Annals of Burns and Fire Disasters - Meditline - Pending Publications

EVALUATION OF THE IMPACT OF EXPOSURE TO HEAT AND

TO BY-PRODUCTS OF COMBUSTION ON THE HEALTH OF
FIREFIGHTERS
IMPACT DE L’EXPOSITION À LA CHALEUR ET AUX PRODUITS DE
COMBUSTION SUR LA SANTÉ DES SAPEURS-POMPIERS
Boggi A.C.,1,4# do Amaral J.B.,1# Bacchi A.L.L.,1,5 Nascimento V.M.,4 Voegels R.L.,2 dos Santos J.M.B.,1
Grimaldi G.,3 Basseto de Oliveira Araújo K.,3 Pavão V.,4 Passaretti D.A.,4 Aldred A.,1 Gomes G.,1
Pezato R.1,2*
1
ENT Research Lab, Department of Otorhinolaryngology and Head and Neck Surgery, Federal University of São
Paulo, São Paulo, Brazil
2
Department of Ophthalmology and Otorhinolaryngology, University ofidade de São Paulo, São Paulo, Brazil
3
Hospital da Polícia Militar, Polícia Militar do Estado de São Paulo, São Paulo, Brazil
4
Fire Department, Escola Superior de Bombeiros -– Polícia Militar do Estado de São Paulo, Franco da Rocha, Brazil

SUMMARY. Firefighters are often exposed to high temperatures and by-products of combustion, which can affect
their health. In this study, we assessed the impact of acute exposure of firefighters in fire simulators. Twenty male
firefighters were exposed to fire simulators, and observed in four phases: pre-exposure (group 0, control) and after
the end of the first (group 1), second (group 2), and fourth (group 3) weeks of training. Blood samples were collected
and dosed to evaluate the response of the immune, inflammatory (C-reactive protein, IL6, and IL10), and endocrine
systems (cortisone, total testosterone, free testosterone, SHBG, bioavailable testosterone, TSH, and free T4). In
groups 0, 1, and 3, a thermographic evaluation was also carried out to study the temperature and body heat flow of
the participants. Regarding the inflammatory process, an increase in C-reactive protein and a reduction in IL-10
were observed. With respect to hormonal markers, an increase in cortisol and reduced levels of free T4 and bioa-
vailable testosterone were found after exposure, with recovery of testosterone levels in the final week of training.
Thermoregulatory adaptation of the organism has been associated with changes in heat flow in the organism in
people subjected to extreme temperatures, with emphasis on the performance of the lower limbs. Our findings de-
monstrate an inflammatory response with hormonal changes after exposure to fire and an adaptive response of
thermal balance, which could aid understanding of the physiology of the human body in extreme situations.

Keywords: firefighting, firefighter, thermoregulation, heat, hormones, inflammation

RÉSUMÉ. Les sapeurs-pompiers (SP) sont régulièrement exposés à la chaleur et aux produits de combus-
tion, qui peuvent avoir un retentissement sur leur santé. Nous avons évalué l’effet d’une exposition aiguë
de 22 SP (tous des hommes) à incendie simulé grâce à la répétition à 4 reprises d’une même batterie d’exa-
mens (avant- T0, et à la fin des 1ère -T1 2ème - T2 et 3ème - T3 semaines d’entraînement). Des paramètres san-
guins relatifs à l’inflammation et l’immunité (CRP, IL6, IL10) ainsi qu’au système endocrinien (cortisol,
testostérones totale, libre et biodisponible, SHBG, TSH et T4 libre) étaient prélevés à chaque évaluation.
Une étude thermographique, évaluant la température corporelle et le flux thermique corporel était réalisée
à T0, T1 et T3. On constatait une augmentation de la CRP et une baisse de IL10. On observait une augmen-
tation de la cortisolémie ainsi qu’une baisse de thyroxine libre et testostérone biodisponible, cette dernière
se normalisant à T3. L’adaptation corporelle à la chaleur se traduit par une augmentation du flux thermique,
en particulier aux membres inférieurs. Nous observons donc des réponses inflammatoire comme endocri-
nienne et une adaptation de la thermorégulation en cas d’exposition à un incendie, constatations pouvant
contribuer à la compréhension de la physiologie humaine en situations extrêmes.
Mots-clés : sapeurs-pompiers, incendie, chaleur, thermorégulation, hormones, inflammation
___________
*
Corresponding author: Rogério Pezato, ENT Research Lab, Department of Otorhinolaryngology - Head and Neck Surgery, Federal University of São Paulo, Rua Pedro
de Toledo 781, 1o andar, sala 3 - Vila Clementino, - São Paulo, - SP - Brazil, CEP 04039-032. Tel.: +55 11 55764848 R:1372; email: pezatobau@gmail.com
#
These authors share first authorship
Manuscript: submitted 26/01/2022, accepted 02/02/2022

