Barotrauma


Barotrauma is physical damage to body tissues caused by a difference in pressure between a gas space inside, or in contact with, the body and the surrounding gas or liquid. The initial damage is usually due to over-stretching the tissues in tension or shear, either directly by an expansion of the gas in the closed space or by pressure difference hydrostatically transmitted through the tissue. Tissue rupture may be complicated by the introduction of gas into the local tissue or circulation through the initial trauma site, which can cause blockage of circulation at distant sites or interfere with the normal function of an organ by its presence. The term is usually applied when the gas volume involved already exists prior to decompression. Barotrauma can occur during both compression and decompression events.
Barotrauma generally manifests as sinus or middle ear effects, lung overpressure injuries and injuries resulting from external squeezes. Decompression sickness is indirectly caused by ambient pressure reduction, and tissue damage is caused directly and indirectly by gas bubbles. However, these bubbles form out of supersaturated solution from dissolved gases, and are not generally considered barotrauma. Decompression illness is a term that includes decompression sickness and arterial gas embolism caused by lung overexpansion barotrauma. It is also classified under the broader term of dysbarism, which covers all medical conditions resulting from changes in ambient pressure.
Barotrauma typically occurs when the organism is exposed to a significant change in ambient pressure, such as when a scuba diver, a free-diver or an airplane passenger ascends or descends or during uncontrolled decompression of a pressure vessel such as a diving chamber or pressurized aircraft, but can also be caused by a shock wave. Ventilator-induced lung injury is a condition caused by over-expansion of the lungs by mechanical ventilation used when the body is unable to breathe for itself and is associated with relatively large tidal volumes and relatively high peak pressures. Barotrauma due to overexpansion of an internal gas-filled space may also be termed volutrauma.

Presentation

Examples of organs or tissues easily damaged by barotrauma are:
  • Middle ear and inner ear
  • Paranasal sinuses
  • Lungs may be affected by both under-pressure or, more commonly, overpressure relative to the external pressure
  • Eyes
  • Skin
  • Brain and cranium
  • Teeth
  • Genital squeeze and associated urinary complications of P-valve use
  • is caused by over-expansion of gas trapped in the intestines during ascent.

    Causes

When diving, the pressure differences which cause the barotrauma are changes in hydrostatic pressure. There are two components to the surrounding pressure acting on the diver: the atmospheric pressure and the water pressure. A descent of 10 metres in water increases the ambient pressure by an amount approximately equal to the pressure of the atmosphere at sea level. So, a descent from the surface to 10 metres underwater results in a doubling of the pressure on the diver. This pressure change will reduce the volume of a flexible gas-filled space by half. Boyle's law describes the relationship between the volume of the gas space and the pressure in the gas.
Barotraumas of descent, also known as compression barotrauma, and squeezes, are caused by preventing the free change of volume of the gas in a closed space in contact with the diver, resulting in a 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. Barotraumas of ascent, also called decompression barotrauma, are also caused when the free change of volume of the gas in a closed space in contact with the diver is prevented. In this case the pressure difference causes a resultant tension in the surrounding tissues which exceeds their tensile strength.
Patients undergoing hyperbaric oxygen therapy must equalize their ears to avoid barotrauma. High risk of otic barotrauma is associated with unconscious patients. Explosive decompression of a hyperbaric environment can produce severe barotrauma, followed by severe decompression bubble formation and other related injury. The Byford Dolphin incident is an example. Rapid uncontrolled decompression from caissons, airlocks, pressurised aircraft, spacecraft, and pressure suits can have similar effects of decompression barotrauma.
Collapse of a pressure resistant structure such as a submarine, submersible, or atmospheric diving suit can cause rapid compression barotrauma. A rapid change of altitude can cause barotrauma when internal air spaces cannot be equalised. Excessively strenuous efforts to equalise the ears using the Valsalva manoeuvre can overpressurise the middle ear, and can cause middle ear and/or inner ear barotrauma. An explosive blast and explosive decompression create a pressure wave that can induce barotrauma. The difference in pressure between internal organs and the outer surface of the body causes injuries to internal organs that contain gas, such as the lungs, gastrointestinal tract, and ear. Lung injuries can also occur during rapid decompression, although the risk of injury is lower than with explosive decompression.
Mechanical ventilation can lead to barotrauma of the lungs. This can be due to either:
The resultant alveolar rupture can lead to pneumothorax, pulmonary interstitial emphysema and pneumomediastinum.
Barotrauma is a recognised complication of mechanical ventilation that can occur in any patient receiving mechanical ventilation, but is most commonly associated with acute respiratory distress syndrome. It used to be the most common complication of mechanical ventilation but can usually be avoided by limiting tidal volume and plateau pressure to less than 30 to 50 cm water column. As an indicator of transalveolar pressure, which predicts alveolar distention, plateau pressure or peak airway pressure may be the most effective predictor of risk, but there is no generally accepted safe pressure at which there is no risk. Risk also appears to be increased by aspiration of stomach contents and pre-existing disease such as necrotising pneumonia and chronic lung disease. Status asthmaticus is a particular problem as it requires relatively high pressures to overcome bronchial obstruction.
When lung tissues are damaged by alveolar over-distension, the injury may be termed volutrauma, but volume and transpulmonary pressure are closely related. Ventilator induced lung injury is often associated with high tidal volumes.
Other injuries with similar causes are decompression sickness and ebullism.

