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Bresser MF, Wingelaar TT, Van Weering JAF, Bresser P, Van Hulst RA. An observational study ascertaining the prevalence of bullae and blebs in young, healthy adults and its possible implications for scuba diving. Front Physiol 2024; 15:1349229. [PMID: 38420621 PMCID: PMC10899502 DOI: 10.3389/fphys.2024.1349229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 01/30/2024] [Indexed: 03/02/2024] Open
Abstract
Introduction: Intrapulmonary air-filled cavities, e.g., bullae, blebs, and cysts, are believed to contribute topulmonary barotrauma (PBT) and arterial gas embolism (AGE) in divers. However, literature is unclear about the prevalence of bullae in healthy adults, ranging from 2.3-33.8%. While this could in part be explained due to increasing quality of radiologic imaging, such as computed tomography (CT) scans, other methodological factors may also affect these findings. This study aims to ascertain the prevalence of bullae in young and healthy adults. Methods: This single-center cross-sectional observational study re-assessed the CT scans of adults (aged 18-40) performed for a clinical suspicion for pulmonary embolism, from 1 January 2016 to 1 March 2020. Presence of bullae was recorded in an electronic database. Chi-square and Fisher exact tests were used for statistical analyses. Additionally, a multivariate logistic regression analysis was performed to study the independent predictive value of identified risk factors. Results: A total of 1,014 cases were identified, of which 836 could be included. Distribution amongst age groups (18-25, 26-30, 31-35, and 36-40) was almost equally, however, 75% of the population was female. Of the male proportion, 41% smoked, compared to 27% in females. In 7.2% (95% CI 5.6-9.1) bullae were identified. The prevalence increased with increasing age (p < 0.001), with odd ratios up to 5.347 (95% CI 2.164-13.213, p < 0.001) in the oldest age group. Males and smokers had higher odds ratios for bullae of 2.460 (95% CI 1.144-4.208; p = 0.001) and 3.406 (95% CI 1.878-6.157, p < 0.001), respectively. Similar results were seen in the multivariate logistic regression analysis, where age, male sex and smoking were all statistically significant independent risk factors for bullae. Discussion: Bullae were seen in 7.2% of a healthy population up to 40 years old. Increasing age, smoking, and being male were identified as statistically significant risk factors, both in independent and in multivariate logistic regression analyses. Our observations may warrant a re-evaluation of the contribution of bullae to PBT and AGE, as the latter two occur very rarely and bullae appear to be more frequently present than earlier assumed.
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Affiliation(s)
- Max F. Bresser
- Department of Respiratory Medicine, OLVG, Amsterdam, Netherlands
- Department of Anesthesiology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Thijs T. Wingelaar
- Department of Anesthesiology, Amsterdam University Medical Center, Amsterdam, Netherlands
- Diving and Submarine Medical Center, Royal Netherlands Navy, Den Helder, Netherlands
| | | | - Paul Bresser
- Department of Respiratory Medicine, OLVG, Amsterdam, Netherlands
| | - Rob A. Van Hulst
- Department of Anesthesiology, Amsterdam University Medical Center, Amsterdam, Netherlands
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Meintjes WA, Davids LR, van Wijk CH. A retrospective review of the utility of chest X-rays in diving and submarine medical examinations. Diving Hyperb Med 2023; 53:237-242. [PMID: 37718298 PMCID: PMC10735703 DOI: 10.28920/dhm53.3.237-242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 07/01/2023] [Indexed: 09/19/2023]
Abstract
Introduction Performance of routine Chest X-rays (CXRs) in asymptomatic individuals to assess hyperbaric exposure risk is controversial. The radiation risk may overshadow the low yield in many settings. However, the yield may be higher in certain settings, such as tuberculosis-endemic countries. We evaluated the utility of routine CXR in diving and submarine medical examinations in South Africa. Methods Records of 2,777 CXRs during 3,568 fitness examinations of 894 divers and submariners spanning 31 years were reviewed to determine the incidence of CXR abnormality. Associated factors were evaluated using odds ratios and a binomial logistic regression model, with a Kaplan-Meier plot to describe the duration of service until first abnormal CXR. Results An abnormal CXR was reported in 1.1% per person year of service, yielding a cumulative incidence of 6.5% (58/894) of the study participants. Only four individuals had a clinical indication for the CXR in their medical history. A range of potential pathologies were seen, of which 15.5% were declared disqualifying and the rest (84.5%) were treated, or further investigation showed that the person could be declared fit. Conclusions In South Africa, a routine CXR has a role to play in detecting abnormalities that are incompatible with pressure exposures. The highest number of abnormalities were found during the initial examinations and in individuals with long service records. Only four individuals had a clinical indication for their CXR during the 31-year span of our study. Similar studies should be performed to make recommendations in other countries and settings.