1
Annals of Burns and Fire Disasters - Meditline - Pending Publications
Introduction
The impact of exposure to heat and products de-
rived from combustion on the firefighter is not yet
fully understood. Hyperthermia, dehydration, respi-
ratory complaints and cancer are associated with fi-
refighter activity.
To understand fire behavior and extinction tactics,
compartmentalized fire simulators are used for training
purposes. This type of training is performed in metallic
environments, with burning pallets and sheets of orien-
ted strand board (OSB), and exposes firefighters to en-
vironments with high temperatures, greater than 400°C,1
with high concentrations of gases and particulates (by-
products of combustion). It is only possible to remain
in these environments while using personal protective
equipment (PPE) and respiratory protective equipment
(RPE) intended for firefighting activities. This training
modality, commonly referred to by the acronym CFBT
(compartment fire behavior training), has been used in
several countries around the world, in order to provide
firefighters with a realistic experience of structural fire-
fighting activity, increasing the understanding of these
professionals on the behavior of fire inside compart-
mented environments and providing them with the op-
portunity to train in techniques and tactics.
Even with the adoption of safety procedures and
the use of protective equipment, training participants
are subjected to increases in temperature, and phy-
sical (the protection kit alone weighs approximately
22 kg) and psychological efforts. In addition, al-
though they remain protected from smoke by the
self-contained breathing apparatus (SCBA), the fi-
refighters are subject to inhalation of residual smoke
in the training environment, as well as direct and in-
direct skin absorption (due to soot impregnated in
the protective kit and equipment).
As a result of the above information, many stu-
dies have demonstrated physiological alterations and
effects on health, resulting from the activity of com-
partment fire behavior training instructors, such as
the increased possibility of cardiovascular and cir-
culatory events,2 impaired airways (Cordeiro et al.,
2021) as well as immunological alterations3 arising
from the environmental temperatures inside the si-
mulators, generating dehydration, physical3-5 and
psychological stress.6
2
From the analysis of the literature it appears that
there are two main mechanisms of aggravation re-
sulting from firefighting activities:7 (1) cardiovascu-
lar alterations, arising from exposure to heat and
increased body temperature, causing vasodilation,
dehydration, and, therefore, increased cardiac out-
put; and (2) systemic and respiratory alterations re-
sulting from chemical exposure to the combustion
by-products (gases, vapors, and particulate solids)
that can be absorbed by inhalation or cutaneous ab-
sorption (facilitated by the elevation of the epidermis
temperature), with toxic effects related to the action
of the absorbed components, as well as alterations
in the airways and pulmonary system.
Systemic alterations include hormonal changes,
as due to the peculiar characteristics of the thyroid
and testicles, their functions can be impacted by the
increase in temperature. The thyroid is located in the
neck region, which receives less thermal protection
and is subject to greater changes in skin temperature,8
while the testicles, in addition to presenting decrea-
sed metabolic activity during stress,9 are also espe-
cially sensitive to temperature rises.10 There is
evidence of a higher incidence of testicular cancer in
firefighters compared to the general population.11
The thermal profile of the body may also be alte-
red; the use of protective clothing decreases the in-
tensity of heat exchanges, essential to protect the
combatant. However, this equipment also hinders
the loss of body heat during the activity, which can
lead to intense thermal stress and altered thermore-
gulation, a crucial factor for maintaining physiolo-
gical homeostasis in the body.
Thus, the aim of this study is to analyze the ef-
fects and the adaptive response of firefighter activity
using structural firefighting simulators as model.
Material and methods
Study participants and ethical guidelines
The study was conducted by the Department of
Otorhinolaryngology - Head and Neck Surgery of
the Federal University of São Paulo, at the São Paulo
State Military Police Superior School of Firefigh-
ters, in October 2019. The work evaluates the impact
of this type of training on the health of the partici-

