Collapsed Lung Underwater

[nitroxbabe]

clownfish301 once bubbled...
I had a case of spontaenous pneumothorax about 7-8 years ago.

I'm about to get a complete physical before I get certified this month, but should I even consider diving because of my past medical history?

Now I'm kinda worried.

You should definately check with DAN, but all the PADI literature states that a history of spontaneous pneumothorax is an absolute contradiction to diving. It's a great sport, but it's not worth your life.

 

[dlegros]

Correct me if I'm wrong, but doesnt a pneumothorax underwater have a tendency to become a tension pneumothorax on ascent?

Dom

 

[pufferfish]

There was a case a few years back of a urologist treating his own pneumothorax while flying as a passenger at 33,000 feet. I am not sure whether this was a spontaneous which converted to a tension or how the guy diagnosed it but in the end with a coat hanger, catheter, and a jar of water he inserted his own chest tube, created underwater drainage, and lived to tell the story.

This unfortunate lady likely ruptured a bleb at depth and had a normal stable spontaneuous pneumothorax as long as she didn't ascend. On land this is a daily occurance in any large ER. A chest tube goes in and depending on the size of the pneumo the patient is home in a day or two. A spontaneous becoming a tension pneumo on land is usually from trauma (rib punctures lung, stabbing, etc.) or from problems with positive pressure ventilation.

The problem in diving is if the bleb ruptures at depth then on ascent the air in the intrapleural space (between lung and chest wall) begins to expand compressing the same side lung initially and eventually with enough expansion of the air mass the lung on the other side is compressed as are all the great vessels carrying the blood to and from the heart. Hypoxia ensues, the venous return to the heart is reduced, and the patient dies.

Recognizing a tension pneumo on land is not easy at the best of times and is a true medical emergency, and in the water I would say diagnosis and treatment impossible. Once back on the boat only the most astute diving doc or paramedic might recognize what had happened but then to treat the problem would have to have a large bore needle on hand and stick this in the chest on the affected side so as to allow the air to escape. Only then would further resuscitation likely to be successful.

This is why a history of a previous spontaneous pneumothorax still remains an absolute contraindication to diving. Recurrence of the spontaneous pneumo does happen from time to time and if in a diver almost surely to result in a death.

 

[bridgediver]

dlegros once bubbled...
Correct me if I'm wrong, but doesnt a pneumothorax underwater have a tendency to become a tension pneumothorax on ascent?

Dom

Dom,
You are correct. This is exactly what the earlier posters have been describing, they just haven't thrown in the medical terms.

FWIW, any pneumo where the space between the lung and chest wall (pleural space) has an opening to the inside of the lung can become a tension pneumo, especially if the chest wall is intact. An ascent from depth would make this already bad situation worse.

 

[clownfish301]

man this really sucks.... I really want to scuba and this pneumo occurrance nearly a decade ago is probably gonna nuke this idea.

and it's not like I can do anything about it (train harder, dive differently, etc.) it's pretty much SOL for me. damn, I feel broken.

gosh... this really bums me out. I'm gonna go get a physical anyways but I'm pretty sure the stuff you guys get to see, I'll just have to watch on TV.

have fun diving folks...

 

[dlegros]

bridgediver once bubbled...


Dom,
You are correct. This is exactly what the earlier posters have been describing, they just haven't thrown in the medical terms.

FWIW, any pneumo where the space between the lung and chest wall (pleural space) has an opening to the inside of the lung can become a tension pneumo, especially if the chest wall is intact. An ascent from depth would make this already bad situation worse.

Thanks bridge,

I've been out of emergency for 2 years now, and I like to try and stop too much info from oozing out of my ears

Dom

 

[The Iceni]

pufferfish once bubbled...
There was a case a few years back of a urologist treating his own pneumothorax while flying as a passenger at 33,000 feet. I am not sure whether this was a spontaneous which converted to a tension or how the guy diagnosed it but in the end with a coat hanger, catheter, and a jar of water he inserted his own chest tube, created underwater drainage, and lived to tell the story.

