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06 December 2022

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Super User

Category: Information

06 December 2022

9789

2025 March;55(1) 

Diving Hyperb Med. 2025 31 March;55(1):2−10. doi: 10.28920/dhm55.1.2-10. PMID: 40090020.

Agreement of precordial and subclavian Doppler ultrasound venous gas emboli grades in a large diving data set

S Lesley Blogg^1,2, Arian Azarang³, Virginie Papadopoulou³, Peter Lindholm²

¹ SLB Consulting, Home Park Barn, Kirkby Stephen, Cumbria, United Kingdom
² Department of Emergency Medicine, University of California at San Diego, California, USA
³ Department of Radiology, The University of North Carolina at Chapel Hill and North Carolina State University, North Carolina, USA

Corresponding author: Dr S Lesley Blogg, SLB Consulting, Home Park Barn, Kirkby Stephen, Cumbria, United Kingdom
ORCiD: 0000-0002-6006-2065
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Keywords
Bubbles; Decompression; Decompression sickness; Diving research 

Abstract
(Blogg SL, Azarang A, Papadopoulou V, Lindholm P. Agreement of precordial and subclavian Doppler ultrasound venous gas emboli grades in a large diving data set. Diving and Hyperbaric Medicine. 2025 31 March;55(1):2−10. doi: 10.28920/dhm55.1.2-10. PMID: 40090020.)
Introduction: Doppler ultrasound is used to detect inert gas bubbles in the body following decompression from dives. Two sites may be monitored, the precordial (PC) and subclavian (SC) positions. PC is the predominant site, allowing observation of bubbles returning from the entire body. However, the SC site provides unambiguous signals, whereas the PC site is noisy and difficult to grade. This retrospective study compared agreement of PC and SC Doppler data.
Methods: Datasets from the large University of California at San Diego Doppler database were graded on the Kisman Masurel (KM) scale and included: one PC measurement at rest followed by three during movement (n = 4 measurements); this was repeated for the left (n = 4 measurements) and right (n = 4 measurements) SC veins, producing a set of 12 grades. Primary analysis included: agreement between resting PC and SC grades, between movement PC and SC grades, and for unmatched grades, whether the SC grade was higher or lower than PC.
Results: Four-hundred and fifty-three datasets were available (5,436 individual recordings). At rest, 281 (62.0%) PC and SC grades matched (weighted kappa agreement 0.33, 95% CI ± 0.04), while only 176 (38.9%) movement grades matched (0.29, ± 0.02). Of the unmatched data, resting SC grades were higher than PC in 70.3% and lower in 29.6%; after movement, SC grades were higher in 45.8% and lower in 54.2%.
Conclusions: These data revealed a large discrepancy between PC and SC grades. Overall, this suggests that Doppler observations from both positions will give the most comprehensive representation of bubble load.

Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in electronic and other forms.

Publication Type: Original article

Diving Hyperb Med. 2025 31 March;55(1):11−17. doi: 10.28920/dhm55.1.11-17. PMID: 40090021.

Longitudinal study of changes in pulmonary function among inside attendants of hyperbaric oxygen therapy

Kubra Canarslan Demir¹, Ahmet Uğur Avci², Selcen Yüsra Abayli¹, Fatma Sena Konyalioglu³, Burak Turgut²

¹ Department of Undersea and Hyperbaric Medicine, Gülhane Research and Training Hospital, Turkey
² Department of Aerospace Medicine, Gülhane Research and Training Hospital, Turkey
³ Department of Monitoring and Evaluation, General Directorate of Health Promotion, Ministry of Health, Turkey

Corresponding author: Dr Kübra Canarslan Demir, SBÜ-Gülhane Eğitim ve Araştırma Hastanesi, Sualtı Hekimliği ve Hiperbarik Tıp Kliniği, Etlik/Ankara, Turkey
ORCiD: 0000-0001-6911-2375
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Keywords
Hyperbaric oxygen treatment; Long-term effects; Nursing; Pulmonary function; Respiratory

Abstract
(Canarslan Demir K, Avci1 AU, Yüsra Abayli S, Konyalioglu FS, Turgut B. Longitudinal study of changes in pulmonary function among inside attendants of hyperbaric oxygen therapy. Diving and Hyperbaric Medicine. 2025 31 March;55(1):11−17. doi: 10.28920/dhm55.1.11-17. PMID: 40090021.)
Introduction: Hyperbaric oxygen therapy (HBOT) administers 100% oxygen in a pressurised chamber at pressures above 1 atmosphere absolute. Inside hyperbaric personnel accompany patients during sessions and breathe compressed air, exposing them to risks like decompression illness and respiratory changes. This study investigated whether hyperbaric exposure affects the long-term lung function of inside hyperbaric personnel.
Methods: An analysis was conducted on spirometry data from 14 personnel working between 2012 and 2023. Lung function tests measured forced vital capacity (FVC), forced expiratory volume in one second (FEV₁), mid breath forced expiratory flow (FEF_25–75), and peak expiratory flow (PEF) before and after hyperbaric exposure. Participants were categorised based on age, body mass index, number of HBOT sessions, and duration of employment.
Results: No clinically or statistically significant differences were found in FVC, FEV₁, or PEF measurements before and after hyperbaric exposures (P > 0.05). However, FEF_25–75, an indicator of small airway function, showed a (mean) 16% reduction in personnel with more than 150 HBOT sessions (P = 0.038). A post-hoc analysis confirmed a significant difference in FEF25–75 between personnel with fewer than 74 sessions and those with 150 or more sessions (P = 0.015). No clinically significant symptoms such as dyspnoea were reported during the study period.
Conclusions: The FEF_25–75 reduction, without changes in FEV₁, FVC, or PEF, could be due to improper performance of the FVC manoeuvre. Maintaining pulmonary health in inside hyperbaric personnel is essential, emphasising the importance of accurate FVC execution in assessments. Further studies are recommended to explore the long-term implications of these findings and the effects of repeated hyperbaric exposure on respiratory health.

Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in electronic and other forms.

Publication Type: Original article

Diving and Hyperb Med. 2025 31 March;55(1):18−26. doi: 10.28920/dhm55.1.18-26. PMID: 40090022.

Divers with large or normal lungs: is the difference justified?

Pieter-Jan AM van Ooij^1,2, Robert A van Hulst³

¹ Diving Medical Centre, Royal Netherlands Navy, Den Helder, the Netherlands
² Department of Respiratory Medicine, Amsterdam University Medical Centre (AUMC), University of Amsterdam, Amsterdam, the Netherlands
³ Department of Anesthesiology and Hyperbaric Medicine, Amsterdam University Medical Centre (AUMC), University of Amsterdam, Amsterdam, the Netherlands

Corresponding author: Dr Pieter-Jan van Ooij, Diving Medical Centre, Royal Netherlands Navy. PO Box 10,000 1781 ZX Den Helder, the Netherlands
ORCiD: 0000-0002-2108-320X
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Keywords
Fitness to dive; Lung function; Medical conditions and problems; Military diving; Pulmonary barotrauma; Risk factors

Abstract
(van Ooij PJAM, van Hulst RA. Divers with large or normal lungs: is the difference justified? Diving and Hyperbaric Medicine. 2025 31 March;55(1):18−26. doi: 10.28920/dhm55.1.18-26. PMID: 40090022.)
Introduction: Measurements of forced vital capacity (FVC) have shown that divers have larger lungs than members of the general population. Bullae or decompression illness (DCI) secondary to pulmonary barotrauma is more likely to occur in large lungs (LLs) than in normal lungs (NLs). This study retrospectively compared lung function, high-resolution CT (HRCT) scan anomalies, the unfit-to-dive rate, and the prevalence of DCI in groups of divers with LLs and NLs.
Methods: The results of fitness examinations of divers with LLs (FVC z-score > 1.96) and NLs (FVC z-score ≤ 1.96) from 2011 to 2020 were retrospectively evaluated.  Data were obtained from lung function tests, HRCT results, fitness examination outcomes, and whether the diver did or did not have DCI.
Results: The study included 1,069 divers, with 65 subjects, all male, fulfilling the requirements for LLs. Subjects with LLs had a significantly higher z-scores for FVC and FEV₁ but a significantly lower FEV₁/FVC ratio, than subjects with NLs.  The rates of bullae, DCI, and unfit-to-dive did not differ significantly in the two groups.
Conclusions: Although FEV₁/FVC ratio was significantly lower in the LL than in the NL group, there were no between-group differences in the rates of bullae and DCI. These findings suggest that subjects with LLs are not at a higher risk of bullae and DCI than are subjects with NLs.

Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in electronic and other forms.

Publication Type: Original article

Diving and Hyperb Med. 2025 31 March;55(1):27−34. doi: 10.28920/dhm55.1.27-34. PMID: 40090023.

The influence of wetsuit thickness (≥ 7 mm) on lung volumes in scuba divers

Graham Stevens¹, David R Smart²

¹ Department of Diving and Hyperbaric Medicine, Royal Hobart Hospital, Hobart, Tasmania, Australia
² Private Consultant. Formerly: Clinical Professor, School of Medicine, University of Tasmania and Department of Diving and Hyperbaric Medicine, Royal Hobart Hospital, Hobart, Tasmania, Australia

Corresponding author: Dr Graham Stevens, Department of Diving and Hyperbaric Medicine, Royal Hobart Hospital, Hobart, Tasmania 7000, Australia
ORCiD: 0009-0001-3341-108X
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Keywords
Diving research; Equipment; Fitness to dive; Lung; Respiratory; Spirometry

Abstract
(Stevens G, Smart DR. The influence of wetsuit thickness (≥ 7 mm) on lung volumes in scuba divers. Diving and Hyperbaric Medicine. 2025 31 March;55(1):27−34. doi: 10.28920/dhm55.1.27-34. PMID: 40090023.)
Introduction: We hypothesised that although thicker (≥ 7 mm) wetsuits delay hypothermia and allow divers to dive in cooler waters, they may hinder pulmonary function. The aim of this study was to investigate whether thicker wetsuits worn by Tasmanian divers affected lung volumes, primarily the forced vital capacity (FVC) and forced expiratory volume, one second (FEV₁).
Methods: Sixty-two volunteer active divers were recruited from recreational dive clubs and Tasmania’s occupational diving industry. After confirming fitness and that the divers were currently active, spirometry testing was performed with and without the divers’ usual wet suits, in a controlled dry environment. Suits were of varying thickness, but all were 
≥ 7 mm thickness.
Results: All divers had significantly reduced lung volumes when wearing ≥ 7 mm wetsuits. Recreational divers had greater decrements (-7% FVC and -5% FEV₁), compared to occupational divers (-3% FVC, -3% FEV₁). Males’ lung volumes declined -4% FVC and -4 % FEV₁, whereas females declined -7 % FVC and -6 % FEV₁. Female recreational divers experienced the greatest negative impact from thicker wetsuits (up to 15% reduction in FVC), and this group also demonstrated an inverse relationship between increasing wetsuit thickness and declining lung volumes.
Conclusions: Wearing thicker wet suits aids in thermal protection in temperate water diving but this study suggests it has negative effects on lung volumes. The real-life impact of this negative effect may be minor in fit healthy divers but might add additional risk to a less fit, recreational diving population with medical comorbidities.

Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in electronic and other forms.

Publication Type: Original article

Diving and Hyperb Med. 2025 31 March;55(1):35−43. doi: 10.28920/dhm55.1.35-43. PMID: 40090024.

