2018 March;48(1)

Diving Hyperb Med. 2018 March;48(1):2–9. doi.10.28920/dhm48.1.2-9. PMID: 29557095.

Transcutaneous oximetry: variability in normal values for the upper and lower limb

Denise F Blake1,2, Derelle A Young3, Lawrence H Brown4,5

1 Emergency Department, The Townsville Hospital, Townsville, Queensland, Australia
2 Marine Biology and Aquaculture, James Cook University, Townsville
3 Hyperbaric Medicine Unit, The Townsville Hospital, Townsville
4 Dell Medical School, University of Texas, Austin, Texas, USA
5 Mount Isa Centre for Rural and Remote Health, Faculty of Medicine, Health and Molecular Sciences, James Cook University, Townsville

Corresponding author: Dr Denise F Blake, IMB 23, Emergency Department, 100 Angus Smith Drive, The Townsville Hospital, Douglas, Queensland 4814, Australia
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Key words
Hyperbaric oxygen therapy; Oxygen; Patient monitoring; Standards; Wounds

Abstract
(Blake DF, Young DA, Brown LH. Transcutaneous oximetry: variability in normal values for the upper and lower limb. Diving and Hyperbaric Medicine. 2018 March;48(1):2–9. doi.10.28920/dhm48.1.2-9. PMID: 29557095.)
Introduction: Published normal transcutaneous oxygen partial pressures (PtcO2) for the chest and lower limb have defined tissue hypoxia as a value of < 40 mmHg (< 30 mmHg in some patients, < 50 mmHg in others).
Aim: To determine ‘normal’ PtcO2 for the upper and lower limb in healthy, non-smoking adults using the Radiometer® TCM400 with tc Sensor E5250.
Method: Thirty-two volunteers had transcutaneous oxygen measurements (TCOM) performed on the chest, upper and lower limbs breathing air, with leg then arm elevated and whilst breathing 100% oxygen.
Results: Room-air PtcO2 (mmHg, mean (95% confidence interval)) were: chest: 53.6 (48.7–58.5); upper arm: 60.0 (56.1−64.0); forearm: 52.3 (44.8–55.8); dorsum of hand: 50.2 (46.1–54.3); thenar eminence: 70.8 (67.7–73.8); hypothenar eminence: 77.9 (75.1–80.7); lateral leg: 50.2 (46.2–54.2); lateral malleolus: 50.5 (46.6–54.3); medial malleolus: 48.9 (45.6–52.1); dorsum, between first and second toe: 53.1 (49.2–57.0); dorsum, proximal to fifth toe: 58.5 (55.0 – -62.0); plantar, 1st MTP: 73.7 (70.3–77.1). Nineteen subjects had at least one room-air PtcO2 below 40 mmHg (nine upper limb, 13 lower limb, four chest). Approximately 10% lower limb PtcO2 were < 100 mmHg on normobaric oxygen. Only one subject at one site had an upper limb PtcO2 < 100 mmHg breathing oxygen.
Conclusion: The broad dispersion in PtcO2 in our healthy cohort reflects the inherent biologic variability in dermal perfusion and oxygen delivery, making it difficult to define narrow, rigid ‘normal’ values. Thus, we cannot recommend a single PtcO2 value as ‘normal’ for the upper or lower limb. A thorough patient assessment is essential to establish appropriateness for hyperbaric oxygen therapy, with TCOM used as an aid to guide this decision and not as an absolute.

Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in electronic and other forms.

Publication Type: Original article


2018 March;48(1)

Diving Hyperb Med. 2018 March;48(1):10–16. doi.10.28920/dhm48.1.10-16. PMID: 29557096.

Long-term changes in spirometry in occupational divers: a 10–25 year audit

Christopher Sames1, Desmond F Gorman2, Simon J Mitchell3, Lifeng Zhou4

1 Slark Hyperbaric Unit, Waitemata District Health Board, Auckland, New Zealand
2 Dept of Medicine, University of Auckland, Auckland
3 Dept of Anaesthesiology, University of Auckland
4 Waitemata and Auckland District Health Boards, Auckland

Corresponding author: Dr Chris Sames, Clinical Director, Slark Hyperbaric Unit, PO Box 32051 Devonport, Auckland 0744, New Zealand
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Key words
Lung function; Fitness to dive; Surveillance; Occupational diving; Medicals – diving