Not quite true, Pufferfish. Everything you say is right apart from the fact that he treated himself. It was a British urologist who treated a lady transatlantic airline passenger with the instruments you describe. He was awarded a medal by the Royal Humane Society.

Not to detract from what pufferfish has posted I would just like to clarify the picture a bit more, if I can;-

A pneumothorax describes any sitution when air has found its way between the lung and chest wall (pneumo = air, thorax = chest) and is most commonly seen in in patients with emphysema, although spontaneous pneumothorax is occassionally seen in tall, fit young men. In these cases the cause is a tear in the lung tissue and is internal.

The second main cause, indeed, is a traumatic pneumothorax, such as a stab wound, or a bullet wound, to the chest. In these cases the air can find its way into the pleural space via the chest wall itself but as with a popped emphysematous bulla, does not always do so.

A tension pneumothorax describes the situation when the pressure (= tension) of the gas between the chest wall and the lungs increases and becomes excessive. In the case of a traumatic "sucking wound of the chest" or any internal tear in the lung tissue, a tension pneumothorax only develops on the surface if architecture of the tear itself acts like a flap valve allowing air into the cavity but not out. In such cases the patient blows up the baloon in his chest at each breath and gradually experiences increasing difficulty in breathing . In addition his circulation will eventually be compromised since the pressure within the chest wall can eventually exceed the pressure of venous return.

It is obvious that any pneumothorax developing underwater will inevitably become a tension pneumothorax because of the rapid, relative, increase in pressure within the chest wall produced by the ascent, without the need for any more gas molecules to enter it.

If you consider how hard a car tyre is when inflated to 25 psi (the pressure at about 15 fsw?) it is not difficult to imaging how rapidly fatal any pneumothorax in any diver would be. The instant cure is to "burst the balloon". Hence the use of chest drains in ERs.

I always carried a 14g (wide bore) needle with me on every diving trip. Pleuroscentesis or needle thoracostomy being the jargon name for this procedure.

 

[bridgediver]

dlegros once bubbled...


Thanks bridge,

I've been out of emergency for 2 years now, and I like to try and stop too much info from oozing out of my ears

Dom

No problem Dom.

I just noticed in your profile that you're familiar with med stuff - didn't mean to overly simplify for you, sorry.

Maybe helpful to other readers though?

 

[Genesis]

If you consider how hard a car tyre is when inflated to 25 psi (the pressure at about 15 fsw?) it is not difficult to imaging how rapidly fatal any pneumothorax in any diver would be.

1 atm is 14.7 psi, and is roughly equal to 33' of sea water.

However, your maximum inhalation or exhalation pressure that you can generate with the diaphram is only a couple of psi. As such even a 5' change in depth (upwardS) is probably enough to hose you, and certainly a full atmosphere of pressure change is likely enough to do fatal damage, even if the pressure can be quickly relieved on the surface.

 

[pufferfish]

Dr Paul Thomas once bubbled...
Not quite true, Pufferfish. Everything you say is right apart from the fact that he treated himself. It was a British urologist who treated a lady transatlantic airline passenger with the instruments you describe. He was awarded a medal by the Royal Humane Society.

Not to detract from what pufferfish has posted I would just like to clarify the picture a bit more, if I can;-

Snipped

I always carried a 14g (wide bore) needle with me on every diving trip. Pleuroscentesis or needle thoracostomy being the jargon name for this procedure.

Paul good to see you back on the board. You know I searched high and low for that story as it had stuck in my head. I think it was a flight out of Hong Kong. My bad for the self treatment error, but still a pretty good feat for a urologist I must say. I know they like to slide tubes into things but usually not the pleural space

Now tell me have you ever seen, heard of, or done a needle thoracostomy on a diver with a tension pneumo? Since they would not be breathing in most cases after ascending and unconscious with no pulse, the decreased ventilation would be missed assuming you had a stethoscope with you to check. That tracheal deviation sign is not always there. I guess the increased JVP might be the tip off assuming no tight wet suit. I guess if one thinks of it and there are the signs then the old 14 gauge would be the thing to do. Then you got to get them a chest tube though if they come around. Not my idea of a fun dive.
Pufferfish