Diving with Disabilities - Part 2

  • Michael B. Strauss, MD, Lientra Q. Lu, BS
  • Volume 09 - Issue 2

This three-part series is extracted from a chapter in the second edition of Diving Science by Michael B. Strauss, MD, et al. which covers special diving types, situations and environments. Part 2 of this series in the current issue of WCHM discusses musculoskeletal disabilities, neuropsychiatric disorders, and respiratory problems.

Musculoskeletal Disabilities

Introduction

Problems involving the musculoskeletal system are easier to conceptualize as handicaps such as a loss of limb as compared to disabilities such as those imposed by heart disease.

The majority of musculoskeletal handicaps with respect to scuba diving consist of three primary problems: loss of limbs, restricted/painful joint motions and loss of function from neurological conditions. How much they interfere with scuba diving needs to be considered on a continuum from almost none to total prevention of the activity. In the majority of scuba divers with disabilities, the dive buddy is a key factor in making the dive safe and enjoyable.

Loss of Limbs

Trauma and circulation problems are the two most frequent causes of amputations, and most occur in the lower extremities. Those individuals with loss of limbs from circulation problems usually have other significant comorbidities such as heart disease and diabetes and consequently are not candidates for scuba diving. Conversely, much attention has been given to scuba diving in patients with traumatic amputations. This is largely a consequence of affording wounded warriors from military conflicts the benefits and pleasures of scuba diving.

For single leg amputations, the restrictions for scuba diving are minimal. Usually all that is needed is an adaptive fin-prosthesis device (Figure 5). For above-knee and bilateral amputees, the designs are more complicated, with the most challenges being the attachment of the swimming prosthesis to the remaining limb stump. What can be done in this regard is dependent on the motivation of the amputee and the ingenuity of the prosthetist. While the amputee may be totally independent on land with crutches or even without walking aids, the transition from the land to the water environment is the primary challenge. This is where the buddy diver is essential and adaptive devices for the transition may be needed, such as a ramp or hydraulic lift device for water entries and exits.

FIGURE 5. Adaptive Fins for Swimming and Diving

FIGURE-5

A variety of options exist for swim fins for amputees. Some amputees have a water employable prosthesis for aquatic activities in addition to the prosthesis they use for walking.

 

Joint, Ligament, Tendon and Muscle Problems

Arthritis is a condition where body joints including the spine have deterioration of their articular (joint) cartilage and no longer function as smooth guiding surfaces. The loss of cartilage can progress to bone erosion and collapse of the joint surfaces. With such, there is marked restriction of the joint’s motion and associated pain with movement of the joint. With decreased movement, the joint capsules, ligaments and muscle-tendon units contract and loss of joint motion is the result. Pain and loss of joint motion have consequences for the scuba diver. They include interfering with the donning and removing diving gear—especially exposure suits, entries to and exits from the water, and ability to use the extremities at a capacity necessary to extricate themselves from emergencies, such as negotiating currents or extrication from entanglements. When the above are realized, the scuba diver typically “retires” from this activity for the reason it is too difficult and/or it is “no longer fun or enjoyable.”

Although musculoskeletal pain and restricted joint movements for land-based activities may severely curtail activities, the buoyancy effects of water unload joints and need for minimal joint movements for motility make swimming and water aerobics an ideal exercise activity. While these have some relationships to scuba diving, the challenges, as previously mentioned, are donning and removing gear and water entries and exits.

Diving with Joint Replacements

Orthopaedic advancements have greatly expanded the possibilities for those with arthritis problems to dive. These advancements are largely due to the successful outcomes of total joint replacements. Most arthritis problems with respect to scuba diving impose only relative contraindications for scuba diving. Patients with arthritis and/or total joint replacements should not categorically be restricted from scuba diving. There is no data available that patients with total joint replacements have increased incidences of medical problems of diving and, in particular, decompression sickness. Consequently, the decision to scuba dive is primarily a function of the patient’s motivation. However, this must be coupled with the joint surgeon’s approval that the joint replacement is sufficiently healed, stable and functional enough that scuba diving is OK.

