Barotrauma is tissue injury caused by a pressure-related change in body compartment gas volume in air-containing areas. During ascent, gas expansion can affect the lungs and gastrointestinal (GI) tract; during descent, gas compression can affect ears, sinuses, air spaces in tooth fillings, and space contained by the diving face mask. Manifestations depend on the affected area. Diagnosis is clinical but sometimes requires imaging tests. Treatment generally is supportive but may include oxygen and chest tube placement for pneumothorax.
(See also Overview of Diving Injuries.)
Risk of barotrauma (often called "squeeze" by divers) is greatest from the surface to 10 m (33 ft). Risk is increased by any condition that can interfere with equilibration of pressure (eg, sinus congestion, eustachian tube blockage, structural anomaly, infection) in the air-containing spaces of the body.
Ear barotrauma constitutes about two thirds of all diving injuries.
In divers who inspire even a single breath of air or other gas at depth and do not let it escape freely during ascent, or when ascent is rapid, the expanding gas may overinflate the lungs, causing pulmonary barotrauma. Lung overinflation occurs mostly in divers breathing compressed air but can occur even in swimming pools when compressed air is inspired at depths 1 m (3 to 4 ft) below the surface (eg, when scuba gear is used there).
Barotrauma can also affect the GI tract (gastrointestinal barotrauma), teeth (dental barotrauma), eyes (eye barotrauma), ears and sinuses (ear and sinus barotrauma), and face (mask barotrauma).
Symptoms and Signs of Barotrauma
Manifestations depend on the affected area; all occur almost immediately when pressure changes. Symptoms may include ear pain, vertigo, hearing loss, sinus pain, epistaxis, and abdominal pain. Dyspnea and alteration or loss of consciousness can be life threatening and may result from alveolar rupture and pneumothorax.
Some medical disorders, if they cause symptoms at depth, may be disabling or disorienting and thus lead to drowning (see table Specific Medical Contraindications to Diving). Secondary infection is sometimes a late complication.
Diagnosis of Barotrauma
Clinical evaluation
Imaging tests
Diagnosis is primarily clinical; imaging tests can sometimes confirm barotrauma. Sometimes patients are evaluated for other problems or organ dysfunction.
Treatment of Barotrauma
Symptomatic treatment
Other treatment dependent on specific injury
Most barotrauma injuries require only symptomatic treatment and outpatient follow-up; however, some injuries are life threatening. Potentially life-threatening barotrauma emergencies are those involving pneumothorax or gastrointestinal rupture, particularly in patients who present with any of the following:
Neurologic symptoms or signs, including altered consciousness
Dyspnea
Peritoneal signs
Abnormal vital signs
Initial stabilizing treatment includes high-flow 100% oxygen and, if respiratory failure appears imminent, endotracheal intubation. Positive pressure ventilation may cause or exacerbate pneumothorax.
Patients with suspected pneumothorax who are hemodynamically unstable or have signs of tension pneumothorax require immediate chest decompression with a large-bore (eg, 14-gauge) needle placed into the 2nd intercostal space in the midclavicular line, followed by tube thoracostomy. Patients with neurologic symptoms or other evidence of arterial gas embolism are transported to a recompression chamber for treatment as soon as transportation can be arranged.
When stable, patients are treated for the specific type of barotrauma sustained. For patients with inner ear barotrauma, prompt surgical treatment of labyrinthine window tears can reverse hearing loss.
Patients treated for severe or recurrent diving-related injuries should not return to diving until they have consulted with a diving medicine specialist.
(See also Diving Precautions and Prevention of Diving Injuries.)
Key Points
Most barotrauma is ear barotrauma.
Symptomatic treatment is sufficient for barotrauma unless patients have manifestations of potential life-threats (eg, neurologic symptoms, pneumothorax, peritoneal signs, abnormal vital signs) or are suspected of having inner ear barotrauma.
Treat patients who have potentially life-threatening injuries with 100% oxygen and other stabilizing measures as necessary.
When patients are stable, treat the specific type of barotrauma sustained.
More Information
The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.
Divers Alert Network: 24-hour emergency hotline, 919-684-9111
Duke Dive Medicine: Physician-to-physician consultation, 919-684-8111
