Hypobaric Decompression and White Matter Hyperintensities: An Evaluation of the NATO Standard.

In their seminal work, McGuire and colleagues reported an increased incidence of white matter hyperintensities (WMH) in a cohort of U2 pilots and hypobaric chamber personnel. WMH burden was higher in U2 pilots with previous reports of decompression sickness (DCS), and McGuire's reports have raised concerns regarding adverse outcomes in the aftermath of hypobaric exposures. Accordingly, a NATO working group has recently revised its standard recommendations regarding hypobaric exposures, including measures to mitigate the risk of WMH. Mandatory recovery time for up to 72 h between repeated exposures has been suggested on the basis of experimental evidence. However, we argue that the evidence is scarce which supports restricting repeated exposures to mitigate WMH. It is plausible that WMH is correlated with DCS and emphasis should be made on limiting the duration of exposures rather than restricting short and repeated exposures. The profiles in the NATO recommendations are meant to mitigate the risk of DCS. Still, they will potentially expose NATO Air Force and Special Operations personnel to flight profiles that can give rise to DCS incidence above 35%. Awaiting reliable data, we recommend limiting the duration of exposures and allowing for short repeated exposures.