Decompression sickness

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Caisson disease

[decompression sickness]

ICD-10 T70.3
ICD-9 993.3
DiseasesDB 3491
MeSH C21.866.120.248

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Synonyms and Keywords: Decompression illness; DCS; the diver's disease; the bends; Caisson disease.

Overview

Decompression sickness is the name given to a variety of symptoms suffered by a person exposed to a reduction in the pressure surrounding their body. It is a type of diving hazard and dysbarism.

Clinical Scenarios

Decompression sickness can happen in these situations:

  • A diver ascends rapidly from a dive or does not carry out decompression stops after a long or deep dive.
  • An unpressurized aircraft flies upwards.
  • The cabin pressurization system of an aircraft fails.
  • Divers flying in any aircraft shortly after diving. Pressurized aircraft are not risk-free since the cabin pressure is not maintained at sea-level pressure. Commercial aircraft cabin pressure is often maintained to about 8,000 feet above sea level.
  • A worker comes out of a pressurized caisson or out of a mine, which has been pressurized to keep water out.
  • An astronaut exits a space vehicle to perform a space-walk or extra-vehicular activity where the pressure in his spacesuit is lower than the pressure in the vehicle.
File:Preparing for recompression.jpg
This surfacing diver must enter a recompression chamber to avoid the bends.

These situations cause inert gases, generally nitrogen, which are normally dissolved in body fluids and tissues, to come out of physical solution (i.e., outgas) and form gas bubbles.

According to Henry’s Law, when the pressure of a gas over a liquid is decreased, the amount of gas dissolved in that liquid will also decrease. One of the best practical demonstrations of this law is offered by opening a soft drink can or bottle. When you remove the cap from the bottle, you can clearly hear gas escaping and see bubbles forming in the soda. This is carbon dioxide gas coming out of solution as a result of the pressure inside the container reducing to atmospheric pressure.

Similarly, nitrogen is an inert gas normally stored throughout the human body, such as tissues and fluids, in physical solution. When the body is exposed to decreased pressures, such as when flying an un-pressurized aircraft to altitude or during a scuba ascent through water, the nitrogen dissolved in the body outgases. If nitrogen is forced to come out of solution too quickly, bubbles form in parts of the body causing the signs and symptoms of the "bends" which can be itching skin and rashes, joint pain, sensory system failure, paralysis, and death.

An air embolism, caused by other processes, can have many of the same symptoms as DCS. The two conditions are grouped together under the name decompression illness or DCI.

History

  • 1841: First documented case of decompression sickness, reported by a mining engineer who observed pain and muscle cramps among coal miners working in mine shafts air-pressurized to keep water out.
  • 1867: The submarine pioneer Julius H. Kroehl died of decompression sickness during experimental dives with the Sub Marine Explorer.
  • 1869: An early case resulting from diving activities while wearing an air-pumped helmet.
  • 1872: Washington Roebling suffered from caisson disease while working as the chief engineer on the Brooklyn Bridge. (He took charge after his father John Augustus Roebling died of tetanus.) Washington's wife Emily helped manage the construction of the bridge, after his sickness confined him to his home in Brooklyn. He battled the after-effects of the disease for the rest of his life.

