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Barotrauma is physical damage to body tissues caused by a difference in
pressure Pressure (symbol: ''p'' or ''P'') is the force applied perpendicular to the surface of an object per unit area over which that force is distributed. Gauge pressure (also spelled ''gage'' pressure)The preferred spelling varies by country and e ...
between a
gas Gas is one of the four fundamental states of matter (the others being solid, liquid, and plasma). A pure gas may be made up of individual atoms (e.g. a noble gas like neon), elemental molecules made from one type of atom (e.g. oxygen), or ...
space inside, or contact with, the body and the surrounding gas or liquid. The initial damage is usually due to over-stretching the tissues in
tension Tension may refer to: Science * Psychological stress * Tension (physics), a force related to the stretching of an object (the opposite of compression) * Tension (geology), a stress which stretches rocks in two opposite directions * Voltage or el ...
or
shear Shear may refer to: Textile production *Animal shearing, the collection of wool from various species **Sheep shearing *The removal of nap during wool cloth production Science and technology Engineering *Shear strength (soil), the shear strength ...
, either directly by an expansion of the gas in the closed space or by
pressure Pressure (symbol: ''p'' or ''P'') is the force applied perpendicular to the surface of an object per unit area over which that force is distributed. Gauge pressure (also spelled ''gage'' pressure)The preferred spelling varies by country and e ...
difference hydrostatically transmitted through the tissue. Tissue rupture may be complicated by the introduction of gas into the local tissue or circulation through the initial
trauma Trauma most often refers to: * Major trauma, in physical medicine, severe physical injury caused by an external source * Psychological trauma, a type of damage to the psyche that occurs as a result of a severely distressing event *Traumatic i ...
site, which can cause blockage of circulation at distant sites or interfere with the normal function of an organ by its presence. Barotrauma generally manifests as
sinus Sinus may refer to: Anatomy * Sinus (anatomy), a sac or cavity in any organ or tissue ** Paranasal sinuses, air cavities in the cranial bones, especially those near the nose, including: *** Maxillary sinus, is the largest of the paranasal sinuses, ...
or
middle ear The middle ear is the portion of the ear medial to the eardrum, and distal to the oval window of the cochlea (of the inner ear). The mammalian middle ear contains three ossicles, which transfer the vibrations of the eardrum into waves in the ...
effects, lung overpressure injuries and injuries resulting from external squeezes.
Decompression sickness Decompression sickness (abbreviated DCS; also called divers' disease, the bends, aerobullosis, and caisson disease) is a medical condition caused by dissolved gases emerging from solution as bubbles inside the body tissues during decompressio ...
is indirectly caused by ambient pressure reduction, and tissue damage is caused directly and indirectly by gas bubbles. However, these bubbles form out of supersaturated solution from dissolved gases, and are not generally considered barotrauma.
Decompression illness Decompression Illness (DCI) comprises two different conditions caused by rapid decompression of the body. These conditions present similar symptoms and require the same initial first aid. Scuba divers are trained to ascend slowly from depth to av ...
is a term that includes decompression sickness and arterial gas embolism caused by
lung The lungs are the primary organs of the respiratory system in humans and most other animals, including some snails and a small number of fish. In mammals and most other vertebrates, two lungs are located near the backbone on either side of t ...
overexpansion barotrauma. It is also classified under the broader term of
dysbarism Dysbarism refers to medical conditions resulting from changes in ambient pressure. Various activities are associated with pressure changes. Underwater diving is the most frequently cited example, but pressure changes also affect people who work i ...
, which covers all medical conditions resulting from changes in ambient pressure. Barotrauma typically occurs when the organism is exposed to a significant change in
ambient pressure Ambient or Ambiance or Ambience may refer to: Music and sound * Ambience (sound recording), also known as atmospheres or backgrounds * Ambient music, a genre of music that puts an emphasis on tone and atmosphere * ''Ambient'' (album), by Moby * ...
, such as when a
scuba diver Scuba diving is a mode of underwater diving whereby divers use breathing equipment that is completely independent of a surface air supply. The name "scuba", an acronym for "Self-Contained Underwater Breathing Apparatus", was coined by Chris ...
, a
free-diver Freediving, free-diving, free diving, breath-hold diving, or skin diving is a form of underwater diving that relies on breath-holding until resurfacing rather than the use of breathing apparatus such as scuba gear. Besides the limits of breath- ...
or an airplane passenger ascends or descends or during
uncontrolled decompression Uncontrolled decompression is an unplanned drop in the pressure of a sealed system, such as an aircraft cabin or hyperbaric chamber, and typically results from human reliability, human error, fatigue (material), material fatigue, engineering failur ...
of a
pressure vessel A pressure vessel is a container designed to hold gases or liquids at a pressure substantially different from the ambient pressure. Construction methods and materials may be chosen to suit the pressure application, and will depend on the size o ...
such as a
diving chamber A diving chamber is a vessel for human occupation, which may have an entrance that can be sealed to hold an internal pressure significantly higher than ambient pressure, a pressurised gas system to control the internal pressure, and a supply of ...
or pressurized aircraft, but can also be caused by a
shock wave In physics, a shock wave (also spelled shockwave), or shock, is a type of propagating disturbance that moves faster than the local speed of sound in the medium. Like an ordinary wave, a shock wave carries energy and can propagate through a med ...
.
Ventilator-induced lung injury Ventilator-associated lung injury (VALI) is an acute lung injury that develops during mechanical ventilation and is termed ventilator-induced lung injury (VILI) if it can be proven that the mechanical ventilation caused the acute lung injury. In c ...
(VILI) is a condition caused by over-expansion of the lungs by mechanical
ventilation Ventilation may refer to: * Ventilation (physiology), the movement of air between the environment and the lungs via inhalation and exhalation ** Mechanical ventilation, in medicine, using artificial methods to assist breathing *** Ventilator, a m ...
used when the body is unable to breathe for itself and is associated with relatively large tidal volumes and relatively high peak pressures. Barotrauma due to overexpansion of an internal gas-filled space may also be termed volutrauma.
Bats Bats are mammals of the order Chiroptera.''cheir'', "hand" and πτερόν''pteron'', "wing". With their forelimbs adapted as wings, they are the only mammals capable of true and sustained flight. Bats are more agile in flight than most bi ...
can be killed by lung barotrauma when flying in low-pressure regions close to operating
wind-turbine A wind turbine is a device that converts the kinetic energy of wind into electrical energy. Hundreds of thousands of large turbines, in installations known as wind farms, now generate over 650 gigawatts of power, with 60 GW added each year. ...
blades, and fish with sealed swim bladders experience barotrauma when pulled up from the depths. The
diagnosis Diagnosis is the identification of the nature and cause of a certain phenomenon. Diagnosis is used in many different disciplines, with variations in the use of logic, analytics, and experience, to determine " cause and effect". In systems engin ...
and contribution of barotrauma to bat deaths near wind turbine blades have been called into question by other research.


