Pulmonary Barotrauma and Related Events in Divers

doi:10.1378/chest.107.6.1648

Chest

Volume 107, Issue 6, June 1995, Pages 1648-1652

https://doi.org/10.1378/chest.107.6.1648 Get rights and content

Although pulmonary barotrauma (PBT) is a well-known clinical entity, its recognition in divers is sometimes delayed and its implications for future diving often are unappreciated. The pulmonary complications of diving activities range from mere discomfort from mediastinal emphysema or pneumothorax, or both, to life-threatening gas embolization. In nine cases described here, only minor manifestations were associated with PBT which occurred at or close to the surface, but three of these four divers were found to have abnormal pulmonary function. More serious manifestations resulted from PBT which took place at depths of 16 to 120 ft. Even minor forms of PBT should be considered a contraindication to further diving, since they are prone to recur. Such recurrences—even at shallow depths—may cause serious complications.

Section snippets

Methods

The subjects described in this report were cared for directly or referred for consultation or evaluation by other physicians. All were nonsmokers.
All pulmonary function measurements were made in a pulmonary laboratory at sea level, with subjects in the seated position. Spirometry testing was done with a Stead-Wells device (Warren E. Collins, Braintree, Mass), using the best of three successive efforts. The subject's results were compared with the normal values reported by Knudson and coworkers.

Case 1

A 19-year-old white male diving medical technician was being trained in “drown-proofing,” a technique to prolong in water survival¹⁵ (breath-holding for 15-s periods at total lung capacity is alternated with rapid vital capacity breaths). After one such maneuver, the training supervisor noted that the voice of diver 1 had changed, taking on a “tinny” nasal quality, soon followed by neck pain and difficulty swallowing. Examination showed a bulging neck with crepitus extending over the

Discussion

This series of cases has a simple message: a variety of in-water activities can cause divers to develop pneumothorax or mediastinal and subcutaneous emphysema, or all, even at the surface with or without equipment malfunction. Those cases which occurred at or near the surface caused relatively minor discomfort in divers 1 to 4, but they raise the possibility—given continued diving—that recurrences⁹ might develop at substantial depths. Recurrences are likely, as is emphasized by the evidence of

ACKNOWLEGMENTS

I thank Dr. Joseph R. Rodarte for his review of the manuscript, and Drs. John W. Brackett, Edward T. Flynn, Harvey Gerhard, Maxwell W. Goodman, and James P. Smith for referral of cases.

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Cited by (42)