Diving-related fatalities in Victoria, Australia, 2000 to 2022

John Lippmann^1,2,3

¹ Australasian Diving Safety Foundation, Canterbury, Victoria, Australia
² Department of Public Health and Preventive Medicine, Monash University, Victoria, Australia
³ Royal Life Saving Society Australia, Sydney, Australia

Corresponding author: Dr John Lippmann, Australasian Diving Safety Foundation, PO Box 478, Canterbury, VIC 3126, Australia
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Keywords
Diving deaths; Obesity; Scuba diving; Seafood collection; Snorkelling; Surface supplied breathing apparatus (SSBA)

Abstract
(Lippman J. Diving-related fatalities in Victoria, Australia, 2000 to 2022. Diving and Hyperbaric Medicine. 2025 31 March;55(1):35−43. doi: 10.28920/dhm55.1.35-43. PMID: 40090024.)
Introduction: The aim was to examine the diving-related fatalities in Victoria, Australia from 2000 to 2022, identify trends and assess existing and potential countermeasures.
Methods: The National Coronial Information System and the Australasian Diving Safety Foundation (ADSF) database were searched to identify compressed gas diving and snorkelling/breath-hold diving deaths in Victoria for 2000–2022, inclusive. Data were extracted and analysed, and chain of events analyses conducted.
Results: Thirty-six scuba divers, one diver using surface supplied breathing apparatus (SSBA) and 25 snorkellers/breath-hold divers were identified. Compressed gas divers were older than snorkellers (medians 47 vs 36 years) with a higher proportion being overweight or obese (89% vs 61%), half with pre-existing medical conditions which likely contributed to their deaths. Most snorkellers died from primary drowning, often associated with inexperience. Half of all victims were inexperienced, and more than half of the accidents occurred while diving for seafood, often in rough conditions. Only one third of victims were with a buddy at the time of their accident. Of those known to be wearing weights, three-quarters were still wearing them when found.
Conclusions: Diving medical assessment in divers aged 45 years or older needs to be strengthened and obesity should trigger medical assessment in older divers. Other identified risks included seafood collection, diving in adverse conditions, ineffective or no buddy system, overweighting, poor buoyancy control and failure to ditch weights. Many are longstanding problems, so relevant messages are still not penetrating the community. Constant reinforcement through formal training, internet forums and targeted educational campaigns is required.

Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in electronic and other forms.

Publication Type: Original article

Diving and Hyperb Med. 2025 31 March;55(1):44−50. doi: 10.28920/dhm55.1.44-50. PMID: 40090025.

Venous gas emboli (VGE) in 2-D echocardiographic images following movement: grading and association with cumulative incidence of decompression sickness

Joshua B Currens^1,2, David J Doolette^1,3, F Gregory Murphy¹

¹ Navy Experimental Diving Unit, Panama City, Florida, USA
² Department of Radiology and Joint Department of Biomedical Engineering, University of North Carolina – Chapel Hill, NC, USA
³ Department of Anaesthesiology, University of Auckland, Auckland, New Zealand

Corresponding author: Associate Professor David J Doolette, Navy Experimental Diving Unit, Panama City, Florida, USA
ORCID: 0000-0001-9027-3536
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Keywords
Bubbles; Decompression illness; Decompression sickness; Diving; Echocardiography; Risk

Abstract
(Currens JB, Doolette DJ, Murphy FG. Venous gas emboli (VGE) in 2-D echocardiographic images following movement: grading and association with cumulative incidence of decompression sickness. Diving and Hyperbaric Medicine. 2025 31 March;55(1):44−50. doi: 10.28920/dhm55.1.44-50. PMID: 40090025.)
Introduction: Venous gas emboli (VGE) are a common surrogate experimental endpoint for decompression sickness (DCS). VGE numbers are graded, and the peak post-dive grade is associated with the probability of DCS (PDCS). VGE are typically graded with the subject at rest when bubble numbers are stable, and again after limb flexions which elicit a transient shower of bubbles. Detection of VGE using two-dimensional (2-D) echocardiography has become common, but the principal grading scales do not specify how to grade VGE after limb movement.
Methods: This was a retrospective analysis of 1,196 man-dives following which VGE were detected using 2-D echocardiography and graded on a scale 0–4 and 41 cases of DCS occurred. PDCS was estimated for each peak post-dive VGE grade from the cumulative incidence of DCS. Two different definitions of movement VGE grades were assessed in 84 measurements; the grade was either the maximum VGE number sustained for one diastole (1-cycle) or for six cardiac cycles (6-cycle).
Results: For each peak post-dive VGE grade (maximum of rest or movement) the cumulative incidences of DCS (%) were: grade 0 (0%); grade 1 (1.3%); grade 2 (2.5%); grade 3 (4.6%); grade 4 (5.7%). When grading movement VGE, 57% of 1-cycle grade 4 were reduced to grade 3 using the 6-cycle definition.
Conclusions: There is a need for consensus in the research community on how to assign movement VGE grades when using 2-D echocardiography. Publications should carefully explain methodology for assigning VGE grades and consider differences in methodologies when comparing historical data sets.

Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in electronic and other forms.

Publication Type: Original article

Diving and Hyperb Med. 2025 31 March;55(1):51−55. doi: 10.28920/dhm55.1.51-55. PMID: 40090026.