 

FIGURE 6. Musculoskeletal Handicaps that Have Ramifications for SCUBA Diving

FIGURE-6

Five conditions encompass almost all the musculoskeletal conditions that can affect divers. When mild-to-moderate they only impose relative or temporary contraindications. For example, bone necrosis can lead to arthritis, which can be mitigated with joint replacements. With adaptive equipment and dive planning, most not impose absolute contraindications for SCUBA diving.

 

Soft Tissue Musculoskeletal Disorders

Other musculoskeletal problems such as shoulder rotator cuff tears, tendinitis, contractures, joint instabilities, knee meniscus tears and low back pain, in general, only impose temporary contraindications for scuba diving, Almost all of these conditions can be mitigated with rest, medications(especially non-steroidal, anti-inflammatory agents), physical therapy and/or surgery. Since conditions just mentioned can interfere with mobility, dive planning and selection of dive sites are important. Conditions to avoid are dive sites where strong currents are present and where water exits require removal of equipment while dangling from a safety line or ladder in turbulent waters.

DIVE SCENARIO  While scuba diving in somewhat arduous conditions in a dive that almost exceeded the dive computer’s no decompression limits, the diver needed to hang onto a safety line from a boat bobbing in the rough sea to remove his gear.

In the process of doing such, he was repeatedly tugged and twisted while holding onto the safety line with one hand and removing his gear with the other. After climbing aboard with the ladder bouncing up and down, he immediately experienced pain in the shoulder used to hold the safety line.

Decompression sickness (DCS) was suspected, but a shoulder rotator cuff tear (RCT) could not be ruled out.

A trial of hyperbaric oxygen recompression did not resolve the symptoms. The patient was subsequently evaluated and managed for a rotator cuff tear.

COMMENT When decompression sickness is suspected, a trial of hyperbaric oxygen recompression (HBO RC) should always be done. The scenario shows how the history helped to justify DCS as a possible cause of the patient’s shoulder complaints.

It is possible that both diagnoses (e.g. DCS and RCT) could have coexisted. With the HBO RC treatment, pain symptoms without moving the shoulder would be expected to resolve. However, pain with shoulder motions and lifting with the extremity would remain and confirm the presence of the RCT.

Bone Necrosis

Osteonecrosis (osteo = bone, necrosis = death) is a condition where bone cells die. It has other names such as avascular necrosis, femoral head necrosis (although it can occur in other bones), bone necrosis, diver’s bone disease and bone rot. Although the etiology has not been clearly established, it is hypothesized that bubbles form in the blood vessels supplying the bone cells, the cells die from hypoxia and if in a joint area, collapse, cause irregularity of the joint surfaces and result in arthritis. There are reported associations of this condition occurring in saturation divers, divers who do repetitive long, deep dives and those divers who have omitted decompression. However, the incidences are so infrequent as compared to post-traumatic, coagulopathy-related and idiopathic age-related, wear-and-tear arthritis, that the significance of the diving activity can be questioned. However, if osteonecrosis occurs in the relatively young diver, the diving history must be considered.

Osteonecrosis is not a disability unless arthritis and joint collapse occurs. If detected, diving practices should be reviewed and avoidance of diving activities that could further the problem avoided. Consequently, osteonecrosis becomes a relative contraindication for scuba and other compressed gas diving. Hyperbaric oxygen has been reported to prevent progression of femoral head necrosis before it progresses to joint collapse.12 If a joint replacement is required, commercial diving activities are not recommended.

However, as mentioned before, with due considerations, scuba diving with joint replacements should be placed in the relative contraindications category.

 

Neuropsychiatric Disorders

Spinal Cord Injuries and Peripheral Nerve Problems

Neuropsychiatric disorders have two major components, those that affect the brain and those that affect spinal cord/peripheral nervous system. Spinal cord and peripheral nervous system problems mainly concern loss of function. Paraplegic patients who have plateaued in their recovery present relative contraindications for diving. Wounded warriors and other athletic individuals are the major candidates for scuba diving.

