Barotrauma/Decompression Sickness Overview

Barotrauma refers to medical problems that arise from the pressure differences between areas of the
body and the environment and is a particular concern for scuba divers.

Certain laws of physics apply to this topic. Boyle's law states that the product of the multiplication of
pressure and volume remains a constant. As the pressure increases, the volume decreases and vice
versa. As you dive deeper when scuba diving, pressure increases and this volume change in gas-filled
spaces and organs within your body accounts for the distortion and damage to surrounding tissues.

Decompression sickness, or "the bends," is related more to Henry's Law, which states that more gas
will be dissolved in a liquid when the gas is pressurized. Because of the water pressure, body tissue
absorbs nitrogen gas faster as a diver descends than when ascending to the surface. However, if a
diver ascends too quickly, nitrogen gas bubbles will form in body tissue rather than being exhaled. The
nitrogen bubbles cause severe pain.
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. 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 or a very rapid
descent. 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 include the following. All involve air trapped in an enclosed area
where pressure cannot equalize during descent causing a vacuum effect where it occurs.
o Sinus squeeze: When air becomes trapped in the sinuses because of congestion or cold
symptoms, a sinus squeeze can occur.
o Face mask squeeze: This occurs if you do not exhale through your nose into the dive mask while
descending (equalizing).
o Suit squeeze: A dry diving suit tightly encloses an area of skin.
o 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.
o Tooth squeeze: This occurs during an ascent while scuba diving and air becomes trapped in a
filling or cavity.
o Gastric squeeze (aerogastralgia): This occurs when gas swallowed during diving expands during
ascent. This happens more often with novice divers and causes temporary pain but rarely
significant damage.
Barotrauma can occur during ascent also. A reverse squeeze occurs in the 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. During "bounce diving" the eustachian tube may become inflamed
and lead to a middle ear squeeze.
Pulmonary barotrauma (pulmonary overpressurization syndrome, POPS, or burst lung) can occur if
the diver fails to expel air from the lungs during ascent. As the diver rises, the volume of the gas in the
lung expands and can cause damage if the excess is not exhaled.
Air embolism is the most serious and most feared consequence of diving.
o While scuba diving, gas bubbles can enter the circulatory system through small ruptured veins in
the lungs.
o These bubbles expand during ascent, following Boyle's Law, and can pass through the heart to
obstruct blood flow in the arteries of the 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.
The brain is affected more than other organs because gas rises, and most divers are in a vertical
position while ascending.
Decompression sickness (DCS, "the bends") involves gases diffusing into the tissues and getting
trapped there. The diver now has gas bubbles in places where there should be none. Nitrogen is the
usual culprit.
o During descent and while on the bottom, the diver absorbs nitrogen into the tissues until they reach
a pressure balance.
o When the diver ascends at the right rate, the gas diffuses from the tissues. However, if the diver
ascends too rapidly to allow diffusion, the nitrogen bubbles will expand in the tissues as pressure
decreases.
o 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
Decompression sickness is caused by the elevated pressures of the gas mixture inhaled underwater
that diffuse into the body tissues, and then the inadequate diffusion of the gas from the tissues if the
diver surfaces too quickly.
Middle ear squeezes occur because of obstruction of the Eustachian tube.
o The most common cause is an upper respiratory infection (cold), creating congestion.
o Other causes of obstruction include congestion caused by allergies orsmoking, 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 aerogastralgia (swallowing air) include performing Valsalva maneuvers with the
head down (which allows air swallowing), consuming carbonated beverages or heavy meals prior to
diving, or chewing gum while diving.
Pulmonary barotrauma occurs from the diver holding their breath during ascent, which allows pressure
to rise in the lungs.
o The pressure increase results in rupture.
o Air also may penetrate into the tissue around the lungs.
 The classic description of a dive causing an air embolism is rapidly ascending to the surface because
of panic.
Failure to make recommended decompression stops during ascent usually causes decompression
sickness. Stops are based on diving tables or charts, which factor into account the depth, duration of
the dive, and previous dives completed and give you guidelines on the proper rate of ascent.

Barotrauma/Decompression Sickness Symptoms

Patient CommentsShare Your Story

You should consider the signs and symptoms of diving injuries with regard to your overall dive plan,
including what part of the dive you were performing when the problems occurred.

The history of the dive is very important to medical personnel and should always be included when
assistance is required.
o Barotrauma such as squeezes will commonly occur during descent, and the symptoms will
frequently prevent a diver from reaching the desired depth.
o You will notice symptoms of aerogastralgia, pulmonary barotrauma, air embolism, and
decompression sickness both during and after ascent.

The 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 (gastric squeeze): Abdominal fullness, colicky pain (severe pain with fluctuating
severity), belching, and flatulence (gas expelled through the anus).
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
o Lymphatic obstruction which can cause localized swelling
o Musculoskeletal symptoms include joint pain that worsens with movement and commonly involves
the elbows and shoulders
o Nervous system after-effects include paralysis, sensory disturbances, and bladder problems,
usually the inability to urinate.
o Pulmonary symptoms include chest pain, cough, and shortness of breath.
o Symptoms 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.
o 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

Most problems that arise from barotrauma will require medical diagnosis or treatment. The most important
thing the patient can do if they 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 the patient has been seen by a doctor.