Joint position statement on atrial shunts (persistent [patent] foramen ovale and atrial septal defects) and diving: 2025 update. South Pacific Underwater Medicine Society (SPUMS) and the United Kingdom Diving Medical Committee (UKDMC)

David Smart¹, Peter Wilmshurst², Neil Banham³, Mark Turner⁴, Simon J Mitchell^5,6,7

¹ Private Consultant. Formerly: Clinical Professor, School of Medicine, University of Tasmania and Department of Diving and Hyperbaric Medicine, Royal Hobart Hospital, Hobart, Tasmania, Australia
² Cardiology Department, Royal Stoke University Hospital, Stoke-on-Trent, Staffordshire, United Kingdom
³ Department of Hyperbaric Medicine, Fiona Stanley Hospital, Murdoch, Western Australia
⁴ Bristol Heart Institute, Marlborough Street, Bristol, United Kingdom
⁵ Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
⁶ Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand
⁷ Slark Hyperbaric Unit, North Shore Hospital, Auckland, New Zealand

Corresponding author: Clinical Professor David Smart, School of Medicine, University of Tasmania and Department of Diving and Hyperbaric Medicine, Royal Hobart Hospital, Hobart, Tasmania, 7000, Australia
ORCiD: 0000-0001-6769-2791
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Keywords
Decompression illness; Decompression sickness; Echocardiography; Fitness to dive; Health surveillance; PFO; Right-to-left shunt

Abstract

(Smart D, Wilmshurst P, Banham N, Turner M, Mitchell SJ. Joint position statement on atrial shunts (persistent [patent] foramen ovale and atrial septal defects) and diving: 2025 update. South Pacific Underwater Medicine Society and the United Kingdom Diving Medical Committee. Diving and Hyperbaric Medicine. 2025 31 March;55(1):51−55. doi: 10.28920/dhm55.1.51-55. PMID: 40090026.)
This consensus statement is the product of a workshop at the South Pacific Underwater Medicine Society Annual Scientific Meeting 2024 with representation of the United Kingdom Diving Medical Committee (UKDMC) present, and subsequent discussions included the entire UKDMC. A large right-to-left shunt across a persistent (patent) foramen ovale (PFO), an atrial septal defect (ASD) or a pulmonary shunt is a risk factor for some types of decompression sickness (DCS). It is agreed that routine screening for a right-to-left shunt is not currently justifiable, but certain high risk sub-groups can be identified. Individuals with a history of cerebral, spinal, vestibulocochlear, cardiovascular or cutaneous DCS, migraine with aura or cryptogenic stroke; a family history of PFO or ASD and individuals with other forms of congenital heart disease have a higher prevalence, and for those individuals screening should be considered. If screening is undertaken, it should be by bubble contrast transthoracic echocardiography with provocative manoeuvres (including Valsalva release and sniffing). Appropriate quality control is important. If a shunt is present, advice should be provided by an experienced diving physician taking into account the clinical context and the size of shunt. If shunt-mediated DCS is diagnosed, the safest option is to stop diving. Another is to perform dives with restrictions to reduce the inert gas load, which is facilitated by limiting depth and duration of dives, breathing a gas with a lower percentage of nitrogen and reducing repetitive diving. Divers may consider transcatheter device closure of the PFO or ASD in order to return to normal diving. If transcatheter PFO or ASD closure is undertaken, repeat bubble contrast echocardiography must be performed to confirm adequate reduction or abolition of the right-to-left shunt, and the diver should have stopped taking potent anti-platelet therapy (low dose aspirin is acceptable) before resuming diving.

Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in electronic and other forms.

Publication Type: Guideline

Diving and Hyperb Med. 2025 31 March;55(1):56−58. doi: 10.28920/dhm55.1.56-58. PMID: 40090027.

A case of facial vascular occlusion after hyaluronic acid cosmetic filler injection treated with adjunctive hyperbaric oxygen

Graham Stevens¹, Iestyn Lewis¹

¹ Department of Diving and Hyperbaric Medicine, Royal Hobart Hospital, Hobart, Tasmania

Corresponding author: Dr Graham Stevens, Department of Diving and Hyperbaric Medicine, Royal Hobart Hospital, Hobart, Tasmania 7000, Australia
ORCiD: 0009-0001-3341-108X
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Keywords
Case report; Hyperbaric oxygen treatment; Ischaemia; Skin

Abstract

(Stevens G, Lewis I. A case of facial vascular occlusion after hyaluronidase cosmetic filler injection treated with adjunctive hyperbaric oxygen. Diving and Hyperbaric Medicine. 2025 31 March;55(1):56−58. doi: 10.28920/dhm55.1.56-58. PMID: 40090027.)
Treatment of suspected upper lip area vascular occlusion caused by facial hyaluronic acid filler injections with hyperbaric oxygen is reported. The patient was initially treated with hyaluronidase injections in the cosmetic clinic then again in the emergency department. Persistent symptoms and signs of occlusion prompted hyperbaric oxygen treatment at 284 kPa (nine treatments over seven days). The outcome was positive for this patient and adds supportive evidence to the sparse literature, which are mainly case studies.

Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in electronic and other forms.

Publication Type: Case Report

Diving and Hyperb Med. 2025 31 March;55(1):59−64. doi: 10.28920/dhm55.1.59-64. PMID: 40090028.

Severe neurological decompression sickness associated with right ventricular dilatation and a persistent foramen ovale

Jeremy S Mason¹, Peter Wilmshurst², Ian C Gawthrope^1,3, Neil D Banham¹

¹ Department of Hyperbaric Medicine, Fiona Stanley Hospital, Murdoch, WA, Australia
² Cardiology Department, Royal Stoke University Hospital, Stoke on Trent, United Kingdom
³ University of Notre Dame, Fremantle, WA, Australia

Corresponding author: Dr Jeremy Mason, Department of Hyperbaric Medicine, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, WA 6150, Australia
ORCiD: 0000-0002-9133-2179
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Keywords
Arterial gas embolism; Case reports; Decompression illness; Diving incidents; Persistent (patent) foramen ovale (PFO); Scuba diving; Right-to-left shunt

Abstract

(Mason JS, Wilmshurst P, Gawthrope IC, Banham ND. Severe neurological decompression sickness associated with right ventricular dilatation and a persistent foramen ovale. Diving and Hyperbaric Medicine. 2025 31 March;55(1):59−64. doi: 10.28920/dhm55.1.59-64. PMID: 40090028.)
We present the case of a 28-year-old female diver who performed a scuba air dive with significant omitted decompression obligation. She developed constitutional and neurological symptoms. Brain magnetic resonance imaging post treatment demonstrated multifocal embolic infarcts and transthoracic echocardiogram with bubble contrast on day three revealed a persistent foramen ovale (PFO) and severe right ventricular (RV) dilatation.
We postulate that the high venous bubble load from the provocative decompression caused an increase in pulmonary artery pressure, leading  to RV dilatation and increased right to left shunting of bubbles across her PFO, resulting in significant neurological deficits. This mechanism is analogous to that seen in acute thromboembolic pulmonary embolism.

Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in electronic and other forms.

Publication Type: Case Report

Diving and Hyperb Med. 2025 31 March;55(1):65. doi: 10.28920/dhm55.1.65. PMID: 40090029.

PFO and DCS of hyperbaric personnel

Jacek Kot

Corresponding author: Professor Jacek Kot, MD, PhD, National Centre for Hyperbaric Medicine, Institute of Maritime and Tropical Medicine, Medical University of Gdansk, Powstania Styczniowego 9B, 81-519 Gdynia, Poland
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Keywords

Decompression sickness; Hyperbaric oxygen treatment; Persistent (patent) foramen ovale (PFO); Risk factors; Safety

Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in electronic and other forms.

Publication Type: Letter to the Editor

Diving and Hyperb Med. 2025 31 March;55(1):66. doi: 10.28920/dhm55.1.66. PMID: 40090030.

Reply – PFO and DCS of hyperbaric personnel

Peter T Wilmshurst¹, Chris Edge²

¹ Royal Stoke University Hospital, Cardiology Department, United Kingdom
² Imperial College, Department of Life Sciences, United Kingdom

Corresponding author: Peter T Wilmshurst, Royal Stoke University Hospital, Cardiology Department, United Kingdom
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Keywords

Decompression sickness; Echocardiography; Hyperbaric oxygen; Occupational health; Persistent (patent) foramen ovale (PFO)

Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in electronic and other forms.

Publication Type: Letter to the Editor

Diving and Hyperb Med. 2025 31 March;55(1):67. doi: 10.28920/dhm55.1.67. PMID: 40090031.

Dive medicine capability at Rothera Research Station (British Antarctic Survey), Adelaide Island, Antarctica

Felix N R Wood^1,2, Katie Bowen¹, Rosemary Hartley¹, Jonathon Stevenson⁴, Matt Warner¹, Doug Watts^1,3

¹ British Antarctic Survey Medical Unit, Plymouth, United Kingdom
² Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, United Kingdom
³ DDRC Healthcare, Plymouth, United Kingdom
⁴ British Antarctic Survey, Cambridge, United Kingdom

Corresponding author: Dr Felix Wood, British Antarctic Survey Medical Unit, Science Park, Plymouth, PL6 8BU, United Kingdom
ORCiD: 0000-0002-5706-852X
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Keywords
Cold; Diving; Diving emergencies; Drysuit; Recompression; Remote locations

In December, we published an article titled “Dive Medicine Capability at Rothera Research Station (British Antarctic Survey), Adelaide Island, Antarctica” by Wood FNR, Bowen K, Hartley R, et al.

The corresponding author would like to include an additional author, as their contribution was significant but was inadvertently omitted in the initial online publication. While this correction has been made in several versions circulated by the journal, not all have been updated. As a result, we are issuing an erratum. The correct authors are listed here.

Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in electronic and other forms.

Publication Type: Erratum

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Super User

Category: Information

06 December 2022

1650

Click to download each article. This will download a PDF that is password protected from any changes, these individual article PDFs are not for public distribution and for society members personal use. 

Copyright: These articles are the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in electronic and other forms.

Back

Super User

Category: Information

06 December 2022

8789

2022 December;52(4) 

Diving Hyperb Med. 2022 December 20;52(4):237–244. doi: 10.28920/dhm52.4.237-244. PMID: 36525681. PMCID: PMC9767826.

Hypoxia signatures in closed-circuit rebreather divers

Daniel Popa¹, Craig Kutz², Morgan Carlile², Kaighley Brett³, Esteban A Moya⁴, Frank Powell⁴, Peter Witucki², Richard Sadler⁵, Charlotte Sadler²

¹ Hennepin County Medical Center, Department of Emergency Medicine, Division of Hyperbaric and Undersea Medicine, Minneapolis, MN, USA
² UCSD Department of Emergency Medicine, Division of Hyperbaric and Undersea Medicine, San Diego, CA, USA
³ Canadian Armed Forces, Toronto, Canada
⁴ UCSD Department of Medicine, Division of Physiology, La Jolla, CA, USA
⁵ Dive Rescue International, Fort Collins, CO, USA

Corresponding author: Dr Daniel Popa, Hennepin County Medical Center, Department of Emergency Medicine, Division of Hyperbaric and Undersea Medicine, 701 Park Ave, Mail Code P1, Minneapolis, MN 55415, USA
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Keywords
Physiology; Rescue; Safety; Technical diving; Training