pants, through the analysis of hormonal and inflam-
matory markers, and body temperature variations in
the 20 participants of the structural fire-fighting ins-
tructor course. All firefighters were male, aged bet-
ween 18 and 50 years, and healthy, approved by the
institution’s medical and physical inspections (Table
I).
Table I - Anthropometric data of the participants
Min Max Mean SD
Age (years) 30 49 36.1 5.9
Height (cm) 166 189 177.2 7.5
Weight (Kg) 65 100 80.7 10.7
BMI (Kg/m2) 21.5 30.9 22.34 1.79
The study was approved by a research ethics
committee (CAAE: 09843919.2.0000,5505). Writ-
ten informed consent was obtained from all partici-
pants, making relevant data to the study, including
infrared images, available for scientific studies and
publication. Only after acceptance and terms subs-
cription, did the participants have their data and in-
frared image collected. All the study protocols
adhered to relevant ethical guidelines.
National Fire Protection Association guidelines
Firefighting training is based on the guidelines
established by norm number 1403 of the National
Fire Protection Association (NFPA),12 which esta-
blishes strict safety procedures that include: the use
of rapid intervention teams (for the need for real as-
sistance to any of the participants); redundant
sources of water supply; and instructors, in adequate
numbers and specially qualified for this purpose (at
least: one instructor in charge, one instructor for fire
control, and one instructor designated as security of-
ficer). In addition, all participants (students and ins-
tructors) must use the complete kit of individual
protection measures to combat the structural fire,
consisting of capes, pants, balaclava, gloves, and
boots fabricated in accordance with the NFPA
1971,13 structural firefighting helmet, in accordance
with EN (European Norm) 443/2008,14 and a respi-
ratory protection set in accordance with NFPA
198115 or EN 137 certification.16
This type of training is as close as possible, while
Annals of Burns and Fire Disasters - Meditline - Pending Publications
in controlled environments, to structural firefighting
activities, making it a great opportunity to unders-
tand the effects of this activity, not only for training
but for the entire firefighting service.
Study design
To carry out the research, we opted to follow the
course of firefighting instructors, because we aimed
to evaluate the effects of repeated exposure in simu-
lators, which forms part of the dynamics of this trai-
Median
ning. During the course, which lasts 4 weeks (20
learning days), firefighters undergo training in these
34.5
simulators on 10 of the days. The fires last approxi-
176.5
mately 25 minutes and each volunteer participates
in 2 to 3 sessions of training in the simulators per
77.5
day. The volunteers are divided into groups and all
24.24
take part in the same number of activities (24 ses-
sions per volunteer, over the entire period).
In order to conduct the study, 4 groups were for-
med (composed of the same 20 volunteers): group 0
(control), prior to exposure in the simulators; group
1 after acute exposure in the firefighting simulators
carried out in the first week; group 2 after acute ex-
posure in firefighting simulators carried out in the
second week; and group 3 after acute exposure in fi-
refighting simulators carried out in the final week of
the course.
The exercises were carried out inside modular en-
vironments with a metallic structure (consisting of
marine containers) specifically adapted for this pur-
pose. The fire charge used to perform the fires is 5
sheets of OSB (Fig.1A), and around 3 pine pallets.
The fire lasts approximately 30 minutes, and, during
Fig.1 - A) Compartmented metallic environments; B) Fire charge;
C) Protective equipment and environmental conditions of the exercise;
D) Thermal image being collected –BTT; and E) Full body hotspot.
3
Annals of Burns and Fire Disasters - Meditline - Pending Publications
this period, the environment is saturated with real
smoke with low visibility conditions.The students
are only able to remain there due to the use of pro-
tective equipment (Fig.1B-C) (clothing to withstand
heat and autonomous respiratory protection equip-