Presentation

Examples of
organs In biology, an organ is a collection of tissues joined in a structural unit to serve a common function. In the hierarchy of life, an organ lies between tissue and an organ system. Tissues are formed from same type cells to act together in a f ...
or tissues easily damaged by barotrauma are: *
Middle ear The middle ear is the portion of the ear medial to the eardrum, and distal to the oval window of the cochlea (of the inner ear). The mammalian middle ear contains three ossicles, which transfer the vibrations of the eardrum into waves in the ...
and
inner ear The inner ear (internal ear, auris interna) is the innermost part of the vertebrate ear. In vertebrates, the inner ear is mainly responsible for sound detection and balance. In mammals, it consists of the bony labyrinth, a hollow cavity in the ...
(barotitis or aerotitis) *
Paranasal sinus Paranasal sinuses are a group of four paired air-filled spaces that surround the nasal cavity. The maxillary sinuses are located under the eyes; the frontal sinuses are above the eyes; the ethmoidal sinuses are between the eyes and the sphenoid ...
es (causing
aerosinusitis Aerosinusitis, also called barosinusitis, sinus squeeze or sinus barotrauma is a painful inflammation and sometimes bleeding of the membrane of the paranasal sinus cavities, normally the frontal sinus. It is caused by a difference in air pressures ...
) *
Lungs The lungs are the primary organs of the respiratory system in humans and most other animals, including some snails and a small number of fish. In mammals and most other vertebrates, two lungs are located near the backbone on either side of th ...
*
Eyes Eyes are organs of the visual system. They provide living organisms with vision, the ability to receive and process visual detail, as well as enabling several photo response functions that are independent of vision. Eyes detect light and conve ...
(the under-pressure air space is inside the
diving mask Diving most often refers to: * Diving (sport), the sport of jumping into deep water * Underwater diving, human activity underwater for recreational or occupational purposes Diving or Dive may also refer to: Sports * Dive (American football), a ...
) *
Skin Skin is the layer of usually soft, flexible outer tissue covering the body of a vertebrate animal, with three main functions: protection, regulation, and sensation. Other cuticle, animal coverings, such as the arthropod exoskeleton, have diffe ...
(when wearing a
diving suit A diving suit is a garment or device designed to protect a diver from the underwater environment. A diving suit may also incorporate a breathing gas supply (such as for a standard diving dress or atmospheric diving suit). but in most cases the te ...
which creates an air space) *
Brain A brain is an organ that serves as the center of the nervous system in all vertebrate and most invertebrate animals. It is located in the head, usually close to the sensory organs for senses such as vision. It is the most complex organ in a v ...
and
cranium The skull is a bone protective cavity for the brain. The skull is composed of four types of bone i.e., cranial bones, facial bones, ear ossicles and hyoid bone. However two parts are more prominent: the cranium and the mandible. In humans, the ...
(temporal lobe injury secondary to temporal bone rupture) *
Teeth A tooth ( : teeth) is a hard, calcified structure found in the jaws (or mouths) of many vertebrates and used to break down food. Some animals, particularly carnivores and omnivores, also use teeth to help with capturing or wounding prey, tear ...
(causing
barodontalgia Barodontalgia, commonly known as tooth squeeze, is a dental pain, pain in a tooth caused by a change in ambient pressure. The pain usually ceases at ground level. Dental barotrauma is a condition in which such changes in barometric pressure change ...
, i.e., barometric pressure related
dental pain Toothache, also known as dental pain,Segen JC. (2002). ''McGraw-Hill Concise Dictionary of Modern Medicine''. The McGraw-Hill Companies. is pain in the teeth or their supporting structures, caused by dental diseases or pain referred to the te ...
, or dental fractures) *
Genital A sex organ (or reproductive organ) is any part of an animal or plant that is involved in sexual reproduction. The reproductive organs together constitute the reproductive system. In animals, the testis in the male, and the ovary in the female, a ...
squeeze and associated
urinary The urinary system, also known as the urinary tract or renal system, consists of the kidneys, ureters, bladder, and the urethra. The purpose of the urinary system is to eliminate waste from the body, regulate blood volume and blood pressure, co ...
complications of '' P-valve'' use.


Causes

Any cause of sufficiently large and rapid environmental pressure change can potentially cause barotrauma. Several commonly recognised examples are listed below.


Pressure differences while diving

When diving, the
pressure Pressure (symbol: ''p'' or ''P'') is the force applied perpendicular to the surface of an object per unit area over which that force is distributed. Gauge pressure (also spelled ''gage'' pressure)The preferred spelling varies by country and e ...
differences which cause the barotrauma are changes in hydrostatic pressure: There are two components to the surrounding pressure acting on the diver: the
atmospheric pressure Atmospheric pressure, also known as barometric pressure (after the barometer), is the pressure within the atmosphere of Earth. The standard atmosphere (symbol: atm) is a unit of pressure defined as , which is equivalent to 1013.25 millibars, 7 ...
and the water pressure. A descent of 10 metres (33 feet) in water increases the ambient pressure by an amount approximately equal to the pressure of the atmosphere at sea level. So, a descent from the surface to 10 metres (33 feet) underwater results in a doubling of the pressure on the diver. This pressure change will reduce the volume of a flexible gas-filled space by half.
Boyle's law Boyle's law, also referred to as the Boyle–Mariotte law, or Mariotte's law (especially in France), is an experimental gas law that describes the relationship between pressure and volume of a confined gas. Boyle's law has been stated as: The ...
describes the relationship between the
volume Volume is a measure of occupied three-dimensional space. It is often quantified numerically using SI derived units (such as the cubic metre and litre) or by various imperial or US customary units (such as the gallon, quart, cubic inch). The de ...
of the gas space and the pressure in the gas. Barotraumas of descent are caused by preventing the free change of volume of the gas in a closed space in contact with the diver, resulting in a pressure difference between the tissues and the gas space, and the unbalanced force due to this pressure difference causes deformation of the tissues resulting in cell rupture. Barotraumas of ascent are also caused when the free change of volume of the gas in a closed space in contact with the diver is prevented. In this case the pressure difference causes a resultant tension in the surrounding tissues which exceeds their tensile strength.


Use of a hyperbaric chamber

Patients undergoing
hyperbaric oxygen therapy Hyperbaric medicine is medical treatment in which an ambient pressure greater than sea level atmospheric pressure is a necessary component. The treatment comprises hyperbaric oxygen therapy (HBOT), the medical use of oxygen at an ambient pressure ...
must equalize their ears to avoid barotrauma. High risk of otic barotrauma is associated with unconscious patients.


Rapid decompression of a pressurised artificial environment

Explosive decompression Uncontrolled decompression is an unplanned drop in the pressure of a sealed system, such as an aircraft cabin or hyperbaric chamber, and typically results from human error, material fatigue, engineering failure, or impact, causing a pressure vesse ...
of a hyperbaric environment can produce severe barotrauma, followed by severe decompression bubble formation and other related injury. The ''
Byford Dolphin ''Byford Dolphin'' was a semi-submersible, column-stabilised drilling rig operated by Dolphin Drilling, a Fred Olsen Energy subsidiary. It drilled seasonally for various companies in the United Kingdom, Danish and Norwegian sectors of the Nort ...
'' incident is an example. Rapid uncontrolled decomression from caissons, airlocks, pressurised aircraft, spacecraft, and pressure suits can have similar effects of decompression barotrauma.


Rapid pressurisation of an artificial environment

Collapse of a pressure resistant structure such as a
submarine A submarine (or sub) is a watercraft capable of independent operation underwater. It differs from a submersible, which has more limited underwater capability. The term is also sometimes used historically or colloquially to refer to remotely op ...
,
submersible A submersible is a small watercraft designed to operate underwater. The term "submersible" is often used to differentiate from other underwater vessels known as submarines, in that a submarine is a fully self-sufficient craft, capable of ind ...
, or
atmospheric diving suit An atmospheric diving suit (ADS) is a small one-person articulated submersible which resembles a suit of armour, with elaborate pressure joints to allow articulation while maintaining an internal pressure of one atmosphere. An ADS can enable di ...
can cause rapid compression barotrauma.