Design and implementation of MOEMS based optical diaphragm using Photonic Crystal for the prevention of barotrauma
2021, Results in Optics
Citation Excerpt :
The design is a conceptual design that is not in the scale. When the actual design for fabrication will be made the design will be validated to the required scale depending on the use of an earplug or ear implant (Raymond, 1995). Fig. 6 shows the semicircular ring resonator placed on a diaphragm of an earplug or headphone.
When there is stress on the eardrum because of a change in air pressure is known as Barotrauma. If there is excessive pressure than 20 KPa, damage to the eardrum may occur. During air travel, Barotrauma can occur due to pressure differences at high altitudes. This paper presented a MOEMS based pressure sensor using Photonic crystal. Two variants of sensor designs are a ring resonator and a semicircular resonator structure. Some of the potential use of a nanoscale pressure sensor is to measure the pressure inserted on the eardrum during scuba diving and the impact of an automobile airbag. The novelty of the work is to detect low-pressure between 5 KPa and 20 KPa. When applying pressure to the sensor, a variation in the refractive index occurs proportional to the stress imparted. The change in optical property caused the shift in the wavelength for pressure level. The impact of stress on a sensor placed on the diaphragm separating two media (air and water) were analyzed using 3D modelling and simulations. The designed sensor can be placed in an earplug to monitor pressure change. The Q-Factor observed is 3877.80 for ring structure and 4933.77 for semicircular structure. The novelty of the work is the development of Photonic Crystal based pressure sensor for Barotrauma detection and reduction of the sensor’s size.
The relationship between the occurrence of spontaneous pneumothorax and atmospheric pressure
2019, Revue des Maladies Respiratoires
Cette étude analyse la relation entre la survenue du pneumothorax spontané et la pression atmosphérique.
Étude prospective concernant 74 patients hospitalisés au service des maladies respiratoires du CHU de Ibn Rochd de Casablanca de janvier 2013 à juin 2014 pour pneumothorax spontané. Les valeurs de la pression atmosphérique au moment de la survenue du pneumothorax ont été enregistrées et analysées.
La moyenne d’âge était de 46 ans avec 70 hommes et 4 femmes. Quatre-vingt un pour-cent des patients étaient tabagiques et 89 % des patients habitaient dans une zone urbaine. Les pneumothorax survenus en situation anticyclonique constituaient 79,7 % des cas avec une médiane de 1018 hectoPascal (hPa) ± 4,18. Les pneumothorax survenus en situation de dépression atmosphérique représentaient 12,2 % des cas avec une médiane de 1010 hPa ± 1,92 et 8,1 % des pneumothorax sont survenus dans des conditions isobarométriques. Les pneumothorax survenaient dans des zones d’anticyclone de manière significativement plus élevée par rapport aux autres groupes (p <0,001 ; odds ratio : 28,41 ; risque relatif : 6,56 [3,52 < RR < 12,22]). On ne trouvait pas de différence statistiquement significative concernant l’âge, le terrain de bronchopneumopathie chronique obstructive ou de pneumothorax idiopathique entre les différents groupes.
La pression atmosphérique élevée est un facteur de risque du pneumothorax spontané indépendamment de l’âge et de la pathologie pulmonaire sous-jacente.
This study analyzes the relationship between the occurrence of spontaneous pneumothorax and atmospheric pressure.
We conducted a retrospective study on 74 patients hospitalized for spontaneous pneumothorax in the department of respiratory diseases from the Ibn Roshd university hospital of Casablanca between January 2013 and June 2014. The value of atmospheric pressure at the time of the occurrence of pneumothorax was recorded and analyzed.
The mean age was 46 years with 70 men and 4 women. Eighty-one percent of patients were smokers and 89% lived in an urban zone. Overall, 79.7% of pneumothoraces occurred in anticyclonic conditions, with a median atmospheric pressure of 1018 hPa ± 4.18. In all, 12.2% of pneumothoraces occurred in atmospheric depression with a median atmospheric pressure of 1010 hPa ± 1.92. The remaining 8.1% occurred in isobaric conditions. Pneumothoraces occurred significantly more during periods of high pressure compared to other periods (P <0.001; odds ratio: 28.41; relative risk 6.56 [3.52 < RR < 12.22]). There was no difference in the age, number pf patients with chronic obstructive pulmonary disease or idiopathic pneumothorax between the atmospheric condition groups.
Increased atmospheric pressure is a risk factor for spontaneous pneumothorax independent of age or the presence of underlying lung disease.
Diving medicine
2012, Science and Sports
Lors de l’immersion, les contraintes environnementales induisent chez l’individu un certain nombre de modifications physiologiques liées en majeure partie à la compressibilité des gaz, à leur dissolution et à leur toxicité. Ces phénomènes sont à la base des mécanismes physiopathologiques des accidents pouvant survenir en scaphandre autonome et en apnée. Les accidents de plongée sous-marine se caractérisent par leur polymorphisme. Certains peuvent mettre en jeu le pronostic vital ou laissent subsister un handicap fonctionnel important. On distingue les accidents neurologiques de désaturation, les barotraumatismes de la sphère ORL, digestifs et pulmonaires, les œdèmes pulmonaires d’immersion et les accidents biochimiques.