ment). The temperature inside the container can ex-
ceed 600°C (Fig.1C).
In all groups (0, 1, 2 and 3), blood samples were
taken to measure immune and inflammatory system
markers (serology for Hepatitis B, C-reactive protein,
IL6, and IL10), and endocrine markers (cortisone, total
testosterone, free testosterone, SHBG, bioavailable
testosterone, TSH, free T-4). In groups 0, 1 and 3, a
thermographic evaluation was also carried out to col-
lect temperature measurements of the participants.
For the control group, thermal images and blood
collections were taken before the beginning of the
course, in an air-conditioned environment and
exempt from previous exposure to this type of trai-
ning. Temperature images and blood samples from
each of the three acute exposure groups were taken
on the training ground, just after the participants left
the simulators, in three separate weeks.
Serological sample analysis
The blood samples collected were subjected to
centrifugation and separation of the supernatant and
were stored in a refrigerator at -80C, in the ENT Re-
search Lab of the Federal University of São Paulo.
Dosage of cytokines (IL6 and IL10): – the blood
containing EDTA was centrifuged at 800 G for 8 mi-
nutes. Next, the collected plasma was stored and
subsequently analyzed by ELISA test commercial
kit Invitrogen by Thermo Fisher Scientific, (Vienna,
Austria).
C-reactive protein (CRP): - dosed in Siemens
(Munich, Germany) Dimension EXL 200” equip-
ment, using the Immunoturbidimetry method.
Hormonal dosage: - cortisol, total testosterone,
free testosterone, SHBG, bioavailable testosterone,
TSH, and free T-4 were measured with Architect
i2000SR equipment, an ABBOTT (Chicago, Illinois,
USA) device, using the chemiluminescence micro-
particle immunoassay method (CMIA).
Infrared thermographic analysis
The infrared images were taken using an infrared
4
digital camera model T540 (Flir Systems - thermal
sensitivity <40mK, and a resolution of 464 × 348
pixels, allowing a matrix of 161,472 data for tempe-
rature) (Wilsonville, Oregon, EUA).
The quantitative variables evaluated were: tem-
perature of the brain temperature tunnel (BTT - hi-
ghest temperature measured in the medial corner of
the eye, right or left) (Fig. 1D), maximum total body
temperature (highest temperature measured in the
body, analyzing the anterior, posterior, right and left,
taking images of 360°, including the soles of the feet
and hands) (Fig. 1E). We used an emissivity of 0.98,
as this value is used in biological tissues.
In addition, heart and respiratory rates and peri-
pheral oxygen saturation were also measured in the
groups in which thermographic measurements were
taken, using a G-Tech portable oximeter.
Statistical analysis
The data obtained were tabulated in Excel. The
thermographic collections resulted in an n=12, as
some of the participants did not attend the collection
point and/or removed their protective equipment
ahead of time, resulting in a total of 12 firefighters
who obtained valid data in the 3 groups for which
the measurements were taken (0, 1 and 3). For sero-
logical markers, n=19 was obtained, since nineteen
participants had valid collections in the 4 groups in
which this collection was performed.
The data were evaluated by statistical comparison
using JAMOVI software. The markers were evaluated
analytically and graphically for distribution, in terms of
mean, median, standard deviation, kurtosis and slope,
and were also subjected to the normality test (Shapiro -
Wilk) and homogeneity of variances (Levene).
The groups were compared using the Friedman
test, with the paired comparison test of Durbin and
Conover as a post-hoc test in order to verify which
groups presented alterations.
Qualitative data, referring to temperature measu-
rements, were compared using the chi-square test of
independence (Pearson). In all analyses, p values
lower than α = 0.05 (5%) were considered statisti-
cally significant. The results are presented as mean
(µ) and standard deviation (σ), for parametric data,
and as medians (M) and interquartile amplitudes
(IQR), for nonparametric data.
 Annals of Burns and Fire Disasters - Meditline - Pending Publications