Abstract
(Popa D, Kutz C, Carlile M, Brett K, Moya EA, Powell F, Witucki P, Sadler R, Sadler C. Hypoxia signatures in closed-circuit rebreather divers. Diving and Hyperbaric Medicine. 2022 December 20;52(4):237–244. doi: 10.28920/dhm52.4.237-244. PMID: 36525681. PMCID: PMC9767826.)
Introduction: Faults or errors during use of closed-circuit rebreathers (CCRs) can cause hypoxia. Military aviators face a similar risk of hypoxia and undergo awareness training to determine their ‘hypoxia signature’, a personalised, reproducible set of symptoms. We aimed to establish a hypoxia signature among divers, and to investigate their ability to detect hypoxia and self-rescue while cognitively overloaded.
Methods: Eight CCR divers and 12 scuba divers underwent an initial unblinded hypoxia exposure followed by three trials; a second hypoxic trial and two normoxic trials in randomised order. Hypoxia was induced by breathing on a CCR with no oxygen supply. Subjects pedalled on a cycle ergometer while playing a neurocognitive computer game to simulate real world task loading. Subjects identified hypoxia symptoms by pointing to a board listing common hypoxia symptoms, and were instructed to perform a ‘bailout’ procedure to mimic self-rescue if they perceived hypoxia. Divers were prompted to bailout if peripheral oxygen saturation fell to 75%, or after six minutes during normoxic trials. Subsequently we interviewed subjects to determine their ability to distinguish hypoxia from normoxia.
Results: Ninety-five percent of subjects (19/20) showed agreement between unblinded and blinded hypoxia symptoms. Subjects correctly identified the gas mixture in 85% of the trials. During unblinded hypoxia, only 25% (5/20) of subjects performed unprompted bailout. Fifty-five percent of subjects (11/20) correctly performed the bailout but only when prompted, while 15% (3/20) were unable to bailout despite prompting. During blinded hypoxia 45% of subjects (9/20) performed the bailout unprompted while 15% (3/20) remained unable to bailout despite prompting.
Conclusions: Although our data support a normobaric hypoxia signature among both CCR and scuba divers under experimental conditions, most subjects were unable to recognise hypoxia in real time and perform a self-rescue unprompted, although this improved in the second hypoxia trial. These results do not support hypoxia exposure training for CCR divers.

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2022 December;52(4) 

Diving Hyperb Med. 2022 December 20;52(4):245−259. doi: 10.28920/dhm52.4.245-259. PMID: 36525682. PMCID: PMC9767825.

A review of accelerated decompression from heliox saturation in commercial diving emergencies

Jean-Pierre Imbert¹, Jean-Yves Massimelli², Ajit Kulkarni³, Lyubisa Matity⁴, Philip Bryson⁵

¹ Divetech, 1543 ch. des vignasses, Biot, France
² Flash Tekk Engineering, Singapore
³ Hyperbaric Solutions, Bandra East, Mumbai, India
⁴ Hyperbaric and Tissue Viability Unit, Gozo General Hospital, Malta
⁵ International SOS, Forest Grove House, Aberdeen, UK

Corresponding author: Dr Philip Bryson, International SOS, Forest Grove House, Foresterhill Road, Aberdeen, AB25 2ZP, UK
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Keywords
Decompression sickness; Diving incidents; Emergency ascent; Emergency response; Saturation diving

Abstract
(Imbert J-P, Massimelli J-Y, Kulkarni A, Matity L, Bryson P. A review of accelerated decompression from heliox saturation in commercial diving emergencies. Diving and Hyperbaric Medicine. 2022 December 20;52(4):245−259. doi: 10.28920/dhm52.4.245-259. PMID: 36525682. PMCID: PMC9767825.)
Introduction: Saturation diving is a specialised method of intervention in offshore commercial diving. Emergencies may require the crew to be evacuated from the diving support vessel. Because saturation divers generally need several days to reach surface, the emergency evacuation of divers is based on dedicated hyperbaric rescue systems. There are still potential situations for which these systems cannot be used or deployed, and where an emergency decompression provides an alternative solution.
Methods: Our objective was to describe historical cases and assess the benefit of emergency decompressions, with the collection of data from the authors’ direct experience and networks, providing witness or first-hand information.
Results: We documented three cases of emergency decompression following bell evacuations, and six cases of accelerated decompression performed in the chamber or hyperbaric rescue chamber. Review of these cases showed: 1) the complicated nature of such emergencies that make decisions difficult; 2) the variety of solutions implemented; and 3) the surprisingly safe and successful outcomes of several operations. Analysis of the accelerated decompression occurrences allowed derivation of the options used; upward initial excursion, increased chamber partial pressure of oxygen associated to increased ascent rates, and inert gas switching. We identified four published procedures for accelerated decompression.
Conclusions: Despite modern hyperbaric rescue systems, accelerated decompression remains an essential tool in case of emergency. The diving industry needs clear guidance on what can be achieved, depending on the saturation depth and the level of emergency.

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2022 December;52(4) 

Diving Hyperb Med. 2022 December 20;52(4):260−270. doi: 10.28920/dhm52.4.260-270. PMID: 36525683. PMCID: PMC10017198.

Effects of high oxygen tension on healthy volunteer microcirculation

Nicolas Cousin¹, Julien Goutay¹, Patrick Girardie¹, Raphaël Favory¹, Elodie Drumez², Daniel Mathieu¹, Julien Poissy¹, Erika Parmentier¹, Thibault Duburcq¹

¹ Pôle de réanimation, hôpital Roger Salengro, CHU Lille, Lille, France
² Unité de méthodologie – biostatistique et data management, CHU Lille, Lille, France

Corresponding author: Dr Thibault Duburcq, Centre Hospitalier Universitaire de Lille, Hôpital Roger Salengro – Centre de réanimation, Avenue du Professeur Emile Laine , 59037 LILLE Cedex, France
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Keywords
Hyperbaric oxygen treatment; Hyperoxia; Laser Doppler flowmetry; Near-infrared spectroscopy; Perfusion

