Barotrauma


Article Author:
Amanda Battisti


Article Editor:
Heather Murphy-Lavoie


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
8/28/2019 12:11:54 PM

Introduction

Barotrauma is physical tissue damage caused by a pressure difference between an unvented space inside the body and surrounding gas or fluid. The damage is due to shear or overstretching of tissues. As a gas-filled space expands or contracts, it can cause damage to the local tissue. Occasionally, tears in tissue can allow gas to enter the body through the initial trauma site. This causes potential blockage of circulation at distant sites or interferes with normal organ function.  Barotrauma can cause sinus injury, ear injury, facial injury, tooth injury, gastrointestinal (GI) cramping, pneumothorax, pulmonary hemorrhage, and subcutaneous emphysema. Sometimes pulmonary barotrauma is a precursor to arterial gas embolism. The most commonly affected sites are the middle ear and sinuses.[1][2][3][4][5]

Etiology

Barotrauma occurs most commonly while scuba diving, but also may occur during flying, mountain climbing, or skiing. During scuba diving, barotrauma may be caused by ascending or descending too rapidly or by breath-holding. The squeezes are caused by the inability to equalize pressure on the descent. Types are mask, sinus, and ear. Mask squeeze can cause skin ecchymosis in the mask pattern, conjunctival hemorrhage, and rarely, orbital hemorrhage. Ear squeeze can occur in the ear canal or middle ear. Risk factors for barotrauma include asthma, chronic obstructive pulmonary disease (COPD), seizures, sinus and ear problems, syncope, panic disorders, vertigo, poor training, inexperience, and Eustachian tube dysfunction.

Any patient receiving mechanical ventilation is at risk for barotrauma, but it is most commonly associated with acute respiratory distress syndrome (ARDS). Historically, this was the most common complication of mechanical ventilation, but modern strategies have mitigated the incidence of ventilator-associated ARDS by limiting tidal volume (6 to 8 mL/kg) and plateau pressure to less than 30 to 50 cm. As an indicator of transalveolar pressure, which predicts alveolar distention, plateau pressure is the best predictor of risk, but there is no accepted safe pressure at which there is no risk.  Aspiration of stomach contents and pre-existing diseases such as pneumonia and chronic lung disease also increase risk.

Epidemiology

About 500 to 1000 nonfatal dive injuries in the United States and Canada each year. Many of these are related to barotrauma.

Pathophysiology

Barotrauma of descent is caused by a lack of free exchange of gas in a closed space in contact with the diver. The resulting pressure difference between the tissues and the gas space and the unbalanced force due to this pressure difference causes deformation of the tissues resulting in cell rupture.[6][7][8][9]

Barotrauma of ascent is also caused by prevention of the free exchange of volume of the gas in a closed space. In this instance, pressure change causes a difference in tension of the adjacent tissues exceeding their tensile strength. Aside from rupture of tissues, the overpressure may cause gases to enter the tissues further down the circulatory system. This pulmonary barotrauma (PBt) of ascent is also known as a pulmonary over-inflation syndrome (POIS), lung over-pressure injury (LOP), and burst lung. Consequent injuries may include pneumothorax, mediastinal, interstitial, or subcutaneous emphysema, and possibly arterial gas embolism, not usually all at the same time.

Breathing gas at depth during SCUBA causes the in gas in the lungs to be at a higher pressure than the atmospheric pressure. While a freediver can dive to 33 feet or 10 meters and safely go up without exhaling because the gas in the lungs had been inhaled at atmospheric pressure, a diver who inhales compressed gas from scuba at 10 meters and ascends without exhaling will rupture his lungs and have extensive pulmonary barotrauma. The lungs in the second scenario would contain twice the amount of gas at atmospheric pressure and therefore need to expand to twice the normal volume upon surfacing.

Descending diving injuries include the squeezes, specifically, ear or sinus squeeze which can result in middle ear pain, sinus pain, vertigo, and/or tinnitus. With ear squeeze, pressure does not equalize in the middle ear through the Eustachian tube. This is common when diving with an upper respiratory tract infection (URI) and may result in severe pain and eardrum rupture. Water can then enter the middle ear causing vertigo/incapacitation. If pressure does not equalize in the frontal or maxillary sinus, which is common when diving with URI, one may have severe pain.

Breath-holding causes lung trauma-pulmonary overpressure syndrome (POPS) during ascent. Compressed air in the lungs expands, and lung tissue ruptures, resulting in pneumothorax, pneumomediastinum, subcutaneous emphysema, or pulmonary arterial gas embolism. This may occur with an ascent from shallow depths. Symptoms are usually present on surfacing or within 10 minutes.