Predisposing factors

  • Magnitude of the pressure reduction: A large pressure reduction is more likely to cause DCS than a small one. For example, the ambient pressure halves by ascending during a dive from 10 metres / 33 feet (2 bar) to the surface (1 bar), or by flying from sea level (1 bar) to an altitude of 16,000 feet / 5,000 metres (0.5 bar) in an un-pressurized aircraft. Diving and then flying shortly afterwards increases the pressure reduction as does diving at high altitude.
  • Repetitive exposures: Repetitive dives or ascents to altitudes above 18,000 feet within a short period of time (a few hours) also increase the risk of developing altitude DCS.
  • Rate of ascent: The faster the ascent, the greater the risk of developing altitude DCS. An individual exposed to a rapid decompression (high rate of ascent) above 18,000 feet has a greater risk of altitude DCS than being exposed to the same altitude but at a lower rate of ascent.
  • Time at altitude: The longer the duration of the flight to altitudes of 18,000 feet and above, the greater the risk of altitude DCS.
  • Age: There are some reports indicating a higher risk of altitude DCS with increasing age.
  • Previous injury: There is some indication that recent joint or limb injuries may predispose individuals to developing "the bends."
  • Ambient temperature: There is some evidence suggesting that individual exposure to very cold ambient temperatures may increase the risk of altitude DCS.
  • Body Type: Typically, a person who has a high body fat content is at greater risk of altitude DCS. Due to poor blood supply, nitrogen is stored in greater amounts in fat tissues. Although fat represents only 15 percent of a normal adult body, it stores over half of the total amount of nitrogen (about 1 litre) normally dissolved in the body.
  • Exercise: When a person is physically active, or performing strenuous activity before or after a dive (such as rowing to and from a dive site), there is greater risk of DCS.*Rate of Air Consumption: If you tend to consume more air than what may be considered "normal" for scuba diving, you will certainly be more susceptible to DCS if you skirt the no-decompression limits.*Alcohol consumption/dehydration: While conventional wisdom would have one believe that the after effects of alcohol consumption increase the susceptibility to DCS through increased dehydration and decreased motor coordination/mental acuity, one study concluded that alcohol consumption did not increase the risk of DCS.[1]. The high surface tension of water is generally regarded as helpful in controlling bubble size, hence staying hydrated is recommended by most experts.* Patent foramen ovale: A hole between the atrial chambers of the heart in the fetus is normally closed by a flap with the first breaths at birth. In up to 20 percent of adults the flap does not seal, however, allowing blood through the hole with coughing or other activities which raise chest pressure. In diving, this can allow blood with microbubbles in the venous blood from the body to return directly to the arteries (including arteries to the brain, spinal cord and heart) rather than pass through the lungs, where the bubbles would otherwise be filtered out by the lung capillary system. In the arterial system, bubbles (arterial gas embolism) are far more dangerous because they block circulation and cause infarction (tissue death, due to local loss of blood flow). In the brain, infarction results in stroke, in the spinal cord it may result in paralysis, and in the heart it results in myocardial infarction (heart attack).

Signs and symptoms

Bubbles can form anywhere in the body, but symptomatic sensation is most frequently observed in the shoulders, elbows, knees, and ankles.This table gives symptoms for the different DCS types. The "bends" (joint pain) accounts for about 60 to 70 percent of all altitude DCS cases, with the shoulder being the most common site. These types are classifed medically as DCS I. Neurological symptoms are present in 10 to 15 percent of all DCS cases with headache and visual disturbances the most common. DCS cases with neurological symptoms are generally classified as DCS II. The "chokes" are rare and occur in less than two-percent of all DCS cases. Skin manifestations are present in about 10 to 15 percent of all DCS cases.{| cellspacing="0" border="1" bgcolor="white"|+ Table 1. Signs and symptoms of decompression sickness.|- ! DCS Type! Bubble Location! Signs & Symptoms (Clinical Manifestations)|- ! BENDS| Mostly large joints of the body
(elbows, shoulders, hip,
wrists, knees, ankles)|* Localized deep pain, ranging from mild (a "niggle") to excruciating. Sometimes a dull ache, but rarely a sharp pain.* Active and passive motion of the joint aggravates the pain.* The pain may be reduced by bending the joint to find a more comfortable position.* If caused by altitude, pain can occur immediately or up to many hours later.|- ! rowspan="3" | NEUROLOGIC| Brain|* Confusion or memory loss* Headache* Spots in visual field (scotoma), tunnel vision, double vision (diplopia), or blurry vision* Unexplained extreme fatigue or behaviour changes* Seizures, dizziness, vertigo, nausea, vomiting and unconsciousness may occur, mainly due to labyrinthitis|- | Spinal Cord|* Abnormal sensations such as burning, stinging, and tingling around the lower chest and back* Symptoms may spread from the feet up and may be accompanied by ascending weakness or paralysis* Girdling abdominal or chest pain|- | Peripheral Nerves|* Urinary and rectal incontinence* Abnormal sensations, such as numbness, burning, stinging and tingling (paresthesia)* Muscle weakness or twitching|- ! CHOKES| Lungs|* Burning deep chest pain (under the sternum)* Pain is aggravated by breathing* Shortness of breath (dyspnea)* Dry constant cough|- ! SKIN BENDS| Skin|* Itching usually around the ears, face, neck arms, and upper torso* Sensation of tiny insects crawling over the skin* Mottled or marbled skin usually around the shoulders, upper chest and abdomen, with itching* Swelling of the skin, accompanied by tiny scar-like skin depressions (pitting edema)|}

Treatment

Recompression is the only effective treatment for severe DCS, although rest and oxygen (increasing the percentage of oxygen in the air being breathed via a tight fitting oxygen mask) applied to lighter cases can be effective. Recompression is normally carried out in a recompression chamber. In diving, a high-risk alternative is in-water recompression.Oxygen first aid treatment is useful for suspected DCS casualties or divers who have made fast ascents or missed decompression stops. Most fully closed-circuit rebreathers can deliver sustained high concentrations of oxygen-rich breathing gas and could be used as an alternative to pure open-circuit oxygen resuscitators.