Results

None of the laboratory markers (obtained by se-

rological tests) presented normality in all groups;
only the temperature data, obtained through thermo-
graphic measurements (face temperature and total
body temperature) showed normal distribution, ho-
wever, they did not present homogeneity of va-
riances (Levene’s test). For this reason, considering
also the low numbers in the samples (12 for the ther-
mographic data), it was decided to treat these data
as non-parametric, using the Friedman test and the
Durbin and Conover post-hoc.

Serological testing results

IL-6 and IL-10 cytokines: In the dosage of IL-6,
no statistically significant differences were observed
between the groups.
With respect to the dosage of IL-10, there was a
statistically significant difference between the
groups (Friedman test: p = 0.007), with reductions
being identified in group 1 (M = 5.9 pg/ml, IQR =
11.5 pg/ml) and group 2 (M = 3.08 pg/ml, IQR =
5.49 pg/ml), when compared to group 0 (M = 9.62
pg/ml, IQR = 14.4 pg/ml), with p<0.01 and p<0.02,
respectively (Fig. 2A).
C-reactive protein (CRP): The CRP presented a
statistically significant difference between the groups
(Friedman test: p = 0.037), with increases in group 1
(M = 2.96 pg/dl, IQR = 0.91 mg/dl) and in group 3
(M = 3.01 pg/dl, IQR = 1.18 mg/d l), when compared
to group 0 (M = 2.65 mg/dl, IQR = 0.97 pg/dl), with
p <0.05 and p < 0.01, respectively (Fig. 2B).
Hormonal markers: Cortisol presented a statisti-
cally significant difference between groups (Fried-
man test: p <0.001), with increases in group 1 (M =
19.5 μg/dL, IQR = 9.3 μg/dl), group 2 (M = 14.7
μg/dl, IQR = 3.0 μg/dl), and group 3 (M = 12.5 μg/dl,
IQR = 5.0 μg/dl), when compared to group 0 (M =
9, 4 μg/dl, IQR = 4.45 μg/dl), with p<0.01, p<0.01,
and p<0.03, respectively. The differences observed
in the comparisons between the other groups showed
the following levels of significance: (p<0.01) bet-
ween groups 1 and 3; (p<0.01) between groups 1 and Fig. 2 - Quantification of Fig. 3: A) Interleukin 10; B) T4 C-Reactive Pro-
3; and (p<0.03) between groups 2 and 3 (Fig. 2C). tein; C) Cortisol; D) Free T4; E) Total testosterone; F) SHBG; G) Free
testosterone; H) Bioavailable testosterone; I) Facial temperature;
Free T4 presented a statistically significant diffe- J) Total body temperature.
rence between groups (Friedman test: p<0.017),