Abstract
(Cousin N, Goutay J, Girardie P, Favory R, Drumez E, Mathieu D, Poissy J, Parmentier E, Duburcq. Effects of high oxygen tension on healthy volunteer microcirculation. Diving and Hyperbaric Medicine. 2022 December 20;52(4):260−270. doi: 10.28920/dhm52.4.260-270. PMID: 36525683. PMCID: PMC10017198.)
Introduction: Previous studies have highlighted hyperoxia-induced microcirculation modifications, but few have focused on hyperbaric oxygen (HBO) effects. Our primary objective was to explore hyperbaric hyperoxia effects on the microcirculation of healthy volunteers and investigate whether these modifications are adaptative or not.
Methods: This single centre, open-label study included 15 healthy volunteers. Measurements were performed under five conditions: T0) baseline value (normobaric normoxia); T1) hyperbaric normoxia; T2) hyperbaric hyperoxia; T3) normobaric hyperoxia; T4) return to normobaric normoxia. Microcirculatory data were gathered via laser Doppler, near-infrared spectroscopy and transcutaneous oximetry (PtcO₂). Vascular-occlusion tests were performed at each step. We used transthoracic echocardiography and standard monitoring for haemodynamic investigation.
Results: Maximal alterations were observed under hyperbaric hyperoxia which led, in comparison with baseline, to arterial hypertension (mean arterial pressure 105 (SD 12) mmHg vs 95 (11), P < 0.001) and bradycardia (55 (7) beats·min-1 vs 66 (8), P < 0.001) while cardiac output remained unchanged. Hyperbaric hyperoxia also led to microcirculatory vasoconstriction (rest flow 63 (74) vs 143 (73) perfusion units, P < 0.05) in response to increased PtcO2 (104.0 (45.9) kPa vs 6.3 (2.4), P < 0.0001); and a decrease in laser Doppler parameters indicating vascular reserve (peak flow 125 (89) vs 233 (79) perfusion units, P < 0.05). Microvascular reactivity was preserved in every condition.
Conclusions: Hyperoxia significantly modifies healthy volunteer microcirculation especially during HBO exposure. The rise in PtcO2 promotes an adaptative vasoconstrictive response to protect cellular integrity. Microvascular reactivity remains unaltered and vascular reserve is mobilised in proportion to the extent of the ischaemic stimulus.

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2022 December;52(4) 

Diving Hyperb Med. 2022 December 20;52(4):271−276. doi: 10.28920/dhm52.4.271-276. PMID: 36525684. PMCID: PMC10026386.

Delayed treatment for decompression illness: factors associated with long treatment delays and treatment outcome

Sofia A Sokolowski¹, Anne K Räisänen-Sokolowski^2,3, Laura J Tuominen^2,4, Richard V Lundell^2,5 

¹ University of Eastern Finland, Kuopio, Finland
² Department of Pathology, Helsinki University, Helsinki, Finland
³ HUSLAB, Pathology, Helsinki University Hospital, Helsinki, Finland 
⁴ Department of Anaesthesia, Tampere University Hospital, Tampere, Finland
⁵ Diving Medical Centre, Centre for Military Medicine, Finnish Defence Forces, Helsinki, Finland

Corresponding author: Dr Richard V Lundell, Diving Medical Centre, Centre for Military Medicine, Finnish Defence Forces, Helsinki, Finland
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Keywords
Decompression sickness; Hyperbaric oxygen treatment; Epidemiology; First aid oxygen; Remote locations; Treatment sequelae

Abstract
(Sokolowski SA, Räisänen-Sokolowski AK, Tuominen LJ, Lundell RV. Delayed treatment for decompression illness: factors associated with long treatment delays and treatment outcome. Diving and Hyperbaric Medicine. 2022 December 20;52(4):271−276. doi: 10.28920/dhm52.4.271-276. PMID: 36525684. PMCID: PMC10026386.)
Introduction: Effectiveness of delayed hyperbaric oxygen treatment (HBOT) for decompression illness (DCI) and factors affecting treatment delays have not been studied in large groups of patients.
Methods: This retrospective study included 546 DCI patients treated in Finland in the years 1999–2018 and investigated factors associated with recompression delay and outcome. Treatment outcome was defined as fully recovered or presence of residual symptoms on completion of HBOT. The symptoms, use of first aid oxygen, number of recompression treatments needed and characteristics of the study cohort were also addressed.
Results: Delayed HBOT (> 48 h) remained effective with final outcomes similar to those treated within 48 h. Cardio-pulmonary symptoms were associated with a shorter treatment delay (median 15 h vs 28 h without cardiopulmonary symptoms, P < 0.001), whereas mild sensory symptoms were associated with a longer delay (48 vs 24 h, P < 0.001). A shorter delay was also associated with only one required HBOT treatment (median 24 h vs 34 h for those requiring multiple recompressions) (P = 0.002). Tinnitus and hearing impairment were associated with a higher proportion of incomplete recoveries (78 and 73% respectively, P < 0.001), whereas a smaller proportion of cases with tingling/itching (15%, P = 0.03), nausea (27%, P = 0.03), motor weakness (33%, P = 0.05) and visual disturbances (36%, P = 0.04) exhibited residual symptoms. Patients with severe symptoms had a significantly shorter delay than those with mild symptoms (median 24 h vs 36 h respectively, P < 0.001), and a lower incidence of complete recovery.
Conclusions: Delayed HBOT remains an effective and useful intervention. A shorter delay to recompression is associated with fewer recompressions required to achieve recovery or recovery plateau.

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2022 December;52(4) 

Diving Hyperb Med. 2022 December 20;52(4):277−280. doi: 10.28920/dhm52.4.277-280. PMID: 36525685. PMCID: PMC10017199.