Signs and symptoms include shortness of breath, crackles, crepitance, tachypnea, respiratory distress, substernal chest pain, and in the case of pneumothorax, diminished breath sounds.

Breath-holding can cause an arterial gas embolism during ascent leading to lung tissue tears, air entering pulmonary circulation, air entering the left heart, pumped to systemic circulation, and clogging of the cerebral circulation.

History and Physical

When taking the history of a diver, it is essential to note the events preceding the dive, temperature, sea conditions, dive conditions, depth of dive, the onset of symptoms concerning the dive profile (on the descent, at the bottom, on ascent or after surfacing). Ask about chest pain, shortness of breath, hemoptysis, epistaxis, vertigo, nausea, vomiting, or loss of consciousness. On physical exam check sinuses for anatomic obstructions or hemorrhage. Check tympanic membranes for fluid, hemorrhage, or rupture.

A complete neurologic exam is indicated for anyone with pulmonary barotrauma to screen for signs of arterial gas embolism (AGE) which could include numbness, weakness, paralysis, visual deficits, ataxia, aphasia, sensory loss, nystagmus, and confusion.

Evaluation

History and physical is the most important key to making this diagnosis. Laboratory studies are not very useful. Arterial blood gas may be of value to look for a-a gradient in those suspected of having an air embolism. Rising creatine phosphokinase (CPK) levels may signal worsening tissue damage due to microemboli.

Perform radiographic studies as needed according to symptoms: chest x-ray, CT head. An echocardiogram may show gas bubbles in the heart in patients with AGE.

Treatment / Management

Treat supportively for mild injuries such as sinus squeeze, middle ear squeeze. Use NSAIDs, decongestants, or analgesics as needed. For tympanic membrane (TM) rupture, prescribe oral amoxicillin/clavulanate and fluoroquinolone ear drops. Otolaryngology referral is also warranted for TM ruptures.

Most pulmonary barotrauma can be treated conservatively with rest and oxygen as needed. The exception is pneumothorax with often requires decompression (needle, pigtail, or chest tube).[10][11][12]

Differential Diagnosis

Differential diagnoses include acute coronary syndrome (ACS), substance abuse/intoxication, asthma exacerbation, myocardial infarction, stroke pulmonary embolism, head injury, hypothermia, shock, otitis media/externa, bacterial sinusitis, pneumothorax, pneumonia, dental caries, dental infection, arterial gas embolism, and decompression sickness (DCS).

Prognosis

The prognosis for barotrauma is good, most of these conditions are self-limiting.

Pearls and Other Issues

  • In diving, descending injuries include squeezes; ascending injuries include POPS or AGE.
  • On resurfacing and immediate symptoms: AGE
  • Delayed symptoms 1 to 6 hours: DCS
  • Lower tidal volumes and plateau pressures can largely prevent pulmonary barotrauma during mechanical ventilation.
  • In diving, descending injuries include the squeezes whereas ascending injuries are more likely to include POPS which can lead to AGE.
  • On resurfacing and immediate symptoms: AGE
  • Delayed symptoms of 1 to 6 hours: Usually not barotrauma and more likely DCS
  • Flying too soon after diving can precipitate DCS.
  • Absolute contraindications to diving include spontaneous pneumothorax, acute asthma with abnormal PFTs, cystic or cavitary lung disease, obstructive or restrictive lung disease, seizures, atrial septal defect (ASD), symptomatic coronary artery disease (CAD), chronic perforated TM, inability to equalize sinus or middle ear pressure, or intraorbital gas.

Enhancing Healthcare Team Outcomes

Barotrauma can occur during diving or in patients on a mechanical ventilator. Barotrauma is usually managed by an interdisciplinary team that includes a pulmonologist, emergency department physician, intensivist, ICU specialist, and a surgeon. Critical care, emergency department, and other specialty care nurses must be aware of the signs and symptoms of this condition in order to avoid catastrophic outcomes and report their concerns to the interdisciplinary team. Most mild cases in divers are treated supportively. NSAIDs, decongestants, or analgesics are used as needed. For tympanic membrane (TM) rupture, prescribe oral amoxicillin/clavulanate and fluoroquinolone ear drops. Otolaryngology referral is also warranted for TM ruptures. The pharmacist should assist with patient education regarding medications and compliance. They should also evaluate for potential drug-drug interactions and report to the interdisciplinary team their concerns.