Rapid change of altitude

A rapid change of altitude can cause barotrauma when internal air spaces cannot be equalised.


Self inflicted barotrauma

Excessively strenuous efforts to equalise the ears using the Valsalva manoeuvre can overpressurise the middle ear, and can cause middle ear and/or inner ear barotrauma.


Blast-induced barotrauma

An explosive blast and
explosive decompression Uncontrolled decompression is an unplanned drop in the pressure of a sealed system, such as an aircraft cabin or hyperbaric chamber, and typically results from human error, material fatigue, engineering failure, or impact, causing a pressure vesse ...
create a pressure wave that can induce barotrauma. The difference in pressure between internal organs and the outer surface of the body causes injuries to internal organs that contain gas, such as the
lungs The lungs are the primary organs of the respiratory system in humans and most other animals, including some snails and a small number of fish. In mammals and most other vertebrates, two lungs are located near the backbone on either side of th ...
,
gastrointestinal tract The gastrointestinal tract (GI tract, digestive tract, alimentary canal) is the tract or passageway of the digestive system that leads from the mouth to the anus. The GI tract contains all the major organ (biology), organs of the digestive syste ...
, and
ear An ear is the organ that enables hearing and, in mammals, body balance using the vestibular system. In mammals, the ear is usually described as having three parts—the outer ear, the middle ear and the inner ear. The outer ear consists of ...
. Lung injuries can also occur during
rapid decompression Uncontrolled decompression is an unplanned drop in the pressure of a sealed system, such as an aircraft cabin or hyperbaric chamber, and typically results from human error, material fatigue, engineering failure, or impact, causing a pressure vesse ...
, although the risk of injury is lower than with explosive decompression.


Ventilator-induced barotrauma

Mechanical ventilation Mechanical ventilation, assisted ventilation or intermittent mandatory ventilation (IMV), is the medical term for using a machine called a ventilator to fully or partially provide artificial ventilation. Mechanical ventilation helps move air ...
can lead to barotrauma of the lungs. This can be due to either: * absolute pressures used in order to ventilate
non-compliant In general, compliance means conforming to a rule, such as a specification, policy, standard or law. Compliance has traditionally been explained by reference to the deterrence theory, according to which punishing a behavior will decrease the viol ...
lungs. * shearing forces, particularly associated with rapid changes in gas
velocity Velocity is the directional speed of an object in motion as an indication of its rate of change in position as observed from a particular frame of reference and as measured by a particular standard of time (e.g. northbound). Velocity is a ...
. The resultant alveolar rupture can lead to
pneumothorax A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases, a one-way valve ...
,
pulmonary interstitial emphysema Pulmonary interstitial emphysema (PIE) is a collection of air outside of the normal air space of the pulmonary alveoli, found instead inside the connective tissue of the peribronchovascular sheaths, interlobular septa, and visceral pleura. (This ...
(PIE) and
pneumomediastinum Pneumomediastinum (from Greek ''pneuma'' – "air", also known as mediastinal emphysema) is pneumatosis (abnormal presence of air or other gas) in the mediastinum, the central part of the chest cavity. First described in 1819 by René Laennec, ...
. Barotrauma is a recognised complication of mechanical ventilation that can occur in any patient receiving mechanical ventilation, but is most commonly associated with acute respiratory distress syndrome. It used to be the most common complication of mechanical ventilation but can usually be avoided by limiting tidal volume and plateau pressure to less than 30 to 50 cm water column (30 to 50 mb). As an indicator of transalveolar pressure, which predicts alveolar distention, plateau pressure or peak airway pressure (PAP) may be the most effective predictor of risk, but there is no generally accepted safe pressure at which there is no risk. Risk also appears to be increased by aspiration of stomach contents and pre-existing disease such as necrotising
pneumonia Pneumonia is an inflammatory condition of the lung primarily affecting the small air sacs known as alveoli. Symptoms typically include some combination of productive or dry cough, chest pain, fever, and difficulty breathing. The severity ...
and chronic lung disease. Status asthmaticus is a particular problem as it requires relatively high pressures to overcome bronchial obstruction. When lung tissues are damaged by alveolar over-distension, the injury may be termed volutrauma, but volume and transpulmonary pressure are closely related. Ventilator induced lung injury is often associated with high tidal volumes (Vt).


Pathophysiology


Lung overpressure injury

A
free-diver Freediving, free-diving, free diving, breath-hold diving, or skin diving is a form of underwater diving that relies on breath-holding until resurfacing rather than the use of breathing apparatus such as scuba gear. Besides the limits of breath- ...
can dive and safely ascend without exhaling, because the gas in the lungs had been inhaled at atmospheric pressure, is compressed during the descent, and expands back to the original volume during ascent. A
scuba Scuba may refer to: * Scuba diving ** Scuba set, the equipment used for scuba (Self-Contained Underwater Breathing Apparatus) diving * Scuba, an in-memory database developed by Facebook * Submillimetre Common-User Bolometer Array, either of two in ...
or surface-supplied diver breathing gas at depth from
underwater breathing apparatus Underwater breathing apparatus is equipment which allows the user to breathe underwater. The three major categories of ambient pressure underwater breathing apparatus are: *Open circuit scuba, where the diver carries the gas supply, and exhaled ga ...
fills their lungs with gas at a ambient pressure greater than atmospheric pressure. At 10 metres the lungs contain twice the amount of gas that they would contain at atmospheric pressure, and if they ascend without exhaling the gas will expand to match the decreasing pressure until the lungs reach their elastic limit, and begin to tear, and is very likely to sustain life-threatening lung damage. Besides tissue rupture, the overpressure may cause ingress of gases into the tissues through the ruptures, and further afield through the circulatory system. Pulmonary barotrauma (PBt) of ascent is also known as pulmonary over-inflation syndrome (POIS), lung over-pressure injury (LOP) and burst lung. Consequent injuries may include
arterial gas embolism An air embolism, also known as a gas embolism, is a blood vessel blockage caused by one or more bubbles of air or other gas in the circulatory system. Air can be introduced into the circulation during surgical procedures, lung over-expansion i ...
,
pneumothorax A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases, a one-way valve ...
, mediastinal, interstitial and subcutaneous
emphysema Emphysema, or pulmonary emphysema, is a lower respiratory tract disease, characterised by air-filled spaces ( pneumatoses) in the lungs, that can vary in size and may be very large. The spaces are caused by the breakdown of the walls of the alve ...
s, depending on where the gas ends up, not usually all at the same time.


Arterial gas embolism

Gas in the arterial system can be carried to the blood vessels of the brain and other vital organs. It typically causes transient embolism similar to thromboembolism but of shorter duration. Where damage occurs to the endothelium inflammation develops and symptoms resembling stroke may follow. The bubbles are generally distributed and of various sizes, and usually affect several areas, resulting in an unpredictable variety of neurological deficits. Unconsciousness or other major changes to the state of consciousness within about 10 minutes of surfacing are generally assumed to be gas embolism until proven otherwise. The belief that the gas bubbles themselves formed static emboli which remain in place until recompression has been superseded by the knowledge that the gas emboli are normally transient, and the damage is due to inflammation following endothelial damage and secondary injury from inflammatory mediator upregulation. Hyperbaric oxygen can cause downregulation of the inflammatory response and resolution of oedema by causing hyperoxic arterial vasoconstriction of the supply to capillary beds. High concentration normobaric oxygen is appropriate as first aid but is not considered definitive treatment even when the symptoms appear to resolve. Relapses are common after discontinuing oxygen without recompression.


