inefficient and of little use in the environment of a space station; so, it is necessary to have special equipment that facilitates endotracheal intubation. In an environment of minimal gravity or zero gravity the main problem will be the proper positioning of the patient to achieve proper alignment and approach of the airway, since without the help of terrestrial gravity the patient's body and personnel attempting Airway management lack adequate support, hence the need for creating a fixation device is paramount. The need to make these attachments has made are tested in simulators that create environments with minimal gravity or

Assessment of respiratory failure or the need for airway management can be evaluated by assessment that includes observation of the ventilatory pattern, pulse oximetry and vital signs; after which and if required, the patient must being moved

*Simulation of microgravity environment and intubation in restrained mannequin with a demonstration of* 

**222**

**Figure 1.**

*sniffing position.*

to a special area for medical or surgical procedure that indicate airway management, which could be affected in microgravity environments [28]. So it is necessary to provide a mean of fixation of the patient and the person who will secure the airway so that positioning would be easier also decreasing the possibility of complications that might happens during laryngoscopy using a restraint system [24].

A study published in 2005, which simulated a least gravity environment within a deep pool, in which the ability to manage the airway by expert staff and non-expert staff with and without devices holding and optimizing the alignment position; it was found that the success rate for the airway approach was equally rare for inexperienced staff and expert personnel in the free floating condition with the head of the mannequin caught between the knees, and in the fixation condition using a stability device while the dummy tied to a surface, this opens the discussion about using devices to restrain the patient either mandatory or using simple techniques is quite sufficient [25].

So the use of other alternative methods is required to overcome this difficulty like the practice for tracheal intubation as a single hand in free floating attitude or using a device that facilitate intubation indirectly, such as laryngeal masks would be alternatively possibly useful [22].

Studying all the difficulties which is possible to happen in space flights is challenging due to the difficulty of creating a simulated environment, and the research in this field have great limitations. This research field needs an interest to develop the necessary devices, and train flight personnel under these circumstances and manufacture airway approach instruments that makes their approach easier [23].

Moreover, the accessibility of telecare, use of telecommunication and information technologies in order to provide clinical health care assistance at a distance will be unavailable. Managing critical conditions may necessitate some measures, that needs the help of anesthesia provider, but the flight staff might be deficient or unskilled. So, proper training and skills of airway management are essential to perform this procedure during microgravity or aviation circumstances whilst they are in outer space journey.