Motivation of the paraplegic diver is the key factor in association with a high level of fitness and a nearly ideal body mass index. Next is establishing a dedicated support team. This includes usual and customary scuba diving training as well as the unique considerations for how to deal with functionless, insensate lower extremity limbs in an environment that provides near neutral buoyancy. The dive buddy and support team need to help with donning and removing diving gear and water entries and exits as well as guiding the handicapped diver through the course of the dive. Of special concern is avoiding the dandling of paralyzed lower extremities onto potential injury-producing marine animals such as barnacles, sea urchins and fire corals.

TABLE 5. Mental Conditions and Diving
Condition Major Problem(s) Concerns and Recommendations for Diving
Alzheimer's Similar to development delays If affliction is mild and especially if the patient enjoys the water and had dove before, diving in controlled environments may be beneficial

Anxiety Disorder

(less severe than neuroses)

Innate fear of water, drowning, or sharks while able to function well in other situations As with neuroses diving should not be forced on people with anxiety disorders for aquatic environments
Autism Lack of communication skills, inability to pay attention, lack of interest If successfully snorkels, then with close supervision in controlled environments, diving may have therapeutic benefits
Cerebral Palsy Uncontrolled muscle movements, lack of coordination, spasticity, contractures Mobility limitations: difficulty handling diving gear, donning and removing it. If mild, planned diving with supervision OK
Developmental Delay/Mental Retardation Inability to understand or follow instructions. Subject to panicking and doing dangerous things such as "bolting" to the surface breathing or descending to dangerous depths If moderate to mild impairment, close supervision in controlled environments possibly OK for diving. Better to teach and engage in snorkeling activities
Neuroses Anxiety, obsessive-compulsive behavior, lack of focus extends to all activities Spectrum ranging from complete avulsion to diving, sharks, etc. to obsessions with safety, hygiene, contaminants, pollution and behavior that interferes with other divers' enjoyment
Post Traumatic Stress Disorder Analogous to neuroses Diving may be a superb diversionary activity with the water environment; supervisions and controlled environments are essential
Psychoses Depression, mania, paranoia Suicidal behavior, risky activities, harm to others due to hallucinations, loss of reality, or wanting to hurt others. Diving not recommended
Sociopathic Behavior Drug use, intoxications, deviant behavior Safety concerns regarding diving; makes the diving experience potentially dangerous for others
Traumatic Brain Injury Similiar to Alzheimer's Similar recommendations to Alzheimer's

The third consideration is selection of the “ideal” diving site where minimal cold water exposure gear and weights to establish neutral buoyancy are needed, water entries and exits are easy (such as off of a boat), the water visibility is good, and waves, currents or swells are at a minimum. The dive profiles should be very conservative because the on and offgassing of nitrogen is likely to be much different in extremities that are immobile due to the paralysis. Mixed gas and closed-circuit rebreather scuba diving is not recommended for the paraplegic patient. Not unexpected, it is likely to be very satisfying psychologically for a paralyzed diver to “conquer” the aquatic environment and do things most terrestrial bound people are afraid and/or are unwilling to do. Likewise, for the dive buddy it is a real achievement and a measure of the highest level of scuba diving skills to be able to execute safely the diving activity for the handicapped diver.

Other nerve-related disorders such as carpal tunnel syndromes, tennis elbow, diabetic neuropathy, peripheral neuritis, sciatica, radicular pain, etc., present relative contraindications to diving. Most are remedial with medication and/or surgical management. The physician attending to the patient’s problem can usually provide clearance for scuba diving. If in doubt, referral to a diving medicine physician for advice is recommended.

Vision and Other Sensory Organ Impairments or Losses

The major considerations are those that deal with hearing, vision and sensation. Much has been written about scuba diving with eye conditions; most are relative or temporary (e.g. after surgical procedures) contraindications for scuba diving.13  Radial keratotomy and laser refractive surgery (photorefractive keratotomy) impose only temporary contraindications for scuba diving that allow time for healing. The ophthalmologist performing the surgery is expected to provide the clearance as when it is OK to scuba dive after such procedures.