Descriptive study of decompression illness in a hyperbaric medicine centre in Bangkok, Thailand from 2015 to 2021

Pitchaya Chevasutho¹, Hansa Premmaneesakul², Atipong Sujiratana²

¹ Occupational Medicine Center, Chonburi Hospital, Chonburi, Thailand
² Maritime Medicine Division, Somdech Phra Pinklao Hospital, Naval Medical Department, Bangkok, Thailand

Corresponding author: Dr Pitchaya Chevasutho, Occupational Medicine Center, Chonburi Hospital, 69 Moo 2, Sukhumvit Rd, Chonburi, Thailand 20000
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Keywords
Arterial gas embolism; Decompression sickness; Diving incidents; Hyperbaric oxygen treatment

Abstract
(Chevasutho P, Premmaneesakul H, Sujiratana A. Descriptive study of decompression illness in a hyperbaric medicine centre in Bangkok, Thailand from 2015 to 2021. Diving and Hyperbaric Medicine. 2022 December 20;52(4):277−280. doi: 10.28920/dhm52.4.277-280. PMID: 36525685. PMCID: PMC10017199.)
Introduction: This study aimed to determine the characteristics of decompression illness patients and their treatment outcomes, at the Center of Hyperbaric Medicine, Somdech Phra Pinklao Hospital, one of the largest centres in Thailand.
Methods: Past medical records of patients with decompression illness from 2015 to 2021 were retrieved and analysed.
Results: Ninety-eight records of diving-related illness from 97 divers were reviewed. Most of the divers were male (n = 50), Thai (n = 86), and were certified at least open water or equivalent (n = 88). On-site first aid oxygen inhalation was provided to 17 divers. Decompression sickness (DCS) cases were characterised according to organ systems involved. The most prominent organ system involved was neurological (57%), followed by mixed organs (28%), musculoskeletal (13%), and pulmonary (2%). There were three cases of arterial gas embolism (AGE). Median presentation delay was three days. Ninety patients were treated with US Navy Treatment Table 6. At the end of their hyperbaric oxygen treatment, most divers (65%) recovered completely.
Conclusions: Despite oxygen first aid being given infrequently and long delays before definitive treatment, treatment outcome was satisfactory. Basic knowledge and awareness of diving-related illnesses should be promoted among divers and related personnel in Thailand along with further studies.

Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in electronic and other forms.

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Full article available here.

2022 December;52(4) 

Diving Hyperb Med. 2022 December 20;52(4):281−285. doi: 10.28920/dhm52.4.281-285. PMID: 36525686. PMCID: PMC10017197.

Agreement between ultrasonic bubble grades using a handheld self-positioning Doppler product and 2D cardiac ultrasound

Oscar Plogmark^1,2, Carl Hjelte^1,2,3, Magnus Ekström¹, Oskar Frånberg^2,4

¹ Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Lund, Sweden
² Swedish Armed Forces Diving and Naval Medicine Center, Swedish Armed Forces, Karlskrona, Sweden
³ Sahlgrenska University Hospital, Anesthesia and Intensive Care. Gothenburg, Sweden
⁴ Blekinge Institute of Technology, Department of Mathematics and Natural Science, Karlskrona, Sweden

Corresponding author: Oscar Plogmark, Sten Bergmans väg 21, 121 46 Johanneshov, Sweden
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Keywords
Decompression; Decompression illness; Decompression sickness; Diving research; Echocardiography; Ultrasound; Venous gas emboli

Abstract
(Plogmark O, Hjelte C, Ekström M, Frånberg O. Agreement between ultrasonic bubble grades using a handheld self-positioning Doppler product and 2D cardiac ultrasound. Diving and Hyperbaric Medicine. 2022 December 20;52(4):281−285. doi: 10.28920/dhm52.4.281-285. PMID: 36525686. PMCID: PMC10017197.)
Introduction: Intravascular bubble load after decompression can be detected and scored using ultrasound techniques that measure venous gas emboli (VGE). The aim of this study was to analyse the agreement between ultrasonic bubble grades from a handheld self-positioning product, the O’Dive^TM, and cardiac 2D ultrasound after decompression.
Methods: VGE were graded with both bilateral subclavian vein Doppler ultrasound (modified Spencer scale) and 2D cardiac images (Eftedal Brubakk scale). Agreement was analysed using weighted kappa (Kw). Analysis with Kw was made for all paired grades, including measurements with and without zero grades, and for each method’s highest grades after each dive.
Results: A total of 152 dives yielded 1,113 paired measurements. The Kw agreement between ultrasound VGE grades produced by cardiac 2D images and those from the O’Dive was ‘fair’; when zero grades were excluded the agreement was ‘poor’. The O’Dive was found to have a lower sensitivity to detect VGE compared to 2D cardiac image scoring.
Conclusions: Compared to 2D cardiac image ultrasound, the O’Dive yielded generally lower VGE grades, which resulted in a low level of agreement (fair to poor) with Kw.

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2022 December;52(4) 

Diving Hyperb Med. 2022 December 20;52(4):286−288. doi: 10.28920/dhm52.4.286-288. PMID: 36525687. PMCID: PMC10017196.

Electric shock leading to acute lung injury in a scuba diver

Kelly Johnson-Arbor

Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington DC, USA

Corresponding author: Dr Kelly Johnson-Arbor, Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, 3800 Reservoir Road NW, Washington DC, 20007, USA
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Keywords
Burns; Diving; Electric injuries; Salt water aspiration

Abstract
(Johnson-Arbor K. Electric shock leading to acute lung injury in a scuba diver. Diving and Hyperbaric Medicine. 2022 December 20;52(4):286−288. doi: 10.28920/dhm52.4.286-288. PMID: 36525687. PMCID: PMC10017196.)
Introduction: Electrical injuries are a rarely reported complication of scuba diving.
Case report: A 33-year-old woman wore a 12-volt heated shirt designed for motorcycling, powered by a canister light battery, while scuba diving. A leak in her drysuit allowed water to make contact with an electrified connector from the heated shirt, and she experienced painful electrical shocks. She was able to disconnect the power source and finish the dive, but she developed progressive fevers and dyspnoea several hours later. She was diagnosed with acute lung injury and treated with bronchodilators. Her symptoms resolved over subsequent weeks.
Discussion: Acute lung injury is rarely reported after low voltage electrical injury. In this case, the use of a heated shirt that was not intended for underwater activities heightened the patient’s risk for electric shock that likely resulted in aspiration of sea water and subsequent acute lung injury. To reduce risk of injury, divers should use equipment that is designed for underwater submersion. Medical professionals who treat the diving population should be aware that divers may use modified equipment that increases the risk of diving-related complications.

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