Pneumothorax

A
pneumothorax A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases, a one-way valve ...
is an abnormal collection of air in the
pleural space The pleural cavity, pleural space, or interpleural space is the potential space between the pleurae of the pleural sac that surrounds each lung. A small amount of serous pleural fluid is maintained in the pleural cavity to enable lubrication bet ...
between the
lung The lungs are the primary organs of the respiratory system in humans and most other animals, including some snails and a small number of fish. In mammals and most other vertebrates, two lungs are located near the backbone on either side of t ...
and the chest wall. Symptoms typically include sudden onset of sharp, one-sided
chest pain Chest pain is pain or discomfort in the chest, typically the front of the chest. It may be described as sharp, dull, pressure, heaviness or squeezing. Associated symptoms may include pain in the shoulder, arm, upper abdomen, or jaw, along with n ...
and
shortness of breath Shortness of breath (SOB), also medically known as dyspnea (in AmE) or dyspnoea (in BrE), is an uncomfortable feeling of not being able to breathe well enough. The American Thoracic Society defines it as "a subjective experience of breathing disc ...
. In a minority of cases, a one-way valve is formed by an area of damaged tissue, and the amount of air in the space between chest wall and lungs increases; this is called a tension pneumothorax. This can cause a steadily worsening oxygen shortage and
low blood pressure Hypotension is low blood pressure. Blood pressure is the force of blood pushing against the walls of the arteries as the heart pumps out blood. Blood pressure is indicated by two numbers, the systolic blood pressure (the top number) and the dia ...
. This leads to a type of shock called obstructive shock, which can be fatal unless reversed. Very rarely, both lungs may be affected by a pneumothorax. It is often called a "collapsed lung", although that term may also refer to
atelectasis Atelectasis is the collapse or closure of a lung resulting in reduced or absent gas exchange. It is usually unilateral, affecting part or all of one lung. It is a condition where the alveoli are deflated down to little or no volume, as distinct ...
.
Divers Diver or divers may refer to: *Diving (sport), the sport of performing acrobatics while jumping or falling into water *Practitioner of underwater diving, including: **scuba diving, **freediving, **surface-supplied diving, **saturation diving, a ...
who breathe from an underwater apparatus are supplied with breathing gas at
ambient pressure Ambient or Ambiance or Ambience may refer to: Music and sound * Ambience (sound recording), also known as atmospheres or backgrounds * Ambient music, a genre of music that puts an emphasis on tone and atmosphere * ''Ambient'' (album), by Moby * ...
, which results in their lungs containing gas at higher than atmospheric pressure. Divers breathing compressed air (such as when
scuba diving Scuba diving is a mode of underwater diving whereby divers use breathing equipment that is completely independent of a surface air supply. The name "scuba", an acronym for "Self-Contained Underwater Breathing Apparatus", was coined by Chris ...
) may develop a pneumothorax as a result of barotrauma from ascending just while breath-holding with their lungs fully inflated. An additional problem in these cases is that those with other features of
decompression sickness Decompression sickness (abbreviated DCS; also called divers' disease, the bends, aerobullosis, and caisson disease) is a medical condition caused by dissolved gases emerging from solution as bubbles inside the body tissues during decompressio ...
are typically treated in a
diving chamber A diving chamber is a vessel for human occupation, which may have an entrance that can be sealed to hold an internal pressure significantly higher than ambient pressure, a pressurised gas system to control the internal pressure, and a supply of ...
with hyperbaric therapy; this can lead to a small pneumothorax rapidly enlarging and causing features of tension. Diagnosis of a pneumothorax by
physical examination In a physical examination, medical examination, or clinical examination, a medical practitioner examines a patient for any possible medical signs or symptoms of a medical condition. It generally consists of a series of questions about the patien ...
alone can be difficult (particularly in smaller pneumothoraces). A
chest X-ray A chest radiograph, called a chest X-ray (CXR), or chest film, is a projection radiograph of the chest used to diagnose conditions affecting the chest, its contents, and nearby structures. Chest radiographs are the most common film taken in med ...
, computed tomography (CT) scan, or
ultrasound Ultrasound is sound waves with frequency, frequencies higher than the upper audible limit of human hearing range, hearing. Ultrasound is not different from "normal" (audible) sound in its physical properties, except that humans cannot hea ...
is usually used to confirm its presence. Other conditions that can result in similar symptoms include a
hemothorax A hemothorax (derived from hemo- lood+ thorax hest plural ''hemothoraces'') is an accumulation of blood within the pleural cavity. The symptoms of a hemothorax may include chest pain and difficulty breathing, while the clinical signs may incl ...
(buildup of
blood Blood is a body fluid in the circulatory system of humans and other vertebrates that delivers necessary substances such as nutrients and oxygen to the cells, and transports metabolic waste products away from those same cells. Blood in the c ...
in the pleural space),
pulmonary embolism Pulmonary embolism (PE) is a blockage of an pulmonary artery, artery in the lungs by a substance that has moved from elsewhere in the body through the bloodstream (embolism). Symptoms of a PE may include dyspnea, shortness of breath, chest pain p ...
, and
heart attack A myocardial infarction (MI), commonly known as a heart attack, occurs when blood flow decreases or stops to the coronary artery of the heart, causing damage to the heart muscle. The most common symptom is chest pain or discomfort which may tr ...
. A large
bulla Bulla (Latin, 'bubble') may refer to: Science and medicine * Bulla (dermatology), a bulla * Bulla, a focal lung pneumatosis, an air pocket in the lung * Auditory bulla, a hollow bony structure on the skull enclosing the ear * Ethmoid bulla, pa ...
may look similar on a chest X-ray.


Pneumomediastinum

Also known as mediastinal emphysema to divers,
pneumomediastinum Pneumomediastinum (from Greek ''pneuma'' – "air", also known as mediastinal emphysema) is pneumatosis (abnormal presence of air or other gas) in the mediastinum, the central part of the chest cavity. First described in 1819 by René Laennec, ...
is a volume of gas inside the mediastinum, the central cavity in the chest between the lungs and surrounding the heart and central blood vessels, usually formed by gas escaping from the lungs as a result of lung rupture. Gas bubbles escaping from a ruptured lung can travel along the outside of
bronchioles The bronchioles or bronchioli (pronounced ''bron-kee-oh-lee'') are the smaller branches of the bronchial airways in the lower respiratory tract. They include the terminal bronchioles, and finally the respiratory bronchioles that mark the start o ...
and blood vessels until they reach the mediastinal cavity round the heart, major blood vessels, oesophagus and trachea. Gas trapped in the mediastinum expands as the diver continues to rise. The pressure of the trapped gas may cause intense pain inside the rib cage and in the shoulders, and the gas may compress the respiratory passageways, making breathing difficult, and collapse blood vessels. Symptoms range from pain under the sternum, shock, shallow breathing, unconsciousness, respiratory failure, and associated cyanosis. The gas will usually be absorbed by the body over time, and when the symptoms are mild, no treatment may be necessary. Otherwise it may be vented through a hypodermic needle inserted into the mediastinum. Recompression is not usually indicated.