Abstract
(Sames C, Gorman D, Mitchell S, Zhou L. Long-term changes in spirometry in occupational divers: a 10–25 year audit. Diving and Hyperbaric Medicine. 2018 March;48(1):10–16. doi.10.28920/dhm48.1.10-16. PMID: 29557096.)
Aim: To determine whether long-term engagement in occupational diving causes significant changes in spirometric measurements.
Method: All divers with adequate spirometric records spanning at least 10 years were identified from the New Zealand occupational diver database. Changes in lung function over time were compared with normative values derived using published prediction equations. Any significant changes were tested for correlation with age, duration of occupational diving, gender, smoking history and body mass index (BMI).
Results: Spirometry data spanning periods of 10 to 25 years were analysed for 232 divers. Forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) declined with increasing duration of diving, but slightly less than predicted with increasing age, while peak expiratory flow (PEF) declined more than expected for age in longer-term divers. The changes in PEF were statistically significant, and correlated with duration of diving exposure, initial age and final BMI. Nevertheless, the changes were small and probably clinically insignificant.
Conclusion: We compared changes in spirometric parameters over long periods of occupational diving with normative data and found no clinically significant differences that could be attributed to diving. We found no justification for routine spirometry in asymptomatic divers.

Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in electronic and other forms.

Publication Type: Original article


2018 March;48(1)

Diving Hyperb Med. 2018 March;48(1):17–22. doi.10.28920/dhm48.1.17-22. PMID: 29557097.

Modern assessment of pulmonary function in divers cannot rely on old reference values

Thijs T Wingelaar1,2, Paul Clarijs1, Pieter-Jan AM van Ooij1, Dave AA Koch1, Rob A van Hulst2

1 Royal Netherlands Navy Diving Medical Centre, Den Helder, The Netherlands
2 Department of Anesthesiology, Academic Medical Centre, University of Amsterdam, The Netherlands

Corresponding author: Thijs T Wingelaar, Royal Netherlands Navy Diving Medical Centre, Rijkszee en marinehaven, 1780 CA Den Helder, The Netherlands
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Key words
Fitness to dive; Flowchart; Global lung initiative; Lung function; Standards; Military diving

Abstract
(Wingelaar TT, Clarijs P, van Ooij PJAM, Koch DAA, van Hulst RA. Modern assessment of pulmonary function in divers cannot rely on old reference values. Diving and Hyperbaric Medicine. 2018 March;48(1):17–22. doi.10.28920/dhm48.1.17-22. PMID: 29557097.)
Introduction: Pulmonary function testing (PFT) is an important part of dive medical examinations. Depending on the standard used to assess fitness to dive, different reference sets and fixed cut-off points are used. Reference values are part of an ongoing debate regarding the validity and accuracy related to different age groups, sex and ethnic backgrounds. The Global Lung Initiative (GLI) has provided an all-age reference set which corrects for sex and ethnicity (GLI-2012); this has had substantial impact on pulmonary medicine.
Method: We present an algorithm that can be used to standardise analysis of PFT in divers using the GLI-2012 reference set. Differences in the analysis of PFT between the ECSC/ERS-1993 and the GLI-2012 reference values are illustrated by means of three case reports.
Conclusion: Using a valid database of reference values increases accuracy and might prevent additional medical investigations and/or incorrect assessment of fitness to dive. Although our algorithm needs further evaluation to ensure its validity, the preliminary results are promising. Whatever algorithm is used, we urge dive medical physicians to consider using valid reference sets when analysing PFT for assessment of fitness to dive.

Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in electronic and other forms.

Publication Type: Original article


2018 March;48(1)

Diving Hyperb Med. 2018 March;48(1):23–30. doi.10.28920/dhm48.1.23-30. PMID: 29557098.

