Laboratory Studies

Acute decompression sickness (DCS) is a purely clinical diagnosis that requires a fair amount of clinical suspicion to avoid missing cases.^[34]Most of the time, the "test" is improvement with hyperbaric oxygen (HBO) therapy. No specific tests exist for DCS. When diving is involved, consider determining whether the patient has any pressure-related injuries. Obtain baseline laboratory studies, but these will have no bearing on initial management. They may be useful in the differential diagnosis while undergoing HBO therapy. They may also be useful in expanding the knowledge base about this disorder.

Do not delay HBO therapy (and transfer, if necessary). In individuals with change in mental status, prudence dictates obtaining studies to help further evaluation. If the individual is in extremis (ie, shock), obtain appropriate resuscitation studies.

For changes in mental status, evaluate the following:

Blood glucose level, CBC count
Sodium, magnesium, calcium, and phosphorous levels
Oxygen saturation
Ethanol level and drug screen
Carboxyhemoglobin level

For shock, evaluate the following:

Blood glucose level, CBC count
Electrolytes and BUN level
Creatinine levels, lactic acid
Type and screen/cross
Prothrombin time/international normalized ratio, activated partial thromboplastin time
Carboxyhemoglobin level

Chest radiography

Because dysbaric injuries involving the lungs and chest can occur concomitantly with decompression sickness (DCS), obtain a chest radiograph to screen for overpressurization injuries. Chest radiography reveals evidence of pneumothorax, pneumomediastinum, subcutaneous emphysema, pneumopericardium, alveolar hemorrhage, and decreased pulmonary blood flow caused by nitrogen pulmonary emboli.

Head CT scanning

If mental status does not initially improve in response to hyperbaric repressurization, consider other etiologies. Pursuing a noncontrast CT scan of the head to evaluate for structural issues is part of that consideration.

Chest or abdominal/pelvis CT scanning

In a patient with persistent symptoms of dyspnea or discomfort in the thorax that have normal conventional chest radiographs, CT scanning can identify subtle or early findings for pneumothorax or pneumomediastinum. If available, noncontrasted CT does not take long to accomplish. Identification of these barotraumas before doing HBO therapy is useful as the pressure changes can exacerbate these conditions.

Differentiating pneumoperitoneum from DCS as the cause for abdominal pain can be of similar importance. A unique gas pattern has been documented in the venous systems related to DCS.^[129]Gas appeared in the portal venous system, omental veins, and peripheral veins in the pelvis.

See Dysbarism for more information.

MRI

MRI has been found useful in the management of neurologic DCS.^{[130, 131, 132, 133]}The diagnosis is still clinical, and the patient's transfer to an HBO facility should not be delayed. MRI has revealed focal spinal lesions that correlated with the patient's symptoms and examination. MRI readily detects cerebral damage in arterial gas embolization (AGE),^[134]but iy yields low sensitivity in DCS. MRI may prove useful in patients who do not show initial improvement to HBO therapy. In these individuals, the MRI may localize the area of DCS injury or exclude other etiologies for the patient's symptoms.

Spinal MRI found lesions more commonly in divers with severe spinal DCS and none at all in those that ultimately had a favorable outcome. Therefore, in an HBO center, it may be a useful diagnostic adjunct to help guide management after the first, or subsequent, treatment.^[35]A normal MRI correlates with better outcome.^[135]Do not delay HBO treatment to obtain an MRI.

MRI is also useful for monitoring injured divers through successive HBO treatments.

Cerebral MRI has even identified abnormalities in the brain that correlated with hours of diving in the air-breathing range even when no clinical or historical signs of neurologic DCS were present.^[136]

Note that negative MRI findings do not exclude the possibility of AGE or DCS. Also, improvement in MRI findings does not necessarily correlate with clinical improvement.^[137]It has also been correlated with neuropsychological deficits in older divers.^[138]

Diffusion Tensor MRI (DTI) has been demonstrated to be useful for investigating DCS.^[139]

MRI in a guinea pig model was able to identify small bubbles and blood in the inner ear. It may have future utility in management of inner-ear DCS.^[140]

The decision to pursue HBO referral should be based on the purely clinical presentation and not be guided, or delayed, by obtaining MRI or other diagnostic findings.

Other Tests

Other tests may include ECG and/or oxygen saturation evaluation.

Diagnostic repressurization

If diagnosis of decompression sickness (DCS) versus dysbarism or some other entity is unclear, order repressurization in a hyperbaric chamber (transfer if necessary) for diagnostic and therapeutic reasons.

Intubation

Intubation delivers 100% oxygen when less-invasive delivery methods do not work or are inappropriate.

Needle decompression and thoracostomy

These procedures help in the treatment of tension pneumothorax, simple pneumothorax, tension pneumoperitoneum, and subcutaneous emphysema.

See Dysbarism for more information.