During the immersion, environmental requirements induce at the individual a certain number of physiological modifications largely due to the compressibility of gases, to their dissolution and to their toxicity. These phenomenons are at the basis of the pathophysiological mechanisms of the accidents, which can occur in scuba and breath-hold diving. The diving accidents are characterized by their polymorphism. Some can be life-threatening or let remain an important functional handicap. There are neurological decompression accidents, barotraumas of ENT sphere, of digestive tract and lung, immersion pulmonary edemas and biochemical accidents.
Fatal diving accidents: Two case reports and an overview of the role of forensic examinations
2008, Forensic Science International
Citation Excerpt :
For example, air trapping could lead to laceration of the lung tissue with subsequent pneumomediastinum or mediastinal or skin emphysema. Other consequences could include pneumothoraxes or arterial gas embolies, which are the most feared result of the pulmonary barotraumas because of high lethality [1,10–13]. During autopsy, pneumothorax, arterial gas embolie, and small lacerations of the lung tissue should be excluded by appropriate testing.
During the years 2004–2006, seven divers, who had deadly accidents, underwent post-mortem examination at the Institute of Legal Medicine of the University of Munich. The cause of death in all divers was drowning with typical pathomorphological findings. This should be regarded as separated to the triggering reason for drowning. The trigger for accident was established in four of seven cases by technical analysis and police investigation. High risk-taking, lack of technical service, and deficiency of dive equipment care were main reasons for death. We present two of these cases which showed several problems occurring concurrently. Autopsy always is necessary to look for indices for application of force or to exclude competitive reasons for death.
Pneumothorax and Barotrauma
2008, Critical Care Medicine: Principles of Diagnosis and Management in the Adult
Atmospheric pressure influences the risk of pneumothorax: Beware of the storm!
2007, Chest
Citation Excerpt :
Our study suggests that the transpulmonary pressure gradient that originates from variations in Patm is sufficient to cause pneumothorax in some individuals. Exposure to important changes of pressure is a known predisposing factor for pneumothorax.45 For comparison, diving to a depth of 10 m results in a pressure increase of 750 mm Hg, whereas commercial airline flights expose the individual to pressure variations of approximately 190 mm Hg.
Idiopathic spontaneous pneumothorax (ISP) results from rupture of blebs, bullas, or diseased alveolar walls. Initiating mechanisms may relate to increased transpulmonary pressure. The possible impact of changes in atmospheric pressure (Patm) on the occurrence of ISP remains uncertain.
We studied the relationship between the occurrence of ISP and meteorological conditions during a 4-year period in the urban area of Bologna, Italy, in which all cases of pneumothorax can be exhaustively identified. For each day of the study period, Patm and ambient temperature were obtained from the local meteorological institute. A cluster was defined as the admission of at least two patients with pneumothorax within 3 days of each other.
There were 294 episodes of ISP; 247 (84%) occurred in 76 clusters. Clusters were significantly associated with wider differences in Patm between the index day (ie, the first day of the cluster) and the previous day (ie, the difference in mean [± SEM] Patm, −1.23 ± 0.45 vs + 0.04 ± 0.12 mm Hg, respectively; p = 0.01[analysis of variance]). Similarly, pneumothorax and storms (but not temperature) were significantly associated (p < 0.0001 [χ² test]).
This large-scale study shows that patients with ISP are hospitalized in clusters and suggests that important variations in Patm may be involved. The knowledge of this relationship may help to understand the pathophysiology of the disease.

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: revision accepted October 27.

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Chest

Clinical Investigations: BarotraumaPulmonary Barotrauma and Related Events in Divers

Section snippets

Methods

Case 1

Discussion

ACKNOWLEGMENTS

Chest

Am J Med

Chest

Respir Physiol

Respir Physiol

Respir Physiol

Subcutaneous and mediastinal emphysema: pathophysiology, diagnosis and management

Arch Intern Med

Pulmonary barotrauma

Pulmonary barotrauma in divers and the treatment of cerebral arterial embolism

Aviat Space Environ Med

Response of pulmonary veins to increased intracranial pressure and pulmonary air embolization

J Appl Physiol Respir Environ Exercise Physiol

Clinical Investigations: Barotrauma
Pulmonary Barotrauma and Related Events in Divers