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Scuba Diving, the Bends, and Hyperbaric Oxygenation
Decompression sickness (DCS; also known as divers' disease, the bends or caisson disease) describes a condition arising from dissolved gases coming out of solution into bubbles inside the body on depressurisation. DCS most commonly refers to a specific type of underwater diving hazard, but may be experienced in other depressurization events such as caisson working, flying in unpressurized aircraft, and extra-vehicular activity from spacecraft.
Hyperbaric medicine, also known as hyperbaric oxygen therapy (HBOT), is the medical use of oxygen at a level higher than atmospheric pressure. The equipment required consists of a pressure chamber, as seen in Figure 1, which may be of rigid or flexible construction and a means of delivering 100% oxygen. The operation is performed to a predetermined schedule by trained personnel who monitor the patient and may adjust the schedule as required. HBOT found early use in the treatment of decompression sickness but it has also shown great effectiveness in treating conditions such as gas gangrene and carbon monoxide poisoning. More recent research has examined the possibility that it may also have value for other conditions such as cerebral palsy and multiple sclerosis, but no significant evidence has been found.
Several therapeutic principles are made use of in HBOT. The increased overall pressure is of therapeutic value when HBOT is used in the treatment of decompression sickness and air embolism. For many other conditions, the therapeutic principle of HBOT lies in its ability to drastically increase partial pressure of oxygen in the tissues of the body. The oxygen partial pressures achievable using HBOT are much higher than those achievable while breathing pure oxygen at normobaric conditions (i.e. at normal atmospheric pressure). A related effect is the increased oxygen transport capacity of the blood. Under normal atmospheric pressure, oxygen transport is limited by the oxygen binding capacity of hemoglobin in red blood cells and very little oxygen is transported by blood plasma. Because the hemoglobin of the red blood cells is almost saturated with oxygen under atmospheric pressure, this route of transport cannot be exploited any further. Oxygen transport by plasma, however, is significantly increased using HBOT as the stimulus. Recent evidence notes that exposure to hyperbaric oxygen (HBOT) mobilizes stem/progenitor cells from the bone marrow by a nitric oxide (·NO) -dependent mechanism. This mechanism may account for the patient cases that suggest recovery of damaged organs and tissues with HBOT.
HBOT was developed as a treatment for diving disorders involving bubbles of gas in the tissues, such as decompression sickness and gas embolism. The chamber cures decompression sickness and gas embolism by increasing pressure, reducing the size of the gas bubbles, and improving the transport of blood to downstream tissues. The high concentrations of oxygen in the tissues are beneficial in keeping oxygen-starved tissues alive, and have the effect of removing the nitrogen from the bubble, making it smaller until it consists only of oxygen, which is re-absorbed into the body. After elimination of bubbles, the pressure is gradually reduced back to atmospheric levels.
An HBOT treatment for longer-term conditions is often a series of 20 to 40 dives, or compressions. Again, these dives last for about an hour and can be administered via a hard, high-pressure chamber or a soft, low-pressure chamber - the major difference being per-dive "dose" of oxygen. Many conditions do quite well with the lower dose, lower cost-per-hour, soft chambers. Emergency HBOT for decompression illness follows treatment schedules laid out in treatment tables. Most cases employ a recompression to 2.8 bars (41 psi) absolute, the equivalent of 18 meters (60 ft) of water, for 4.5 to 5.5 hours with the casualty breathing pure oxygen, but taking air breaks every 20 minutes to reduce oxygen toxicity. For extremely serious cases resulting from very deep dives, the treatment may require a chamber capable of a maximum pressure of eight bars (120 psi), the equivalent of 70 meters (230 ft) of water, and the ability to supply heliox as a breathing gas.
Decompression sickness describes a condition arising from dissolved gases coming out of solution into bubbles inside the body on depressurization. DCS most commonly refers to a specific type of underwater diving hazard, but may be experienced in other depressurization events such as caisson working, flying in unpressurized aircraft, and extra-vehicular activity from spacecraft. Since bubbles can form in or migrate to any part of the body, DCS can produce many symptoms, and its effects may vary from joint pain and rashes to paralysis and death. Individual susceptibility can vary from day to day, and different individuals under the same conditions may be affected differently or not at all. The classification of types of DCS by its symptoms has evolved since its original description over a hundred years ago. Although DCS is not a common event, its potential severity is such that much research has gone into preventing it, and underwater divers use dive tables or dive computers to set limits on their exposure to pressure and their ascent speed. Treatment is by hyperbaric oxygen therapy in a recompression chamber. If treated early, there is a significantly higher chance of successful recovery.
increased pressure reduces size of carbon monoxide gas bubbles in blood, delivers 100% oxygen in pressure chamber, higher pressure increases oxygen transport in blood plasma, or increased pressure reduces size of nitrogen gas bubbles in blood