Treatment & Management

Auten JD, Kuhne MA, Walker HM 2nd, Porter HO. Neurologic decompression sickness following cabin pressure fluctuations at high altitude. Aviat Space Environ Med. 2010 Apr. 81(4):427-30. [QxMD MEDLINE Link].
AIDA International. World Records. Association Internationale pour le Développement de l'Apnée. Available at https://www.aidainternational.org/competitive/worlds-records. Accessed: March 17, 2014.
John Liang. Herbert Nitsch Speaks To DeeperBlue.com About His Recovery From His 2012 Dive Attempt. Deeper Blue. Available at http://www.deeperblue.com/herbert-nitsch-speaks-deeperblue-com-recovery-2012-dive-attempt/. Accessed: March 17, 2014.
Camporesi EM. Diving and pregnancy. Semin Perinatol. 1996 Aug. 20(4):292-302. [QxMD MEDLINE Link].
Lemaitre F, Carturan D, Tourney-Chollet C, Gardette B. Circulating venous bubbles in children after diving. Pediatr Exerc Sci. 2009 Feb. 21(1):77-85. [QxMD MEDLINE Link].
Geyer L, Brockmeier K, Graf C, Kretzschmar B, Schmitz KH, Webering F, et al. Bubble Formation in Children and Adolescents after Two Standardised Shallow Dives. Int J Sports Med. 2019 Jan. 40 (1):31-37. [QxMD MEDLINE Link].
Blatteau JE, Souraud JB, Gempp E, Boussuges A. Gas nuclei, their origin, and their role in bubble formation. Aviat Space Environ Med. 2006 Oct. 77(10):1068-76. [QxMD MEDLINE Link].
Thom SR, Milovanova TN, Bogush M, Bhopale VM, Yang M, Bushmann K, et al. Microparticle production, neutrophil activation, and intravascular bubbles following open-water SCUBA diving. J Appl Physiol (1985). 2012 Apr. 112(8):1268-78. [QxMD MEDLINE Link].
Møllerløkken A, Breskovic T, Palada I, Valic Z, Dujic Z, Brubakk AO. Observation of increased venous gas emboli after wet dives compared to dry dives. Diving Hyperb Med. 2011 Sep. 41(3):124-8. [QxMD MEDLINE Link].
Swan JG, Wilbur JC, Moodie KL, Kane SA, Knaus DA, Phillips SD, et al. Microbubbles are detected prior to larger bubbles following decompression. J Appl Physiol (1985). 2014 Apr. 116(7):790-6. [QxMD MEDLINE Link].
Vallee N, Meckler C, Risso JJ, Blatteau JE. Neuroprotective role of the TREK-1 channel in decompression sickness. J Appl Physiol (1985). 2012 Apr. 112(7):1191-6. [QxMD MEDLINE Link].
Bao XC, Fang YQ, Ma J, Meng M. [Change of adhesion molecules in the lungs of rat with decompression sickness]. Zhongguo Ying Yong Sheng Li Xue Za Zhi. 2012 Jul. 28(4):369-72. [QxMD MEDLINE Link].
Lambrechts K, de Maistre S, Abraini JH, Blatteau JE, Risso JJ, Vallée N. Tirofiban, a Glycoprotein IIb/IIIa Antagonist, Has a Protective Effect on Decompression Sickness in Rats: Is the Crosstalk Between Platelet and Leukocytes Essential?. Front Physiol. 2018. 9:906. [QxMD MEDLINE Link].
Thom SR, Bennett M, Banham ND, Chin W, Blake DF, Rosen A, et al. Association of microparticles and neutrophil activation with decompression sickness. J Appl Physiol (1985). 2015 Sep 1. 119 (5):427-34. [QxMD MEDLINE Link].
Yang M, Barak OF, Dujic Z, Madden D, Bhopale VM, Bhullar J, et al. Ascorbic acid supplementation diminishes microparticle elevations and neutrophil activation following SCUBA diving. Am J Physiol Regul Integr Comp Physiol. 2015 Aug 15. 309 (4):R338-44. [QxMD MEDLINE Link].
Thom SR, Yang M, Bhopale VM, Milovanova TN, Bogush M, Buerk DG. Intramicroparticle nitrogen dioxide is a bubble nucleation site leading to decompression-induced neutrophil activation and vascular injury. J Appl Physiol (1985). 2013 Mar 1. 114(5):550-8. [QxMD MEDLINE Link].
Pontier JM, Gempp E, Ignatescu M. Blood platelet-derived microparticles release and bubble formation after an open-sea air dive. Appl Physiol Nutr Metab. 2012 Oct. 37(5):888-92. [QxMD MEDLINE Link].
Philp RB, Freeman D, Francey I, Bishop B. Hematology and blood chemistry in saturation diving: I. Antiplatelet drugs, aspirin, and VK744. Undersea Biomed Res. 1975 Dec. 2(4):233-49. [QxMD MEDLINE Link].
Pontier JM, Blatteau JE, Vallée N. Blood platelet count and severity of decompression sickness in rats after a provocative dive. Aviat Space Environ Med. 2008 Aug. 79(8):761-4. [QxMD MEDLINE Link].
Pontier JM, Jimenez C, Blatteau JE. Blood platelet count and bubble formation after a dive to 30 msw for 30 min. Aviat Space Environ Med. 2008 Dec. 79(12):1096-9. [QxMD MEDLINE Link].
Blatteau JE, Brubakk AO, Gempp E, Castagna O, Risso JJ, Vallée N. Sidenafil pre-treatment promotes decompression sickness in rats. PLoS One. 2013. 8(4):e60639. [QxMD MEDLINE Link]. [Full Text].
Taylor LH. A Diver's Guide To Nitrogen Species. University of Michigan. Available at http://www-personal.umich.edu/~lpt/nitrogen.htm. Accessed: April 1, 2014.
Thom SR, Bhopale VM, Yu K, Yang M. Provocative decompression causes diffuse vascular injury in mice mediated by microparticles containing interleukin-1β. J Appl Physiol (1985). 2018 Aug 16. [QxMD MEDLINE Link].
Thom SR, Milovanova TN, Bogush M, Yang M, Bhopale VM, Pollock NW, et al. Bubbles, microparticles, and neutrophil activation: changes with exercise level and breathing gas during open-water SCUBA diving. J Appl Physiol (1985). 2013 May 15. 114(10):1396-405. [QxMD MEDLINE Link].
Jang DH, Owiredu S, Ranganathan A, Eckmann DM. Acute decompression following simulated dive conditions alters mitochondrial respiration and motility. Am J Physiol Cell Physiol. 2018 Nov 1. 315 (5):C699-C705. [QxMD MEDLINE Link].
Boussuges A, Succo E, Juhan-Vague I, Sainty JM. Activation of coagulation in decompression illness. Aviat Space Environ Med. 1998 Feb. 69(2):129-32. [QxMD MEDLINE Link].
Oode Y, Yanagawa Y, Inoue T, Oomori K, Osaka H, Okamoto K. Cutaneous manifestation of decompression sickness: cutis marmorata. Intern Med. 2013. 52(21):2479. [QxMD MEDLINE Link].
Kemper TC, Rienks R, van Ooij PJ, van Hulst RA. Cutis marmorata in decompression illness may be cerebrally mediated: a novel hypothesis on the aetiology of cutis marmorata. Diving Hyperb Med. 2015 Jun. 45 (2):84-8. [QxMD MEDLINE Link].
Wilmshurst PT. Cutis marmorata and cerebral arterial gas embolism. Diving Hyperb Med. 2015 Dec. 45 (4):261. [QxMD MEDLINE Link].
Rozenblat M, Ziv M. Image Gallery: Cutis marmorata as a manifestation of decompression sickness. Br J Dermatol. 2018 Jul. 179 (1):e1. [QxMD MEDLINE Link].
Germonpre P, Balestra C, Obeid G, Caers D. Cutis Marmorata skin decompression sickness is a manifestation of brainstem bubble embolization, not of local skin bubbles. Med Hypotheses. 2015 Dec. 85 (6):863-9. [QxMD MEDLINE Link].
Xu W, Liu W, Huang G, Zou Z, Cai Z, Xu W. Decompression illness: clinical aspects of 5278 consecutive cases treated in a single hyperbaric unit. PLoS One. 2012. 7(11):e50079. [QxMD MEDLINE Link]. [Full Text].
Mitchell SJ, Bennett MH, Bryson P, Butler FK, Doolette DJ, Holm JR, et al. Consensus guideline: Pre-hospital management of decompression illness: expert review of key principles and controversies. Undersea Hyperb Med. 2018 May-Jun. 45 (3):273-286. [QxMD MEDLINE Link].
Hennedige T, Chow W, Ng YY, Chung-Tsing GC, Lim TC, Kei PL. MRI in spinal cord decompression sickness. J Med Imaging Radiat Oncol. 2012 Jun. 56(3):282-8. [QxMD MEDLINE Link].
Gempp E, Blatteau JE, Stephant E, Pontier JM, Constantin P, Pény C. MRI findings and clinical outcome in 45 divers with spinal cord decompression sickness. Aviat Space Environ Med. 2008 Dec. 79(12):1112-6. [QxMD MEDLINE Link].