5
Annals of Burns and Fire Disasters - Meditline - Pending Publications
with a reduction in group 3 (M = 0.93 ng/dl, IQR =
0.1 ng/dl), when compared to group 1 (M = 0.98
ng/dl, IQR = 0.16 ng/dl) and group 2 (M = 1.0 ng/dl,
IQR = 0.15 ng/dl) with p<0.01 and p< 0.03, respec-
tively (Fig. 2D).
The thyroid-stimulating hormone did not present
significant differences between the groups.
Total testosterone presented a statistically signi-
ficant difference between groups (Friedman test: p<
0.001), with an increase in group 3 (M = 564 ng/dl,
IQR = 276 ng/dl), when compared to group 0 (M =
452 ng/dl, IQR = 147 ng/dl), group 1 (M = 395
ng/dl, IQR = 211 ng/dl), and group 2 (M = 393 ng/dl,
IQR = 248 ng/dl) with p<0.01 in the three compari-
sons described (Fig. 2E).
The sex hormone binding globulin (SHBG) pre-
sented a statistically significant difference between
the groups (Friedman test: p=0.035), with an in-
crease in group 2 (M = 33.9 nmol/L, IQR = 13.5
nmol/L), when compared to group 0 (M = 29.8
nmol/L, IQR = 11.7 nmol/L) and group 1 (M = 30.6
nmol/L, IQR = 15.0 nmol/L), with p<0.03 and
p<0.01, respectively (Fig. 2F).
Free testosterone presented a statistically signifi-
cant difference between groups (Friedman test:
p=0.001), with an increase in group 3 (M = 10.7
ng/dL, IQR = 5.35 ng/dl), when compared to the
group 0 (M = 8.7 ng/dl, IQR = 4.33 ng/dl), group 1
(M = 7.09 ng/dl, IQR = 4.91 ng/dl), and group 2 (M
= 6.66 ng/dl, IQR = 5.36 ng/dl), with p<0.01 in the
three described comparisons (Fig. 2G).
Bioavailable testosterone showed a statistically si-
gnificant difference between groups (Friedman test:
p <0.001), with an increase in group 3 (M = 250
ng/dL, IQR = 134 ng/dl), when compared to group 0
(M = 204 ng/dl, IQR = 106 ng/dl), group 1 (M = 166
ng/dl, IQR = 115 ng/dl), and group 2 (M = 156 ng/dl,
IQR = 126 ng/dl), with p <0.01 in the three described
comparisons. There was also a reduction in group 2
when compared to group 0, with p<0.05 (Fig. 2H).
Infrared thermographic analysis
In the evaluation of the temperature of the (TIC)
(thermographic records obtained in the inner canthus
of the eye, analyzing both eyes, with the highest
temperature being recorded), an increase in tempe-
rature was observed in group 1, compared to groups
6
0 and 3; the values verified in the groups were: 0 (M
= 35.5, IQR = 0.42), 1 (M = 37.3, IQR = 0.65), and
3 (M = 35.4, IQR = 1.3). Levels of significance (p
<0.01) were obtained between groups 0 and 1 and
between groups 1 and 3 (Fig. 2I).
In the evaluation of the total body temperature
(thermographic record of the point of highest tem-
perature in the body surface, regardless of its loca-
tion), there was an increase in temperature after
exposures in groups 1 and 3, with the following va-
lues being observed in the groups: 0 (M = 35.3 IQR
= 0.65), 1 (M = 37.2 IQR = 0.77), and 3 (M = 37.0
IQR = 1.63). Levels of significance (p <0.01) were
obtained between groups 0 and 1 and between
groups 0 and 3 (Fig. 2J).
From a qualitative aspect, with respect to body
thermoregulation, differences were observed in the
thermoregulatory flow of the organism.
In group 0 (control), the highest measured body
temperatures were found in the region of the head
and upper limbs (58% of the individuals had the
point of highest body temperature in the medial cor-
ner of the eye (BTT), 25% in the acoustic meatus re-
gion, and 17% in the armpit region) (Fig. 3A).
In group 1 (after exposure in the 1st week), the
highest measured body temperatures were distribu-
ted as follows: 50% in the medial corner of the eye,
17% in the acoustic meatus region, 8% in the shoul-
der region, 8% in the umbilical region, and 17% in
the feet (Fig. 3B).
In group 3 (after exposure in the 4th week), the
highest measured body temperatures were distributed
as follows: 25% in the feet, 17% in the posterior re-
gion of the head, 17% in the knee region, 9% in the
medial corner of the eye, 8% in the acoustic meatus
region, 8% in the auricular pavilion, 8% in the chest
region, and 8% in the umbilical region (Fig 3C).
It was noted that after the exposures the body
heat flow presented different dynamics; the measu-
rements of group 0, taken in an air-conditioned en-
vironment and without exposure to the simulators,
show that the points of greatest heat are concentra-
ted in the region of the head and upper limbs, while
after exposures the measurements show the lower
limbs standing out (including the extremities) as
heated points, sometimes being the hottest in the
body (Fig. 3D).