Diagnosis

Diagnosis of barotrauma generally involves a history of exposure to a source of pressure which could cause the injury suggested by the symptoms. This can vary from the immediately obvious if exposed to explosive blast, or mask squeeze, to rather complex discrimination between possibilities of inner ear decompression sickness and inner ear barotrauma, which may have nearly identical symptoms but different causative mechanism and mutually incompatible treatments. The detailed dive history may be necessary in these cases. In terms of ''barotrauma'' the diagnostic workup for the affected individual could include the following: Laboratory: *
Creatine kinase Creatine kinase (CK), also known as creatine phosphokinase (CPK) or phosphocreatine kinase, is an enzyme () expressed by various tissues and cell types. CK catalyses the conversion of creatine and uses adenosine triphosphate (ATP) to create phosp ...
(CPK) level: Increases in CPK levels indicate tissue damage associated with decompression sickness. *
Complete blood count A complete blood count (CBC), also known as a full blood count (FBC), is a set of medical laboratory tests that provide cytometry, information about the cells in a person's blood. The CBC indicates the counts of white blood cells, red blood cell ...
(CBC) *
Arterial blood gas An arterial blood gas (ABG) test, or arterial blood gas analysis (ABGA) measures the amounts of arterial gases, such as oxygen and carbon dioxide. An ABG test requires that a small volume of blood be drawn from the radial artery with a syringe an ...
(ABG) determination Imaging: * Chest
radiography Radiography is an imaging technique using X-rays, gamma rays, or similar ionizing radiation and non-ionizing radiation to view the internal form of an object. Applications of radiography include medical radiography ("diagnostic" and "therapeut ...
can show pneumothorax, and is indicated if there is chest discomfort or breathing difficulty * Computed tomography (CT) scans and magnetic resonance imaging (MRI) may be indicated when there is severe headache or severe back pain after diving. * CT is the most sensitive method to evaluate for pneumothorax. It can be used where barotrauma-related pneumothorax is suspected and chest radiograph findings are negative. *
Echocardiography An echocardiography, echocardiogram, cardiac echo or simply an echo, is an ultrasound of the heart. It is a type of medical imaging of the heart, using standard ultrasound or Doppler ultrasound. Echocardiography has become routinely used in t ...
can be used to detect the number and size of gas bubbles in the right side of the heart.


Ear barotrauma

Barotrauma can affect the external, middle, or inner ear.
Middle ear barotrauma Middle ear barotrauma (MEBT), also known to underwater divers as ear squeeze and reverse ear squeeze, is an injury caused by a difference in pressure between the external ear canal and the middle ear. It is common in underwater divers and usuall ...
(MEBT) is the most common diving injury, being experienced by between 10% and 30% of divers and is due to insufficient equilibration of the middle ear. External ear barotrauma may occur if air is trapped in the
external auditory canal The ear canal (external acoustic meatus, external auditory meatus, EAM) is a pathway running from the outer ear to the middle ear. The adult human ear canal extends from the pinna to the eardrum and is about in length and in diameter. Stru ...
. Diagnosis of middle and external ear barotraume is relatively simple, as the damage is usually visible if severe enough to require intervention.


External auditory canal

Barotrauma can occur in the external auditory canal if it is blocked by cerumen, exostoses, a tight-fitting diving suit hood or earplugs, which create an airtight, air-filled space between the eardrum and the blockage. On descent, a preeure differential develops between the ambient water and the interior of this space, and this can cause swelling and haemorrhagic blistering of the canal. Treatment is usually analgesics and topical steroid eardrops. Complications may include local infection. This form of barotrauma is usually easily avoided.


Middle ear

Middle ear barotrauma (MEBT) is an injury caused by a difference in pressure between the external ear canal and the middle ear. It is common in
underwater divers This is a list of underwater divers whose exploits have made them notable. Underwater divers are people who take part in underwater diving activities – Underwater diving is practiced as part of an occupation, or for recreation, where t ...
and usually occurs when the diver does not equalise sufficiently during descent or, less commonly, on ascent. Failure to equalise may be due to inexperience or eustachian tube dysfunction, which can have many possible causes. Unequalised ambient pressure increase during descent causes a pressure imbalance between the middle ear air space and the external auiditory canal over the eardrum, referred to by divers as ear squeeze, causing inward stretching, serous effusion and haemorrhage, and eventual rupture. During ascent internal over-pressure is normally passively released through the eustachian tube, but if this does not happen the volume expansion of middle ear gas will cause outward bulging, stretching and eventual rupture of the eardrum known to divers as . This damage causes local pain and hearing loss. Tympanic rupture during a dive can allow water into the middle ear, which can cause severe vertigo from caloric stimulation. This may cause nausea and vomiting underwater, which has a high risk of aspiration of vomit or water, with possible fatal consequences.


