*5.2.6 Telemedicine and information technology*

Telemedicine, as a medium for healthcare delivery, has tremendously improved and finds great many applications, in the current healthcare setting. Today, availing a virtual opinion, of an expert, at a remote location, is fairly uncomplicated. This becomes very useful during spaceflight operations. However, a delay of about 20 minutes to receive one way communication is to be expected during a journey to Mars [4]. Since anaesthetic procedures and airway management require prompt and expedient responses, telemedicine—with its inherent latency issues—may not prove to be the most optimal solution. Hence, other advanced on-board information systems will need to supplement telemedicine technology in space [17].

#### **5.3 Human factors**

#### *5.3.1 Medical skills and training*

It must be borne in mind that the crew is unlikely to have a trained physician on board. Therefore anaesthetic procedures and airway management may have to be carried out by non-anaesthetists and non-physicians [35]. At present the Crew Medical Officer in each mission receives a training of about 80 hours [17]. Fading of skills during flight is an important concern and continuous training of the crew members is essential [1]. Fatigue and sleep debt during long duration space flight [2] can further affect performance of the medical officer during emergencies.

#### *5.3.2 Incomplete knowledge about human physiology in partial gravity*

At present we have very little information about human physiology in partial gravity. This knowledge is important in helping to plan the mission as well as preparing for medical contingencies. The moon has about one-sixth the Earth's gravity and Mars has about one-third. The Apollo moon missions did not include extensive physiological experiments unfortunately.

We have information about short term changes from transitioning from 1G to partial gravity levels. This has been obtained during parabolic flight, head-up tilt, lower body unweighting experiments. However, physiological impact of prolonged stay in reduced gravity is not available [16].

#### **6. Airway management in space**

An integrated space surgery research found that most procedures performed on Earth can be performed in microgravity with the right equipment and with the operator, subject and tools sufficiently restrained [38].

#### **6.1 Training of crew**

The medical team identified for the space exploration mission can be as lean as a single crew medical officer (CMO)—who is not necessarily a medical doctor [35].

On Earth, anaesthesia techniques, in high income countries, are performed only by experienced practitioners. In space, however, sophisticated medical expertise may be absent, or the CMO may have become injured, incapacitated or seriously ill, even requiring anaesthesia [35]. Since real-time telemedical support is not immediately forthcoming, the crew will have to be self-reliant. It may be imperative that lifesaving procedures may then have to be performed by personnel with limited training. Until now, neither an anaesthetic technique nor human surgery has been performed in space, except for local infiltration [50].

Simulation and ground research are important programmes in framing protocols since there is a poor knowledge base about managing medical events in space. Simulation tools and techniques are routinely used in the medical field for continuous training of doctors [51–53]. The benefits of such training on their performance has been well documented [51, 54]. Needless to say, the simulation setup must resemble the target environment as closely as possible [54, 55].

In low income countries, especially ones facing a shortage of trained medical professionals, non-physician medical professionals regularly provide anaesthesia and perform surgical procedures. Many of them have a modest medical background [7]. They are trained mostly on the job and often work alone, even

**205**

*Challenges to Airway Management in Space DOI: http://dx.doi.org/10.5772/intechopen.98932*

procedures, in the remotest of settings [35].

measures could also simplify the training programme [7].

cian is a subject for discussion [61, 62].

common emergencies [7].

**6.2 Equipment**

the procedure.

microgravity [1].

enced clinicians [68–70].

factor [7].

lacking recommended equipment and safety levels [35, 56–60] Ketamine based anaesthesia combined with the considerable skills that the providers acquire in a limited time could explain the perioperative mortality rate in these countries—which is "only" about two to three times more— when compared to high resource ones [35]. However, a crucial difference between anaesthesia providers in these low income countries and future space exploration missions is that the former treat a high number of patients and therefore skill redundancy is not a

Personnel with modest medical training may be able to perform invasive procedures safely which is being witnessed in austere environments in different parts of the world. Astronauts are perhaps best positioned to respond to such a challenge [35]. Apart from their multitude of skills, astronauts are also selected for their ability to tolerate extreme stress. They are unquestionably among the best candidates, besides healthcare providers, to be able to perform advanced and invasive medical

Currently, the International Space Station (ISS) has an on-board crew medical officer (CMO), who is not necessarily a trained medical doctor [7]. Given the uniqueness of future long distance space missions, the ideal profile of a crew physi-

The CMO will need to possess a broad spectrum of knowledge, be competent in basic surgical skills and in the management of the critically ill [61–63]. He/She will have to be resourceful and flexible in his/her thinking and approach, and have the ability to improvise for unanticipated medical scenarios [62]. A single physician is required to manage both surgery and anaesthesia. If the CMO herself becomes ill, injured, incapacitated or dies, it is imperative that non-physicians take over. It is therefore prudent to train several of the crew members to manage at least the most

Recently, progress has been made in the field of artificial intelligence, especially in its application in medicine. It is now possible to achieve better monitoring, improve disease detection and bring in more efficient clinical decision support systems. Safety of crew members could be improved by autonomous diagnostic systems, closed-loop automated anaesthesia or other clinical decision support systems. Furthermore, these

Devices for airway management that are brought on board the space shuttles, comprise of: a face mask, a pressure-cycled ventilator, a single-bladed laryngoscope,

Care has to be taken to ensure that the airway equipment carried on board is adequately restrained and made conveniently accessible to the person performing

Cuffed endotracheal tube is the recommended device in view of the changes in gastric motility and reflux. However several studies have shown that nonanaesthesiologists can secure the airway more easily with supraglottic airways than with endotracheal intubation [65–67]. A laryngoscope is not required to be used in order to insert these devices and hence one hand is now available to stabilise the head as well as the neck [64]. The second generation supraglottic airways provides a better seal and also allow gastric drainage making it a good fit for emergencies, in

Videolaryngoscopy may also be used with increased success in these scenarios since they have better glottic visualisation and a higher success rate with less experi-

tracheal tubes, an introducer, a capnograph, and a tracheostomy kit [64].

