2020 September;50(3)

Diving Hyperb Med. 2020 September 30;(3):206–213. doi: 10.28920/dhm50.3.206-213. PMID: 32957121.

The effect of hyperbaric oxygen treatment on late radiation tissue injury after breast cancer: A case-series of 67 patients

Nicole E Spruijt1, Roy van den Berg1

1 Da Vinci Clinic, Nieuwendijk 49, 5664HB Geldrop, the Netherlands

Corresponding author: Dr Nicole E Spruijt, Da Vinci Clinic, Nieuwendijk 49, 5664HB Geldrop, the Netherlands
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Key words
Radiotherapy; Soft-tissue radionecrosis; Hyperbaric medicine; Pain

Abstract
(Spruijt NE, van den Berg R. The effect of hyperbaric oxygen treatment on late radiation tissue injury after breast cancer: A case-series of 67 patients. Diving and Hyperbaric Medicine. 2020 September 30;50(3):206–213. doi: 10.28920/dhm50.3.206-213. PMID: 32957121.)
Introduction: Late radiation tissue injury (LRTI) after breast cancer may benefit from hyperbaric oxygen treatment (HBOT). This study aimed to report the LRTI symptom scores up to 12 months after HBOT and identify risk factors for poor scores.
Methods: A case-series of 67 patients who underwent a mean of 44 sessions of HBOT was analysed. LRTI symptoms were scored at four time points using the LENT-SOMA scale (Late Effects in Normal Tissues – Subjective, Objective, Management, and Analytic), a visual analog scale for pain, and the range of shoulder motion.
Results: Between starting HBOT and 12 months after HBOT 57 patients (85%) reported at least one point improvement in their LENT-SOMA score. Median pain and fibrosis scores improved significantly between the start and end of HBOT
(P < 0.001), and remained stable three and 12 months after HBOT. The median breast oedema score improved significantly 12 months after HBOT (P = 0.003). Median shoulder abduction increased significantly from 90 to 165 degrees (P = 0.001) and median shoulder anteflexion increased significantly from 115 to 150 degrees (P = 0.004). Various risk factors were identified for poor scores despite HBOT; the most common risk factor was a poor score at start of HBOT.
Conclusions: In this case-series, patients who underwent HBOT for LRTI after breast cancer reported significant improvement in pain, fibrosis, oedema, and shoulder movement. The improvement persisted up to 12 months after HBOT. A poor score at the start of HBOT was predictive for a poor score 12 months after HBOT.

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


2020 September;50(3)

Diving Hyperb Med. 2020 September 30;(3):214–220. doi: 10.28920/dhm50.3.214-219. PMID: 32957122.

Endothelial function may be enhanced in the cutaneous microcirculation after a single air dive

François Guerrero1, Kate Lambrechts1, Qiong Wang1, Aleksandra Mazur1, Michael Théron1, Alessandro Marroni2

1 Univ Brest, ORPHY EA4324, IBSAM, 6 avenue Le Gorgeu, 29200 Brest, France
2 DAN Europe, Roseto degli Abruzzi, Italy

Corresponding author: François Guerrero, EA4324 ORPHY, 6 Av. Le Gorgeu CS 93837, 29238 BREST Cedex 3, France
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Key words
Scuba diving; Circulation; Skin; Endothelium; Doppler; Iontophoresis

Abstract
(Guerrero F, Lambrechts K, Wang Q, Mazur A, Théron M, Marroni A. Endothelial function may be enhanced in the cutaneous microcirculation after a single air dive. Diving and Hyperbaric Medicine. 2020 September 30;50(3):214–220. doi: 10.28920/dhm50.3.214-219. PMID: 32957122.)
Introduction: The effects of scuba diving on the vessel wall have been studied mainly at the level of large conduit arteries. Data regarding the microcirculation are scarce and indicate that these two vascular beds are affected differently by diving.
Methods: We assessed the changes in cutaneous microcirculation before an air scuba dive, then 30 min and 24 h after surfacing. Endothelium-dependent and independent vasomotion were successively elicited by iontophoretic administration of acetylcholine and sodium nitroprusside respectively, and cutaneous blood flux was monitored by laser Doppler flowmetry.
Results: The response to sodium nitroprusside was significantly lower 30 min after surfacing than before diving
(50 (SEM 6)% of the pre-dive values, P = 0.0003) and returned to normal values 24 h post-dive (102 (29)% of the pre-dive values, P = 0.113). When compared to pre-dive values, acetylcholine elicited a hyperaemia which was not statistically different 30 min after surfacing (123 (17)% of the pre-dive values, P = 0.230), but significantly increased 24 h post-dive (148 (10)% of the pre-dive values, P = 0.005).
Conclusion: Microvascular smooth muscle function is transiently impaired after diving. On the contrary, microvascular endothelial function is enhanced for up to 24 h after diving. This further suggests that the microcirculation reacts differently than large conduit arteries to scuba diving. The impact of modifications occurring in the microvascular bed on the physiological effects of diving merits further study.