Blatteau JE, Gempp E, Simon O, Coulange M, Delafosse B, Souday V, et al. Prognostic factors of spinal cord decompression sickness in recreational diving: retrospective and multicentric analysis of 279 cases. Neurocrit Care. 2011 Aug. 15(1):120-7. [QxMD MEDLINE Link].
Mathew B, Laden G. Management of severe spinal cord injury following hyperbaric exposure. Diving Hyperb Med. 2015 Sep. 45 (3):210. [QxMD MEDLINE Link].
Schipke JD, Tetzlaff K. Why predominantly neurological decompression sickness in breath-hold divers?. J Appl Physiol (1985). 2016 Jun 15. 120 (12):1474-7. [QxMD MEDLINE Link].
James PB. Hyperbaric oxygenation in fluid microembolism. Neurol Res. 2007 Mar. 29(2):156-61. [QxMD MEDLINE Link].
Latham E, van Hoesen K, Grover I. Diplopia due to mask barotrauma. J Emerg Med. 2008 Nov 6. [QxMD MEDLINE Link].
Livingstone DM, Smith KA, Lange B. Scuba diving and otology: a systematic review with recommendations on diagnosis, treatment and post-operative care. Diving Hyperb Med. 2017 Jun. 47 (2):97-109. [QxMD MEDLINE Link].
Uzun C, Yagiz R, Tas A, Adali MK, Inan N, Koten M, et al. Alternobaric vertigo in sport SCUBA divers and the risk factors. J Laryngol Otol. 2003 Nov. 117(11):854-60. [QxMD MEDLINE Link].
Klingmann C, Benton PJ, Ringleb PA, Knauth M. Embolic inner ear decompression illness: correlation with a right-to-left shunt. Laryngoscope. 2003 Aug. 113(8):1356-61. [QxMD MEDLINE Link].
Klingmann C, Praetorius M, Baumann I, Plinkert PK. Barotrauma and decompression illness of the inner ear: 46 cases during treatment and follow-up. Otol Neurotol. 2007 Jun. 28(4):447-54. [QxMD MEDLINE Link].
Klingmann C. Inner ear decompression sickness in compressed-air diving. Undersea Hyperb Med. 2012 Jan-Feb. 39(1):589-94. [QxMD MEDLINE Link].
Gempp E, Louge P. Inner ear decompression sickness in scuba divers: a review of 115 cases. Eur Arch Otorhinolaryngol. 2013 May. 270(6):1831-7. [QxMD MEDLINE Link].
Goplen FK, Grønning M, Irgens A, Sundal E, Nordahl SH. Vestibular symptoms and otoneurological findings in retired offshore divers. Aviat Space Environ Med. 2007 Apr. 78(4):414-9. [QxMD MEDLINE Link].
Mitchell SJ, Doolette DJ. Selective vulnerability of the inner ear to decompression sickness in divers with right-to-left shunt: the role of tissue gas supersaturation. J Appl Physiol. 2009 Jan. 106(1):298-301. [QxMD MEDLINE Link].
Ignatescu M, Bryson P, Klingmann C. Susceptibility of the inner ear structure to shunt-related decompression sickness. Aviat Space Environ Med. 2012 Dec. 83(12):1145-51. [QxMD MEDLINE Link].
Tremolizzo L, Malpieri M, Ferrarese C, Appollonio I. Inner-ear decompression sickness: 'hubble-bubble' without brain trouble?. Diving Hyperb Med. 2015 Jun. 45 (2):135-6. [QxMD MEDLINE Link].
Mitchell SJ, Doolette DJ. Pathophysiology of inner ear decompression sickness: potential role of the persistent foramen ovale. Diving Hyperb Med. 2015 Jun. 45 (2):105-10. [QxMD MEDLINE Link].
Kitajima N, Sugita-Kitajima A, Kitajima S. Superior canal dehiscence syndrome associated with scuba diving. Diving Hyperb Med. 2017 Jun. 47 (2):123-126. [QxMD MEDLINE Link].
Lampert R. Evaluation and management of arrhythmia in the athletic patient. Prog Cardiovasc Dis. 2012 Mar-Apr. 54(5):423-31. [QxMD MEDLINE Link].
Mukundakrishnan K, Ayyaswamy PS, Eckmann DM. Computational simulation of hematocrit effects on arterial gas embolism dynamics. Aviat Space Environ Med. 2012 Feb. 83(2):92-101. [QxMD MEDLINE Link]. [Full Text].
Williams ST, Prior FG, Bryson P. Hematocrit change in tropical scuba divers. Wilderness Environ Med. 2007. 18(1):48-53. [QxMD MEDLINE Link].
Newton HB, Burkart J, Pearl D, Padilla W. Neurological decompression illness and hematocrit: analysis of a consecutive series of 200 recreational scuba divers. Undersea Hyperb Med. 2008 Mar-Apr. 35(2):99-106. [QxMD MEDLINE Link].
Fahlman A, Dromsky DM. Dehydration effects on the risk of severe decompression sickness in a swine model. Aviat Space Environ Med. 2006 Feb. 77(2):102-6. [QxMD MEDLINE Link].
Gempp E, Blatteau JE, Pontier JM, Balestra C, Louge P. Preventive effect of pre-dive hydration on bubble formation in divers. Br J Sports Med. 2009 Mar. 43(3):224-8. [QxMD MEDLINE Link].
Morin J, Simon K, Chadelaud F, Delarbre D, Druelle A, Blatteau JE. [Capillary leak syndrome secondary to decompression sickness: A case report]. Rev Med Interne. 2019 Jan. 40 (1):38-42. [QxMD MEDLINE Link].
Hjelde A, Bergh K, Brubakk AO, Iversen OJ. Complement activation in divers after repeated air/heliox dives and its possible relevance to DCS. J Appl Physiol. 1995 Mar. 78(3):1140-4. [QxMD MEDLINE Link].
Huang KL, Lin YC. Activation of complement and neutrophils increases vascular permeability during air embolism. Aviat Space Environ Med. 1997 Apr. 68(4):300-5. [QxMD MEDLINE Link].
Shastri KA, Logue GL, Lundgren CE, Logue CJ, Suggs DF. Diving decompression fails to activate complement. Undersea Hyperb Med. 1997 Jun. 24(2):51-7. [QxMD MEDLINE Link].
Koch AE, Kirsch H, Reuter M, Warninghoff V, Rieckert H, Deuschl G. Prevalence of patent foramen ovale (PFO) and MRI-lesions in mild neurological decompression sickness (type B-DCS/AGE). Undersea Hyperb Med. 2008 May-Jun. 35(3):197-205. [QxMD MEDLINE Link].
Koch AE, Wegner-Bröse H, Warninghoff V, Deuschl G. Viewpoint: the type A- and the type B-variants of Decompression Sickness. Undersea Hyperb Med. 2008 Mar-Apr. 35(2):91-7. [QxMD MEDLINE Link].
Bove AA. Risk of decompression sickness with patent foramen ovale. Undersea Hyperb Med. 1998. 25(3):175-8. [QxMD MEDLINE Link].
Germonpre P, Dendale P, Unger P, Balestra C. Patent foramen ovale and decompression sickness in sports divers. J Appl Physiol. 1998 May. 84(5):1622-6. [QxMD MEDLINE Link].
Wilmshurst PT, Morrison WL, Walsh KP. Comparison of the size of persistent foramen ovale and atrial septal defects in divers with shunt-related decompression illness and in the general population. Diving Hyperb Med. 2015 Jun. 45 (2):89-93. [QxMD MEDLINE Link].
Germonpré P. Persistent (patent) foramen ovale (PFO): implications for safe diving. Diving Hyperb Med. 2015 Jun. 45 (2):73-4. [QxMD MEDLINE Link].
Aslam F, Shirani J, Haque AA. Patent foramen ovale: assessment, clinical significance and therapeutic options. South Med J. 2006 Dec. 99(12):1367-72. [QxMD MEDLINE Link].
Drighil A, El Mosalami H, Elbadaoui N, Chraibi S, Bennis A. Patent foramen ovale: a new disease?. Int J Cardiol. 2007 Oct 31. 122(1):1-9. [QxMD MEDLINE Link].
Harrah JD, O'Boyle PS, Piantadosi CA. Underutilization of echocardiography for patent foramen ovale in divers with serious decompression sickness. Undersea Hyperb Med. 2008 May-Jun. 35(3):207-11. [QxMD MEDLINE Link].
Honěk J, Šefc L, Honěk T, Šrámek M, Horváth M, Veselka J. Patent Foramen Ovale in Recreational and Professional Divers: An Important and Largely Unrecognized Problem. Can J Cardiol. 2015 Aug. 31 (8):1061-6. [QxMD MEDLINE Link].
Gempp E, Lyard M, Louge P. Reliability of right-to-left shunt screening in the prevention of scuba diving related-decompression sickness. Int J Cardiol. 2017 Dec 1. 248:155-158. [QxMD MEDLINE Link].
Cartoni D, De Castro S, Valente G, Costanzo C, Pelliccia A, Beni S, et al. Identification of professional scuba divers with patent foramen ovale at risk for decompression illness. Am J Cardiol. 2004 Jul 15. 94(2):270-3. [QxMD MEDLINE Link].