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Affiliation(s)
- Willem Aj Meintjes
- Division of Health Systems and Public Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
- Corresponding author: Dr Willem AJ Meintjes, Division of Health Systems and Public Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa, ORCiD ID: 0000-0002-4909-5421,
| | - LaDonna R Davids
- Division of Health Systems and Public Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
- Institute for Maritime Medicine, Simon's Town, Cape Town, South Africa
| | - Charles H van Wijk
- Division of Health Systems and Public Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
- Institute for Maritime Medicine, Simon's Town, Cape Town, South Africa
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Schaap JP, Zuluaga Fernandez ME, Houtkooper A, Endert EL, van Ooij PJAM. How fit are military hyperbaric personnel after an asymptomatic or mild symptomatic COVID-19 infection? A retrospective study. Diving Hyperb Med 2023; 53:120-128. [PMID: 37365129 PMCID: PMC10584392 DOI: 10.28920/dhm53.2.120-128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 04/08/2023] [Indexed: 06/28/2023]
Abstract
INTRODUCTION In the diving community there is a special need to know if asymptomatic or mild COVID-19 disease impacts the cardiopulmonary functioning of individuals with occupational exposure to extreme environments. To date, no controlled studies have been conducted comparing COVID-19-infected hyperbaric employees and non-COVID-19-infected peers in a military setting. METHODS Between June 2020 and June 2021, healthy, hyperbaric, military personnel aged between 18 and 54 years old, who had recovered from asymptomatic or subclinical COVID-19 disease at least one month earlier, were analysed. Non-COVID-infected peers with medical assessments during the same period were used as the control group. Somatometry, spirometry, VO₂ max, and DLCO were measured for each group. RESULTS No clinically relevant differences in somatometry, lung function tests, and exercise testing were found between the COVID-19 group and the controls. However, the percentage of individuals with a decrease in estimated VO2-max of 10% or more was significantly greater in the COVID group than in the control group (24 vs. 7.8%, P = 0.004). CONCLUSIONS After asymptomatic or mild symptomatic COVID-19 infections, military hyperbaric employees are as fit as those who had not encountered COVID-19. As this research was based on a military population, it cannot be extrapolated to a nonmilitary population. Further studies in nonmilitary populations are necessary to determine the medical relevance of the present findings.
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Affiliation(s)
- Jan-Peter Schaap
- Royal Netherlands Navy Diving and Submarine Medical Center, 1780 CA Den Helder, The Netherlands
| | | | - Antoinette Houtkooper
- Royal Netherlands Navy Diving and Submarine Medical Center, 1780 CA Den Helder, The Netherlands
| | - Edwin L Endert
- Royal Netherlands Navy Diving and Submarine Medical Center, 1780 CA Den Helder, The Netherlands
| | - Pieter-Jan A M van Ooij
- Royal Netherlands Navy Diving and Submarine Medical Center, 1780 CA Den Helder, The Netherlands
- Department of Pulmonary Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Corresponding author: Dr Pieter-Jan AM van Ooij, Royal Netherlands Navy Diving and Submarine Medical Center, 1780 CA Den Helder, The Netherlands,
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Bonnemaison B, Castagna O, de Maistre S, Blatteau JÉ. Chest CT scan for the screening of air anomalies at risk of pulmonary barotrauma for the initial medical assessment of fitness to dive in a military population. Front Physiol 2022; 13:1005698. [PMID: 36277200 PMCID: PMC9585318 DOI: 10.3389/fphys.2022.1005698] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 09/21/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction: The presence of intra-pulmonary air lesions such as cysts, blebs and emphysema bullae, predisposes to pulmonary barotrauma during pressure variations, especially during underwater diving activities. These rare accidents can have dramatic consequences. Chest radiography has long been the baseline examination for the detection of respiratory pathologies in occupational medicine. It has been replaced since 2018 by the thoracic CT scan for military diving fitness in France. The objective of this work was to evaluate the prevalence of the pulmonary abnormalities of the thoracic CT scan, and to relate them to the characteristics of this population and the results of the spirometry. Methods: 330 records of military diving candidates who underwent an initial assessment between October 2018 and March 2021 were analyzed, in a single-center retrospective analysis. The following data were collected: sex, age, BMI, history of respiratory pathologies and smoking, treatments, allergies, diving practice, results of spirometry, reports of thoracic CT scans, as well as fitness decision. Results: The study included 307 candidates, mostly male, with a median age of 25 years. 19% of the subjects had abnormal spirometry. We identified 25% of divers with CT scan abnormalities. 76% of the abnormal scans were benign nodules, 26% of which measured 6 mm or more. Abnormalities with an aerial component accounted for 13% of the abnormal scans with six emphysema bullae, three bronchial dilatations and one cystic lesion. No association was found between the presence of nodules and the general characteristics of the population, whereas in six subjects emphysema bullae were found statistically associated with active smoking or abnormal spirometry results. Conclusion: The systematic performance of thoracic CT scan in a young population free of pulmonary pathology revealed a majority of benign nodules. Abnormalities with an aerial component are much less frequent, but their presence generally leads to a decision of unfitness. These results argue in favor of a systematic screening of aeric pleuro-pulmonary lesions during the initial assessment for professional divers.