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


2020 September;50(3)

Diving Hyperb Med. 2020 September 30;(3):220–229. doi: 10.28920/dhm50.3.220-229. PMID: 32957123.

Scuba diving fatalities in Australia 2001 to 2013: Chain of events

John Lippmann1,2, David McD Taylor3,4

1 Australasian Diving Safety Foundation, Canterbury, Victoria, Australia
2 Department of Public Health and Preventive Medicine, Monash University, Victoria, Australia
3 Emergency Department, Austin Hospital, Victoria, Australia
4 Department of Medicine, Melbourne University, Victoria, Australia

Corresponding author: Dr John Lippmann, Australasian Diving Safety Foundation, P.O. Box 478 Canterbury VIC 3126 Australia
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Key words
Coroners findings; Diving incidents; Deaths; Drowning; Fitness to dive; Medical conditions and problems; Root cause analysis

Abstract
(Lippmann J, Taylor DM. Scuba diving fatalities in Australia 2001 to 2013: Chain of events. Diving and Hyperbaric Medicine. 2020 September 30;50(3):220–229. doi: 10.28920/dhm50.3.220-229. PMID: 32957123.)
Introduction: We aimed to identify the possible chain of events leading to fatal scuba diving incidents in Australia from 2001–2013 to inform appropriate countermeasures.
Methods: The National Coronial Information System was searched to identify scuba diving-related deaths from 2001–2013, inclusive. Coronial findings, witness and police reports, medical histories and autopsies, toxicology and equipment reports were scrutinised. These were analysed for predisposing factors, triggers, disabling agents, disabling injuries and causes of death using a validated template.
Results: There were 126 known scuba diving fatalities and 189 predisposing factors were identified, the major being health conditions (59; 47%), organisational/training/experience/skills issues (46; 37%), planning shortcomings (29; 23%) and equipment inadequacies (24; 19%). The 138 suspected triggers included environmental (68; 54%), exertion (23; 18%) and gas supply problems (15; 12%) among others. The 121 identified disabling agents included medical-related (48; 38%), ascent-related (21; 17%), poor buoyancy control (18; 14%), gas supply (17; 13%), environmental (13; 10%) and equipment (4; 3%). The main disabling injuries were asphyxia (37%), cardiac (25%) and cerebral arterial gas embolism/pulmonary barotrauma (15%).
Conclusions: Chronic medical conditions, predominantly cardiac-related, are a major contributor to diving incidents. Divers with such conditions and/or older divers should undergo thorough fitness-to-dive assessments. Appropriate local knowledge, planning and monitoring are important to minimise the potential for incidents triggered by adverse environmental conditions, most of which involve inexperienced divers. Chain of events analysis should increase understanding of diving incidents and has the potential to reduce morbidity and mortality in 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 


2020 September;50(3)

Diving Hyperb Med. 2020 September 30;50(3):230–237. doi: 10.28920/dhm50.3.230-237. PMID: 32957124.

Evaluation of pressure in water-filled endotracheal tube cuffs in intubated patients undergoing hyperbaric oxygen treatment

Younès Benzidi1, Thibault Duburcq1, Daniel Mathieu1, Erika Parmentier-Decrucq1

1 Intensive Care Unit and Hyperbaric Center, Lille University Hospital, Lille, France

Corresponding author: Erika Parmentier-Decrucq, Pôle de Réanimation Médicale, Hôpital Salengro, CHU, 2 rue Emile Laisne, 59037 Lille cedex, France
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Key words
Intensive care medicine; Mechanical ventilation; Cuff pressure; Patient monitoring; Ventilators

Abstract
(Benzidi Y, Duburcq T, Mathieu D, Parmentier-Decrucq E. Evaluation of pressure in water-filled endotracheal tube cuffs in intubated patients undergoing hyperbaric oxygen treatment. Diving and Hyperbaric Medicine. 2020 September 30;50(3):230–237. doi: 10.28920/dhm50.3.230-237. PMID: 32957124.)
Introduction: Inflating endotracheal tube cuffs using water instead of air before hyperbaric oxygen treatment (HBOT) is common. The objective of this study was to assess cuff pressure (Pcuff), when the cuff was inflated using water, in normobaric conditions and during HBOT.
Methods: This was a prospective, observational study taking place in hyperbaric centre and intensive care unit of the University Hospital of Lille. Every patient who required tracheal intubation and HBOT at 253.3 kPa (2.5 atmospheres absolute [atm abs]) was included. Pcuff was measured using a pressure transductor connected to the cuff inflating port. Measurements were performed at 'normobaria' (1 atm abs) and during HBOT at 2.5 atm abs.
Results: Thirty patients were included between February and April 2016. Recordings were analysable in 27 patients. Mean Pcuff at normobaria was 60.8 (SD 42) cmH2O. Nineteen (70%) of patients had an excessive Pcuff (higher than 30 cmH2O). Coefficient of variation was 69%. Mean Pcuff at 2.5 atm abs was 51.6 (40.7) cmH2O, significantly lower than at normobaria (P < 0.0001). Coefficient of variation was 79%. In only five (18%) patients was Pcuff < 20 cmH2O at 2.5 atm abs.
Conclusions: In normobaric conditions, when the cuff was inflated using water and not specifically controlled Pcuff was not predictable. The cuff was typically over-inflated exceeding safe pressure. During HBOT Pcuff decreased slightly.