Trevett AJ, Sheehan C, Forbes R. Decompression illness presenting as breast pain. Undersea Hyperb Med. 2006 Mar-Apr. 33(2):77-9. [QxMD MEDLINE Link].
Honek T, Veselka J, Tomek A, Srámek M, Janugka J, Sefc L, et al. [Paradoxical embolization and patent foramen ovale in scuba divers: screening possibilities]. Vnitr Lek. 2007 Feb. 53(2):143-6. [QxMD MEDLINE Link].
Rasmussen W. Saline Shunt Study for the Evaluation of an ASD or PFO. Imaging Skills for Echocardiography. Available at http://echocardiographyskills.com/saline-shunt-study-asd-and-pfo. Accessed: June 30, 2016.
Lippmann J, McD Taylor D, Stevenson C, Williams J, Mitchell SJ. Diving with pre-existing medical conditions. Diving Hyperb Med. 2017 Sep. 47 (3):180-190. [QxMD MEDLINE Link].
Beda RD, Gill EA Jr. Patent foramen ovale: does it play a role in the pathophysiology of migraine headache?. Cardiol Clin. 2005 Feb. 23(1):91-6. [QxMD MEDLINE Link].
Wilmshurst PT, Nightingale S, Walsh KP, Morrison WL. Effect on migraine of closure of cardiac right-to-left shunts to prevent recurrence of decompression illness or stroke or for haemodynamic reasons. Lancet. 2000 Nov 11. 356(9242):1648-51. [QxMD MEDLINE Link].
Sastry S, MacNab A, Daly K, Ray S, McCollum C. Transcranial Doppler detection of venous-to-arterial circulation shunts: criteria for patent foramen ovale. J Clin Ultrasound. 2009 Jun. 37(5):276-80. [QxMD MEDLINE Link].
Honek J, Honek T, Januška J, Sebesta P, Novotný S, Sefc L, et al. [Patent foramen ovale and the risk of paradoxical embolization of venous bubbles in divers - cave for foam sclerotization of varicose veins]. Rozhl Chir. 2012 Jul. 91(7):378-80. [QxMD MEDLINE Link].
Billinger M, Zbinden R, Mordasini R, Windecker S, Schwerzmann M, Meier B, et al. Patent foramen ovale closure in recreational divers: effect on decompression illness and ischaemic brain lesions during long-term follow-up. Heart. 2011 Dec. 97(23):1932-7. [QxMD MEDLINE Link].
Leffler CT, White JC. Recompression treatments during the recovery of TWA Flight 800. Undersea Hyperb Med. 1997 Winter. 24(4):301-8. [QxMD MEDLINE Link].
Schultz GJ. Accusations "reckless and a mistake," says co-author. America's NAVY. Available at http://www.navy.mil/navydata/nav_legacy.asp?id=284. 2009 Sep 16; Accessed: June 30, 2016.
Huang KL, Wu CP, Chen YL, Kang BH, Lin YC. Heat stress attenuates air bubble-induced acute lung injury: a novel mechanism of diving acclimatization. J Appl Physiol. 2003 Apr. 94(4):1485-90. [QxMD MEDLINE Link].
Su CL, Wu CP, Chen SY, Kang BH, Huang KL, Lin YC. Acclimatization to neurological decompression sickness in rabbits. Am J Physiol Regul Integr Comp Physiol. 2004 Nov. 287(5):R1214-8. [QxMD MEDLINE Link].
Chen Y, Montcalm-Smith E, Schlaerth C, Auker C, McCarron RM. Acclimation to decompression: stress and cytokine gene expression in rat lungs. J Appl Physiol (1985). 2011 Oct. 111(4):1007-13. [QxMD MEDLINE Link].
Suzuki N, Yagishita K, Enomoto M, Kojima Y, Oyaizu T, Shibayama M, et al. A case-control questionnaire survey of decompression sickness risk in Okinawa divers. Undersea Hyperb Med. 2018 Jan-Feb. 45 (1):41-48. [QxMD MEDLINE Link].
Cialoni D, Pieri M, Balestra C, Marroni A. Flying after diving: should recommendations be reviewed? In-flight echocardiographic study in bubble-prone and bubble-resistant divers. Diving Hyperb Med. 2015 Mar. 45 (1):10-5. [QxMD MEDLINE Link].
Buch DA, El Moalem H, Dovenbarger JA, Uguccioni DM, Moon RE. Cigarette smoking and decompression illness severity: a retrospective study in recreational divers. Aviat Space Environ Med. 2003 Dec. 74(12):1271-4. [QxMD MEDLINE Link].
Morgan WP, Raglin JS, O'Connor PJ. Trait anxiety predicts panic behavior in beginning scuba students. Int J Sports Med. 2004 May. 25(4):314-22. [QxMD MEDLINE Link].
Cialoni D, Pieri M, Balestra C, Marroni A. Dive Risk Factors, Gas Bubble Formation, and Decompression Illness in Recreational SCUBA Diving: Analysis of DAN Europe DSL Data Base. Front Psychol. 2017. 8:1587. [QxMD MEDLINE Link].
Schellart NA, van Rees Vellinga TP, van Hulst RA. Body fat does not affect venous bubble formation after air dives of moderate severity: theory and experiment. J Appl Physiol (1985). 2013 Mar 1. 114(5):602-10. [QxMD MEDLINE Link].
Schellart NA, Vellinga TP, van Dijk FJ, Sterk W. Doppler bubble grades after diving and relevance of body fat. Aviat Space Environ Med. 2012 Oct. 83(10):951-7. [QxMD MEDLINE Link].
Mendez-Dominguez N, Huchim-Lara O, Chin W, Carrillo-Arceo L, Camara-Koyoc I, Cárdenas-Dajdaj R, et al. Body mass index in association with decompression sickness events: cross-sectional study among small-scale fishermen-divers in southeast Mexico. Undersea Hyperb Med. 2018 Jul-Aug. 45 (4):445-451. [QxMD MEDLINE Link].
van Ooij PJA. Decompression sickness, fatness and active hydrophobic spots. Diving Hyperb Med. 2018 Sep 30. 48 (3):130-131. [QxMD MEDLINE Link].
Fahlman A. Allometric scaling of decompression sickness risk in terrestrial mammals; cardiac output explains risk of decompression sickness. Sci Rep. 2017 Feb 2. 7:40918. [QxMD MEDLINE Link].
Kaczerska D, Pleskacz K, Siermontowski P, Olszański R, Krefft K. Risk factors increasing health hazards after air dives. Undersea Hyperb Med. 2015 Nov-Dec. 42 (6):565-72. [QxMD MEDLINE Link].
Arieli R. Fatty diet, active hydrophobic spots, and decompression sickness. Diving Hyperb Med. 2018 Sep 30. 48 (3):197. [QxMD MEDLINE Link].
Pollock NW. Re: Don't dive cold when you don't have to. Diving Hyperb Med. 2015 Sep. 45 (3):209. [QxMD MEDLINE Link].
Gerth WA. On diver thermal status and susceptibility to decompression sickness. Diving Hyperb Med. 2015 Sep. 45 (3):208. [QxMD MEDLINE Link].
Sporting Goods Manufacturers Association. Sports Participation in America Topline Report 2004. August 2004. Available at http://sgma.affiniscape.com/associations/5119/files/sport-part-topline2004.pdf.
Sporting Goods Manufacturers Association. Sports Participation in America 2004. August 2004. Available at http://www.sgma.com/associations/5119/files/p27-02-04-m.pdf.
Sporting Goods Manufacturers Association. 2007 Sports and Fitness Participation Report. 2007. Available at http://www.sgma.com/associations/5119/files/topline07.pdf.
The Sports & Fitness Industry Association. Scuba Diving Participation Report 2013. SFIA. Available at http://www.sfia.org/reports/84_Scuba-Diving-Participation-Report-2013. Accessed: March 17, 2014.
Glazer TA, Telian SA. Otologic Hazards Related to Scuba Diving. Sports Health. 2016 Feb 8. [QxMD MEDLINE Link].
Lee YI, Ye BJ. Underwater and hyperbaric medicine as a branch of occupational and environmental medicine. Ann Occup Environ Med. 2013 Dec 19. 25(1):39. [QxMD MEDLINE Link]. [Full Text].
van der Hulst GA, Buzzacott PL. Diver Health Survey score and probability of decompression sickness among occupational dive guides and instructors. Diving Hyperb Med. 2012 Mar. 42(1):18-23. [QxMD MEDLINE Link].
Gempp E, Blatteau JE. Preconditioning methods and mechanisms for preventing the risk of decompression sickness in scuba divers: a review. Res Sports Med. 2010 Jul. 18(3):205-18. [QxMD MEDLINE Link].
