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Barotrauma

By Alfred A. Bove, MD, PhD

Barotrauma is tissue injury caused by a pressure-related change in body compartment gas volume; it affects air-containing areas, including lungs, ears, sinuses, GI tract, air spaces in tooth fillings, and space contained by the diving face mask. Manifestations depend on the affected area. Diagnosis is clinical but sometimes requires imaging tests. Treatment generally is supportive but may include O2 and chest tube placement for pneumothorax.

Risk of barotrauma (often called squeeze by divers) is greatest from the surface to 10 m (33 ft). Risk is increased by any condition that can interfere with equilibration of pressure (eg, sinus congestion, eustachian tube blockage, structural anomaly, infection) in the air-containing spaces of the body.

Ear barotrauma constitutes about two thirds of all diving injuries.

In divers who inspire even a single breath of air or other gas at depth and do not let it escape freely during ascent, or when ascent is rapid, the expanding gas may overinflate the lungs, causing pulmonary barotrauma. Lung overinflation occurs mostly in divers breathing compressed air but can occur even in swimming pools when compressed air is inspired at the bottom of the pool (eg, when scuba gear is used there) and, rarely, from an inverted bucket.

Barotrauma can also affect the GI tract ( gastrointestinal barotrauma), teeth ( dental barotrauma), eyes ( eye barotrauma), and face ( mask barotrauma).

Symptoms

Manifestations depend on the affected area; all occur almost immediately when pressure changes. Symptoms may include ear pain, vertigo, hearing loss, sinus pain, epistaxis, and abdominal pain. Dyspnea and loss of consciousness can be life-threatening and may result from alveolar rupture and pneumothorax.

Some medical disorders, if they cause symptoms at depth, may be disabling or disorienting and thus lead to drowning (see Table: Specific Medical Contraindications to Diving). Secondary infection is sometimes a late complication.

Diagnosis

  • Clinical evaluation

  • Imaging tests

Diagnosis is primarily clinical; imaging tests can sometimes confirm barotrauma. Sometimes patients are evaluated for other problems or organ dysfunction.

Treatment

  • Symptomatic treatment

  • Other treatment dependent on specific injury

Most barotrauma injuries require only symptomatic treatment and outpatient follow-up; however, some injuries are life threatening. Potentially life-threatening barotrauma emergencies are those involving alveolar or GI rupture, particularly in patients who present with any of the following:

  • Neurologic symptoms

  • Pneumothorax

  • Peritoneal signs

  • Abnormal vital signs

Initial stabilizing treatment includes high-flow 100% O2 and, if respiratory failure appears imminent, endotracheal intubation. Positive pressure ventilation may cause or exacerbate pneumothorax.

Patients with suspected pneumothorax who are hemodynamically unstable or have signs of tension pneumothorax require immediate chest decompression with a large-bore (eg, 14-gauge) needle placed into the 2nd intercostal space in the midclavicular line, followed by tube thoracostomy. Patients with neurologic symptoms or other evidence of arterial gas embolism are transported to a recompression chamber for treatment as soon as transportation can be arranged.

When stable, patients are treated for the specific type of barotrauma sustained.

Patients treated for severe or recurrent diving-related injuries should not return to diving until they have consulted with a diving medicine specialist.

Key Points

  • Most barotrauma is ear barotrauma.

  • Symptomatic treatment is sufficient for barotrauma unless patients have manifestation of potential life-threats (neurologic symptoms, pneumothorax, peritoneal signs, abnormal vital signs).

  • Treat patients who have potentially life-threatening injuries with 100% O2 and other stabilizing measures as necessary.

  • When patients are stable, treat the specific type of barotrauma sustained.

More Information

* This is the Professional Version. *