Fig. 3 - Full Body Hot Spot: A) Group 0; B) Group 1; C) Group 3;
D) Pre-and post-exposure image; E) Distribution of the highest total
body temperature points.
In order to better assess these alterations, the dis-
tribution was simplified by subdividing the points of
highest temperature into two categories, the first of
which is made up of individuals with the hottest
points on the body in the region above the xiphoid
appendix (a situation more similar to that of the in-
dividuals not subjected to exposure), while the se-
cond was composed of individuals who presented
regions under this line as the hottest points. The
groups differed when compared with each other
using the chi-square test for independent samples,
with statistical significance regarding the distribu-
tion of points in these two categories (χ² = 8.00, p =
0.018)
Using this categorization, no individuals pre-
sented the hottest spots in regions below the xiphoid
appendix in group 0, while three individuals (25%)
in group 1 and six individuals (50%) in group 3 pre-
sented the hottest spots in this region (Fig. 3E).
The observed respiratory rate data were higher in
T Annals of Burns and Fire Disasters - Meditline - Pending Publications
group 2 (µ = 35.8; σ = 7.6), compared to group 3
(µ = 25.3; σ = 4.3), which, in turn, were higher than
in group 0 (µ = 17.6; σ = 2.3). Heart rate data were
higher in group 3 (µ = 150.2; σ = 19.4), compared
to group 1 (µ = 121.8; σ = 13) which, in turn, were
higher than in group 0 (µ = 121.8; σ = 13). Periph-
eral oxygen saturation presented higher values in
group 1 (µ = 97.1; σ = 1.4), compared to group 2
(µ = 95.9; σ = 1.9), which, in turn, were higher than
in group 3 (µ = 92; σ = 5.3) (Table II).
Table II - Heart rate, respiratory rate, and saturation
Group 0 Group 1 Group 3
Mean SD Mean SD Mean SD
Respiratory rate (per minute) 17.6 2.3 35.8 7.6 25.3 4.3
Heart rate (per minute) 67.8 8.2 121.8 13 150.2 19.4
Peripheral oxygen saturation % 97.1 1.4 95.9 1.9 92 5.3
Discussion
The results showed an increase in inflammatory
markers: IL-10 (an anti-inflammatory interleukin)
reduced in groups 1 and 2, compared to group 0
(control) and C-Reactive Protein increased in groups
1 and 3, compared to group 0. Still in this sense, it
should be noted that, among the hormonal markers,
cortisol presented an increase after exposure during
firefighting in all phases, corroborating findings in
the literature that establish cortisol as an index of
heat intolerance.17
CRP is an acute-phase protein and a marker of
systemic inflammation, which presented elevations
in groups 1 and 3. Cortisol is a potent anti-inflam-
matory which presented statistically significant ele-
vations in all post-exposure groups (1, 2 and 3).
IL-10 is an anti-inflammatory cytokine and showed
a fall after exposure in groups 1 and 2. The analysis
of these markers together suggests an acute phase
inflammatory process in post-exposure measure-
ments (elevation of CRP and cortisol). A reduction
in IL-10 after smoke inhalation during firefighting
activities is reported in the literature,18 corroborating
our findings. A plausible explanation for this is the
negative association found between IL-10 and cor-
7
Annals of Burns and Fire Disasters - Meditline - Pending Publications
tisol production, which may explain the low IL-10.19
Among the hormonal markers associated with
testosterone, there was an increase in SHBG, which
was matched by a reduction in bioavailable testos-
terone in phases 1 and 2. The male reproductive
organ is sensitive to temperature rises,10 which can
lead to temporary infertility,9,20 which is perhaps re-
lated to the greater propensity for the development
of testicular cancer11 in firefighters, when compared
to the general population. In the particular case of
an increase in sex hormone-binding globulin levels
in group 2, accompanied by a reduction in bioavail-
able testosterone levels in the same group, this phe-
nomenon can be explained by the fact that sex
hormone-binding globulin has a high affinity for
testosterone, binding both free testosterone and al-
bumin-bound testosterone (weak binding), consist-
ing of these two markers, therefore the increase in
SHBG corresponds to a higher level of testosterone
linked to this globulin and the reduction in testos-
terone available for ready use. There was also an in-
crease in all forms of testosterone after prolonged
exposure (fourth week, group 3), which seems to in-
dicate an adaptation of the organism to training.
In the current study, the decrease in bioavailable
testosterone was observed very occasionally in
phase 2, and it can be conjectured that this decrease
is related to the elevation of SHBG as the body’s
metabolic response to control homeostasis, in an at-
tempt to reduce metabolic activity. This reduction
was statistically significant, and although for the
group (group 2), both the mean and the median re-
mained within the reference values, for 4 partici-
pants, the levels of free testosterone and bioavailable
testosterone fell below the reference minimum (3.03
and 71 ng/dl, respectively). These findings demon-
strate the need for more studies with a larger sample
size and a longer evaluation period to better assess
the dynamics of testosterone production and avail-
ability when faced with thermal stress, with a strong
elevation of this hormone throughout the exposures
after the body adapts to this new thermal reality.
When we analyzed thyroid-related hormones,
free thyroxine (T4) showed a significant reduction
in group 3 (fourth week), when compared to group
0, while TSH did not demonstrate significant alter-
ations.
8
The thyroid is located in the neck region, which
is less thermally protected.8 Internal effects in this
region were demonstrated by alterations in the lar-
ynx after exposure to firefighting simulators,21,22
which could explain the occurrence of interferences
in this gland. In addition, thyroxine (T4) has a regu-
latory function on the body’s metabolic processes,
influencing the control of its internal temperature,
with indications that reductions in free thyroxine
levels may be associated with adaptive processes to
high temperature environments in humans23 and
even to acute exposures, as seen in studies with
mice,24 and this adaptive response mechanism does
not involve changes in TSH levels. In this context it
is likely that the reduction in T4 in group 3 is an
adaptive effect because its decrease serves to reduce
metabolism and, consequently, temperature, repre-
senting a desirable mechanism for maintaining ther-
mal balance and avoiding hyperthermia and its
consequences, ranging from muscle fatigue, altered
state of consciousness, multiple organ failure, and
death.25
Thermographic measurements were not taken in
group 2 due to technical limitations on this date.
Here, too, testosterone and T4 levels are suggestive
of a compensatory mechanism of adaptation to the
firefighter’s activity to avoid hyperthermia, given
that there are indications that the organism becomes
more efficient in dispersing heat, especially in pe-
ripheral regions, improving homeostasis control. A
reverse process occurs, with a decrease in blood cir-
culation in the extremities, when the body is exposed
to cold, focusing on preservation of vital regions.
The TIC temperature, taken at the inner canthus
corner of the eye, offers a good idea of the internal
temperature26-28 or the brain temperature or brain in-
juries.29 This marker presented a significant increase
in group 1 (after exposure in the first week) both in
relation to group 0 (control) and in relation to group
3 (after exposure in the fourth week), with the latter
showing no statistically significant change in these
measures in relation to group 0 (control).
On the other hand, the measurements of total
body temperature, which consider the hottest point
in the body, regardless of where it is located, were
significantly higher in both group 1 and group 3,
when compared with the control group, showing that