Inner ear

Inner ear barotrauma (IEBt), though much less common than MEBT, shares a similar external cause. Mechanical trauma to the inner ear can lead to varying degrees of
conductive In physics and electrical engineering, a conductor is an object or type of material that allows the flow of charge (electric current) in one or more directions. Materials made of metal are common electrical conductors. Electric current is gener ...
and
sensorineural hearing loss Sensorineural hearing loss (SNHL) is a type of hearing loss in which the root cause lies in the inner ear or sensory organ (cochlea and associated structures) or the vestibulocochlear nerve (cranial nerve VIII). SNHL accounts for about 90% of rep ...
as well as
vertigo Vertigo is a condition where a person has the sensation of movement or of surrounding objects moving when they are not. Often it feels like a spinning or swaying movement. This may be associated with nausea, vomiting, sweating, or difficulties w ...
. It is also common for conditions affecting the inner ear to result in auditory hypersensitivity. Two possible mechanisms are associated with forced Valsalva manoeuvre. In the one, the Eustachian tube opens in response to the pressure, and a sudden rush of high pressure air into the middle ear causes stapes footplate dislocation and inward rupture of the oval or round window. In the other, the tube remains closed and increased cerebrospinal fluit pressure is transmitted through the cochlea and causes outward rupture of the round window. Inner ear barotrauma can be difficult to distinguish from
Inner ear decompression sickness Inner ear decompression sickness, (IEDCS) or audiovestibular decompression sickness is a medical condition of the inner ear caused by the formation of gas bubbles in the tissues or blood vessels of the inner ear. Generally referred to as a form o ...
. Both conditions manifest as cochleovestibular symptoms. The similarity of symptoms makes differential diagnosis difficult, which can delay appropriate treatment or lead to inappropriate treatment.
Nitrogen narcosis Narcosis while diving (also known as nitrogen narcosis, inert gas narcosis, raptures of the deep, Martini effect) is a reversible alteration in consciousness that occurs while diving at depth. It is caused by the anesthetic effect of certain g ...
,
oxygen toxicity Oxygen toxicity is a condition resulting from the harmful effects of breathing molecular oxygen () at increased partial pressures. Severe cases can result in cell damage and death, with effects most often seen in the central nervous system, lu ...
,
hypercarbia Hypercapnia (from the Greek ''hyper'' = "above" or "too much" and ''kapnos'' = "smoke"), also known as hypercarbia and CO2 retention, is a condition of abnormally elevated carbon dioxide (CO2) levels in the blood. Carbon dioxide is a gaseous pr ...
, and hypoxia can cause disturbances in balance or vertigo, but these appear to be central nervous system effects, not directly related to effects on the vestibular organs.
High-pressure nervous syndrome High-pressure nervous syndrome (HPNS – also known as high-pressure neurological syndrome) is a neurological and physiological diving disorder which can result when a diver descends below about using a breathing gas containing helium. The eff ...
during
heliox Heliox is a breathing gas mixture of helium (He) and oxygen (O2). It is used as a medical treatment for patients with difficulty breathing because mixture generates less resistance than atmospheric air when passing through the airways of the lung ...
compression is also a central nervous system dysfunction. Inner ear injuries with lasting effects are usually due to
round window The round window is one of the two openings from the middle ear into the inner ear. It is sealed by the secondary tympanic membrane (round window membrane), which vibrates with opposite phase to vibrations entering the inner ear through the oval ...
ruptures, often associated with
Valsalva maneuver The Valsalva maneuver is performed by a forceful attempt of exhalation against a closed airway, usually done by closing one's mouth and pinching one's nose shut while expelling air out as if blowing up a balloon. Variations of the maneuver can ...
or inadequate middle ear equalisation. Inner ear barotraume is often concurrent with middle ear barotrama as the external causes are generally the same. A variety of injuries may be present, which may include inner ear haemorrhage, intralabyrinthine membrane tear, perilymph fistula, and other pathologies. Divers who develop cochlear and/or vestibular symptoms during descent to any depth, or during shallow diving in which decompression sickness is unlikely, should be treated with bed rest with head elevation, and should avoid any activity which could cause raised
cerebrospinal fluid Cerebrospinal fluid (CSF) is a clear, colorless body fluid found within the tissue that surrounds the brain and spinal cord of all vertebrates. CSF is produced by specialised ependymal cells in the choroid plexus of the ventricles of the bra ...
and intralabyrinthine pressure. If there is no improvement in symptoms after 48 hours, exploratory tympanotomy may be considered to investigate possible repair of a labyrinthine window
fistula A fistula (plural: fistulas or fistulae ; from Latin ''fistula'', "tube, pipe") in anatomy is an abnormal connection between two hollow spaces (technically, two epithelialized surfaces), such as blood vessels, intestines, or other hollow or ...
. Recompression therapy is contraindicated in these cases, but is the definitive treatment for inner ear decompression sickness, making an early and accurate
differential diagnosis In healthcare, a differential diagnosis (abbreviated DDx) is a method of analysis of a patient's history and physical examination to arrive at the correct diagnosis. It involves distinguishing a particular disease or condition from others that p ...
important for deciding on appropriate treatment. IEBt in divers may be difficult to distinguish from inner ear decompression sickness (IEDCS), and as a dive profile alone cannot always eliminate either of the possibilities, the detailed dive history may be necessary to diagnose the more likely injury. It is also possible for both to occur at the same time, and IEDCS is more likely to affect the semicircular canals, causing severe vertigo, while IEBt is more likely to affect the cochlea, causing hearing loss, but these are just statistical probabilities, and in reality it can go either way or both. It is accepted practice to assume that if any symptom typical of DCS is present, that the diver has DCS and will be treated accordingly with recompression. Limited case data suggest that recompression does not usually cause harm if the differential diagnosis between IEBt vs IEDCS is doubtful.


Barosinusitis

The
sinuses Paranasal sinuses are a group of four paired air-filled spaces that surround the nasal cavity. The maxillary sinuses are located under the eyes; the frontal sinuses are above the eyes; the ethmoidal sinuses are between the eyes and the sphenoid ...
, like other air-filled cavities, are susceptible to barotrauma if their openings become obstructed. This can result in pain as well as epistaxis (
nosebleed A nosebleed, also known as epistaxis, is bleeding from the nose. Blood can flow down into the stomach, and cause nausea and vomiting. In more severe cases, blood may come out of both nostrils. Rarely, bleeding may be so significant that low bloo ...
). Diagnosis is usually simple provided the history of pressure exposure is mentioned. Barosinusitis, is also called aerosinusitis, sinus squeeze or sinus barotrauma. Sinus barotrauma can be caused by external or internal overpressure. External over-pressure is called sinus squeeze by divers, while internal over-pressure is usually referred to as reverse block or reverse squeeze.


Mask squeeze

If a diver's mask is not equalized during descent the relative negative internal pressure can produce petechial hemorrhages in the area covered by the mask along with
subconjunctival hemorrhage Subconjunctival bleeding, also known as subconjunctival hemorrhage or subconjunctival haemorrhage, is bleeding from a small blood vessel over the whites of the eye. It results in a red spot in the white of the eye. There is generally little to no ...
s.


Helmet squeeze

A problem mostly of historical interest, but still relevant to surface supplied divers who dive with the helmet sealed to the dry suit. If the air supply hose is ruptured near or above the surface, the pressure difference between the water around the diver and the air in the hose can be several bar. The non-return valve at the connection to the helmet will prevent backflow if it is working correctly, but if absent, as in the early days of helmet diving, or if it fails, the pressure difference will tend to squeeze the diver into the rigid helmet, which can result in severe trauma. The same effect can result from a large and rapid increase in depth if the air supply is insufficient to keep up with the increase in ambient pressure. On a helmet with a neck dam, the neck dam will allow water to flood the helmet before serious barotrauma can occur. This can happen with helium
reclaim helmet A diving helmet is a rigid head enclosure with a breathing gas supply used in underwater diving. They are worn mainly by professional divers engaged in surface-supplied diving, though some models can be used with scuba equipment. The upper par ...
s if the reclaim regulator system fails, so there is a manual bypass valve, which allows the helmet to be purged so breathing can continue on open circuit.


Pulmonary barotrauma

Lung over-pressure injury in ambient pressure divers using underwater breathing apparatus is usually caused by breath-holding on ascent. The compressed gas in the lungs expands as the ambient pressure decreases causing the lungs to over-expand and rupture unless the diver allows the gas to escape by maintaining an open
airway The respiratory tract is the subdivision of the respiratory system involved with the process of respiration in mammals. The respiratory tract is lined with respiratory epithelium as respiratory mucosa. Air is breathed in through the nose to th ...
, as in normal breathing. The lungs do not sense pain when over-expanded giving the diver little warning to prevent the injury. This does not affect breath-hold divers as they bring a lungful of air with them from the surface, which merely re-expands safely to near its original volume on ascent. The problem only arises if a breath of ambient pressure gas is taken at depth, which may then expand on ascent to more than the lung volume. Pulmonary barotrauma may also be caused by explosive decompression of a pressurised aircraft, as occurred on 1 February 2003 to the crew in the Space Shuttle ''Columbia'' disaster.