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


2020 September;50(3)

Diving Hyperb Med. 2020 September 30;50(3):238–243. doi: 10.28920/dhm50.3.238-243. PMID: 32957125.

Assessment of insulin sensitivity during hyperbaric oxygen treatment

David Wilkinson1,2, Suzy Szekely1, Brian Gue2, Charmaine S Tam3, Ian Chapman2, Leonie K Heilbronn2

1 Hyperbaric Medicine Unit, Royal Adelaide Hospital, Adelaide, Australia
2 Adelaide Medical School, The University of Adelaide, Adelaide, Australia
3 Centre for Translational Data Science and Northern Clinical School, Sydney, Australia

Corresponding author: Dr David Wilkinson, Hyperbaric Medicine Unit, Royal Adelaide Hospital, Port Road, Adelaide, SA 5000, Australia
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Key words
Endocrinology; Hyperbaric research; Obesity; Metabolism; Physiology

Abstract
(Wilkinson D, Szekely S, Gue B, Tam CS, Chapman I, Heilbronn LK. Assessment of insulin sensitivity during hyperbaric oxygen treatment. Diving and Hyperbaric Medicine. 2020 September 30;50(3):238–243. doi: 10.28920/dhm50.3.238-243. PMID: 32957125.)
Introduction: Previous studies using a hyperinsulinaemic, euglycaemic glucose clamp have demonstrated an increase in peripheral insulin sensitivity in men with and without Type-2 diabetes mellitus on the third and thirtieth hyperbaric oxygen treatment (HBOT) session. In two studies using different techniques for assessment of insulin sensitivity, we investigated the onset and duration of this insulin-sensitising effect of HBOT.
Methods: Men who were obese or overweight but without diabetes were recruited. One study performed a hyperinsulinaemic euglycaemic glucose clamp (80 mU.m-2.min-1) at baseline and during the first HBOT exposure (n = 9) at a pressure of 203 kPa. Data were analysed by paired t-test. The other study assessed insulin sensitivity by a frequently sampled intravenous glucose tolerance test (FSIGT) at three time points: baseline, during the third HBOT and 24-hours post-HBOT (n = 9). Results were analysed by repeated-measures ANOVA.
Results: There was a significant 23% increase in insulin sensitivity by clamp measured during the first HBOT exposure. The FSIGT showed no significant changes in insulin sensitivity.
Conclusions: The hyperinsulinaemic, euglycaemic glucose clamp demonstrated a significant increase in peripheral insulin sensitivity during a single, 2-hour HBOT session in a group of men who were obese or overweight but without diabetes. As an alternate technique for assessing insulin sensitivity during HBOT, the FSIGT failed to show any changes during the third HBOT and 24-hours later, however modification of the study protocol should be considered.

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


2020 September;50(3)

Diving Hyperb Med. 2020 September 30;50(3):244–249. doi: 10.28920/dhm50.3.244-249. PMID: 32957126.

The evaluation of in-chamber sound levels during hyperbaric oxygen applications: Results of 41 centres

Taylan Zaman1, Abdusselam Celebi2, Bengusu Mirasoglu3, Akin Savas Toklu3

1 Gulhane Research and Training Hospital, Underwater and Hyperbaric Medicine Department, Ankara, Turkey
2 Iskenderun State Hospital, Underwater and Hyperbaric Medicine Department, Hatay, Turkey
3 Istanbul Faculty of Medicine, Underwater and Hyperbaric Medicine Department, Istanbul, Turkey

Corresponding author: Dr Bengusu Mirasoglu, Istanbul Tip Fakultesi, Sualti Hekimligi ve Hiperbarik Tip Anabilim Dali, 34093 Fatih, Istanbul, Turkey
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Key words
Noise; Hyperbaric facilities; Health; Hearing; Noise-induced hearing loss (NIHL); Multiplace chamber

Abstract
(Zaman T, Celebi A, Mirasoglu B, Toklu AS. The evaluation of in-chamber sound levels during hyperbaric oxygen applications: Results of 41 centres. Diving and Hyperbaric Medicine. 2020 September 30;50(3):244–249. doi: 10.28920/dhm50.3.244-249. PMID: 32957126.)
Introduction: Noise has physical and psychological effects on humans. Recommended exposure limits are exceeded in many hospital settings; however, information about sound levels in hyperbaric oxygen treatment chambers is lacking. This study measured in-chamber sound levels during treatments in Turkish hyperbaric centres.
Methods: Sound levels were measured using a sound level meter (decibel meter). All chambers were multiplace with similar dimensions and shapes. Eight measurements were performed in each of 41 chambers; three during compression, three during decompression, and two at treatment pressure, one during chamber ventilation (flushing) and one without ventilation. At each measurement a sound sample was collected for 25 seconds and A-weighted equivalent (LAeq) and C-weighted peak (LCpeak) levels were obtained. Recorded values were evaluated in relation to sound level limits in regulations.
Results: The highest sound level measured in the study was 100.4 dB(A) at treatment pressure while ventilation was underway and the lowest was 40.5 dB(A) at treatment pressure without ventilation. Most centres had sound levels between 70 dB and 85 dB throughout the treatment. Ventilation caused significant augmentation of noise.
Conclusions: The chambers were generally safe in terms of noise exposure. Nevertheless, hyperbaric chambers can be very noisy environments so could pose a risk for noise-related health problems. Therefore, they should be equipped with appropriate noise control systems. Silencers are effective in reducing noise in chambers. Thus far, hyperbaric noise research has focused on chambers used for commercial diving. To our knowledge, this is the first study to investigate noise in hospital-based chambers during medical treatments.