Challenges in profiling Australian scuba divers through surveys

John Lippmann1,4, David McD Taylor2,3, Christopher Stevenson4, Joanne W Williams4

1 Divers Alert Network Asia-Pacific, Ashburton, Victoria, Australia
2 Department of Emergency Medical Research, Austin Hospital, Melbourne, Victoria
3 Department of Medicine, Melbourne University, Victoria
4 School of Health and Social Development, Deakin University, Melbourne

Corresponding author: John Lippmann, Divers Alert Network Asia Pacific, PO Box 384 Ashburton, VIC 3147, Australia
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Key words
Survey; Fitness to dive; Health surveillance; Cardiovascular; Scuba divers; Recreational divers

Abstract
(Lippmann J, McD Taylor D, Stevenson C, Williams J. Challenges in profiling Australian scuba divers through surveys. Diving and Hyperbaric Medicine. 2018 March;48(1):23–30. doi.10.28920/dhm48.1.23-30. PMID: 29557098.)
Introduction: This study aimed to compare the results from three Australian scuba diver surveys. As the surveys differed in recruitment methods, the expectation was that respondents would differ in some important characteristics.
Methodology: Anonymous, online, cross-sectional surveys of the demographics, health, diving practices and outcomes were distributed to: (1) Divers Alert Network Asia-Pacific (DAN AP) members; (2) Professional Association of Diving Instructors (PADI) Asia-Pacific members; and (3) divers who had received any PADI non-leadership certification within the previous four years. Only data from divers resident in Australia were analysed.
Results: A total of 2,275 responses were received from current Australian residents, comprising 1,119 of 4,235 (26.4%) DAN members; 350 of 2,600 (13.5%) PADI members; and 806 of 37,000 (2.2%) PADI divers. DAN and PADI members had similar diving careers (medians 14 and 15 years, respectively). PADI members had undertaken more dives (median 800) than DAN members (330) and PADI divers (28). A total of 692 respondents reported suffering from diabetes or a cardiovascular, respiratory, neurological or psychological condition and included 34% of the DAN members and 28% of each of the PADI cohorts. Eighty-four divers had been treated for decompression illness (approximately 5% of DAN and PADI member groups and 1% of the PADI divers). Eighty-seven of 1,156 (7.5%) PADI respondents reported a perceived life-threatening incident while diving.
Conclusions: Despite low response rates, this study indicates clear differences in the characteristics of the divers in the three cohorts. Therefore, a survey of a single cohort may represent that diving population alone and the findings may be misleading. This bias needs to be clearly understood and any survey findings interpreted accordingly.

Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in electronic and other forms.

Publication Type: Original article


2018 March;48(1)

Diving Hyperb Med. 2018 March;48(1):31–35. doi.10.28920/dhm48.1.31-35. PMID: 29557099.

Hyperbaric oxygen treatment in thromboangiitis obliterans: a retrospective clinical audit

Dogus Hemsinli1, Gokalp Altun2, Safiye Tuba Kaplan3, Furkan Yildirim4, Gamze Cebi5

1 Cardiovascular Surgery Department, Health Sciences University, Kanuni Research and Training Hospital, Trabzon, Turkey
2 Cardiovascular Surgery Department, Karadeniz Technical University, Faculty of Medicine, Trabzon
3 Internal Medicine Department, Health Sciences University, Kanuni Research and Training Hospital, Trabzon
4 Underwater and Hyperbaric Medicine Department, Health Sciences University, Antalya Research and Training Hospital, Antalya, Turkey
5 Underwater and Hyperbaric Medicine Department, Health Sciences University, Kanuni Research and Training Hospital, Trabzon

Corresponding author: Dogus Hemsinli, Cardiovascular Surgery Department, Health Sciences University, Kanuni Research and Training Hospital, Kasustu Mahallesi, Topal Osman Sokak, No:7, 61290 Yomra, Trabzon, Turkey
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Key words
Buerger’s disease; Chronic wounds; Pain; Outcome