Patients who have surgeries for the above conditions generally have good outcomes. However, convalescence and restoration of full function takes much more time than just the time it takes the incision to heal.
Is back surgery a contraindication for scuba diving? Laminectomies, nerve root decompressions, and fusions are frequently done. While swimming with the neutral buoyancy afforded by the aquatic environment is ideal for rehabilitation, consideration for the “burden” (tanks, weight belt, increased lever arms to the hip and low back musculature imposed by swimming with fins, etc.) of the diving equipment must be considered in making a decision whether to scuba dive or not.
In general, the surgeon and/or the rehab specialist will make the decision whether or not the surgical sites are sound enough to allow scuba diving. If questions arise, the diving physician who is versed in the challenges of the diving environment can provide advice about the feasibility for the patient to scuba dive.

More common considerations are diving with impaired vision, which can usually be managed with corrective lenses. Contact lens use is not a contraindication for scuba diving. Loss of near vision (myopia) is commonly associated with aging. This is somewhat mitigated by the magnification effect of the facemask-water interface, which makes objects appear about a third larger than when visualized in air. Corrective lenses attached to the face mask are a solution to impaired near vision. A more important safety concern is that the loss of near vision makes the reading of dive monitoring equipment difficult and is a reason not to scuba dive without lenses to correct this problem. While blindness is not a contraindication for scuba diving, anecdotal reports exist that legally blind (vision less than 20/200) have done and enjoy scuba diving.14 Loss of color vision is not a contraindication for scuba diving, except for Naval Special Warfare divers (SEALS) and Explosive and Ordinance Demolition (EOD) divers because of the need to differentiate color-coded wiring for setting-up and deactivating demolitions.

A concern raised with scuba diving with contact lenses is that if the dive masks flood, the lenses could become dislodged. Trying to replace the lenses in an aquatic environment is a near impossible undertaking. The dislodgment of contact lenses could raise safety concerns about reading monitoring equipment for the save completion of the dive.
Another consideration is bubbles from decompression can develop in the fluid film between the contact lens and the cornea and affect vision. For this reason if contact lenses are used by the scuba diver, they should be of the “soft” variety.

While glaucoma is not a contraindication for scuba diving, medications to manage it can affect heart rate and becomes a consideration if cardiac conditions are present.

Hearing Impairments

Impaired and total loss of hearing are different considerations. Age-related decreases in hearing (presbycusis), most noticeable with high frequency sounds, is not a contraindication to scuba diving. However, total deafness in one ear is considered by many to be an absolute contraindication to scuba diving. This is because ear structures are among the most vulnerable of all body structures to barotrauma, and diving presents constant, invariable challenges to these structures. Meniere disease is an absolute contraindication for diving.

The cause of Meniere disease is an excessive accumulation of the fluid (endolymph) filling the inner ear structures thought to be due to the impaired absorption of this fluid.
In this sense, it has many analogies to hydrocephalus, a condition caused by the excessive accumulation of cerebrospinal fluid in the brain. The increased accumulation dilates the ventricles of the brain with resultant pressure atrophy of the brain tissues and enlargement of the cranium if it occurs before the skull bones have fused.

Its symptoms include vertigo nausea, vomiting, tinnitus and hearing loss. The hearing loss tends to fluctuate but worsens with time.

Sensory Losses

Sensation has many components such as pain, light touch, two-point discrimination, pressure, stretch/distraction, temperature, and vibration recognition and discrimination. Each has its own sensory organelles for recognition, but the nerve impulses must be transmitted to the brain where they can be interpreted by the sensory cortex. Any perturbation along this transmission and interpretation chain can cause disordered or loss of sensation. While this may seem insignificant since vision is the overwhelming sensory experience during diving, it may have consequences for grasping objects, appreciating marine animal injuries, protecting from cold exposure, and handling safety equipment. Again, dive planning and dive buddies can compensate for diving with rare and unusual sensory nerve problems resulting from diabetes mellitus, trauma, multiple sclerosis, radiculopathies (impingement of nerves leaving the spinal cord), and nerve compression syndromes such as carpal tunnel syndrome.