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


2020 September;50(3)

Diving Hyperb Med. 2020 September 30;50(3):250–255. doi: 10.28920/dhm50.3.250-255. PMID: 32957127.

An observational trial to establish the effect of hyperbaric oxygen treatment on pelvic late radiation tissue injury due to radiotherapy

James Andren1, Michael H Bennett1,2

1 Department of Diving and Hyperbaric Medicine, Prince of Wales Hospital, Sydney, Australia
2 Prince of Wales Clinical School, University of New South Wales, Sydney, Australia

Corresponding author: Dr James Andren, 4 Adelaide Place, Canterbury CT1 2QA, England
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Key words
Endothelium; Gastro-intestinal tract; Genito-urinary tract; Pain; Soft-tissue radionecrosis; Cancer

Abstract
(Andren J, Bennett MH. An observational trial to establish the effect of hyperbaric oxygen treatment on pelvic late radiation tissue injury due to radiotherapy. Diving and Hyperbaric Medicine. 2020 September 30;50(3):250–255. doi: 10.28920/dhm50.3.250-255. PMID: 32957127.)
Introduction: Rates of pelvic cancer are growing globally with around half of these patients receiving radiotherapy. In a small proportion, radiotherapy results in significant late radiation tissue injury (LRTI) to surrounding tissue, most commonly affecting the bladder and bowel mucosa. We conducted a combined prospective and retrospective observational trial to establish the effectiveness of hyperbaric oxygen treatment (HBOT) in improving the symptoms and signs of LRTI in these patients.
Methods: Fifty-two patients were included after receiving radiotherapy for cancers of the bowel, bladder, cervix, prostate or vulva. They received HBOT at 203−243 kPa (2.0−2.4 atmospheres absolute (atm abs)) for 90 minutes with the median number of treatments being 30 (IQR 1). Late effects normal tissues – subjective, objective, management, analytic (LENT-SOMA) scores were recorded before and after treatment.
Results: The mean LENT-SOMA scores before and after HBOT were 11.7 (SD 5.3) and 8.1 (5.1) respectively. This reduction in score of 3.7 (95% CI 2.6 to 4.8) was statistically significant (P < 0.001). For radiation cystitis the mean reduction was 3.7 (95% CI 2.4 to 5.0, P < 0.001) and for radiation proctitis was 3.8 (95% CI 1.4 to 6.1, P = 0.004). There were no significant adverse effects recorded.
Conclusions: Hyperbaric oxygen treatment may be an effective and safe treatment for pelvic late tissue radiation injury.

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


2020 September;50(3)

Diving Hyperb Med. 2020 September 30;50(3):256–263. doi: 10.28920/dhm50.3.256-263. PMID: 32957128.

Thermal balance of spinal cord injured divers during cold water diving: A case control study

Urska Gajsek1,2, Arne Sieber3,4, Zarko Finderle2

1 Department of Abdominal and General Surgery, University Clinical Center Maribor, Maribor, Slovenia
2 Institute of Physiology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
3 Seabear Diving Technology, Leoben, Austria
4 Chalmers University of Technology, Gothenburg, Sweden

Corresponding aurthor: Urska Gajsek, Department of Abdominal and General Surgery, University Clinical Center Maribor Ljubljanska 5, 2000 Maribor, Slovenia
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Key words
Scuba diving; Visual analogue scale; Disability; Diving; Disabled diver; Hypothermia

Abstract
(Gajsek U, Sieber A, Finderle Z. Thermal balance of spinal cord injured divers during cold water diving: A case control study. Diving and Hyperbaric Medicine. 2020 September 30;50(3):256–263. doi: 10.28920/dhm50.3.256-263. PMID: 32957128.)
Introduction: This study compared the thermal balance of spinal cord injured (SCI) divers and able-bodied (AB) divers during recreational cold-water dives.
Methods: Ten divers (5 AB, 5 SCI) in matched pairs dived in a shallow lake (temperature 6°C) for 30 to 36 min wearing 5 mm ‘Long John’ neoprene wetsuits. A gastrointestinal temperature radio pill recorded gastro-intestinal temperature (Tgi) prior to, immediately after and at 5, 10, 15, 30, 60, 120 min post-dive. Subjective ratings of temperature perception were recorded concomitantly using a visual analogue scale (VAS).
Results: No difference between SCI and AB divers in Tgi before the dive was observed (P = 0.85). After the dive, SCI divers cooled significantly more than AB at all measured time intervals (P < 0.001). Post dive, the mean maximum fall in Tgi during the recovery phase in SCI divers was 0.85°C (SD 0.20) and in the AB group was 0.48°C (0.48). In addition, there was greater individual variation in SCI divers compared to AB divers. There were no statistically significant differences in temperature perception between the groups either before or at any time after the dives.
Conclusions: In contrast to AB divers, divers with SCI were unable to maintain Tgi during short shallow dives in 6°C water and their temperatures fell further post-dive. The reduction in Tgi was not reflected in the subjective ratings of temperature perception by the SCI divers. The study was too small to assess how the level of spinal injury influenced thermal balance.

