Barotrauma/Decompression Sickness Overview
Barotrauma often refers to medical problems that arise from the effects of water pressure when a scuba diver is beneath the surface. Water is heavier than air, so when you dive, small changes in depth cause large changes in pressure underwater.
- External ear squeeze occurs when your ear canal is blocked by something such as earplugs or earwax. As the water pressure increases while you descend, the air pocket between the obstruction and the tympanic membrane (eardrum) shrinks. This can damage the tissue in the ear canal, usually your eardrum.
- Middle ear squeeze occurs when you cannot equalize the pressure in your middle ear. This is the most common problem for divers. The eustachian tube is a small canal that connects the middle ear to the back part of the nasal cavities and allows pressure to equalize. When there is a problem with the tube, the middle ear volume decreases and pulls the eardrum inward, creating damage and pain. You can try certain maneuvers, called Valsalva maneuvers, such as yawning or trying to blow with your nose and mouth closed, to open the tube and equalize the pressure.
- Inner ear barotrauma occurs from the sudden development of pressure differences between the middle and inner ear. This can result from an overly forceful Valsalva maneuver. The result is usually ringing in the ear, dizziness, and deafness. This injury is less common than a middle ear squeeze.
Less common types of barotrauma involve air trapped in an enclosed area that cannot equalize during descent. This causes a vacuum effect that can result in:
- Sinus squeeze: When air becomes trapped in the sinuses because of congestion or cold symptoms, a sinus squeeze can occur.
- Face mask squeeze: This occurs if you do not exhale into the diver mask while descending.
- Suit squeeze: A dry diving suit tightly encloses an area of skin.
- Lung squeeze: This occurs when you are free-diving, but very few divers can hold their breath to depths that cause this injury to occur.
Barotrauma also can occur during ascent.
- A reverse squeeze occurs to your middle ear or sinus when a diver has an upper respiratory infection (cold) and has used nasal spray to open the breathing passages. As the spray wears off during diving, tissues swell and cause obstruction, resulting in a pressure difference and damage.
- Aerogastria occurs when gas that you swallowed during diving expands during ascent. This happens more often with novice divers and causes temporary pain but rarely significant damage.
- Pulmonary barotrauma (pulmonary overpressurization syndrome, POPS, or burst lung) can occur if you fail to expel air from your lungs during ascent. As you rise, the volume of the gas in your lung expands and can cause damage if the excess is not exhaled.
Air embolism is the most serious and most feared consequence of diving. While you are diving, gas bubbles can enter your circulatory system through small ruptured veins in your lungs. These bubbles expand during ascent and can pass through your heart to obstruct blood flow in the arteries of your brain or heart.
- This most commonly occurs when a diver ascends rapidly because of air shortage or panic.
- The diver then passes out, experiences a stroke, or has other nervous system complaints within minutes of surfacing.
- Your brain is affected more than other organs because gas rises and most divers are vertical while ascending.
Decompression sickness (DCS, or "the bends") involves gases diffusing into your tissues and getting trapped there. You then have gas bubbles in places where there should be none. Nitrogen is the usual culprit.
- During descent and while on the bottom, you absorb nitrogen into your tissues until you reach a pressure balance.
- When you ascend at the right rate, the gas diffuses from your tissues. However, if you ascend too rapidly to allow diffusion, the nitrogen bubbles will expand in your tissues as pressure decreases.
- Different body parts can be affected, depending on where the bubbles are located.
Barotrauma/Decompression Sickness Causes
Two different phenomena cause barotrauma:
- The inability to equalize pressures
- The effect of pressure on an enclosed volume
Middle ear squeezes occur because of obstruction of the eustachian tube.
- The most common cause is an upper respiratory infection (cold) creating congestion.
- Other causes of obstruction include congestion caused by allergies or smoking, mucosal polyps, excessively aggressive Valsalva attempts, or previous facial injuries.
Factors that trigger sinus squeezes include a cold, sinusitis, or nasal polyps.
Contributing factors to aerophagia (excessive air swallowing) include:
- Performing Valsalva maneuvers with your head down, which allows the swallowing of air
- Consuming carbonated beverages or heavy meals prior to diving
- Chewing gum while diving.
Pulmonary barotrauma occurs from holding your breath during ascent, which allows pressure to rise in your lungs. The increase in pressure results in rupture. Air also may penetrate into the tissue around your lungs.
The classic cause of an air embolism is rapidly ascending to the surface because of panic.
Failure to make recommended stops during ascent usually causes decompression sickness. Stops are based on diving tables or charts, which take into account the depth, duration of the dive, and previous dives completed. Based on those factors, the tables will give you guidelines on the proper rate of ascent.
Barotrauma/Decompression Sickness Symptoms
The history of the dive is very important to medical professionals treating you for diving related problems. It's important to let them know what the overall plan for the dive was and what part of the dive you were doing when the problem occurred.
- Barotrauma such as squeezes will commonly occur during descent, and the symptoms will frequently prevent a diver from reaching the desired depth.