Abstract
(Hemsinli D, Altun G, Tuba Kaplan S, Yildirim F, Cebi G. Hyperbaric oxygen therapy in thromboangiitis obliterans: a retrospective clinical audit. Diving and Hyperbaric Medicine. 2018 March;48(1):31–35. doi.10.28920/dhm48.1.31-35. PMID: 29557099.)
Introduction: Wounds refractory to standard treatment in patients with thromboangiitis obliterans (TAO, Buerger’s disease) are associated with amputation, other morbidity and mortality. The purpose of this study was to investigate the effect of hyperbaric oxygen treatment (HBOT) in patients with TAO.
Materials and methods: Ninety-seven patients with TAO with ischaemic wounds treated between January 2007 and July 2016 were included in this dual-centre, non-randomised, retrospective study. Patients receiving HBOT in addition to conventional treatment were enrolled in an HBOT group (n = 47) and those receiving conventional treatment alone in a non-HBOT group (n = 50). All patients were Rutherford grade III at the time of enrolment.
Results: Significant improvement in the major amputation rate was observed in the HBOT group 10 months after starting treatment (2/47 vs. 13/50, P = 0.007). Numbers of patients progressing to Rutherford grade I (27/47 vs. 17/50, P = 0.035), numbers of patients healing completely (21 vs. 11, P = 0.031 and pain scores (visual analogue scale; 1, range 0−8 vs. 6, range 0−9, P < 0.001) were also significantly improved in the HBOT group.
Conclusion: The addition of HBOT to conventional treatment in TAO patients with non-healing ischaemic wounds and severe extremity pain, conferred significant benefits in terms of wound healing and rest pain control. Multi-centre, prospective, randomized studies with blinded outcome analysis are now needed to elicit more reliable results.

Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in electronic and other forms.

Publication Type: Case report


2018 March;48(1)

Diving Hyperb Med. 2018 March;48(1):36–39. doi.10.28920/dhm48.1.36-39. PMID: 29557100.

Vomiting and aspiration of gastric contents: a possible life-threatening combination in underwater diving

František Novomeský1, Martin Janík1, Michal Hájek2, Jozef Krajčovič1, Lubomír Straka1

1 Department of Forensic Medicine and Medicolegal Expertises, Jessenius Faculty of Medicine, Comenius University, University Hospital, Martin, Slovak Republic
2 Hyperbaric Medicine Center, Municipal Hospital, Ostrava, Czech Republic Chair of Biomedical Sciences, Medical Faculty, University of Ostrava, Czech Republic

Corresponding author: Professor František Novomeský, Institute of Forensic Medicine and Medicolegal Expertises, Jessenius Faculty of Medicine, Comenius University, University Hospital, 036 59 Martin, Slovak Republic
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Key words
Pathology; Gastrointestinal tract; Diving incidents; Diving deaths; Autopsy

Abstract

(František Novomeský, Martin Janík, Michal Hájek, Jozef Krajčovič, Lubomír Straka. Vomiting and aspiration of gastric contents: a possible life-threatening combination in underwater diving. Diving and Hyperbaric Medicine. 2018 March;48(1):36–39. doi10.28920/dhm48.1.36-39. PMID: 29557100.)
Vomiting and aspiration of gastric contents into the airways and lungs is a common and well-known clinicopathological entity. This phenomenon might also occur in underwater diving, where it can lead to life-threatening or fatal situations. This article presents two incidents involving diving-related vomiting with associated aspiration of gastric contents. One case, a 39-year-old commercial diver using a full-face diving mask, was fatal and the other was a 33-year-old, female recreational scuba diver in whom underwater vomiting was complicated by pulmonary aspiration of a solid foreign body (a peanut) into the right lower lobe bronchus. The peanut was successfully removed and, following bronchoscopic pulmonary lavage, the patient made an uneventful recovery. The causes and consequences of nausea and vomiting within the underwater environment are discussed and possible interpretative problems are highlighted.

Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in electronic and other forms.

Publication Type: Case report


2018 March;48(1)

Diving Hyperb Med. 2018 March;48(1):40–44. doi.10.28920/dhm48.1.40-44. PMID: 29557101.

Immersion pulmonary oedema in a healthy diver not exposed to cold or strenuous exercise

Olivier Castagna1,2, Sébastien de Maistre3, Bruno Schmid1, Delphine Caudal4, Jacques Regnard5

1 Underwater Research Team (ERRSO), Military biomedical research institute (IRBA), Toulon, France
2 Université de Toulon, LAMHESS (EA 6312), Toulon
3 Department of hyperbaric medicine, HIA St Anne military hospital, Toulon
4 Department of radiology, HIA St Anne military hospital, Toulon
5 University Hospital, EA3920 University Bourgogne Franche-Comté, Besançon, France

Corresponding author: Olivier Castagna, MD, Ph.D. Underwater research team – ERRSO, Military biomedical research institute – IRBA, BP 600, 83800 TOULON, Cedex 9 France
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Key words
Rebreathers/closed circuit; Pulmonary function; Negative pressure breathing; Case reports

