INTRODUCTION: Compared to the previous 47 yr, U-2 pilots reported an increased number of altitude decompression sickness (DCS) incidents with central nervous system (CNS) manifestations during 2002-2009. Due to increasing incident severity during military operations, the U.S. Air Force initiated an investigation to prevent future mishaps. METHODS: We retrospectively examined all neurological DCS cases observed among U-2 pilots during 2002-2009. Urgency to prevent further pilot losses limited this study to using existing, often incomplete data sources. RESULTS: During 2002-2009, 16 confirmed incidents of CNS DCS occurred with 13 pilots, plus 4 possible incidents with 4 pilots. Significantly, 12 of 16 confirmed incidents occurred at 1 operating location, including 4 of 5 life-threatening cases. This series of cases were of a type and severity rarely found in flight operations and correlated temporally with increased sortie frequency/duration associated with combat operations. Multiple investigations confirmed no defects in aircraft, support equipment, or oxygen supplies. Nor were significant trends observed with age, habitus, environmental exposure, medication use, or cardiac defects. In 11 cases, symptom recognition occurred well after the 4-h point where clinical experience indicated risk should stabilize. Symptoms also recurred days later and responded to repeat hyperbaric oxygen therapy in three of four cases. Finally, neuropsychiatric symptoms persisted in six pilots for years and may represent permanent injury. CONCLUSIONS: An increase in U-2 CNS DCS cases probably resulted from more cockpit activity combined with longer, more frequent high-altitude exposures. Adjustments in preoxygenation, cabin altitude, exercise at altitude, and frequency of flights may reduce incidence.
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