Psychiatric and Brain Function Disorders

Of all the disabilities and handicaps that can confront the scuba diver, these are the most difficult for which to provide concrete recommendations. They encompass a spectrum of disorders in alphabetical order from Alzheimer’s disease, to anxiety disorders, to autism, to cerebral palsy, to developmental delay/mental retardation, to neuroses, to post-traumatic stress disorder, to psychoses, to sociopathic behavior, to traumatic brain injury (Table 5). Not to be overlooked in this spectrum is the recognition how scuba diving has benefited those with autism, traumatic brain injury and post-traumatic stress disorder.15,16

Scuba diving is an option that appears to have many benefits for the victims of traumatic brain injury and post- traumatic stress disorder as well as other brain function problems. The aquatic environment with its ability to provide almost neutral buoyancy and move about as a bird flying through the air undoubtedly can help sufferers of these problems from the realities and challenges of functioning on land.
Consequently, decisions to scuba dive or not weigh in favor of allowing the patient with psychiatric and brain function disorders to do this activity. However, each patient is a special consideration in itself requiring input from the patient, family members, and the patient’s care providers as well as the dive buddy/supervisor.

Scuba diving requires a complement of cognitive skills, coordination abilities, interpretations of sensory input, and integrations of motor (muscle) activity. In making decisions about diving, the most likely factor to interfere with the diving activity and/or make the risks of a problem arising during the dive must be considered the critical variable in making the decision (Table 5). The decision to consider or not recommend scuba diving, consequently, rests on input from a variety of sources as well as the patient's own functional abilities, cognitive skills and desires. Not to be disregarded is a diving physician’s role to advise and consent on the diving conditions that would be appropriate for the handicaps in question. The other prerequisites for scuba diving with patients who have mental conditions are diving in a controlled environment with adequate and attentive supervision.

Diving in controlled conditions implies that the diving site is selected for its safety features, accessibility, water visibility, water temperature and weather conditions. Safety features and accessibility include use of fixed diving platforms with safety lines anchored to the bottom, gentle beaches with minimal surf, absence of, or minimal currents.
Water visibility, warm water and good weather conditions are obvious features of diving in a controlled environment and are best achieved by diving in tropical and subtropical waters in lagoons or on the leeward sides of islands or peninsulas.

Respiratory System Problems

Introduction

The respiratory system has a multitude of components from the openings of the mouth and nose to the conduits such as pharynx, larynx, trachea, bronchi, bronchioles and terminal bronchioles, to the alveoli where air exchange occurs, to the lining of the lungs (the pleura), to the alveolar capillaries, to the diaphragm and accessory respiratory muscles, to the rib cage. Each component has conditions that can impose restrictions on divers (Table 6). Two main conditions, asthma and pneumothorax, generate the most questions about making decisions and imposing restrictions on scuba diving. Almost all the other conditions have obvious contraindications for scuba diving or the conditions only impose temporary restrictions as documented in the above-cited table.

The respiratory system is another incredible organ system. Its two main components are the conducting elements and the gas exchange elements. The conducting elements begin with the mouth and nose and continue to the bronchioles. There are 23 divisions or splits of the conducting elements before they reach the alveoli. Not only does the conducting elements provide a conduit, but they also warm and moisturize the inspired air so that it is 100% saturated with moisture and warmed to body temperature before it reaches the alveoli.
All gas exchange (i.e oxygen in and carbon dioxide out, as well as other gases such as nitrogen, carbon dioxide, etc.) occur in the terminal bronchioles (10% of the exchange) and the alveoli 90% of the exchange). There are about 480 million alveoli and if spread out on a flat surface, would cover the area of a tennis court.

Asthma

This condition occurs in about five percent of the population and is a leading cause of illness and restriction of activities in childhood and adolescent age groups. It is a disorder that can be chronic or have acute exacerbations characterized by widespread and largely reversible reductions in the caliber of bronchi and bronchioles due in varying degrees of smooth muscle spasm, mucosal edema, and excessive mucus in the lumens of airways.17 Asthma can impose both absolute and relative contraindications for scuba diving. The main concern with asthma is air retention in the alveoli as a consequence of bronchiole constriction. This interferes both with alveolar filling and alveolar emptying of gas. The consequence of the former is hypoxia and its consequences of inadequate oxygenation of tissues. The consequence of failure to empty is gas retention in the alveoli. This results in carbon dioxide retention plus hypoxia. In the case of a scuba diver, air retention in the alveoli can result in their rupture during ascent as the gas expands in accordance with Boyle’s law. A spectrum of problems collectively termed as extra-alveolar air syndromes can arise from subcutaneous/ mediastinal emphysema to pneumothorax to arterial gas embolism.