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


2020 September;50(3)

Diving Hyperb Med. 2020 September 30;50(3):264–272. doi: 10.28920/dhm50.3.264-272. PMID: 32957129.

Monoplace chamber treatment of decompression illness: Review and commentary

Richard Clarke1

1 National Baromedical Services, Columbia, South Carolina, USA

Corresponding author: Richard Clarke, National Baromedical Services, Nine Richland Medical Park, Suite 440, Columbia, SC 29203, USA
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Key words
Cerebral arterial gas embolism; Decompression sickness; Diving medicine; Patient monitoring; Recompression; Pressure chambers

Abstract
(Clarke R. Monoplace chamber treatment of decompression illness: Review and commentary. Diving and Hyperbaric Medicine. 2020 September 30;50(3):264–272. doi: 10.28920/dhm50.3.264-272. PMID: 32957129.)
This paper summarises the history and capabilities of monoplace chambers in treatment of decompression illness (DCI); both in support of diving operations and in the hospital setting. In the field, monoplace hyperbaric chambers provide victims of DCI immediate access to recompression in settings where traditional multiplace chambers are not available. Alternatively, they may facilitate pressurised transport to a multiplace chamber for continued management. Recently, collapsible lightweight versions have improved suitability for field deployment aboard small vessels in remote settings, and for use by less technically capable military, occupational and civilian operators. The resulting elimination of treatment delays may prove lifesaving and central nervous system sparing, and avoid subsequent diving fitness disqualification. Monoplace chambers thus facilitate diving operations that would otherwise be difficult to condone on health and safety grounds. The 1960s saw the introduction of multiplace hyperbaric chambers into the hospital setting, as a number of non-diving conditions appeared to benefit from hyperbaric oxygen. This coincided with interest in hyperbaric oxygen as a solid tumour radiation sensitiser. Development of a novel acrylic-hulled single occupancy chamber enabled patients to undergo radiotherapy while pressurised within its oxygen atmosphere. Increasing numbers of health care facilities adopted this chamber type as a more economical, less complex alternative to the multiplace chamber. Incorporation of relevant biomedical technologies have allowed monoplace chambers to support increasingly complex patients in a safe, effective manner. Despite these advances, criticism of medical centre-based monoplace chamber treatment of DCI exists. This paper evaluates this controversy and presents relevant counter-arguments.

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: Review article


2020 September;50(3)

Diving Hyperb Med. 2020 September 30;50(3):273–277. doi: 10.28920/dhm50.3.273-277. PMID: 32957130.

South Pacific Underwater Medicine Society guidelines for cardiovascular risk assessment of divers

Nigel Jepson1, Rienk Rienks2, David Smart3, Michael H Bennett4, Simon J Mitchell5,6, Mark Turner7

1 Department of Cardiology, Prince of Wales Hospital, Randwick, Sydney, Australia
2 Central Military Hospital, Lundlaan, Utrecht, the Netherlands
3 Department of Diving and Hyperbaric Medicine, Royal Hobart Hospital, Hobart, Australia
4 Wales Anaesthesia and Department of Diving and Hyperbaric Medicine, Prince of Wales Hospital, Randwick, Sydney, Australia
5 Department of Anaesthesiology, School of Medicine, University of Auckland, Auckland, New Zealand
6 Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand
7 Bristol Heart Institute, Bristol, United Kingdom

Corresponding author: Clinical Professor David Smart, Department of Diving and Hyperbaric Medicine, K3 East, Royal Hobart Hospital, Tasmania 7000, Australia
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Key words
Medicals – diving; Health; Health surveillance; Blood pressure; Persistent (patent) foramen ovale; Implantable devices; Investigations