Common pressure reductions that cause DCS

The main cause of DCS is a reduction in the pressure surrounding the body. Common ways in which the required reduction in pressure occur are:* leaving a high atmospheric pressure environment* rapid ascent through water during a dive* ascent to altitude while flying

Leaving a high pressure environment

The original name for DCS was caisson disease; this term was used in the 19th century, when large engineering excavations below the water table, such as with the piers of bridges and with tunnels, had to be done in caissons under pressure to keep water from flooding the excavations. Workers who spend time in high pressure atmospheric pressure conditions are at risk if they leave that environment and reduce the pressure surrounding them.DCS was a major factor during construction of Eads Bridge, when 15 workers died from what was then a mysterious illness, and later during construction of the Brooklyn Bridge, where it incapacitated the project leader Washington Roebling.

Ascent during a dive

DCS is best known as an injury that affects scuba divers. The pressure of the surrounding water increases as the diver descends and reduces as the diver ascends. The risk of DCS increases by diving long or deep without slowly ascending and making the decompression stops needed to eliminate the inert gases normally, although the specific risk factors are not well understood. Some divers seem more susceptible than others under identical conditions.There have been known cases of bends in snorkellers who have made many deep dives in succession. DCS may be the cause of the disease taravana which affects South Pacific island natives who for centuries have dived without equipment for food and pearls.Two linked factors contribute to divers' DCS, although the complete relationship of causes is not fully understood:* deep or long dives: inert gases in breathing gases, such as nitrogen and helium, are absorbed into the tissues of the body in higher concentrations than normal (Henry's Law) when breathed at high pressure.* fast ascents: reducing the ambient pressure, as happens during the ascent, causes the absorbed gases to come back out of solution, and form "micro bubbles" in the blood. Those bubbles will safely leave the body through the lungs if the ascent is slow enough that the volume of bubbles does not rise too high.The physiologist John Haldane studied this problem in the early 20th century, eventually devising the method of staged, gradual decompression, whereby the pressure on the diver is released slowly enough that the nitrogen comes gradually out of solution without leading to DCS. Bubbles form after every dive: slow ascent and decompression stops simply reduce the volume and number of the bubbles to a level at which there is no injury to the diver. Severe cases of decompression sickness can lead to death. Large bubbles of gas impede the flow of oxygen-rich blood to the brain, central nervous system and other vital organs.Even when the change in pressure causes no immediate symptoms, rapid pressure change can cause permanent bone injury called dysbaric osteonecrosis (DON) "bone cell death from bad pressure". DON can develop from a single exposure to rapid decompression. DON is diagnosed from lesions visible in X-ray images of the bones. Unfortunately, X-rays appear normal for at least 3 months after the permanent damage has occurred; it may take 4 years after the damage has occurred for its effects to become visible in the X-ray images. [2]

Avoidance

Decompression tables and dive computers have been developed that help the diver choose depth and duration of decompression stops for a particular dive profile at depth.Avoiding decompression sickness is not an exact science. Accidents can occur after relatively shallow and short dives. To reduce the risks, divers should avoid long and deep dives and should ascend slowly. Also, dives requiring decompression stops and dives with less than a 16 hour interval since the previous dive increase the risk of DCS. There are many additional risk factors, such as age, obesity, fatigue, use of alcohol, dehydration and a patent foramen ovale. In addition, flying at high altitude less than 24 hours after a deep dive can be a precipitating factor for decompression illness.Astronauts aboard the International Space Station preparing for Extra-vehicular activity "camp out" at low atmospheric pressure (approximately 10 psi = 700 mbar) spending 8 sleeping hours in the airlock chamber before their spacewalk. Their spacesuits can operate at 4.7 psi = 330 mbar for maximum flexibility.