Prevention


In divers

Barotrauma may be caused when diving, either from being crushed, or squeezed, on descent or by stretching and bursting on ascent; both can be avoided by ''equalising'' the pressures. A negative, unbalanced pressure is known as a squeeze, crushing eardrums, dry suit, lungs or mask inwards and can be equalised by putting air into the squeezed space. A positive unbalanced pressure expands internal spaces rupturing tissue and can be equalised by letting air out, for example by exhaling. Both may cause barotrauma. There are a variety of techniques depending on the affected area and whether the pressure inequality is a squeeze or an expansion: *
Ear An ear is the organ that enables hearing and, in mammals, body balance using the vestibular system. In mammals, the ear is usually described as having three parts—the outer ear, the middle ear and the inner ear. The outer ear consists of ...
s and
sinuses Paranasal sinuses are a group of four paired air-filled spaces that surround the nasal cavity. The maxillary sinuses are located under the eyes; the frontal sinuses are above the eyes; the ethmoidal sinuses are between the eyes and the sphenoid ...
: There is a risk of stretched or burst
eardrum In the anatomy of humans and various other tetrapods, the eardrum, also called the tympanic membrane or myringa, is a thin, cone-shaped membrane that separates the external ear The outer ear, external ear, or auris externa is the extern ...
s, usually crushed inwards during descent but sometimes stretched outwards on ascent. The diver can use a variety of methods to let air into or out of the
middle ear The middle ear is the portion of the ear medial to the eardrum, and distal to the oval window of the cochlea (of the inner ear). The mammalian middle ear contains three ossicles, which transfer the vibrations of the eardrum into waves in the ...
s via the
Eustachian tube In anatomy, the Eustachian tube, also known as the auditory tube or pharyngotympanic tube, is a tube that links the nasopharynx to the middle ear, of which it is also a part. In adult humans, the Eustachian tube is approximately long and in d ...
s. Sometimes swallowing will open the Eustachian tubes and equalise the ears. *
Lungs The lungs are the primary organs of the respiratory system in humans and most other animals, including some snails and a small number of fish. In mammals and most other vertebrates, two lungs are located near the backbone on either side of th ...
: There is a risk of
pneumothorax A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases, a one-way valve ...
,
arterial gas embolism An air embolism, also known as a gas embolism, is a blood vessel blockage caused by one or more bubbles of air or other gas in the circulatory system. Air can be introduced into the circulation during surgical procedures, lung over-expansion i ...
, and mediastinal and subcutaneous emphysema during ascent, which are commonly called burst lung or lung overpressure injury by divers. To equalise the lungs, all that is necessary is not to hold the breath during ascent. This risk does not occur when breath-hold diving from the surface, unless the diver breathes from an ambient pressure gas source underwater; breath-hold divers do suffer squeezed lungs on descent, crushing in the chest cavity, but, while uncomfortable, this rarely causes lung injury and returns to normal at the surface. Some people have pathology of the lung which prevent rapid flow of excess air through the passages, which can lead to lung barotrauma even if the breath is not held during rapid depressurisation. These people should not dive as the risk is unacceptably high. Most commercial or military diving medical examinations will look specifically for signs of this pathology. *
Diving mask Diving most often refers to: * Diving (sport), the sport of jumping into deep water * Underwater diving, human activity underwater for recreational or occupational purposes Diving or Dive may also refer to: Sports * Dive (American football), a ...
squeeze enclosing the eyes and nose: The main risk is rupture of the capillaries of the eyes and facial skin because of the negative pressure difference between the gas space and blood pressure, or orbital emphysema from higher pressures. This can be avoided by breathing air into the mask through the nose.
Goggles Goggles, or safety glasses, are forms of protective eyewear that usually enclose or protect the area surrounding the eye in order to prevent particulates, water or chemicals from striking the eyes. They are used in chemistry laboratories and ...
covering only the eyes are not suitable for deep diving as they cannot be equalised. *
Dry suit A dry suit or drysuit provides the wearer with environmental protection by way of thermal insulation and exclusion of water, and is worn by divers, boaters, water sports enthusiasts, and others who work or play in or near cold or contaminated ...
squeeze. The main risk is skin getting pinched and bruised by folds of the dry suit when squeezed on descent. Most dry suits can be equalised against squeeze via a manually operated
valve A valve is a device or natural object that regulates, directs or controls the flow of a fluid (gases, liquids, fluidized solids, or slurries) by opening, closing, or partially obstructing various passageways. Valves are technically fittings ...
fed from a low pressure gas supply. Air must be manually injected during the descent to avoid squeeze and is manually or automatically vented on the ascent to maintain buoyancy control. *
Diving helmet A diving helmet is a rigid head enclosure with a breathing gas supply used in underwater diving. They are worn mainly by professional divers engaged in surface-supplied diving, though some models can be used with scuba equipment. The upper part ...
squeeze: Helmet squeeze will occur if the gas supply hose is severed above the diver and the non-return valve at the helmet gas inlet fails or is not fitted. Severity will depend on the hydrostatic pressure difference. A very rapid descent, usually by accident, may exceed the rate at which the breathing gas supply can equalise the pressure causing a temporary squeeze. The introduction of the non-return valve and high maximum gas supply flow rates have all but eliminated both these risks. In helmets fitted with a neck dam, the dam will admit water into the helmet if the internal pressure gets too low; this is less of a problem than helmet squeeze but the diver may drown if the gas supply is not reinstated quickly. This form of barotrauma is avoidable by controlled descent rate, which is standard practice for commercial divers, who will use
shotline A diving shot line, shot line, or diving shot, a type of downline or descending line (US Navy), is an item of diving equipment consisting of a ballast weight (the shot), a line and a buoy. The weight is dropped on the dive site. The ...
s,
diving stage There are several categories of decompression equipment used to help divers Decompression practice, decompress, which is the process required to allow divers to return to the surface safely after spending time underwater at higher ambient pres ...
s and
wet bell A diving bell is a rigid chamber used to transport divers from the surface to depth and back in open water, usually for the purpose of performing underwater work. The most common types are the open-bottomed wet bell and the closed bell, which c ...
s to control descent and ascent rates.


Medical screening

Professional divers A professional is a member of a profession or any person who works in a specified professional activity. The term also describes the standards of education and training that prepare members of the profession with the particular knowledge and skil ...
are screened for risk factors during initial and periodical medical examination for
fitness to dive Fitness to dive, specifically the medical fitness to dive, is the medical and physical suitability of a diver to function safely in the underwater environment using underwater diving equipment and procedures. Depending on the circumstances it ...
. In most cases recreational divers are not medically screened, but are required to provide a medical statement before acceptance for
training Training is teaching, or developing in oneself or others, any skills and knowledge or Physical fitness, fitness that relate to specific practicality, useful Competence (human resources), competencies. Training has specific goals of improving on ...
in which the most common and easy to identify risk factors must be declared. If these factors are declared, the diver may be required to be examined by a medical practitioner, and may be disqualified from diving if the conditions indicate.
Asthma Asthma is a long-term inflammatory disease of the airways of the lungs. It is characterized by variable and recurring symptoms, reversible airflow obstruction, and easily triggered bronchospasms. Symptoms include episodes of wheezing, cou ...
, Marfan syndrome, and
COPD Chronic obstructive pulmonary disease (COPD) is a type of progressive lung disease characterized by long-term respiratory symptoms and airflow limitation. The main symptoms include shortness of breath and a cough, which may or may not produce mu ...
pose a very high risk of pneumothorax. In some countries these may be considered absolute contraindications, while in others the severity may be taken into consideration. Asthmatics with a mild and well controlled condition may be permitted to dive under restricted circumstances.


Training

A significant part of entry level diver training is focused on understanding the risks and procedural avoidance of barotrauma. Professional divers and recreational divers with rescue training are trained in the basic skills of recognizing and first aid management of diving barotrauma.