Abstract

(Jepson N, Rienks R, Smart D, Bennett MH, Mitchell SJ, Turner M. South Pacific Underwater Medicine Society guidelines for cardiovascular risk assessment of divers. Diving and Hyperbaric Medicine. 2020 September 30;50(3):273–277. doi: 10.28920/dhm50.3.273-277. PMID: 32957130.)
The South Pacific Underwater Medicine Society (SPUMS) diving medical for recreational scuba divers was last reviewed in 2011. From 2011 to 2019, considerable advancements have occurred in cardiovascular risk assessment relevant to divers. The SPUMS 48th (2019) Annual Scientific Meeting theme was cardiovascular risk assessment in diving. The meeting had multiple presentations updating scientific information about assessing cardiovascular risk. These were distilled into a new set of guidelines at the final conference workshop. SPUMS guidelines for medical risk assessment in recreational diving have subsequently been updated and modified including a new Appendix C: Suggested evaluation of the cardiovascular system for divers. The revised evaluation of the cardiovascular system for divers covers the following topics:
1. Background information on the relevance of cardiovascular risk and diving;
2. Defining which divers with cardiovascular problems should not dive, or whom require treatment interventions before further review;
3. Recommended screening procedures (flowchart) for divers aged 45 and over;
4. Assessment of divers with known or symptomatic cardiovascular disease, including guidance on assessing divers with specific diagnoses such as hypertension, atrial fibrillation, cardiac pacemaker, immersion pulmonary oedema, takotsubo cardiomyopathy, hypertrophic cardiomyopathy and persistent (patent) foramen ovale;
5. Additional cardiovascular health questions included in the SPUMS guidelines for medical risk assessment in recreational diving;
6. Updated general cardiovascular medical risk assessment advice;
7. Referencing of relevant literature.
The essential elements of this guideline are presented in this paper.

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: Guideline


2020 September;50(3)

Diving Hyperb Med. 2020 September 30;50(3):278–287. doi: 10.28920/dhm50.3.278-287. PMID: 32957131.

Diving after SARS-CoV-2 (COVID-19) infection: Fitness to dive assessment and medical guidance

Charlotte Sadler1, Miguel Alvarez Villela2, Karen Van Hoesen1, Ian Grover1, Michael Lang1, Tom Neuman1, Peter Lindholm1

1 Department of Emergency Medicine, School of Medicine, Division of Hyperbaric Medicine, University of California, San Diego, California, USA
2 Montefiore Medical Center/Albert Einstein College of Medicine, Department of Medicine, Division of Cardiology, Bronx, NY, USA

Corresponding author: Dr Charlotte Sadler, Department of Emergency Medicine, Division of Hyperbaric Medicine, School of Medicine, University of California, San Diego, California, USA
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Key words
Diving medicine; Health surveillance; Medicals-diving; Occupational health; Pulmonary barotrauma; Exercise;  Cardiovascular

Abstract

(Sadler C, Alvarez Villela M, Van Hoesen K, Grover I, Lang M, Neuman T, Lindholm P. Diving after SARS-CoV-2 (COVID-19) infection: Fitness to dive assessment and medical guidance. Diving and Hyperbaric Medicine. 2020 September 30;50(3):278–287. doi: 10.28920/dhm50.3.278-287. PMID: 32957131.)
Scuba diving is a critical activity for commercial industry, military activities, research, and public safety, as well as a passion for many recreational divers. Physicians are expected to provide return-to-diving recommendations after SARS-CoV-2 (COVID-19) infection based upon the best available evidence, often drawn from experience with other, similar diseases. Scuba diving presents unique physiologic challenges to the body secondary to immersion, increased pressure and increased work of breathing. The long-term sequelae of COVID-19 are still unknown, but if they are proven to be similar to other coronaviruses (such as Middle East respiratory syndrome or SARS-CoV-1) they may result in long-term pulmonary and cardiac sequelae that impact divers’ ability to safely return to scuba diving. This review considers available literature and the pathophysiology of COVID-19 as it relates to diving fitness, including current recommendations for similar illnesses, and proposes guidelines for evaluation of divers after COVID-19. The guidelines are based upon best available evidence about COVID-19, as well as past experience with determination of diving fitness. It is likely that all divers who have contracted COVID-19 will require a medical evaluation prior to return to diving with emphasis upon pulmonary and cardiac function as well as exercise capacity.

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: Guideline


2020 September;50(3)

Diving Hyperb Med. 2020 September 30;50(3):288–291. doi: 10.28920/dhm50.3.288-291. PMID: 32957132.

Pre-hydration strongly reduces decompression sickness occurrence after a simulated dive in the rat

Qiong Wang1, François Guerrero1, Michaël Theron1

1 Laboratory ORPHY, European University of Bretagne, University of Brest, Brest, France

Corresponding author: Dr Michaël Theron, Laboratory ORPHY, European University of Bretagne, University of Brest, 6 Avenue Le Gorgeu, 29238 Brest, France
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Key words
Hydration; Animal model; Rat; Diving deaths