Abstract

(Castagna O, de Maistre S, Schmid B, Caudal D, Regnard J. Immersion pulmonary oedema in a healthy diver not exposed to cold or strenuous exercise. Diving and Hyperbaric Medicine. 2018 March;48(1):40–44. doi10.28920/dhm48.1.40-44. PMID: 29557101.)
In healthy divers, the occurrence of immersion pulmonary oedema (IPE) is commonly caused by contributory factors including strenuous exercise, cold water and negative-pressure breathing. Contrary to this established paradigm, this case reports on a 26-year-old, well-trained combat swimmer who succumbed to acute IPE during static immersion in temperate (21°C) water, while using a front-mounted counterlung rebreather. The incident occurred during repeated depth-controlled ascent practice at the French military diving school. It was discovered that the diver had attempted to stop any gas leakage into the system by over-tightening the automatic diluent valve (ADV) (25th notch of 27) during the dive, thus causing a high resistance to inspiratory flow. The ventilatory constraints imposed by this ADV setting were assessed as a 3.2 Joules∙L-1 inspiratory work of breathing and -5 kPa (-50 mbar) transpulmonary pressure. This report confirms the key role of negative pressure breathing in the development of interstitial pulmonary oedema. Such a breathing pattern can cause a lowering of thoracic, airway and interstitial lung pressure, leading to high capillary pressure during each inspiration. Repetition of the diving drills resulted in an accumulation of interstitial lung water extravasation, causing pathological decompensation and proven symptoms.

Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in electronic and other forms.

Publication Type: Case report


2018 March;48(1)

Diving Hyperb Med. 2018 March;48(1):45–55. doi.10.28920/dhm48.1.45-55. PMID: 29557102.

Pre-hospital management of decompression illness: expert review of key principles and controversies

Simon J Mitchell1, Michael H Bennett2, Phillip Bryson3, Frank K Butler4, David J Doolette5, James R Holm6, Jacek Kot7, Pierre Lafère8

1 Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
2 University of New South Wales, Sydney, Australia
3 International SOS, Aberdeen, United Kingdom
4 Joint Trauma System, Defence Center of Excellence for Trauma, San Antonio, USA
5 University of Auckland, Auckland
6 Virginia Mason Medical Centre, Seattle, USA.
7 National Centre for Hyperbaric Medicine, Institute of Maritime and Tropical Medicine in Gdynia, Medical University of Gdansk, Poland
8 ORPHY Laboratory EA4324, Université de Bretagne Occidentale, Brest, France

Corresponding author: Professor Simon J Mitchell, Department of Anaesthesiology, School of Medicine, University of Auckland, Private Bag 92019, Auckland, New Zealand
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Key words
Decompression sickness; Arterial gas embolism; Recompression; Remote locations; First aid; In-water recompression (IWR); Transport

Abstract

(Mitchell SJ, Bennett MH, Bryson P, Butler FK, Doolette DJ, Holm JR, Kot J, Lafère P. Pre-hospital management of decompression illness: expert review of key principles and controversies. Diving and Hyperbaric Medicine. 2018 March;48(1):45–55. doi.10.28920/dhm48.1.45-55. PMID: 29557102.)
Guidelines for the pre-hospital management of decompression illness (DCI) had not been formally revised since the 2004 Divers Alert Network/Undersea and Hyperbaric Medical Society workshop held in Sydney, entitled “Management of mild or marginal decompression illness in remote locations”. A contemporary review was initiated by the Diver’s Alert Network and undertaken by a multinational committee with members from Australasia, the USA and Europe. The process began with literature reviews by designated committee members on: the diagnosis of DCI; first aid strategies for DCI; remote triage of possible DCI victims by diving medicine experts; evacuation of DCI victims; effect of delay to recompression in DCI; pitfalls in management when DCI victims present at hospitals without diving medicine expertise and in-water recompression. This was followed by presentation of those reviews at a dedicated workshop at the 2017 UHMS Annual Meeting, discussion by registrants at that workshop and finally several committee meetings to formulate statements addressing points considered of prime importance to the management of DCI in the field. The committee placed particular emphasis on resolving controversies around the definition of “mild DCI” arising over 12 years of practical application of the 2004 workshop’s findings, and on the controversial issue of in-water recompression. The guideline statements are promulgated in this paper. The full workshop proceedings are in preparation for publication.

Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in electronic and other forms.

Publication Type: Consensus guideline


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