United States of America. Health Insurance Portability and Accountability Act of 1996. Health Information Privacy. Available at http://www.hhs.gov/ocr/privacy/hipaa/understanding/index.html. Accessed: March 17, 2014.
Bennett PB. What me bent?. Alert Diver (Divers Alert Network). 1997. Vol 2:
Taylor DM, O'Toole KS, Ryan CM. Experienced, recreational scuba divers in Australia continue to dive despite medical contraindications. Wilderness Environ Med. 2002. 13(3):187-93. [QxMD MEDLINE Link].
St Leger Dowse M, Waterman MK, Penny CE, Smerdon GR. Does self-certification reflect the cardiac health of UK sport divers?. Diving Hyperb Med. 2015 Sep. 45 (3):184-9. [QxMD MEDLINE Link].
Divers Alert Network. Report on Decompression Illness, DivingFatalities and Project Dive Exploration 2005 Edition. 2005. Available at http://dan.org/medical/report/2005DCIReport.pdf.
Divers Alert Network. Annual Diving Report 2006 Edition. Oct 11, 2006. Available at http://dan.org/medical/report/2006DANDivingReport.pdf.
Goldhahn RT Jr. Scuba diving deaths: a review and approach for the pathologist. Leg Med Annu. 1977. 1976:109-32. [QxMD MEDLINE Link].
Lewis PR. Skin diving fatalities in New Zealand. N Z Med J. 1979 Jun 27. 89(638):472-5. [QxMD MEDLINE Link].
Buzzacott P. DAN Annual Diving Report 2017 Edition - A report on 2015 diving fatalities, injuries, and incidents. Divers Alert Network. 2017. [QxMD MEDLINE Link]. [Full Text].
Arness MK. Scuba decompression illness and diving fatalities in an overseas military community. Aviat Space Environ Med. 1997 Apr. 68(4):325-33. [QxMD MEDLINE Link].
Klingmann C, Gonnermann A, Dreyhaupt J, Vent J, Praetorius M, Plinkert PK. Decompression illness reported in a survey of 429 recreational divers. Aviat Space Environ Med. 2008 Feb. 79(2):123-8. [QxMD MEDLINE Link].
Eichhorn L, Leyk D. Diving medicine in clinical practice. Dtsch Arztebl Int. 2015 Feb 27. 112 (9):147-57; quiz 158. [QxMD MEDLINE Link].
Denoble PJ, Ranapurwala SI, Vaithiyanathan P, Clarke RE, Vann RD. Per-capita claims rates for decompression sickness among insured Divers Alert Network members. Undersea Hyperb Med. 2012 May-Jun. 39 (3):709-15. [QxMD MEDLINE Link].
Denoble PJ, Pollock NW, Vaithiyanathan P, Caruso JL, Dovenbarger JA, Vann RD. Scuba injury death rate among insured DAN members. Diving Hyperb Med. 2008 Dec. 38 (4):182-8. [QxMD MEDLINE Link].
Hubbard M, Davis FM, Malcolm K, Mitchell SJ. Decompression illness and other injuries in a recreational dive charter operation. Diving Hyperb Med. 2018 Dec 24. 48 (4):218-223. [QxMD MEDLINE Link].
Landsberg PG. South African underwater diving accidents, 1969-1976. S Afr Med J. 1976 Dec 25. 50(55):2155-59. [QxMD MEDLINE Link].
Denoble PJ, Caruso JL, Dear Gde L, Pieper CF, Vann RD. Common causes of open-circuit recreational diving fatalities. Undersea Hyperb Med. 2008 Nov-Dec. 35(6):393-406. [QxMD MEDLINE Link].
Tomassoni AJ. Cardiac problems associated with dysbarism. Cardiol Clin. 1995 May. 13(2):266-71. [QxMD MEDLINE Link].
Schwartz T, Gough-Fibkins S, Santini R, Kopylov D. Abdominal CT Scan Findings of Decompression Sickness: A Case Report. J Radiol Case Rep. 2018 Oct. 12 (10):17-23. [QxMD MEDLINE Link].
Reuter M, Tetzlaff K, Hutzelmann A, Fritsch G, Steffens JC, Bettinghausen E, et al. MR imaging of the central nervous system in diving-related decompression illness. Acta Radiol. 1997 Nov. 38(6):940-4. [QxMD MEDLINE Link].
Sparacia G, Banco A, Sparacia B, Midiri M, Brancatelli G, Accardi M, et al. Magnetic resonance findings in scuba diving-related spinal cord decompression sickness. MAGMA. 1997 Jun. 5(2):111-5. [QxMD MEDLINE Link].
McCormac J, Mirvis SE, Cotta-Cumba C, Shanmuganathan K. Spinal myelopathy resulting from decompression sickness: MR findings in a case and review of the literature. Emerg Radiol. 2002 Oct. 9(4):240-2. [QxMD MEDLINE Link].
Blogg SL, Loveman GA, Seddon FM, Woodger N, Koch A, Reuter M, et al. Magnetic resonance imaging and neuropathology findings in the goat nervous system following hyperbaric exposures. Eur Neurol. 2004. 52(1):18-28. [QxMD MEDLINE Link].
Gao GK, Wu D, Yang Y, Yu T, Xue J, Wang X, et al. Cerebral magnetic resonance imaging of compressed air divers in diving accidents. Undersea Hyperb Med. 2009 Jan-Feb. 36(1):33-41. [QxMD MEDLINE Link].
Chung JM, Ahn JY. Relationship between clinical and radiologic findings of spinal cord injury in decompression sickness. Undersea Hyperb Med. 2017 Jan-Feb. 44 (1):57-62. [QxMD MEDLINE Link].
Aksoy FG. MR imaging of subclinical cerebral decompression sickness. A case report. Acta Radiol. 2003 Jan. 44(1):108-10. [QxMD MEDLINE Link].
Yoshiyama M, Asamoto S, Kobayashi N, Sugiyama H, Doi H, Sakagawa H, et al. Spinal cord decompression sickness associated with scuba diving: correlation of immediate and delayed magnetic resonance imaging findings with severity of neurologic impairment--a report on 3 cases. Surg Neurol. 2007 Mar. 67(3):283-7. [QxMD MEDLINE Link].
Tetzlaff K, Friege L, Hutzelmann A, Reuter M, Holl D, Leplow B. Magnetic resonance signal abnormalities and neuropsychological deficits in elderly compressed-air divers. Eur Neurol. 1999. 42(4):194-9. [QxMD MEDLINE Link].
Hutchinson EB, Sobakin AS, Meyerand ME, Eldridge M, Ferrazzano P. Diffusion tensor MRI of spinal decompression sickness. Undersea Hyperb Med. 2013 Jan-Feb. 40(1):23-31. [QxMD MEDLINE Link]. [Full Text].
Pierce NE, Parell GJ, Jesus RO, Ojano-Dirain CP, Antonelli PJ. Magnetic resonance imaging in a guinea pig model of inner ear decompression sickness and barotrauma. Laryngoscope. 2015 Dec 9. [QxMD MEDLINE Link].
Blatteau JE, Jean F, Pontier JM, Blanche E, Bompar JM, Meaudre E. [Decompression sickness accident management in remote areas. Use of immediate in-water recompression therapy. Review and elaboration of a new protocol targeted for a mission at Clipperton atoll]. Ann Fr Anesth Reanim. 2006 Aug. 25(8):874-83. [QxMD MEDLINE Link].
Gold D, Aiyarak S, Wongcharoenyong S, Geater A, Juengprasert W, Gerth WA. The indigenous fisherman divers of Thailand: diving practices. Int J Occup Saf Ergon. 2000. 6(1):89-112. [QxMD MEDLINE Link].
Gold D, Geater A, Aiyarak S, Juengprasert W, Chuchaisangrat B, Samakkaran A. The indigenous fisherman divers of Thailand: in-water recompression. Int Marit Health. 1999. 50(1-4):39-48. [QxMD MEDLINE Link].
Gold D, Geater A, Aiyarak S, Wongcharoenyong S, Juengprasert W, Johnson M, et al. The indigenous fisherman divers of Thailand: diving-related mortality and morbidity. Int J Occup Saf Ergon. 2000. 6(2):147-67. [QxMD MEDLINE Link].
Huchim-Lara O, Chin W, Salas S, Rivera-Canul N, Cordero-Romero S, Tec J, et al. Decompression sickness among diving fishermen in Mexico: observational retrospective analysis of DCS in three sea cucumber fishing seasons. Undersea Hyperb Med. 2017 Mar-Apr. 44 (2):149-156. [QxMD MEDLINE Link].
Blatteau JE, Pontier JM, Buzzacott P, Lambrechts K, Nguyen VM, Cavenel P, et al. Prevention and treatment of decompression sickness using training and in-water recompression among fisherman divers in Vietnam. Inj Prev. 2016 Feb. 22 (1):25-32. [QxMD MEDLINE Link].
Doolette DJ, Mitchell SJ. In-water recompression. Diving Hyperb Med. 2018 Jun 30. 48 (2):84-95. [QxMD MEDLINE Link].
Naval Sea Systems Command. U.S. Navy Diving Manual. Revision 7. Washington, DC: U.S Government Printing Office; December 1, 2016. [Full Text].