Abstract
(Wang Q, Guerrero F, Theron M. Pre-hydration strongly reduces decompression sickness occurrence after a simulated dive in rat. Diving and Hyperbaric Medicine. 2020 September 30;50(3):288–292. doi: 10.28920/dhm50.3.288-291. PMID: 32957132.)
Introduction: Hydration status is considered a parameter likely to influence the risk of decompression sickness (DCS), but scientific evidence is scarce and conflicting. This experiment aimed to analyse the influence of pre-hydration on DCS occurrence in a rat model.
Methods: Intra-peritoneal injections of saline solution were administered to rats (NaCl 0.9% 0 ml (Control), 0.1 ml (Group 1), or 1 ml·100g-1 body mass (Group 2) at each of 24 h, 12 h, and 30 min prior to simulated air dives (45 min at 1,010 kPa; compression and decompression rates 101 kPa·min-1; stops 5 min at 202 kPa, 5 min at 160 kPa, 10 min at 130 kPa). Evaluation of DCS occurrence and severity was made after decompression.
Results: Pre-dive hydration reduced severe DCS from 47% (Control) to 29% (Group 1) and 0% (Group 2), and increased the proportion of animals without any signs of DCS from 40 (Control) to 57% (Group 1) and 93% (Group 2); Chi2 P = 0.041.
Conclusions: This experiment demonstrated that pre-hydration can drastically reduce the DCS occurrence in an animal model. In the context of scuba diving, this result highlights the importance of elucidating the mechanisms linking hydration status and DCS risk.

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: Short communication


2020 September;50(3)

Diving Hyperb Med. 2020 September 30;50(3):292–294. doi: 10.28920/dhm50.3.292-294. PMID: 32957133.

Arterial gas embolism breathing compressed air in 1.2 metres of water

Neil B Hampson1, Richard E Moon2

1 Virginia Mason Medical Center, Seattle, Washington, USA
2 Duke University Medical Center, Durham, North Carolina, USA

Corresponding author: Dr Neil Hampson, Virginia Mason Medical Center H4-CHM, 1100 Ninth Avenue, Seattle WA 98101, USA
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Key words
Air embolism; Cerebral arterial gas embolism (CAGE); Diving; Pulmonary barotrauma

Abstract

(Hampson NB, Moon RE. Arterial gas embolism breathing compressed air in 1.2 metres of water. Diving and Hyperbaric Medicine. 2020 September 30;50(3):292–294. doi: 10.28920/dhm50.3.292-294. PMID: 32957133.)
Arterial gas embolism (AGE) may result when diving while breathing compressed gas and ascending rapidly or with a closed glottis. Pulmonary over-pressurisation can result in lung stretch injury with entry of bubbles into the pulmonary venous circulation and subsequently the systemic arterial circulation. We present the case of an individual who suffered AGE while breathing compressed air at 1.2 metres’ fresh water (mfw) in a swimming pool and discuss the factors determining the depth at which this form of injury may occur. This case serves to underscore the fact that risk of AGE exists at shallow depths.

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


2020 September;50(3)

Diving Hyperb Med. 2020 September 30;50(3):295–299. doi: 10.28920/dhm50.3.295-299. PMID: 32957134.

Dysbaric osteonecrosis in technical divers: The new ‘at-risk’ group?

Brendan Coleman1, F Michael Davis2

1 Auckland Orthopaedic Practice, Auckland 1543, New Zealand
2 Department of Anaesthesiology, Faculty of Medicine and Health Sciences, The University of Auckland, Auckland, New Zealand

Corresponding author: Dr Brendan Coleman, Auckland Orthopaedic Practice, PO Box 74 446, Auckland 1543, New Zealand
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Key words
Dysbaric osteonecrosis; Technical diving; Decompression sickness; Deep diving; Radiological imaging; Orthopaedics; Case reports

Abstract
(Coleman B, Davis FM. Dysbaric osteonecrosis in technical divers: The new ‘at-risk’ group? Diving and Hyperbaric Medicine. 2020 September 30;50(3):295–299. doi: 10.28920/dhm50.3.295-299. PMID: 32957134.)
Introduction: Dysbaric osteonecrosis (DON) in people working under increased atmospheric pressure is well documented. It is generally less common in military and commercial divers than in caisson workers, except in some high-risk groups, such as in many indigenous diving industries where workers have little or no understanding of decompression principles. With the increasing popularity within the recreational diving community of deep air and mixed-gas decompression diving (‘technical diving’), it is likely that diving physicians may see an increase in the prevalence of DON in this group in the future.
Methods: The case report is presented of a technical diving instructor, with a 30-year history of deep diving, who developed bilateral humeral head DON and required a right shoulder hemi-arthroplasty. A focused literature search was also undertaken to identify published cases of DON in recreational divers.
Results: The frequency, duration and depth of exposure to pressure, inadequate decompression, the occurrence of DCS and increasing age have been common features associated with DON in both divers and caisson workers. Many of these features were present in this technical diver.
Conclusions: Whilst DON is uncommon in recreational air scuba divers, all the above risk factors are present to a greater degree in technical diving. It is suggested that medical review for DON is merited from time to time in this potentially high-risk group of recreational 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: Case report


2020 September;50(3)

Diving Hyperb Med. 2020 September 30;50(3):300–302. doi: 10.28920/dhm50.3.300-302. PMID: 32957135.