In mechanical ventilation

Isolated mechanical forces may not adequately explain ventilator induced lung injury (VILI). The damage is affected by the interaction of these forces and the pre-existing state of the lung tissues, and dynamic changes in alveolar structure may be involved. Factors such as plateau pressure and positive end-expiratory pressure (PEEP) alone do not adequately predict injury. Cyclic deformation of lung tissue may play a large part in the cause of VILI, and contributory factors probably include tidal volume, positive end-expiratory pressure and respiratory rate. There is no protocol guaranteed to avoid all risk in all applications.


Treatment

Treatment of diving barotrauma depends on the symptoms, which depend on the affected tissues. Lung over-pressure injury may require a chest drain to remove air from the
pleura The pulmonary pleurae (''sing.'' pleura) are the two opposing layers of serous membrane overlying the lungs and the inside of the surrounding chest walls. The inner pleura, called the visceral pleura, covers the surface of each lung and dips b ...
or
mediastinum The mediastinum (from ) is the central compartment of the thoracic cavity. Surrounded by loose connective tissue, it is an undelineated region that contains a group of structures within the thorax, namely the heart and its vessels, the esophagu ...
. Recompression with hyperbaric oxygen therapy is the definitive treatment for arterial gas embolism, as the raised pressure reduces bubble size, the reduced blood inert gas concentration may accelerate inert gas solution, and high oxygen partial pressure helps oxygenate tissues compromised by the emboli. Care must be taken when recompressing to avoid a
tension pneumothorax A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases, a one-way valve i ...
. Barotraumas that do not involve gas in the tissues are generally treated according to severity and symptoms for similar trauma from other causes.


First aid

Pre-hospital care for lung barotrauma includes basic life support of maintaining adequate oxygenation and perfusion, assessment of airway, breathing and circulation, neurological assessment, and managing any immediate life-threatening conditions. High-flow oxygen up to 100% is considered appropriate for diving accidents. Large-bore venous access with isotonic fluid infusion is recommended to maintain blood pressure and pulse.


Emergency treatment

Pulmonary barotrauma: *
Endotracheal intubation Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway or to serve as a conduit through which to administer certain drugs. It is frequently ...
may be required if the airway is unstable or hypoxia persists when breathing 100% oxygen. * Needle decompression or tube
thoracostomy A thoracostomy is a small incision of the chest wall, with maintenance of the opening for drainage. It is most commonly used for the treatment of a pneumothorax. This is performed by physicians, paramedics, and nurses usually via needle thoracosto ...
may be necessary to drain a pneumothorax or haemothorax *
Foley catheter In urology, a Foley catheter (named for Frederic Foley, who produced the original design in 1929) is a flexible tube that a clinician passes through the urethra and into the bladder to drain urine. It is the most common type of indwelling urina ...
ization may be necessary for spinal cord AGE if the person is unable to urinate. * Intravenous hydration may be required to maintain adequate blood pressure. *
Therapeutic recompression Hyperbaric medicine is medical treatment in which an ambient pressure greater than sea level atmospheric pressure is a necessary component. The treatment comprises hyperbaric oxygen therapy (HBOT), the medical use of oxygen at an ambient pressure ...
is indicated for severe AGE. The diving medical practitioner will need to know the vital signs and relevant symptoms, along with the recent pressure exposure and breathing gas history of the patient. Air transport should be below if possible, or in a pressurized aircraft which should be pressurised to as low an altitude as reasonably possible. Sinus squeeze and middle ear squeeze are generally treated with
decongestants A decongestant, or nasal decongestant, is a type of pharmaceutical drug that is used to relieve nasal congestion in the upper respiratory tract. The active ingredient in most decongestants is either pseudoephedrine or phenylephrine (the latter o ...
to reduce the pressure differential, with
anti-inflammatory Anti-inflammatory is the property of a substance or treatment that reduces inflammation or swelling. Anti-inflammatory drugs, also called anti-inflammatories, make up about half of analgesics. These drugs remedy pain by reducing inflammation as o ...
medications to treat the pain. For severe pain, narcotic
analgesics An analgesic drug, also called simply an analgesic (American English), analgaesic (British English), pain reliever, or painkiller, is any member of the group of drugs used to achieve relief from pain (that is, analgesia or pain management). It i ...
may be appropriate. Suit, helmet and mask squeeze are treated as trauma according to symptoms and severity.


Medication

The primary medications for lung barotrauma are hyperbaric and normobaric
oxygen Oxygen is the chemical element with the symbol O and atomic number 8. It is a member of the chalcogen group in the periodic table, a highly reactive nonmetal, and an oxidizing agent that readily forms oxides with most elements as wel ...
, hyperbaric heliox or
nitrox Nitrox refers to any breathing gas, gas mixture composed (excepting trace gases) of nitrogen and oxygen. This includes atmospheric air, which is approximately 78% nitrogen, 21% oxygen, and 1% other gases, primarily argon. In the usual applicatio ...
, isotonic fluids, anti-inflammatory medications, decongestants, and analgesics.


Outcomes

Following barotrauma of the ears or lungs from diving the diver should not dive again until cleared by a diving doctor. After ear injury examination will include a hearing test and a demonstration that the middle ear can be autoinflated. Recovery can take weeks to months.


Epidemiology

An estimate of in the order of 1000 dive injuries per year occur in the United States and Canada. Many of these involve barotrauma, with nearly 50% of reported injuries involving middle ear barotrauma. Diving injuries tend to correlate with trait anxiety and a tendency to panic, lack of experience, advancing age and reduction in fitness, alcohol usage, obesity, asthma, chronic sinusitis and otitis.


Barotrauma in other animals

Whales and dolphins develop severely disabling barotrauma when exposed to excessive pressure changes induced by navy sonar, oil industry airguns, explosives, undersea earthquakes and volcanic eruptions. Injury and mortality of fish, marine mammals, including sea otters, seals, dolphins and whales, and birds by underwater explosions has been recorded in several studies. Bats can suffer fatal barotrauma in the low pressure zones behind the blades of wind turbines due to their more fragile mammalian lung structure in comparison with the more robust avian lungs, which are less affected by pressure change.


Swim bladder overexpansion

Fish with isolated
swim bladder The swim bladder, gas bladder, fish maw, or air bladder is an internal gas-filled Organ (anatomy), organ that contributes to the ability of many bony fish (but not cartilaginous fish) to control their buoyancy, and thus to stay at their curren ...
s are susceptible to barotrauma of ascent when brought to the surface by fishing. The swim bladder is an organ of buoyancy control which is filled with gas extracted from solution in the blood, and which is normally removed by the reverse process. If the fish is brought upwards in the water column faster than the gas can be resorbed, the gas will expand until the bladder is stretched to its elastic limit, and may rupture. Barotrauma can be directly fatal or disable the fish rendering it vulnerable to predation, but
rockfish Rockfish is a common term for several species of fish, referring to their tendency to hide among rocks. The name rockfish is used for many kinds of fish used for food. This common name belongs to several groups that are not closely related, and ca ...
are able to recover if they are returned to depths similar to those they were pulled up from, shortly after surfacing. Scientists at NOAA developed the Seaqualizer to quickly return rockfish to depth. The device could increase survival in caught-and-released rockfish.


See also


References


External links

{{Use dmy dates, date=September 2019 Diving medicine Aviation medicine Medical emergencies