Pathophysiology

Lung overpressure injury

A free-diver can dive and safely ascend without exhaling, because the gas in the lungs had been inhaled at atmospheric pressure, is compressed during the descent, and expands back to the original volume during ascent. A scuba or surface-supplied diver breathing gas at depth from underwater breathing apparatus fills their lungs with gas at an ambient pressure greater than atmospheric pressure. At 10 metres the lungs contain twice the amount of gas that they would contain at atmospheric pressure, and if they ascend without exhaling the gas will expand to match the decreasing pressure until the lungs reach their elastic limit, and begin to tear, and is very likely to sustain life-threatening lung damage. Besides tissue rupture, the overpressure may cause ingress of gases into the tissues through the ruptures, and further afield through the circulatory system. Pulmonary barotrauma of ascent is also known as pulmonary over-inflation syndrome, lung over-pressure injury and burst lung. Consequent injuries may include arterial gas embolism, pneumothorax, mediastinal, interstitial and subcutaneous emphysemas, depending on where the gas ends up, not usually all at the same time.
POIS may also be caused by mechanical ventilation.

Arterial gas embolism

Gas in the arterial system can be carried to the blood vessels of the brain and other vital organs. It typically causes transient embolism similar to thromboembolism but of shorter duration. Where damage occurs to the endothelium inflammation develops and symptoms resembling stroke may follow. The bubbles are generally distributed and of various sizes, and usually affect several areas, resulting in an unpredictable variety of neurological deficits. Unconsciousness or other major changes to the state of consciousness within about 10 minutes of surfacing are generally assumed to be gas embolism until proven otherwise. The belief that the gas bubbles themselves formed static emboli which remain in place until recompression has been superseded by the knowledge that the gas emboli are normally transient, and the damage is due to inflammation following endothelial damage and secondary injury from inflammatory mediator upregulation.
Hyperbaric oxygen can cause downregulation of the inflammatory response and resolution of oedema by causing hyperoxic arterial vasoconstriction of the supply to capillary beds. High concentration normobaric oxygen is appropriate as first aid but is not considered definitive treatment even when the symptoms appear to resolve. Relapses are common after discontinuing oxygen without recompression.

Pneumothorax

A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases, a one-way valve is formed by an area of damaged tissue, and the amount of air in the space between chest wall and lungs increases; this is called a tension pneumothorax. This can cause a steadily worsening oxygen shortage and low blood pressure. This leads to a type of shock called obstructive shock, which can be fatal unless reversed. Very rarely, both lungs may be affected by a pneumothorax. It is often called a "collapsed lung", although that term may also refer to atelectasis.
Divers who breathe from an underwater apparatus are supplied with breathing gas at ambient pressure, which results in their lungs containing gas at higher than atmospheric pressure. Divers breathing compressed air may develop a pneumothorax as a result of barotrauma from ascending just while breath-holding with their lungs fully inflated. An additional problem in these cases is that those with other features of decompression sickness are typically treated in a diving chamber with hyperbaric therapy; this can lead to a small pneumothorax rapidly enlarging and causing features of tension.
Diagnosis of a pneumothorax by physical examination alone can be difficult. A chest X-ray, computed tomography scan, or ultrasound is usually used to confirm its presence. Other conditions that can result in similar symptoms include a hemothorax, pulmonary embolism, and heart attack. A large bulla may look similar on a chest X-ray.