Cerebral arterial gas embolism proven by computed tomography following transthoracic echocardiography using bubble contrast

Neil DG Banham1, Jacqui Saw2, Graeme J Hankey3,4, Darshan Ghia2,4

1 Hyperbaric Medicine Unit, Fiona Stanley Hospital, Perth, Western Australia
2 Department of Neurology, Fiona Stanley Hospital, Perth, Western Australia
3 Department of Neurology, Sir Charles Gairdner Hospital, Perth, Western Australia
4 Medical School, University of Western Australia, Perth, Western Australia

Corresponding author: Neil DG Banham, Director, Hyperbaric Medicine Unit, Fiona Stanley Hospital, Perth, Western Australia
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Key words
Central nervous system; Stroke; Doppler; Persistent (patent) foramen ovale (PFO); Radiological imaging; Hyperbaric oxygen treatment; Case reports

Abstract

(Banham NDG, Saw J, Hankey GJ, Ghia D. Cerebral arterial gas embolism proven by computed tomography following transthoracic echocardiography using bubble contrast. Diving and Hyperbaric Medicine. 2020 September 30;50(3):300–302. doi: 10.28920/dhm50.3.300-302. PMID: 32957135.)
A 75 year-old male developed features of an acute stroke following bubble contrast echocardiography, which was shown on emergent computed tomography scanning to be a result of cerebral arterial gas embolism (CAGE) to the left middle cerebral artery. Ischaemic stroke symptoms have previously been reported as a rare complication of bubble contrast echocardiography. Radiologically proven CAGE from bubble contrast echocardiography had not been reported at the time this case occurred. Immediate provision of 100% oxygen and administration of hyperbaric oxygen are recommended treatments for CAGE and were associated with a substantial recovery for this patient.

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


2020 September;50(3)

Diving Hyperb Med. 2020 September 30;50(3):303–305. doi: 10.28920/dhm50.2.303-305. PMID: 32957136.

Hyperbaric oxygen treatment in a patient with Guillain-Barré syndrome receiving mechanical ventilation

Lisha Song1, Baopeng Xing1, Weimin Yang1, Haifeng Li1

1 Department of Emergency, The First Hospital of Jilin University, Changchun, Jilin, 130021, China

Corresponding author: Dr Haifeng Li, Department of Emergency, The First Hospital of Jilin University, Changchun, Jilin, 130021, China
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Key words
Spinal cord injury; Neurology; Intensive care medicine; Case reports

Abstract

(Song L, Xing B, Yang W, Li H. Hyperbaric oxygen treatment in a patient with Guillain-Barré syndrome receiving mechanical ventilation. Diving and Hyperbaric Medicine. 2020 September 30;50(3):303–305. doi: 10.28920/dhm50.2.303-305. PMID: 32957136.)
The mortality rate of patients with Guillain-Barré syndrome (GBS) who develop respiratory muscle paralysis and need mechanical ventilation is increased. Though an unestablished indication, hyperbaric oxygen treatment (HBOT) has been used to treat patients with mild GBS who do not have respiratory muscle paralysis. The use of HBOT in severe cases has not been reported. We present a patient with severe GBS who received HBOT while ventilated in a multiplace hyperbaric chamber. Three courses of HBOT (one session per day, 10 sessions per course) were administered with a 2-day rest period between each course. The HBOT protocol was 40 minutes at 220 kPa with 25 minutes of compression and decompression. Following weeks of gradual deterioration, motor function improved after the first HBOT session. After eight HBOT sessions, the patient was successfully discontinued from mechanical ventilation and after 10 sessions the patient’s muscle strength was significantly improved. After 30 HBOT sessions, the patient had normal breathing and speech, and did not cough when eating. Upper limb muscle strength was graded as 4 on the Medical Research Council (MRC) scale, lower limb muscle strength was graded as MRC 3. The patient was successfully discharged. Mechanically ventilated GBS patients may benefit from HBOT but studies are required to separate spontaneous recovery rates from treatment benefit.

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


2020 September;50(3)

Diving Hyperb Med. 2020 September 30;50(3):306. doi: 10.28920/dhm50.2.306. PMID: 32957137.

Central nervous system oxygen toxicity during 100% oxygen breathing at normobaric pressure

Richard Moon

Corresponding author: Richard Moon, Duke University Medical Center, Durham, North Carolina, USA
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Key words
Carbon dioxide; Hypercapnia; Hyperoxia; Toxicity; Side effects; Letters (to the Editor)

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: Letter to the Editor


2020 September;50(3)

Diving Hyperb Med. 2020 September 30;50(3):306–307. doi: 10.28920/dhm50.2.306-307. PMID: 32957138.

Central nervous system oxygen toxicity during 100% oxygen breathing at normobaric pressure: Reply

Mirit Eynan

1 Department of Emergency, The First Hospital of Jilin University, Changchun, Jilin, 130021, China

Corresponding author: Mirit Eynan, Israel Naval Medical Institute, Israel Defense Forces Medical Corps, Haifa, Israel
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Key words
Carbon dioxide; Hypercapnia; Hyperoxia; Toxicity; Diving; Letters (to the Editor)

 

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: Letter to the Editor

Diving and Hyperbaric Medicine is indexed on MEDLINE, Science Citation Index Expanded (SciSearch®) and Embase/Scopus and complies with the International Committee of Medical Journal Editors (ICMJE) Recommendation for the Conduct, Report, Editing and Publication of Scholarly Work in Medical Journals.
Articles from 2017 are deposited in PubMed Central
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