#### *Challenges to Airway Management in Space DOI: http://dx.doi.org/10.5772/intechopen.98932*

*Special Considerations in Human Airway Management*

physiological experiments unfortunately.

stay in reduced gravity is not available [16].

operator, subject and tools sufficiently restrained [38].

performed in space, except for local infiltration [50].

resemble the target environment as closely as possible [54, 55].

**6. Airway management in space**

**6.1 Training of crew**

It must be borne in mind that the crew is unlikely to have a trained physician on board. Therefore anaesthetic procedures and airway management may have to be carried out by non-anaesthetists and non-physicians [35]. At present the Crew Medical Officer in each mission receives a training of about 80 hours [17]. Fading of skills during flight is an important concern and continuous training of the crew members is essential [1]. Fatigue and sleep debt during long duration space flight [2] can further affect performance of the medical officer during emergencies.

At present we have very little information about human physiology in partial gravity. This knowledge is important in helping to plan the mission as well as preparing for medical contingencies. The moon has about one-sixth the Earth's gravity and Mars has about one-third. The Apollo moon missions did not include extensive

We have information about short term changes from transitioning from 1G to partial gravity levels. This has been obtained during parabolic flight, head-up tilt, lower body unweighting experiments. However, physiological impact of prolonged

An integrated space surgery research found that most procedures performed on Earth can be performed in microgravity with the right equipment and with the

The medical team identified for the space exploration mission can be as lean as a single crew medical officer (CMO)—who is not necessarily a medical doctor [35]. On Earth, anaesthesia techniques, in high income countries, are performed only by experienced practitioners. In space, however, sophisticated medical expertise may be absent, or the CMO may have become injured, incapacitated or seriously ill, even requiring anaesthesia [35]. Since real-time telemedical support is not immediately forthcoming, the crew will have to be self-reliant. It may be imperative that lifesaving procedures may then have to be performed by personnel with limited training. Until now, neither an anaesthetic technique nor human surgery has been

Simulation and ground research are important programmes in framing protocols since there is a poor knowledge base about managing medical events in space. Simulation tools and techniques are routinely used in the medical field for continuous training of doctors [51–53]. The benefits of such training on their performance has been well documented [51, 54]. Needless to say, the simulation setup must

In low income countries, especially ones facing a shortage of trained medical

professionals, non-physician medical professionals regularly provide anaesthesia and perform surgical procedures. Many of them have a modest medical background [7]. They are trained mostly on the job and often work alone, even

*5.3.2 Incomplete knowledge about human physiology in partial gravity*

**5.3 Human factors**

*5.3.1 Medical skills and training*

**204**

lacking recommended equipment and safety levels [35, 56–60] Ketamine based anaesthesia combined with the considerable skills that the providers acquire in a limited time could explain the perioperative mortality rate in these countries—which is "only" about two to three times more— when compared to high resource ones [35]. However, a crucial difference between anaesthesia providers in these low income countries and future space exploration missions is that the former treat a high number of patients and therefore skill redundancy is not a factor [7].

Personnel with modest medical training may be able to perform invasive procedures safely which is being witnessed in austere environments in different parts of the world. Astronauts are perhaps best positioned to respond to such a challenge [35]. Apart from their multitude of skills, astronauts are also selected for their ability to tolerate extreme stress. They are unquestionably among the best candidates, besides healthcare providers, to be able to perform advanced and invasive medical procedures, in the remotest of settings [35].

Currently, the International Space Station (ISS) has an on-board crew medical officer (CMO), who is not necessarily a trained medical doctor [7]. Given the uniqueness of future long distance space missions, the ideal profile of a crew physician is a subject for discussion [61, 62].

The CMO will need to possess a broad spectrum of knowledge, be competent in basic surgical skills and in the management of the critically ill [61–63]. He/She will have to be resourceful and flexible in his/her thinking and approach, and have the ability to improvise for unanticipated medical scenarios [62]. A single physician is required to manage both surgery and anaesthesia. If the CMO herself becomes ill, injured, incapacitated or dies, it is imperative that non-physicians take over. It is therefore prudent to train several of the crew members to manage at least the most common emergencies [7].

Recently, progress has been made in the field of artificial intelligence, especially in its application in medicine. It is now possible to achieve better monitoring, improve disease detection and bring in more efficient clinical decision support systems. Safety of crew members could be improved by autonomous diagnostic systems, closed-loop automated anaesthesia or other clinical decision support systems. Furthermore, these measures could also simplify the training programme [7].

#### **6.2 Equipment**

Devices for airway management that are brought on board the space shuttles, comprise of: a face mask, a pressure-cycled ventilator, a single-bladed laryngoscope, tracheal tubes, an introducer, a capnograph, and a tracheostomy kit [64].

Care has to be taken to ensure that the airway equipment carried on board is adequately restrained and made conveniently accessible to the person performing the procedure.

Cuffed endotracheal tube is the recommended device in view of the changes in gastric motility and reflux. However several studies have shown that nonanaesthesiologists can secure the airway more easily with supraglottic airways than with endotracheal intubation [65–67]. A laryngoscope is not required to be used in order to insert these devices and hence one hand is now available to stabilise the head as well as the neck [64]. The second generation supraglottic airways provides a better seal and also allow gastric drainage making it a good fit for emergencies, in microgravity [1].

Videolaryngoscopy may also be used with increased success in these scenarios since they have better glottic visualisation and a higher success rate with less experienced clinicians [68–70].