the energy transmitted in the form of heat by physi-
cal exercise and exposure to high temperatures con-
tinued in group 3, although apparently directed to
peripheral portions due to alterations in blood flow.
This result reinforces the hypothesis of the organ-
ism’s adaptive response to thermal stress, in devel-
oping efficient mechanisms to maintain homeostatic
control.
As can be seen by the analysis of the hottest point
on the body performed in group 0 (control), in 83%
of the individuals the highest point of body temper-
ature was in the head region; 58% in the medial cor-
ner of the eye, 25% in the acoustic meatus region,
and the remaining 17% in the armpits, and in all in-
dividuals the most heated point was on the head or
upper portion of the trunk. After exposure in the first
week, this distribution changed; 50% of the individ-
uals continued to present the medial corner of the
eye as the most heated point, 17% the acoustic mea-
tus, 16% parts of the trunk, and another 17% the feet.
After the exposure in the fourth week, this distribu-
tion was even more altered: only 9% of the partici-
pants presented the medial corner of the eye as the
hottest point and 8% the acoustic meatus, 17% the
region of the knees, 25% the feet, and the rest were
distributed in the upper part of the body. This grad-
ual and progressive change in the points of higher
body temperature to the lower regions during expo-
sures, demonstrated in this study, indicates a change
in blood flow to peripheral regions, increasing the
dispersion of heat.
Normally, the highest body temperatures are reg-
istered in the head region (as seen in group 0). The
change was noteworthy during the weeks in which
it was observed that a large part of the firefighters
started to present the highest body temperatures in
their lower limbs, including their extremities (feet).
This is a region of lower blood flow and, therefore,
of lower expected temperature, suggesting some
kind of thermoregulatory modification (acclimatiza-
tion) resulting from the activity, which uses the feet
to cool the body more efficiently.30-33
The human body has a thermal comfort zone for
maintaining homeostasis and physiological
processes in environments for which humans are
thermally adapted. In this zone, heat exchanges in-
volve a minimum of energy expenditure to prevent
Annals of Burns and Fire Disasters - Meditline - Pending Publications
loss and facilitate heat absorption (response to cold),
or to hinder entry and facilitate loss (response to
heat).33 In both processes, the individual expends en-
ergy executing conduction, convection, and radia-
tion processes, or using evaporative water loss
cooling (sweat - evaporative cooling), which de-
pends on an environment not saturated by water
vapor,34 in addition to other metabolic and behav-
ioral alterations. These complex processes are in-
volved in body thermoregulation and allow the
maintenance of the optimum temperature for the
physiological and biochemical processes of our
species. Heat stress generates rapid responses, such
as the closure of arteriovenous anastomoses, causing
the dilation of the arterioles of the vascular vein of
the skin, increasing capillary blood flow, and circu-
lation of peripheral regions, which are further away
from vital organs and have higher ratios between
surface and volume (thermal windows) favoring
heat loss.30-33
This is consistent with the observations of body
temperature flux, which show that in group 3 there
was lower participation of the head region and in-
creased participation of the lower limbs (including
their extremities - feet) as regions of higher body
temperature in thermographic images. It is empha-
sized that this phenomenon can be observed to a
lesser extent in group 1. It can also be noted that
group 3 presented a higher mean heart rate than
group 1, but a lower mean respiratory rate, suggest-
ing that a homeostasis maintenance mechanism is
being employed, since increased circulation helps to
eliminate heat, while reduced metabolic rates, di-
rectly related to oxygen consumption,33 decreases
thermogenesis.
The fact that group 1 recorded the highest median
of face temperature, which better reflects the core
body temperature, while group 3 had the lowest
mean, seems to indicate that the organisms have be-
come more efficient in dealing with heat.
The observation of this behavior of alteration in
the body thermal flow, using the lower limbs to dis-
sipate excess heat in people submitted to extreme
temperature rises, may help in understanding the
physiology of the human body in extreme situations,
and this new knowledge can be used to optimize the
lower limbs, including the feet, as a cooling point
9
Annals of Burns and Fire Disasters - Meditline - Pending Publications
(thermal window). In this direction, it could be in-
teresting to guide these professionals who, in addi-
tion to removing their firefighting suit, should also
remove their boots to take advantage of this phe-
nomenon for heat loss and rapid reestablishment of
the basal temperature,31 as these professionals use
longer, rubberized, and thermally insulated special
boots which are not as easy to remove from contact
with the body as easily as the rest of the firefighting
suits. It should be noted that there is evidence in the
literature that cooling the feet by immersion in cold
water is an efficient way to reduce thermal stress in
users of chemical protective clothing.32
The use of the clothing protects the firefighter by
thermally isolating them from the external environ-
ment. This equipment also features an impermeable
layer, so whoever wears it is temporarily protected
from high external temperatures, but their ability to
dissipate body heat is also limited since the same
barrier that restricts the thermal radiation from the
environment to the fireman, also restricts the thermal
radiation of body heat to the environment (even if
the external temperatures are not high). This phe-
nomenon will favor the process of body sweating
and also dehydration, up to a certain limit, because
the saturation of steam resulting from the retention
of moisture by the waterproof barrier can limit the
cooling mechanism by evaporative loss. This high-
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