Helium

Nitrogen is not the only breathing gas that causes DCS. Gas mixtures such as trimix and heliox include helium, which can also be implicated in decompression sickness.Helium both enters and leaves the body faster than nitrogen, and for dives of three or more hours in duration, the body almost reaches saturation of helium. For such dives the decompression time is shorter than for nitrogen-based breathing gases such as air.There is some debate as to the decompression effects of helium for shorter duration dives. Most divers do longer decompressions, whereas some groups like the WKPP have been pioneering the use of shorter decompression times by including deep stops.Decompression time can be significantly shortened by breathing rich nitrox (or pure oxygen in very shallow water) during the decompression phase of the dive. The reason is that the nitrogen outgases at a rate proportional to the difference between the ppN2 (partial pressure of nitrogen) in the diver's body and the ppN2 in the gas that he or she is breathing; but the likelihood of bubbles is proportional to the difference between the ppN2 in the diver's body and the total surrounding air or water pressure.

Ascent to altitude

People flying in un-pressurized aircraft at high altitude, such as stowaways, or passengers in a cabin that has experienced rapid decompression, or pilots in an open cockpit, can suffer from decompression sickness. Even Lockheed U-2 pilots experienced altitude DCS in the mid-'50s during the Cold War flying over their targets. Divers who dive and then fly in aircraft are at risk even in pressurized aircraft because the cabin air pressure is less than the air pressure at sea level. The same applies to divers going into higher elevations by land after diving. Altitude DCS became a commonly observed problem associated with high-altitude balloon and aircraft flights in the 1930s. In present-day aviation, technology allows civilian aircraft (commercial and private) to fly higher and faster than ever before. Though modern aircraft are safer and more reliable, occupants are still subject to the stresses of high-altitude flight and the unique problems that go with these lofty heights. A century-and-a-half after the first DCS case was described, our understanding of DCS has improved and a body of knowledge has accumulated; however, this problem is far from being solved. Altitude DCS is still a risk to the occupants of modern aircraft.There is no specific altitude threshold that can be considered safe for everyone below which it can be assured that no one will develop altitude DCS. However, there is very little evidence of altitude DCS occurring among healthy individuals at pressure altitudes below 18,000 feet who have not been scuba diving. Individual exposures to pressure altitudes between 18,000 and 25,000 feet have shown a low occurrence of altitude DCS. Most cases of altitude DCS occur among individuals exposed to pressure altitudes of 25,000 feet or higher. A US Air Force study of altitude DCS cases reported that only 13 percent occurred below 25,000 feet The higher the altitude of exposure, the greater the risk of developing altitude DCS. It is important to clarify that although exposures to incremental altitudes above 18,000 feet show an incremental risk of altitude DCS they do not show a direct relationship with the severity of the various types of DCS (see Table 1).Arterial gas embolism and DCS have very similar treatment because they are both the result of gas bubbles in the body. Their spectra of symptoms also overlap, although those from arterial gas embolism are more severe because they often cause infarction and tissue death as noted above. In a diving context, the two are joined under the general term of decompression illness. Another term, dysbarism, encompasses decompression sickness, arterial gas embolism, and barotrauma.Ascent to altitude can happen without flying in places such as the Ethiopia and Eritrea highland (8000 feet = about 1.5 miles above sea level) and the Peru and Bolivia altiplano and Tibet (2 to 3 miles above sea level).

Medical treatment

Mild cases of the "bends" and skin bends (excluding mottled or marbled skin appearance) may disappear during descent from high altitude but still require medical evaluation. If the signs and symptoms persist during descent or reappear at ground level, it is necessary to provide hyperbaric oxygen treatment immediately (100-percent oxygen delivered in a high-pressure chamber). Neurological DCS, the "chokes," and skin bends with mottled or marbled skin lesions (see Table 1) should always be treated with hyperbaric oxygenation. These conditions are very serious and potentially fatal if untreated.

Effects of breathing pure oxygen

One of the most significant breakthroughs in altitude DCS research was oxygen pre-breathing. Breathing pure oxygen before exposure to a low-barometric pressure decreases the risk of developing altitude DCS. Oxygen pre-breathing promotes the elimination or washout of nitrogen from body tissues. Pre-breathing pure oxygen for 30 minutes before starting ascent to altitude reduces the risk of altitude DCS for short exposures (10 to 30 minutes only) to altitudes between 18,000 and 43,000 feet. However, oxygen pre-breathing has to be continued without interruption with in-flight, pure oxygen to provide effective protection against altitude DCS. Furthermore, it is very important to understand that breathing pure oxygen only during flight (ascent, en route, descent) does not decrease the risk of altitude DCS, and should not be used instead of oxygen pre-breathing.Although pure oxygen pre-breathing is an effective method to protect against altitude DCS, it is logistically complicated and expensive for the protection of civil aviation flyers, either commercial or private. Therefore, it is only used now by military flight crews and astronauts for their protection during high altitude and space operations.