TABLE 6. Respiratory System and Its Relevance to Diving
Structure Function Medical Problems Diving Restrictions
Ingress-Egress
Mouth & Nose Gas exchange with outside environments or scuba regulator Upper respiratory infections, congestion can interfere with middle ear clearing Temporarily
Pharynx Gas conduct from mouth/nose to respiratory tract Inflammation tonsillitis; as above regarding middle ear barotrauma Temporarily vs. absolute if chronic & unable to clear ears
Conduits
Larynx Separate alimentary tract from airways tract As above; tracheotomy for reducing dead space of upper airways Inflammations temporary; tracheotomy absolute
Trachea Major conduit from bronchi Inflammation; respiratory tract infections e.g. tracheitis Temporary
Bronchi Two main divisions of the respiratory tree (RT) Same as above; e.g. bronchitis Temporary if acute; relative if chronic and associated with coughing & secreations
Bronchioles Further divisions of RT with 28 in total Same as above; e.g. bronchiolitis Same as above
Ventilation/Gas Exchange
Terminal Bronchioles Muscular control of passage to alveoli; account for 10% of gas exchange Bronchial spasm with restriction of gas passage to alveoli. Partial or complete obstruction from secretions Relative vs. absolute depending on severity; see Asthma in text
Alveoli 90% of gas exchange (e.g. O2 in and CO2 out) Distention as in chronic obstructive pulmonary disease (COPD), collapse as in atelectasis and/or scaring as in pulmonariy fibrosis; pneumothorax Absolute except pneumothorax (see text)
Alveolar Capillaries Gas transport to bloodstream before & after exchange at above 2 levels Ventilation-perfusion inequalities; pulmonary emboli Absolute; if resolved then relative
Gas Movement
Diaphragm Primary motor/muscle system for moving air in &o out of lungs Paralysis; bowel herniation through diaphragm into chest cavity Absolute
Accessory Respiratory Muscles Increase ventilation. Compensate for loss of diaphragm function Paralysis in high spinal cord injury Absolute

In the “Diving in Youth” chapter (Chapter 14), the subject of scuba diving in this age group was detailed. The advice is much the same for the adult scuba diver and imposes a relative restriction. Often childhood asthmatics grow out of their asthma attacks, perhaps by enlargement of airways with growth, a less responsive immune system and/or learning to avoid precipitating factors that initiate the asthma attacks. However, another permutation of asthma is the adult onset asthma presentation. If asthma episodes are infrequent and chronic medications are not required, the patient with a history of asthma should be allowed to scuba dive if asymptomatic and not requiring medications to control his or her breathing before, during and after scuba diving activities. Hydration and avoidance of chilling are important considerations in choosing a diving site since cold air can lead to bronchiole spasm and dehydration leading to excessive and/or inspissation (thickening) of the mucus secretions in the respiratory system. This can further interfere with gas exchange and its consequences of hypoxia and alveolar gas retention.

FIGURE 7. Extra-alveolar air/ Pulmonary Over Pressurization Syndromes

FIGURE-7

Extra-alveolar air syndromes with SCUBA dive evolve in 3 stages. Once gas escapes from the alveoli, it can move to three sites. Which site becomes the target tissue for the gas bubbles depends on the gradient (explosive gradients are likely to lead to arterial gas embolism), the sites of the alveolar ruptures, and the patient's tissue qualities. If pulmonary blebs rupture, pneumothorax is likely to be the outcome with ascents whether breath-holding or not
KEY: SC = Subcutaneous (which also includes mediastinal presentations)

 

Chronic obstructive pulmonary disease (COPD) has analogies to asthma. However, the condition occurs in older individuals typically with a history of smoking. The disease is characterized by progressive and irreversible damage to the microscopic lung tissue. Because of activity restrictions and often the need for supplemental oxygen, patients with this problem are unlikely candidates for scuba diving. Narrowing of the microscopic airway passages with COPD obstruct gas exchange in the alveoli. This leads to hypoxia and carbon dioxide retention.
Another consideration, but almost irrelevant for scuba diving, is that COPD patients can be so decompensated and retain so much carbon dioxide in their tissues that they no longer respond to elevated tissue tensions of this gas and their stimulus to breathe becomes that of low oxygen. Scenarios could be generated where this respiratory adjustment could have consequences for scuba diving with the changes of partial pressures of oxygen (Dalton’s law) with ascents and descents.