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 life saving
tool.
The Divers Alert Network (DAN) at Duke University maintains a list of recompression facilities and can
be reached around the clock at (call local EMS first, then DAN):
o (919) 684-8111 (collect)
o 800-446-2671 (toll free)
o 1-919-684-9111 (Latin America Hotline)
If a diver collapses within 10 minutes of diving, suspect air embolism and seek help immediately. Most
U.S. communities have an emergency access number (911). Find out in advance if such a number is
available and how to activate emergency medical services when diving in a foreign country. A diver
who has collapsed requires oxygen and emergency life support. Lay the person flat and keep the diver
warm until help arrives.

Decompression sickness also requires immediate attention, but its symptoms may not appear as quickly
as those of air embolism.

Information on recompression chambers is important and generally can be obtained through the
emergency medical system (911 in the U.S.).
Divers with complaints consistent with decompression sickness should seek attention through their
doctor or a hospital's emergency department.

Pulmonary barotrauma and lung squeeze will require attention in an emergency department in most
instances because the studies required to evaluate the symptoms and determine the possible treatment
must be performed in the hospital environment.

A doctor can evaluate and treat ear squeezes and sinus squeezes initially and refer the patient to a
specialist if required.

Evaluation may require a dive history.

Ear squeezes require an examination to ensure the eardrum has not ruptured.

The diver needs immediate medical attention if they lose consciousness, show paralysis, or
exhibit stroke symptoms within 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.

If the symptoms are severe enough, contact an ambulance. Otherwise, have someone drive the
patient to the hospital, but do not drive yourself.
These symptoms can be dive-related or could be caused by another condition, such as a heart attack.
This will be sorted out in the hospital.

Decompression sickness, or "the bends, may require an emergency department to control pain and
arrange for recompression services using 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 a
doctor or a local emergency department for advice.

Exams and Tests

The doctor will gather information about the dive and perform a standard physical exam, paying particular
attention to the areas of pain and nervous system.

Depending on the patient's condition, they may be referred immediately to a recompression (hyperbaric)
chamber or may undergo further testing.

The patient's vital signs will be taken, measuring blood pressure, pulse, breathing rate, and
temperature.
Doctors probably will do a pulse oximetry - an instrument that measures the level of oxygen in the
blood - using a sensor on a finger or earlobe.
The most common initial treatments may be oxygen (through a face mask or a tube near the 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 electrocardiogram (ECG) and a chest X-ray.

The doctor will inspect the patient's ear canal and eardrum if they have an ear squeeze, looking for
physical signs 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 referral to an otolaryngologist (ear, nose, and throat
specialist) or audiologist (hearing specialist). They will test the patient's hearing and balance systems to
determine if they have suffered any inner ear problems.

Barotrauma/Decompression Sickness Treatment

 Patient CommentsShare Your Story
The most serious diving complications - air embolism and decompression sickness - will require
recompression therapy in a hyperbaric chamber. These 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, one may experience loud noises or cold as the pressures change.
Similar to diving, one will need to do Valsalva maneuvers to clear the ears while being pressurized. The
patient will be closely monitored and be given specific instructions while they 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.

The patient 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.
"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.
The hyperbaric chamber will increase the air pressure to make any gas bubbles inside the tissues
smaller and to allow them to go away properly to avoid injury.

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 the patient can be
treated with supplemental oxygen and observation. Larger ones require that air be withdrawn from the
body.

Depending on the amount of air in the cavity, the doctor could use a needle or a hollow tube to
withdraw air from the cavity.
The needle will withdraw small amounts of air, and then the patient will be observed for at least 6
hours.
Larger collapses require a catheter, or chest tube, to be placed in the chest wall and remain for a few
days until the lung that has been damaged 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 inappropriate space.

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 the abdominal
discomfort continues to worsen and does not go away in a few hours.

Pain from ear or sinus squeezes can be treated with over-the-counter pain relievers, such
asacetaminophen (Tylenol), ibuprofen (Motrin, Advil), or naproxen (Aleve). The patient should visit a
doctor to exclude possible serious ear injuries.
 Medications

Sinus squeezes usually require oral and nasal decongestants. Antibiotics are usually recommended for a
squeeze involving the frontal sinuses. Pain medication may also be prescribed.

Ear squeezes also require decongestants, both oral and long-acting nasal types. Antibiotics may be given
if the patient had a rupture, a previous infection, or the diving occurred in polluted waters. Pain medication
also may be prescribed.

Follow-up

Doctors will recommend follow-up based on the diagnosis.

Make sure everything has healed and the patient has received clearance before diving again.

Prevention

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 cellular phone. (The location of the nearest recompression facility could be very
important in 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 24 hours of diving to reduce the risk of "the bends" occurring
unexpectedly in the lower air pressure of an airplane cabin.

Outlook

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. Recovery rates for people reaching a recompression chamber have
been high.
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 recommended.
Medically reviewed by Medically reviewed by Donald Lee, DO; Board Certified Family Practice