Recommendations for Mouthpiece Retaining Devices for IWR. Scubaboard. Available at https://www.scubaboard.com/community/threads/recommendations-for-mouthpiece-retaining-devices-for-iwr.560671/. April 29, 2018; Accessed: February 10, 2019.
Longphre JM, Denoble PJ, Moon RE, Vann RD, Freiberger JJ. First aid normobaric oxygen for the treatment of recreational diving injuries. Undersea Hyperb Med. 2007 Jan-Feb. 34(1):43-9. [QxMD MEDLINE Link].
Bessereau J, Coulange M, Genotelle N, Barthélémy A, Michelet P, Bruguerolle B, et al. [Aspirin in decompression sickness]. Therapie. 2008 Nov-Dec. 63(6):419-23. [QxMD MEDLINE Link].
Bessereau J, Genotelle N, Brun PM, Aboab J, Antona M, Chenaitia H, et al. Decompression sickness in urban divers in France. Int Marit Health. 2012. 63(3):170-3. [QxMD MEDLINE Link].
Westerweel PE, Fijen VA, Van Hulst RA. Aspirin in the treatment of decompression sickness: what can we learn from French experience?. Int Marit Health. 2013. 64(1):51. [QxMD MEDLINE Link].
Bessereau J, Annane D. Response to letter to the editor by Westerweel et al., entitled 'aspirin in the treatment of decompression sickness: what can we learn from French experience?' [Int Marit Health 2013; 64, 1: 51]. Int Marit Health. 2013. 64(3):175. [QxMD MEDLINE Link].
Bennett MH, Lehm JP, Mitchell SJ, Wasiak J. Recompression and adjunctive therapy for decompression illness. Cochrane Database Syst Rev. 2012 May 16. 5:CD005277. [QxMD MEDLINE Link].
de Watteville G. [A critical assessment of Trendelenburg's position in the acute phase after a diving accident]. Schweiz Z Sportmed. 1993 Sep. 41(3):123-5. [QxMD MEDLINE Link].
Lippmann J, McD Taylor D, Stevenson C, Mitchell S. The demographics and diving behaviour of DAN Asia-Pacific members with and without pre-existing medical conditions. Diving Hyperb Med. 2016 Dec. 46 (4):200-206. [QxMD MEDLINE Link].
Chin W, Jacoby L, Simon O, Talati N, Wegrzyn G, Jacoby R, et al. Hyperbaric programs in the United States: Locations and capabilities of treating decompression sickness, arterial gas embolisms, and acute carbon monoxide poisoning: survey results. Undersea Hyperb Med. 2016 Jan-Feb. 43 (1):29-43. [QxMD MEDLINE Link].
Goldenberg I, Shupak A, Shoshani O. Oxy-helium treatment for refractory neurological decompression sickness: a case report. Aviat Space Environ Med. 1996 Jan. 67(1):57-60. [QxMD MEDLINE Link].
Shupak A, Melamed Y, Ramon Y, Bentur Y, Abramovich A, Kol S. Helium and oxygen treatment of severe air-diving-induced neurologic decompression sickness. Arch Neurol. 1997 Mar. 54(3):305-11. [QxMD MEDLINE Link].
Clarke D. USN Treatment Table 9. Diving Hyperb Med. 2017 Mar. 47 (1):65. [QxMD MEDLINE Link].
Tempel R, Severance HW. Proposing short-term observation units for the management of decompression illness. Undersea Hyperb Med. 2006 Mar-Apr. 33(2):89-94. [QxMD MEDLINE Link].
Kot J, Sicko Z, Michalkiewicz M, Lizak E, Góralczyk P. Recompression treatment for decompression illness: 5-year report (2003-2007) from National Centre for Hyperbaric Medicine in Poland. Int Marit Health. 2008. 59(1-4):69-80. [QxMD MEDLINE Link].
Gil A, Shupak A, Lavon H, Adir Y. [Decompression sickness in divers treated at the Israel Naval Medical Institute between the years 1992 to 1997]. Harefuah. 2000 May 1. 138(9):751-4, 806. [QxMD MEDLINE Link].
Chin W, Joo E, Ninokawa S, Popa DA, Covington DB. Efficacy of the U.S. Navy Treatment Tables in treating DCS in 103 recreational scuba divers. Undersea Hyperb Med. 2017 Sept-Oct. 44 (5):399-405. [QxMD MEDLINE Link].
Blatteau JE, Gempp E, Constantin P, Louge P. Risk factors and clinical outcome in military divers with neurological decompression sickness: influence of time to recompression. Diving Hyperb Med. 2011 Sep. 41(3):129-34. [QxMD MEDLINE Link].
Mutzbauer TS, Staps E. How delay to recompression influences treatment and outcome in recreational divers with mild to moderate neurological decompression sickness in a remote setting. Diving Hyperb Med. 2013 Mar. 43(1):42-5. [QxMD MEDLINE Link].
Hadanny A, Fishlev G, Bechor Y, Bergan J, Friedman M, Maliar A, et al. Delayed recompression for decompression sickness: retrospective analysis. PLoS One. 2015. 10 (4):e0124919. [QxMD MEDLINE Link].
Dromsky DM, Spiess BD, Fahlman A. Treatment of decompression sickness in swine with intravenous perfluorocarbon emulsion. Aviat Space Environ Med. 2004 Apr. 75(4):301-5. [QxMD MEDLINE Link].
Zhu J, Hullett JB, Somera L, Barbee RW, Ward KR, Berger BE, et al. Intravenous perfluorocarbon emulsion increases nitrogen washout after venous gas emboli in rabbits. Undersea Hyperb Med. 2007 Jan-Feb. 34(1):7-20. [QxMD MEDLINE Link].
Spahn DR. Blood substitutes. Artificial oxygen carriers: perfluorocarbon emulsions. Crit Care. 1999. 3(5):R93-7. [QxMD MEDLINE Link]. [Full Text].
Smith CR, Parsons JT, Zhu J, Spiess BD. The effect of intravenous perfluorocarbon emulsions on whole-body oxygenation after severe decompression sickness. Diving Hyperb Med. 2012 Mar. 42(1):10-7. [QxMD MEDLINE Link].
Zhang RJ, Liu K, Kang ZM, Fan DF, Ni XX, Liu Y, et al. Combined effects of intravenous perfluorocarbon emulsion and oxygen breathing on decompression-induced spinal cord injury in rats. Undersea Hyperb Med. 2011 Sep-Oct. 38(5):335-43. [QxMD MEDLINE Link].
Mahon RT, Auker CR, Bradley SG, Mendelson A, Hall AA. The emulsified perfluorocarbon Oxycyte improves spinal cord injury in a swine model of decompression sickness. Spinal Cord. 2013 Mar. 51(3):188-92. [QxMD MEDLINE Link].
Spiess BD. Perfluorocarbon emulsions as a promising technology: a review of tissue and vascular gas dynamics. J Appl Physiol. 2009 Apr. 106(4):1444-52. [QxMD MEDLINE Link].
Spiess BD, Zhu J, Pierce B, Weis R, Berger BE, Reses J, et al. Effects of perfluorocarbon infusion in an anesthetized swine decompression model. J Surg Res. 2009 May 1. 153(1):83-94. [QxMD MEDLINE Link].
Cronin WA, Senese AL, Arnaud FG, Regis DP, Auker CR, Mahon RT. The effect of the perfluorocarbon emulsion Oxycyte on platelet count and function in the treatment of decompression sickness in a swine model. Blood Coagul Fibrinolysis. 2015 Dec 8. [QxMD MEDLINE Link].
Dainer H, Nelson J, Brass K, Montcalm-Smith E, Mahon R. Short oxygen prebreathing and intravenous perfluorocarbon emulsion reduces morbidity and mortality in a swine saturation model of decompression sickness. J Appl Physiol. 2007 Mar. 102(3):1099-104. [QxMD MEDLINE Link].
Cronin WA, Hall AA, Auker CR, Mahon RT. Perfluorocarbon in Delayed Recompression with a Mixed Gender Swine Model of Decompression Sickness. Aerosp Med Hum Perform. 2018 Jan 1. 89 (1):14-18. [QxMD MEDLINE Link].
Cianci P, Slade JB Jr. Delayed treatment of decompression sickness with short, no-air-break tables: review of 140 cases. Aviat Space Environ Med. 2006 Oct. 77(10):1003-8. [QxMD MEDLINE Link].
Weisher DD. Resolution of neurological DCI after long treatment delays. Undersea Hyperb Med. 2008 May-Jun. 35(3):159-61. [QxMD MEDLINE Link].
Dunford RG, Vann RD, Gerth WA, Pieper CF, Huggins K, Wacholtz C, et al. The incidence of venous gas emboli in recreational diving. Undersea Hyperb Med. 2002. 29(4):247-59. [QxMD MEDLINE Link].
