Heart Rate Variability in Military Pilots During Flight: A Scoping Review

INTRODUCTION: Piloting an aircraft is a complex multitasking activity that involves managing information in a nonautomatic way and generates a high workload (psychological, cognitive, and physical) for the pilot. The excess of these demands can result in decreased performance and may impair flight safety. Heart rate variability (HRV) has been used in recent studies as a method to investigate operator's workload in complex environments. This measure can assess the stress and recovery ability of the autonomic nervous system. However, a better understanding of flight influence on the pilot's autonomic modulation is necessary. Therefore, this scoping review aims to systematically map the studies related to changes in the autonomic modulation in military pilots during flight, in order to characterize their workload at different times and flight profiles. MATERIALS AND METHODS: A literature search was conducted using MEDLINE (by PubMed), SCOPUS, and LILACS databases. Recent records (2002-2022) that analyzed HRV in military pilots during flight were included. Meanwhile, studies in which piloting activity was not performed were excluded. The study was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline extension for Scoping Reviews and the Updated Methodological Guidance for the Conduct of Scoping Reviews. RESULTS: A total of 298 records were obtained, of which 19 were included in the scoping review. The studies analyzed flights performed in high- and low-performance aircrafts, helicopters, and flight simulators, using time domain, frequency domain, and nonlinear HRV indices. Real and simulated flights produced significant autonomic changes. Some flights elicited autonomic nervous system responses that persisted up to 5 h after landing. During real flight, the most sensitive indices for identifying variations in pilot workload were root mean square of successive differences between normal heartbeats, standard deviation of interbeat interval of normal sinus beat (SDNN), ratio of low-frequency to high-frequency power, and Poincaré plot standard deviation perpendicular to the line of identity (SD1), whereas the interbeat interval (RR), SDNN, SD1, and Poincaré plot standard deviation along the line of identity (SD2) were the most sensitive indices when comparing segments of simulated flight with different levels of difficulty. CONCLUSIONS: This scoping review provided insight into the influence of flight on autonomic modulation in military pilots. Some key themes were highlighted: Increased sympathetic activity during flight, sensibility of different domains of HRV to flight demands, and autonomic changes during recovery time. Future research efforts may allow us to enhance the understanding of pilot's workload limits and to elucidate the optimal postflight recovery time.