- Symptoms of aerogastralgia, pulmonary barotrauma, air embolism, and decompression sickness occur both during and after ascent.
Following are symptoms for specific pressure problems:
- External ear squeeze - Pain in your ear canal and blood from your ear.
- Middle ear squeeze - Ear fullness, pain, eardrum rupture, disorientation, nausea, and vomiting.
- Inner ear barotrauma – Feeling that your ear is full, nausea, vomiting, ringing in the ear, dizziness, and hearing loss.
- Sinus squeeze - Sinus pressure, pain, or nasal bleeding.
- Face mask squeeze - "Bloodshot" eyes and redness or bruising of the face under the mask.
- Lung squeeze - Chest pain, cough, bloody cough, and shortness of breath.
- Aerogastralgia - Abdominal fullness, colicky pain (severe pain with fluctuating severity), belching, and flatulence.
- Pulmonary barotrauma - Hoarseness, neck fullness, and chest pain several hours after diving. Shortness of breath, painful swallowing, and loss of consciousness also may occur.
- Air embolism - Sudden loss of consciousness within 10 minutes of surfacing. Other symptoms include paralysis, numbness, blindness, deafness, dizziness, seizures, confusion, or difficulty speaking. The paralysis and numbness can involve several different parts of the body at the same time.
- Decompression sickness - Rashes, itching, or bubbles under your skin. Other symptoms can include:
- Lymphatic obstruction which can cause localized swelling
- Musculoskeletal symptoms including joint pain that worsens with movement and commonly involves the elbows and shoulders
- Nervous system after-effects including paralysis, sensory disturbances, and bladder problems, usually the inability to urinate
- Pulmonary symptoms including chest pain, cough, and shortness of breath.
Symptoms of decompression sickness usually appear within 1 hour of surfacing but can be delayed up to 6 hours. In rare instances symptoms may not appear until 48 hours after the dive.
Flying in a commercial aircraft after diving may cause "the bends" to develop in the airplane because the cabin pressure is less than sea level pressure.
When to Seek Medical Care
Air embolism is life threatening and requires immediate attention. Planning ahead is important.
- Know the location of the nearest emergency facility and recompression (hyperbaric) chamber before you dive.
- Bring emergency phone numbers with you on the dive. A phone can be the best immediate tool.
- The Divers Alert Network at Duke University maintains a list of recompression facilities and can be reached around the clock at 919-684-9111.
- If a diver collapses within 10 minutes of diving, suspect air embolism and seek emergency help immediately. Most communities have an emergency access number (911). These divers require oxygen and emergency life support. Lay the person flat and keep the diver warm until help arrives.
Decompression sickness also requires immediate attention, but symptoms may not appear as quickly as in an air embolism.
- Information on recompression chambers is important and generally can be obtained through the emergency medical system (911).
- Divers with complaints consistent with decompression sickness should seek attention through their doctor or a hospital’s emergency department.
You need immediate medical attention if you lose consciousness, show paralysis, or exhibit stroke symptomswithin 10 minutes of surfacing. You or your diving buddy should contact an ambulance through 911 or the local emergency phone numbers.
Symptoms of chest pain and shortness of breath may occur minutes to hours after a dive. These require emergency department evaluation. Call 911. These symptoms can be dive related or could be caused by another condition, such as a heart attack.
Decompression sickness, or "the bends,” may require an emergency department to control pain and arrange for recompression services. These services use specialized equipment that is available only at regional centers that specialize in barotrauma.
Dizziness or pain from a squeeze may require emergency attention as well. When in doubt, contact your doctor or a local emergency department for advice.
Pulmonary barotrauma and lung squeeze will require attention in an emergency department in most instances. That's because the studies required to evaluate the symptoms and the possible treatment must be performed in the hospital environment.
Most problems that arise from barotrauma will require medical diagnosis and treatment. The most important thing you can do if you experience barotrauma is to seek medical attention and avoid future dives until cleared by a doctor.
Some injuries from barotrauma require immediate medical attention, while others can wait for treatment. In all cases, stop further diving until you see a doctor. Your doctor can evaluate and treat ear squeezes and sinus squeezes initially and then refer you to a specialist if needed.
- Evaluation may require a dive history.
- Ear squeezes require an examination to ensure your eardrum has not ruptured.
Exams and Tests
The doctor will gather information about the dive and perform a standard physical exam, paying particular attention to your areas of pain and your nervous system.
Depending on your condition, you may be referred immediately to a recompression (hyperbaric) chamber or may undergo further testing.
- Your vital signs will be taken, measuring blood pressure, pulse, breathing rate, and temperature
- Doctors will probably do a pulse oximetry, using an instrument that measures the level of oxygen in your blood by placing a sensor on a finger or earlobe.
- The most common initial treatments may be oxygen (through a face mask or a tube near your nose) and intravenous fluids.
