- Overview of Diving Injuries
- Arterial Gas Embolism
- Overview of Barotrauma
- Dental, Mask, and Eye Barotrauma
- Ear and Sinus Barotrauma
- Gastrointestinal Barotrauma
- Pulmonary Barotrauma
- Immersion Pulmonary Edema
- Decompression Sickness
- Gas Toxicity During Diving
- Recompression Therapy
- Diving Precautions and Prevention of Diving Injuries
Barotrauma is tissue injury caused by a pressure-related change in body compartment gas volume in air-containing areas. During ascent from a dive, ambient pressure becomes lower and gas expansion can affect the lungs and gastrointestinal (GI) tract; during descent, ambient pressure becomes higher and gas compression can affect ears, sinuses, air spaces in tooth fillings, and space contained by the diving face mask. This has been described during ascent to altitude in individuals with large bullae, although it is extremely rare. Manifestations depend on the affected area. Diagnosis is clinical but sometimes requires imaging tests. Treatment generally is supportive but may include oxygen and chest tube placement for pneumothorax.
Risk of barotrauma (often called "squeeze" by divers) during deep-water diving is greatest from the surface of the water to 10 m (33 ft) in depth below the surface. 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 is the most common diving injury.
Pulmonary barotrauma may occur when divers 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, because the expanding gas may overinflate the lungs. Lung overinflation occurs mostly in divers breathing compressed air but can occur even in swimming pools when compressed air is inspired at depths 1 m (3 to 4 ft) below the surface (eg, when scuba gear is used there).
Barotrauma can also affect the GI tract (gastrointestinal barotrauma), teeth (dental barotrauma), eyes (eye barotrauma), ears and sinuses (ear and sinus barotrauma), and face (mask barotrauma).
Symptoms and Signs of Barotrauma
Clinical manifestations depend on the affected organ or anatomic location; all develop almost immediately when pressure changes. Symptoms may include ear pain, vertigo (can be severe), hearing loss, sinus pain, epistaxis, and abdominal pain. Dyspnea and alteration or 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 of the middle ear is sometimes a late complication.
Diagnosis of Barotrauma
Primarily history and physical examination
Imaging tests
Diagnosis is primarily clinical based on a patient experiencing pain in the involved organ system; imaging tests can sometimes confirm barotrauma.
Treatment of Barotrauma
Symptomatic treatment
Other treatment depending 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 pneumothorax or gastrointestinal rupture, particularly in patients who present with any of the following:
Abnormal vital signs
Neurologic symptoms or signs, including altered consciousness
Dyspnea
Peritoneal signs
Initial stabilizing treatment includes high-flow 100% oxygen 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 4th or 5th intercostal space in the midaxillary 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. For patients with inner ear barotrauma, prompt surgical treatment of labyrinthine window tears can reverse hearing loss.
Patients treated for severe or recurrent diving-related injuries should not return to diving until they have consulted with a diving medicine specialist.
Divers should be taught about measures to prevent diving injury (see Diving Precautions and Prevention of Diving Injuries).
Key Points
Most barotrauma is ear barotrauma.
Symptomatic treatment is sufficient for barotrauma unless patients have manifestations of potential life-threats (eg, neurologic symptoms, pneumothorax, peritoneal signs, abnormal vital signs) or are suspected of having inner ear barotrauma.
Treat patients who have potentially life-threatening injuries with 100% oxygen and other stabilizing measures as necessary.
When patients are stable, treat the specific type of barotrauma sustained.
More Information
The following English-language resources may be useful. Please note that The Manual is not responsible for the content of these resources.
Divers Alert Network: 24-hour emergency hotline, 919-684-9111
Duke Dive Medicine: Physician-to-physician consultation, 919-684-8111