Barratt DM, Van Meter K. Decompression sickness in Miskito Indian lobster divers: review of 229 cases. Aviat Space Environ Med. 2004 Apr. 75(4):350-3. [QxMD MEDLINE Link].
MacDonald RD, O'Donnell C, Allan GM, Breeck K, Chow Y, DeMajo W. Interfacility transport of patients with decompression illness: literature review and consensus statement. Prehosp Emerg Care. 2006 Oct-Dec. 10(4):482-7. [QxMD MEDLINE Link].
Blake DF, Crowe M, Mitchell SJ, Aitken P, Pollock NW. Vibration and bubbles: a systematic review of the effects of helicopter retrieval on injured divers. Diving Hyperb Med. 2018 Dec 24. 48 (4):235-240. [QxMD MEDLINE Link].
Huchim-Lara O, Hernández-Flores A, Villanueva-Poot R, Garcia E. The cost of decompression illness: the case of lobster and sea cucumber fishery in Yucatan, Mexico. Undersea Hyperb Med. 2018 Sep-Oct. 45:531-539. [QxMD MEDLINE Link].
Bennett PB. Putting on the brakes: extra safety stops and slower ascent rates may help reduce decompression injuries. Alert Diver (Divers Alert Network). 2001. 1.
Bennett PB, Marroni A, Cronje FJ, Cali-Corleo R, Germonpre P, Pieri M, et al. Effect of varying deep stop times and shallow stop times on precordial bubbles after dives to 25 msw (82 fsw). Undersea Hyperb Med. 2007 Nov-Dec. 34(6):399-406. [QxMD MEDLINE Link].
Blatteau JE, Hugon J, Gempp E, Castagna O, Pény C, Vallée N. Oxygen breathing or recompression during decompression from nitrox dives with a rebreather: effects on intravascular bubble burden and ramifications for decompression profiles. Eur J Appl Physiol. 2012 Jun. 112(6):2257-65. [QxMD MEDLINE Link].
Jankowski LW, Tikuisis P, Nishi RY. Exercise effects during diving and decompression on postdive venous gas emboli. Aviat Space Environ Med. 2004 Jun. 75(6):489-95. [QxMD MEDLINE Link].
Dujic Z, Valic Z, Brubakk AO. Beneficial role of exercise on scuba diving. Exerc Sport Sci Rev. 2008 Jan. 36(1):38-42. [QxMD MEDLINE Link].
Dujic Z, Palada I, Obad A, Duplancic D, Bakovic D, Valic Z. Exercise during a 3-min decompression stop reduces postdive venous gas bubbles. Med Sci Sports Exerc. 2005 Aug. 37(8):1319-23. [QxMD MEDLINE Link].
O'Connor PE. The nontechnical causes of diving accidents: can U.S. Navy divers learn from other industries?. Undersea Hyperb Med. 2007 Jan-Feb. 34(1):51-9. [QxMD MEDLINE Link].
Gutvik CR, Brubakk AO. A dynamic two-phase model for vascular bubble formation during decompression of divers. IEEE Trans Biomed Eng. 2009 Mar. 56(3):884-9. [QxMD MEDLINE Link].
Mollerlokken A, Berge VJ, Jorgensen A, Wisloff U, Brubakk AO. Effect of a short-acting NO donor on bubble formation from a saturation dive in pigs. J Appl Physiol. 2006 Dec. 101(6):1541-5. [QxMD MEDLINE Link].
Dujic Z, Palada I, Valic Z, Duplancic D, Obad A, Wisløff U. Exogenous nitric oxide and bubble formation in divers. Med Sci Sports Exerc. 2006 Aug. 38(8):1432-5. [QxMD MEDLINE Link].
Madden LA, Laden G. Gas bubbles may not be the underlying cause of decompression illness - The at-depth endothelial dysfunction hypothesis. Med Hypotheses. 2009 Apr. 72(4):389-92. [QxMD MEDLINE Link].
Blatteau JE, Barre S, Pascual A, Castagna O, Abraini JH, Risso JJ, et al. Protective effects of fluoxetine on decompression sickness in mice. PLoS One. 2012. 7(11):e49069. [QxMD MEDLINE Link]. [Full Text].
Cosnard C, De Maistre S, Abraini JH, Chazalviel L, Blatteau JE, Risso JJ, et al. Thirty-five Day Fluoxetine Treatment Limits Sensory-Motor Deficit and Biochemical Disorders in a Rat Model of Decompression Sickness. Front Physiol. 2017. 8:604. [QxMD MEDLINE Link].
Blatteau JE, de Maistre S, Lambrechts K, Abraini J, Risso JJ, Vallée N. Fluoxetine stimulates anti-inflammatory IL-10 cytokine production and attenuates sensory deficits in a rat model of decompression sickness. J Appl Physiol (1985). 2015 Dec 15. 119 (12):1393-9. [QxMD MEDLINE Link].
Zhang K, Wang D, Xu J, Li R, Cai Z, Liu K, et al. Simvastatin decreases incidence of decompression sickness in rats. Undersea Hyperb Med. 2015 Mar-Apr. 42 (2):115-23. [QxMD MEDLINE Link].
Dujic Z, Obad A, Palada I, Ivancev V, Valic Z. Venous bubble count declines during strenuous exercise after an open sea dive to 30 m. Aviat Space Environ Med. 2006 Jun. 77(6):592-6. [QxMD MEDLINE Link].
Wisløff U, Brubakk AO. Aerobic endurance training reduces bubble formation and increases survival inrats exposed to hyperbaric pressure. J Physiol. 2001 Dec 1. 537(Pt 2):607-11. [QxMD MEDLINE Link].
Dujic Z, Duplancic D, Marinovic-Terzic I, Bakovic D, Ivancev V, Valic Z, et al. Aerobic exercise before diving reduces venous gas bubble formation in humans. J Physiol. 2004 Mar 16. 555(Pt 3):637-42. [QxMD MEDLINE Link].
Loset A Jr, Mollerlokken A, Berge V, Wisloff U, Brubakk AO. Post-dive bubble formation in rats: effects of exercise 24 h ahead repeated 30min before the dive. Aviat Space Environ Med. 2006 Sep. 77(9):905-8. [QxMD MEDLINE Link].
Berge VJ, Jørgensen A, Løset A, Wisløff U, Brubakk AO. Exercise ending 30 min pre-dive has no effect on bubble formation in the rat. Aviat Space Environ Med. 2005 Apr. 76(4):326-8. [QxMD MEDLINE Link].
Blatteau JE, Boussuges A, Gempp E, Pontier JM, Castagna O, Robinet C, et al. Haemodynamic changes induced by submaximal exercise before a dive and its consequences on bubble formation. Br J Sports Med. 2007 Jun. 41(6):375-9. [QxMD MEDLINE Link].
Pendergast DR, Senf C, Lundgren CE. Is the rate of whole-body nitrogen elimination influenced by exercise?. Undersea Hyperb Med. 2012 Jan-Feb. 39(1):595-604. [QxMD MEDLINE Link].
Gennser M, Jurd KM, Blogg SL. Pre-dive exercise and post-dive evolution of venous gas emboli. Aviat Space Environ Med. 2012 Jan. 83(1):30-4. [QxMD MEDLINE Link].
Wisløff U, Richardson RS, Brubakk AO. Exercise and nitric oxide prevent bubble formation: a novel approach to the prevention of decompression sickness?. J Physiol. 2004 Mar 16. 555:825-9. [QxMD MEDLINE Link].
Wisløff U, Richardson RS, Brubakk AO. NOS inhibition increases bubble formation and reduces survival in sedentary but not exercised rats. J Physiol. 2003 Jan 15. 546:577-82. [QxMD MEDLINE Link].
Pontier JM, Guerrero F, Castagna O. Bubble formation and endothelial function before and after 3 months of dive training. Aviat Space Environ Med. 2009 Jan. 80(1):15-9. [QxMD MEDLINE Link].
Qing L, Yi HJ, Wang YW, Zhou Q, Ariyadewa DK, Xu WG. Benefits of hyperbaric oxygen pretreatment for decompression sickness in Bama pigs. J Exp Biol. 2018 Mar 7. 221 (Pt 5):[QxMD MEDLINE Link].
Castagna O, Gempp E, Blatteau JE. Pre-dive normobaric oxygen reduces bubble formation in scuba divers. Eur J Appl Physiol. 2009 May. 106(2):167-72. [QxMD MEDLINE Link].
Mahon RT, Dainer HM, Gibellato MG, Soutiere SE. Short oxygen prebreathe periods reduce or prevent severe decompression sickness in a 70-kg swine saturation model. J Appl Physiol. 2009 Apr. 106(4):1459-63. [QxMD MEDLINE Link].
Sobakin AS, Wilson MA, Lehner CE, Dueland RT, Gendron-Fitzpatrick AP. Oxygen pre-breathing decreases dysbaric diseases in UW sheep undergoing hyperbaric exposure. Undersea Hyperb Med. 2008 Jan-Feb. 35(1):61-7. [QxMD MEDLINE Link].
Wang FF, Fang YQ, You P, Bao XC, Ma J, Zhang S. [Effect of different pressure oxygen pre-breathe in diving decompression sickness of rats]. Zhongguo Ying Yong Sheng Li Xue Za Zhi. 2015 Sep. 31 (5):401-4. [QxMD MEDLINE Link].