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Affiliation(s)
- Brieuc Bonnemaison
- Service de Médecine Hyperbare et d’Expertise Plongée (SMHEP), Hôpital d'Instruction des Armées Sainte-Anne, Toulon, France
| | - Olivier Castagna
- Equipe de Recherche Subaquatique et Hyperbare, Institut de Recherche biomédicale des armées, Toulon, France
- Laboratoire Motricité Humaine Expertise Sport Santé, UPR 6312, Nice, France
| | - Sébastien de Maistre
- Cellule plongée humaine et Intervention sous la Mer (CEPHISMER), Force d’action navale, Toulon, France
| | - Jean-Éric Blatteau
- Service de Médecine Hyperbare et d’Expertise Plongée (SMHEP), Hôpital d'Instruction des Armées Sainte-Anne, Toulon, France
- *Correspondence: Jean-Éric Blatteau,
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Brenna CTA, Khan S, Djaiani G, Buckey Jr. JC, Katznelson R. The role of routine pulmonary imaging before hyperbaric oxygen treatment. Diving Hyperb Med 2022; 52:197-207. [PMID: 36100931 PMCID: PMC9731143 DOI: 10.28920/dhm52.3.197-207] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 08/05/2022] [Indexed: 11/05/2022]
Abstract
Respiratory injury during or following hyperbaric oxygen treatment (HBOT) is rare, but associated pressure changes can cause iatrogenic pulmonary barotrauma with potentially severe sequelae such as pneumothoraces. Pulmonary blebs, bullae, and other emphysematous airspace abnormalities increase the risk of respiratory complications and are prevalent in otherwise healthy adults. HBOT providers may elect to use chest X-ray routinely as a pre-treatment screening tool to identify these anomalies, particularly if a history of preceding pulmonary disease is identified, but this approach has a low sensitivity and frequently provides false negative results. Computed tomography scans offer greater sensitivity for airspace lesions, but given the high prevalence of incidental and insignificant pulmonary findings among healthy individuals, would lead to a high false positive rate because most lesions are unlikely to pose a hazard during HBOT. Post-mortem and imaging studies of airspace lesion prevalence show that a significant proportion of patients who undergo HBOT likely have pulmonary abnormalities such as blebs and bullae. Nevertheless, pulmonary barotrauma is rare, and occurs mainly in those with known underlying lung pathology. Consequently, routinely using chest X-ray or computed tomography scans as screening tools prior to HBOT for low-risk patients without a pertinent medical history or lack of clinical symptoms of cardiorespiratory disease is of low value. This review outlines published cases of patients experiencing pulmonary barotrauma while undergoing pressurised treatment/testing in a hyperbaric chamber and analyses the relationship between barotrauma and pulmonary findings on imaging prior to or following exposure. A checklist and clinical decision-making tool based on suggested low-risk and high-risk features are offered to guide the use of targeted baseline thoracic imaging prior to HBOT.
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Affiliation(s)
- Connor TA Brenna
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Shawn Khan
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - George Djaiani
- Department of Anesthesia, University Health Network, Toronto, ON, Canada
| | - Jay C Buckey Jr.
- Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Rita Katznelson
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, University Health Network, Toronto, ON, Canada
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Andrew B, Boswell G, Sebreros B, Cusmano P. Pulmonary Barotrauma in a BUD/S Candidate Following Shallow Dives Using the MK 25 Rebreather. Mil Med 2022; 188:1300-1303. [PMID: 35575801 DOI: 10.1093/milmed/usac125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 03/29/2022] [Accepted: 04/20/2022] [Indexed: 11/12/2022] Open
Abstract
Pulmonary barotrauma of ascent is a well-recognized risk of compressed air diving in the civilian and military diving communities. Chest imaging is a beneficial adjunct to clinical evaluation in screening select individuals for fitness to dive, evaluating dive-related injuries, and safely returning individuals to diving duty. We present a case of a 26-year-old male U.S. Navy Ensign and Basic Underwater Demolition/SEAL (BUD/S) candidate who experienced pulmonary barotrauma following two shallow dives to a maximum depth of 18 feet of seawater using the MK-25 100% oxygen rebreather. A chest radiograph showed a left upper lobe peripheral wedge-shaped opacity abutting the pleural surface. A subsequent computerized tomography (CT) scan of the chest showed multifocal areas of peripheral pulmonary hemorrhage associated with small pneumatoceles. Two months after the diving injury, chest CT showed resolution of the pulmonary hemorrhage and pneumatoceles. Diving-related pulmonary barotrauma occurs most often secondary to breath-holding on ascent by inexperienced divers and is one of the most common diving injuries seen in BUD/S candidates. The risk of pulmonary barotrauma may be decreased through adequate training and thorough medical screening to include assessing for symptoms of infection before every dive. In cases of acute pulmonary barotrauma, chest radiographs may be used to screen for thoracic injury. Chest CT with inspiratory and expiratory sequences should be used to screen dive candidates on a case-by-case basis and to evaluate lung injury and predisposing pulmonary conditions following pulmonary barotrauma.
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Affiliation(s)
- Brian Andrew
- Department of Radiology, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Gilbert Boswell
- Department of Radiology, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | | | - Paul Cusmano
- Department of Pulmonary Medicine and Critical Care, Naval Medical Center San Diego, San Diego, CA 92134, USA
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