Pneumothorax

This is a condition where gas escapes from the alveoli either spontaneously or after trauma and insinuates itself between the lung pleura (covering membrane) and the lung tissue itself. If leakage is significant, the lung collapses. If the collapsed lung and filling of the pleural space continues unabated, it will compress the unaffected lung leading to the potentially fatal situation of tension pneumothorax. Pneumothoraxes occur rarely in scuba diving with subcutaneous/mediastinal and arterial gas embolism being more frequently reported. Reasons for this are not clear, but probably represent anatomical differences with respect to the anatomy of the interfaces between conduits and the surrounding supporting soft tissues such as the lung pleura. Pulmonary blebs also need to be considered as a cause of the spontaneous pneumothorax. The consensus is that if a spontaneous pneumothorax occurs, the patient should not be allowed to scuba dive. The rationale for this is based on the assumption there is a "weak link" in the respiratory system anatomy and the changes of ambient pressure associated with scuba diving make the diver vulnerable to further extra-alveolar air problems. The US Navy has imposed a restriction on submariners and divers that if a spontaneous pneumothorax occurs, the patient can only resume diving and submarine activities if they remain asymptomatic for five years.

As mentioned before, the extra- alveolar air (EAA) syndromes are a spectrum of disorders from subcutaneous/mediastinal emphysema, to pneumothorax, to arterial gas embolism.
Which problem occurs with EAA is speculative. If the bronchial-pleural interfaces are “loose,” it is conceivable that EAA would dissect into the mediastinum and subcutaneous tissues. If the interfaces are “tight” and the alveolar to pleural cavity leak is not explosive, then the EAA could collapse the lung leading to the pneumothorax. If the alveolar rupture is “explosive,” such as an uncontrolled ascent with breath-holding while scuba diving, concomitant rupture of the alveoli and surrounding blood vessels would lead to gas entry into the vessels and arterial gas embolism.
Another cause of pneumothoraxes is pulmonary blebs. With rupture, the gas in them escapes into the pleural space and collapses the lung. Some blebs can be identified on plain chest X-rays and if they occur, make scuba diving unsafe. This is because of changes of ambient pressure with ascent and descent may lead to rupture of the blebs. Definitive diagnosis of pulmonary blebs can be made with computerized tomography. Removal of blebs can be done surgically (blebectomies) with resultant scaring of lung tissue. Scuba diving may be considered after such surgery is successfully completed (see next text box).

The situation is different for the traumatic pneumothorax because of two considerations. First, there is an identifiable cause such as a fractured rib for the lung collapse, and with healing of the traumatic pneumothorax, there is usually a scar tissue formation reaction around the injured lung tissue, so that it is theoretically more resistant to a pneumothorax than the uninvolved lung tissue. For this reason, patients with traumatic pneumothoraxes are allowed to resume scuba diving when healed, asymptomatic and cleared by the physicians attending to the pneumothorax. The time interval from injury to resuming scuba diving is generally about six months.

Subcutaneous and Mediastinal Emphysema

These are the least serious of the spectrum of extra-alveolar air syndromes. They are believed to be caused by gas escaping the respiratory tree probable at the alveolar level and moving through the hilum of the lung into the mediastinal and/or subcutaneous tissues rather than remaining in the chest cavity (which would lead to a pneumothorax). Since they are associated with scuba diving, over expansion of the lungs with ascent and rupture of the alveoli is the proposed mechanism. Why presentations vary from mediastinal to subcutaneous locations (as well as not having associated pneumothorax) is not known, but probably reflects individual differences in divers’ respiratory system anatomy. Mediastinal emphysema (pneumomediastinum) is characterized by chest pain and labored breathing and is confirmed by chest X-rays.