Zhang R, Yu Y, Manaenko A, Bi H, Zhang N, Zhang L, et al. Effect of helium preconditioning on neurological decompression sickness in rats. J Appl Physiol (1985). 2019 Jan 17. [QxMD MEDLINE Link].
Blatteau JE, Gempp E, Balestra C, Mets T, Germonpre P. Predive sauna and venous gas bubbles upon decompression from 400 kPa. Aviat Space Environ Med. 2008 Dec. 79(12):1100-5. [QxMD MEDLINE Link].
Fismen L, Hjelde A, Svardal AM, Djurhuus R. Differential effects on nitric oxide synthase, heat shock proteins and glutathione in human endothelial cells exposed to heat stress and simulated diving. Eur J Appl Physiol. 2012 Jul. 112(7):2717-25. [QxMD MEDLINE Link].
Ni XX, Ni M, Fan DF, Sun Q, Kang ZM, Cai ZY, et al. Heat-shock protein 70 is involved in hyperbaric oxygen preconditioning on decompression sickness in rats. Exp Biol Med (Maywood). 2013 Jan. 238(1):12-22. [QxMD MEDLINE Link].
Balestra C, Theunissen S, Papadopoulou V, Le Mener C, Germonpré P, Guerrero F, et al. Pre-dive Whole-Body Vibration Better Reduces Decompression-Induced Vascular Gas Emboli than Oxygenation or a Combination of Both. Front Physiol. 2016. 7:586. [QxMD MEDLINE Link].
Germonpré P, Balestra C. Preconditioning to Reduce Decompression Stress in Scuba Divers. Aerosp Med Hum Perform. 2017 Feb 1. 88 (2):114-120. [QxMD MEDLINE Link].
Madden D, Thom SR, Dujic Z. Exercise before and after SCUBA diving and the role of cellular microparticles in decompression stress. Med Hypotheses. 2016 Jan. 86:80-4. [QxMD MEDLINE Link].
Candito M, Candito E, Chatel M, van Obberghen E, Dunac A. [Homocysteinemia and thrombophilic factors in unexplained decompression sickness]. Rev Neurol (Paris). 2006 Sep. 162(8-9):840-4. [QxMD MEDLINE Link].
Candito M, Chatel M, Candito E, Lapoussiere M, Mengual R, Van Obberghen E, et al. [Thrombophilic factors in divers with undeserved decompression sickness]. Pathol Biol (Paris). 2006 Apr. 54(3):155-8. [QxMD MEDLINE Link].
Eftedal OS, Lydersen S, Brubakk AO. The relationship between venous gas bubbles and adverse effects of decompression after air dives. Undersea Hyperb Med. 2007 Mar-Apr. 34(2):99-105. [QxMD MEDLINE Link].
Tufan K, Ademoglu A, Kurtaran E, Yildiz G, Aydin S, Egi SM. Automatic detection of bubbles in the subclavian vein using Doppler ultrasound signals. Aviat Space Environ Med. 2006 Sep. 77(9):957-62. [QxMD MEDLINE Link].
Hugon J, Metelkina A, Barbaud A, Nishi R, Bouak F, Blatteau JE, et al. Reliability of venous gas embolism detection in the subclavian area for decompression stress assessment following scuba diving. Diving Hyperb Med. 2018 Sep 30. 48 (3):132-140. [QxMD MEDLINE Link].
Ball R, Schwartz SL. Kinetic and dynamic models of diving gases in decompression sickness prevention. Clin Pharmacokinet. 2002. 41(6):389-402. [QxMD MEDLINE Link].
Brubakk AO, Arntzen AJ, Wienke BR, Koteng S. Decompression profile and bubble formation after dives with surface decompression: experimental support for a dual phase model of decompression. Undersea Hyperb Med. 2003. 30(3):181-93. [QxMD MEDLINE Link].
Montcalm-Smith E, Caviness J, Chen Y, McCarron RM. Stress biomarkers in a rat model of decompression sickness. Aviat Space Environ Med. 2007 Feb. 78(2):87-93. [QxMD MEDLINE Link].
Lemeshchenko GP, Isaeva NM. [A toxicological evaluation of micromycetes isolated from salmon roe]. Mikrobiol Zh. 1990 Mar-Apr. 52(2):66-9. [QxMD MEDLINE Link].
Kondo Y, Shiohira S, Kamizato K, Teruya K, Fuchigami T, Kakinohana M, et al. Vascular hyperpermeability in pulmonary decompression illness: 'the chokes'. Emerg Med Australas. 2012 Aug. 24(4):460-2. [QxMD MEDLINE Link].
Gempp E, Morin J, Louge P, Blatteau JE. Reliability of plasma D-dimers for predicting severe neurological decompression sickness in scuba divers. Aviat Space Environ Med. 2012 Aug. 83(8):771-5. [QxMD MEDLINE Link].
Blatteau JE, David HN, Vallée N, Meckler C, Demaistre S, Lambrechts K, et al. Xenon Blocks Neuronal Injury Associated with Decompression. Sci Rep. 2015 Oct 15. 5:15093. [QxMD MEDLINE Link].
Wright PJ. Comparison of phosphodiesterase type 5 (PDE5) inhibitors. Int J Clin Pract. 2006 Aug. 60(8):967-75. [QxMD MEDLINE Link].
Koopsen R, Stella PR, Thijs KM, Rienks R. Persistent foramen ovale closure in divers with a history of decompression sickness. Neth Heart J. 2018 Nov. 26 (11):535-539. [QxMD MEDLINE Link].
Gempp E, Louge P, Blatteau JE, Hugon M. Risks factors for recurrent neurological decompression sickness in recreational divers: a case-control study. J Sports Med Phys Fitness. 2012 Oct. 52(5):530-6. [QxMD MEDLINE Link].
Attaran RR, Ata I, Kudithipudi V, Foster L, Sorrell VL. Protocol for optimal detection and exclusion of a patent foramen ovale using transthoracic echocardiography with agitated saline microbubbles. Echocardiography. 2006 Aug. 23 (7):616-22. [QxMD MEDLINE Link].
Woods TD, Patel A. A critical review of patent foramen ovale detection using saline contrast echocardiography: when bubbles lie. J Am Soc Echocardiogr. 2006 Feb. 19 (2):215-22. [QxMD MEDLINE Link].
Tsivgoulis G, Stamboulis E, Sharma VK, Heliopoulos I, Voumvourakis K, Teoh HL, et al. Safety of transcranial Doppler 'bubble study' for identification of right to left shunts: an international multicentre study. J Neurol Neurosurg Psychiatry. 2011 Nov. 82 (11):1206-8. [QxMD MEDLINE Link].
Smart D, Mitchell S, Wilmshurst P, Turner M, Banham N. Joint position statement on persistent foramen ovale (PFO) and diving. South Paciﬁc Underwater Medicine Society (SPUMS) and the United Kingdom Sports Diving Medical Committee (UKSDMC). Diving Hyperb Med. 2015 Jun. 45 (2):129-31. [QxMD MEDLINE Link].
Wilmshurst PT. The role of persistent foramen ovale and other shunts in decompression illness. Diving Hyperb Med. 2015 Jun. 45 (2):98-104. [QxMD MEDLINE Link].
Sheffield Paul, Vann R (ed.). Flying After Diving Workshop Proceedings. Durham, NC: Divers Alert Network; 2004. [Full Text].
Brebeck AK, Deussen A, Range U, Balestra C, Cleveland S, Schipke JD. Beneficial effect of enriched air nitrox on bubble formation during scuba diving. An open-water study. J Sports Sci. 2018 Mar. 36 (6):605-612. [QxMD MEDLINE Link].
Klingmann C, Rathmann N, Hausmann D, Bruckner T, Kern R. Lower risk of decompression sickness after recommendation of conservative decompression practices in divers with and without vascular right-to-left shunt. Diving Hyperb Med. 2012 Sep. 42(3):146-50. [QxMD MEDLINE Link].
Torp KD, Murphy-Lavoie HM. Diving, Return To Diving. StatPearls. 2018 Jan. [QxMD MEDLINE Link]. [Full Text].

Media Gallery

Illustration of Dalton gas law. As an individual descends, the total pressure of breathing air increases and the partial pressures of the individual components have to increase proportionally. Nitrogen at higher partial pressures alters the electrical properties of cerebral cellular membranes, causing an anesthetic effect. Oxygen at higher partial pressures can cause CNS oxygen toxicity.
Illustration of Henry gas law. If nitrogen is added to a bottle, it diffuses into and equilibrates with the fluid. With a sudden release of pressure (decreased), such as when an individual ascends rapidly, a lag occurs before nitrogen can diffuse back to the nonfluid space. This delay causes nitrogen to bubble while still in the fluid.

of 2

Decompression Sickness Workup

Laboratory Studies