Most pulmonary barotrauma can be treated conservatively with rest and oxygen as needed. The exception is pneumothorax with often requires decompression (needle, pigtail, or chest tube). In addition, in patients on a ventilator, barotrauma is always managed with a chest tube. Further, some specialists also insert a prophylactic chest tube on the contralateral side as the risk of pneumothorax in ventilated patients with PEEP is high.[13] (Level V)


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Barotrauma - Questions

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A 25-year-old female is on mechanical ventilation following a near drowning. Upon examination in the intensive care unit, new decreased breath sounds on the left. Barotrauma during mechanical ventilation is most commonly seen in patients with which of the following?



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What is the most serious manifestation of barotrauma in ventilated patients?



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Barotrauma is most likely to occur during flying in which of the following situations?



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Which of the following is true about barotrauma related headaches?



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Which of the following is incorrectly matched?



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A patient in the intensive care unit was intubated for respiratory failure and required high positive end-expiratory pressure (PEEP) for oxygenation. Within 4 hours, the ventilator started to alarm about high ventilatory pressures. The resident on call decided to place a prophylactic chest tube in the right chest. The chest x-ray obtained 15 minutes later is shown below. What is the next step in management?

(Move Mouse on Image to Enlarge)
  • Image 5285 Not availableImage 5285 Not available
    Contributed by Steve Bhimji, MS, MD, PhD
Attributed To: Contributed by Steve Bhimji, MS, MD, PhD



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A 30-year-old diver is descending and starts to feel sudden onset of ear pain. What is the most likely cause?



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A 21-year-old male saw a shark while diving. He panicked and rapidly ascended to the surface. He is found to be very short of breath and describes a pleuritic chest pain. Examination reveals decreased breath sounds on the left with auscultation. What is the most likely diagnosis?



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Barotrauma - References

References

Lo Casto A,Purpura P,Tudisca C,La Tona G,Salerno S, Barotraumatic blowout fracture of the orbit after sneezing: Cone beam CT demonstration. La Clinica terapeutica. 2018 Nov-Dec;     [PubMed]
Geyer L,Brockmeier K,Graf C,Kretzschmar B,Schmitz KH,Webering F,Hoffmann U, Bubble Formation in Children and Adolescents after Two Standardised Shallow Dives. International journal of sports medicine. 2019 Jan;     [PubMed]
Muller A,Rochoy M, [Diving and asthma: Literature review]. Revue de pneumologie clinique. 2018 Dec;     [PubMed]
Aşık MB,Binar M, Retrospective analyses of high-energy explosive devicerelated injuries of the ear and auricular region: experiences in an operative field hospital emergency room. Ulusal travma ve acil cerrahi dergisi = Turkish journal of trauma     [PubMed]
Hlavaty L,Kasper W,Sung L, Suicide by Detonation of Intraoral Firecracker: Case Report and Review of the Literature. The American journal of forensic medicine and pathology. 2019 Mar;     [PubMed]
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Seyithanoğlu MH,Abdallah A,Dündar TT,Kitiş S,Aralaşmak A,Gündağ Papaker M,Sasani H, Investigation of Brain Impairment Using Diffusion-Weighted and Diffusion Tensor Magnetic Resonance Imaging in Experienced Healthy Divers. Medical science monitor : international medical journal of experimental and clinical research. 2018 Nov 17;     [PubMed]
Zeitler DM,Almosnino G,Holm JR, Stability of residual hearing and cochlear implant function following multiple scuba dives: case report. Undersea     [PubMed]
Torp KD,Murphy-Lavoie HM, Return To Diving 2018 Jan;     [PubMed]
Ryan P,Treble A,Patel N,Jufas N, Prevention of Otic Barotrauma in Aviation: A Systematic Review. Otology     [PubMed]
Vagnarelli F,Marini M,Caretta G,Lucà F,Biscottini E,Lavorgna A,Procaccini V,Riva L,Vianello G,Aspromonte N,Pini D,Navazio A,De Maria R,Valente S,Gulizia MM, [Noninvasive ventilation: general characteristics, indications, and review of the literature]. Giornale italiano di cardiologia (2006). 2017 Jun;     [PubMed]
Guo L,Xie J,Huang Y,Pan C,Yang Y,Qiu H,Liu L, Higher PEEP improves outcomes in ARDS patients with clinically objective positive oxygenation response to PEEP: a systematic review and meta-analysis. BMC anesthesiology. 2018 Nov 17;     [PubMed]

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