For recurrent spontaneous pneumothoraxes, scarification (pleurodesis) procedures are an option. This procure involves electrocautery or introducing a scarifying agent such as tetracycline into the pleural space (the space between the surrounding lung pleura and the lung tissue itself). This generates adhesions of the pleura to the lung tissue and reduces the changes of a recurrent pneumothorax.
Return to diving after a successful scarification procedure is probably OK. We recommend a trial of compression in a hyperbaric chamber before clearance for scuba diving. During the pressurization, the patient should do some “stress” actions such as forceful increases of abdominal pressure, Valsalva maneuvers, deep breathing, forceful exhalations and hyperventilation. If OK with these actions, it is reasonable to resume scuba diving with the same healing time considerations after scarification, i.e. about six months, as for the traumatic pneumothorax.

Subcutaneous emphysema symptoms include crepitus (bubbly, sponge-like feeling) of the skin on the neck and lower face from gas dissecting in the subcutaneous tissue planes. The bubbles in this location can also cause changes in the voice, such that the victim sounds like Donald Duck when speaking.

Time and reassurance is the accepted “management” for SE/ME. If there is respiratory distress from labored breathing, supplemental oxygen breathing is employed. However, breathing oxygen does not speed the resolution of the gas bubbles in the tissues.
Hyperbaric oxygen (HBO) has been considered as a treatment for SE/ME since pressurization would expect to reduce the bubble size (Boyle’s law) and the enriched oxygen environment speed up the offgassing (i.e. wash out) of nitrogen ((Dalton’s law). However, this is not an approved indication for HBO, anecdotal information suggests it is not beneficial and ME/SE resolve spontaneously with time.

Subcutaneous and mediastinal emphysema (SE/ME) are self-limiting conditions with spontaneous resolution of the gas with time, usually a week or so. The consensus is that these events do not impose restrictions for future scuba diving. Usually, a detailed history of the dive activity preceding SE/ME can detect breath-holding or unanticipated, rapid ascent portions of the dive. Consequently, the diver should be informed of the probable mechanism of SE/ME and be cautioned to avoid uncontrolled ascents and not to breath-hold during the ascents. If the diver experiences a second occurrence of SE/ME, scuba diving becomes a relative contraindication. In such situations, the diver should be evaluated by a chest medicine physician with imaging studies to rule out lung blebs or other lung pathology before resuming diving.

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About the Authors

                                                                                                        

Michael Strauss, M.D., an orthopaedic surgeon, is the retired medical director of the Hyperbaric Medicine Program at Long Beach Memorial Medical Center in Long Beach, California. He continues to be clinically active in the program and focuses his orthopaedic surgical practice on evaluation, management and prevention of challenging wounds. Dr. Strauss is a clinical professor of orthopaedic surgery at the University of California, Irvine, and the orthopaedic consultant for the Prevention-Amputation Veterans Everywhere (PAVE) Problem Wound Clinic at the VA Medical Center in Long Beach. He is well known to readers of WCHM from his multiple articles related to wounds and diving medicine published in previous editions of the journal. In addition, he has authored two highly acclaimed texts, Diving Science and MasterMinding Wounds. Dr. Strauss is actively studying the reliability and validity of the innovative, user-friendly Long Beach Wound Score, for which he already has authored a number of publications.

 

LIENTRA LU is a research coordinator at the VA Medical Center in Long Beach, California, under the guidance of Dr. Ian Gordon, a vascular surgeon, and Dr. Michael Strauss. She is also an administrative assistant in the accounting department of the Southern California Institute for Research and Education (SCIRE). She received a bachelor of science degree in chemical biology at the University of California, Berkeley, in 2015 and subsequently has taken medically related courses at the University of California, Los Angeles. Miss Lu is helping with diabetic foot and venous leg ulcer studies at the VA Medical Center while also serving as an assistant in patient care at the PAVE Clinic there. She also works with the American Red Cross in her other interest, disaster preparedness.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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