Breathing pure oxygen to remove nitrogen from the bloodstream

Scuba diving before flying

The rule about decompression sickness risk on ascending to lower surrounding pressure, does not stop at sea level (even though decompression tables stop at sea level), but continues when a diver soon after diving goes into air pressure much less than at sea level. Altitude DCS can occur during exposure to altitudes as low as 5,000 feet or less. This can happen:# In an airliner at high altitude the cabin pressure is usually not at full sea level pressure, but like the air pressure at approx. 8,000 feet altitude.# At high altitudes on land: e.g. if you scuba dive in Eritrea, and then go onto the Asmara plateau (where Eritrea's main airport is), which is about 8000 feet or 1.5 miles or 2400 meters above sea level.# Occasionally in cave diving, "Torricellian chambers" are found; they are full of water at less than atmospheric pressure. They arise when the water level drops and there is no way for air to get into the chamber.

What to do if altitude DCS occurs

  • Put on your oxygen mask immediately and switch the regulator to 100% oxygen.* Begin an emergency descent and land as soon as possible. Even if the symptoms disappear during descent, you should still land and seek medical evaluation while continuing to breathe oxygen.* If one of your symptoms is joint pain, keep the affected area still; do not try to work pain out by moving the joint around.* Upon landing seek medical assistance from an aviation authority medical officer, aviation medical examiner (AME), military flight surgeon, or a hyperbaric medicine specialist. Be aware that a physician not specialized in aviation or hypobaric medicine may not be familiar with this type of medical problem. Therefore, be your own advocate.* Definitive medical treatment may involve the use of a hyperbaric chamber operated by specially trained personnel.* Delayed signs and symptoms of altitude DCS can occur after return to ground level whether or not they were present during flight.

Things to remember

  • Altitude DCS is a risk every time you fly in an un-pressurized aircraft above 18,000 feet (or at lower altitude if you scuba dive prior to the flight).* Be familiar with the signs and symptoms of altitude DCS (see Table 1). Monitor all aircraft occupants, including yourself, any time you fly an unpressurized aircraft above 18,000 feet.* Avoid unnecessary strenuous physical activity prior to flying an un-pressurized aircraft above 18,000 feet, and for 24 h after the flight.* Even if you are flying a pressurized aircraft, altitude DCS can occur as a result of sudden loss of cabin pressure (in-flight rapid decompression).* After exposure to an in-flight rapid decompression, do not fly for at least 24 h. In the meantime, stay vigilant for the possible onset of delayed symptoms or signs of altitude DCS. If you present delayed symptoms or signs of altitude DCS, seek medical attention at once.* Keep in mind that breathing 100% oxygen during flight (ascent, en route, descent) without oxygen pre-breathing before take off does not prevent altitude DCS.* Do not ignore any symptoms or signs that go away during the descent. This could confirm that you are suffering altitude DCS. You should be medically evaluated as soon as possible.* If there is any indication that you may have experienced altitude DCS, do not fly again until you are cleared to do so by an aviation authority medical officer, an aviation medical examiner, a military flight surgeon, or a hyperbaric medicine specialist.* Allow at least 24 hours to elapse between scuba diving and flying.* Be prepared for a future emergency by finding where hyperbaric chambers are available in your area of operations. However, keep in mind that not all of the available hyperbaric treatment facilities have personnel qualified to handle altitude DCS emergencies. To obtain information on the locations of hyperbaric treatment facilities capable of handling altitude DCS emergencies, call the Diver's Alert Network at (USA phone number) (919) 684-8111.

Decompression sickness in popular culture

  • In the 1880's, Decompression sickness became known as The Bends because afflicted individuals characteristically arched their backs in a manner reminiscent of a then popular women's fashion called the Grecian Bend.* A diver with decompression sickness flying in an aircraft was part of the plot in the episode Airborne of House, M.D., first aired Tuesday April 11, 2007.* Rock band Radiohead released an album entitled The Bends, a reference to decompression sickness.* Decompression sickness played a part in the anime visual novel "Ever 17"* A character in the series "Dive" by Gordan Korman experiences a case of Decompression sickness.* In an episode of "Jackie Chan Adventures" titled Clash of the Titanics, Jackie experienced decompression sickness* Roger Bochs, a character in the Marvel Comics series Alpha Flight, experiences decompression sickness after battling alongside the Avengers in Atlantis.== References ==
  • http://depts.washington.edu/adai/pubs/pres/LeighRSAPoster.pdf
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