Air embolism and decompression sickness usually will require recompression treatment and repeated physical examinations. After treatment, the doctor may recommend a specialized imaging study (CT scan or MRI) to further evaluate any neurological problems.
Chest pain and shortness of breath associated with pulmonary barotrauma may require an ECG and a chest X-ray.
The doctor will inspect your ear canal and eardrum if you have an ear squeeze looking for physical damage that can range from no visible problems to a small amount of bleeding to eardrum rupture to heavy bleeding.
Any hearing loss or dizziness will probably require referring you to an otolaryngologist (ear, nose, and throat specialist) or audiologist (hearing specialist). They will test your hearing and balance systems to determine if you have suffered any inner ear problems.
Barotrauma/Decompression Sickness Treatment
The most serious diving complications—air embolism and decompression sickness—will require recompression therapy. The required hyperbaric chambers may be freestanding or associated with a local hospital. The chamber itself is typically made of thick metal plates with windows for observation. On the outside there are many pipes and valves. The chamber is usually large enough to accommodate more than one person. Medical personnel may come into the chamber with the patient or stay outside, watch through the window, and communicate by intercom, depending on the severity of the illness. While inside the chamber, you may hear loud noises or feel cold as the pressures change. Similar to diving, you will need to do Valsalva maneuvers to clear the ears while being pressurized. You will be closely monitored and be given specific instructions while you are in the chamber.
Other injuries can be managed at the hospital or doctor's office. All conditions will require avoidance of diving until improved.
You may need to be transported to another location for hyperbaric treatments. This may include low-level flights in an aircraft to minimize further pressure changes. The hyperbaric chamber will increase the air pressure to make any gas bubbles inside your tissues smaller and to allow them to go away properly to avoid injury. "Treatment tables" will determine the length of treatment and treatment steps. These tables take into account the depth, time of dive, decompression stops, and previous dives performed. The hyperbaric specialist will recommend which table to use.
Pulmonary barotrauma may result in a collapsed lung (pneumothorax). If this occurs, the doctor must first determine how much of the lung has collapsed. If the collapse is relatively small you can often be treated with supplemental oxygen and observation. Larger collapses may require that air be withdrawn from your body.
Depending on the amount of air in the cavity, the doctor could use a needle or a hollow tube. The needle will withdraw small amounts of air, and then you will be observed for at least 6 hours.
Larger collapses require a catheter, or chest tube, to be placed in the chest wall that will remain for a few days until the lung can heal. Doctors must insert this tube through the skin into the chest cavity by doing a small surgical procedure. Local anesthetics reduce and generally eliminate any pain associated with this procedure. The tube is attached to a flutter valve or suction to promote air escape from the space where it doesn't belong.
Self-Care at Home
There is no special treatment for face mask and suit squeezes. They usually go away in a few days.
Aerogastralgia symptoms usually clear up on their own and do not require attention unless your abdominal discomfort continues to worsen and does not go away in a few hours.
You can treat pain from ear or sinus squeezes with over-the-counter pain relievers, such as acetaminophen (Tylenol), ibuprofen (Motrin, Advil), or naproxen (Aleve). You should visit your doctor first to exclude possible serious ear injuries.
Ear squeezes also require decongestants, both oral and long-acting nasal types. Antibiotics may be given if you had a rupture, a previous infection, or the diving occurred in polluted waters. Pain medication also may be prescribed.
Next Steps - Follow-up
Doctors will recommend follow-up based on your diagnosis. Make sure everything has healed and you have received clearance before you dive again.
The best prevention against barotrauma is to plan and prepare for your dive properly:
- Make sure you are in good health with no upper respiratory or sinus problems.
- Obtain the proper training and always use the buddy system (never dive alone).
- Check that your equipment is in good working order.
- Know the local emergency phone numbers in advance and have a means of contacting help—for instance, with a cell phone. (The location of the nearest recompression facility could be very important with a problem such as air embolism.)
- Newer "dive computers" designed to maximize safety can be used and may allow longer diving times and fewer or shorter decompression stops. They provide information similar to the original diving tables but are more precise. Be certain you are familiar with their use before depending on them.
- Avoid flying in a plane within 12 to 48 hours of diving (depending on the diving history) to reduce the risk of "the bends" occurring unexpectedly in the lower air pressure of an airplane cabin.
Most people recover from their diving accidents and are able to participate in future dives.
Air embolism can be the most devastating complication from a diving accident. The initial problems that occur can be very dramatic. Appropriate measures, including recompression, must be taken quickly to minimize disabilities.
Decompression sickness can also generally be treated effectively and result in very good recovery rates when recompression is performed, even several days after the initial onset.
Pulmonary barotrauma associated with a collapsed lung (pneumothorax) may require several days in the hospital if a chest tube is placed. There is always a risk of recurrence once a diver has a collapsed lung. Complete recovery will usually take several weeks to months.
Mild ear squeezes usually take about 1-2 weeks to recover. More significant ones, typically associated with eardrum rupture, may take longer. Depending on the severity and amount of damage, surgery may be needed.