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Semin Respir Crit Care Med 2023; 44(05): 705-718
DOI: 10.1055/s-0043-1770065
Review Article

Pulmonary Physiology and Medicine of Diving

Kay Tetzlaff
1   Department of Sports Medicine, University Hospital of Tuebingen, Tuebingen, Germany
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Abstract

Pulmonary physiology is significantly altered during underwater exposure, as immersion of the body and increased ambient pressure elicit profound effects on both the cardiovascular and respiratory systems. Thoracic blood pooling, increased breathing gas pressures, and variations in gas volumes alongside ambient pressure changes put the heart and lungs under stress. Normal physiologic function and fitness of the cardiovascular and respiratory systems are prerequisites to safely cope with the challenges of the underwater environment when freediving, or diving with underwater breathing apparatus. Few physicians are trained to understand the physiology and medicine of diving and how to recognize or manage diving injuries. This article provides an overview of the physiologic challenges to the respiratory system during diving, with or without breathing apparatus, and outlines possible health risks and hazards unique to the underwater environment. The underlying pathologic mechanisms of dive-related injuries are reviewed, with an emphasis on pulmonary physiology and pathophysiology.

Keywords

breath-hold diving - immersion - scuba-diving - glossopharyngeal insufflation - decompression illness - pulmonary barotrauma - pulmonary edema - arterial gas embolism


Publication History

Article published online:
27 June 2023

© 2023. Thieme. All rights reserved.

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  • References

  • 1 Number of participants in scuba diving in the United States from 2006 to 2020. Accessed April 20, 2023 at: https://www.statista.com/statistics/191304/participants-in-scuba-diving-in-the-us-since-2006/
    PubMed
  • 2 Competitive freediving. Accessed April 20, 2023 at: https://usafreediving.com/competitive-freediving/
    PubMed
  • 3 Tillmans F. ed. DAN Annual Diving Report 2020 Edition - A Report on 2018 Diving Fatalities, Injuries, and Incidents. Durham, NC: Divers Alert Network; 2020
  • 4 Vann RD, Lang MA. eds. Recreational Diving Fatalities. Proceedings of the Divers Alert Network 2010 April 8–10. Workshop. Durham, NC: Divers Alert Network; 2011
  • 5 Bove AA. Diving medicine. Am J Respir Crit Care Med 2014; 189 (12) 1479-1486
    CrossrefPubMedGoogle Scholar
  • 6 British Thoracic Society Fitness to Dive Group, Subgroup of the British Thoracic Society Standards of Care Committee. British Thoracic Society guidelines on respiratory aspects of fitness for diving. Thorax 2003; 58 (01) 3-13
    CrossrefPubMedGoogle Scholar
  • 7 Arborelius Jr M, Ballidin UI, Lilja B, Lundgren CE. Hemodynamic changes in man during immersion with the head above water. Aerosp Med 1972; 43 (06) 592-598
    PubMedGoogle Scholar
  • 8 Pendergast DR, Lundgren CE. The underwater environment: cardiopulmonary, thermal, and energetic demands. J Appl Physiol 2009; 106 (01) 276-283
    CrossrefPubMedGoogle Scholar
  • 9 Prefaut C, Lupi-h E, Anthonisen NR. Human lung mechanics during water immersion. J Appl Physiol 1976; 40 (03) 320-323
    CrossrefPubMedGoogle Scholar
  • 10 Guyatt AR, Newman F, Cinkotai FF, Palmer JI, Thomson ML. Pulmonary diffusing capacity in man during immersion in water. J Appl Physiol 1965; 20 (05) 878-881
    CrossrefPubMedGoogle Scholar
  • 11 Foster GE, Sheel AW. The human diving response, its function, and its control. Scand J Med Sci Sports 2005; 15 (01) 3-12
    CrossrefPubMedGoogle Scholar
  • 12 Heusser K, Dzamonja G, Tank J. et al. Cardiovascular regulation during apnea in elite divers. Hypertension 2009; 53 (04) 719-724
    CrossrefPubMedGoogle Scholar
  • 13 Eichhorn L, Erdfelder F, Kessler F. et al. Influence of apnea-induced hypoxia on catecholamine release and cardiovascular dynamics. Int J Sports Med 2017; 38 (02) 85-91
    PubMedGoogle Scholar
  • 14 Joulia F, Lemaitre F, Fontanari P, Mille ML, Barthelemy P. Circulatory effects of apnoea in elite breath-hold divers. Acta Physiol (Oxf) 2009; 197 (01) 75-82
    CrossrefPubMedGoogle Scholar
  • 15 Eichhorn L, Doerner J, Luetkens JA. et al. Cardiovascular magnetic resonance assessment of acute cardiovascular effects of voluntary apnoea in elite divers. J Cardiovasc Magn Reson 2018; 20 (01) 40
    CrossrefPubMedGoogle Scholar
  • 16 Costalat G, Coquart J, Castres I. et al. The oxygen-conserving potential of the diving response: a kinetic-based analysis. J Sports Sci 2017; 35 (07) 678-687
    CrossrefPubMedGoogle Scholar
  • 17 Perini R, Tironi A, Gheza A, Butti F, Moia C, Ferretti G. Heart rate and blood pressure time courses during prolonged dry apnoea in breath-hold divers. Eur J Appl Physiol 2008; 104 (01) 1-7
    CrossrefPubMedGoogle Scholar
  • 18 Olsen CR, Fanestil DD, Scholander PF. Some effects of apneic underwater diving on blood gases, lactate, and pressure in man. J Appl Physiol 1962; 17: 938-942
    CrossrefPubMedGoogle Scholar
  • 19 Scholander PF, Hammel HT, Lemessurier H, Hemmingsen E, Garey W. Circulatory adjustment in pearl divers. J Appl Physiol 1962; 17: 184-190
    CrossrefPubMedGoogle Scholar
  • 20 Hansel J, Solleder I, Gfroerer W. et al. Hypoxia and cardiac arrhythmias in breath-hold divers during voluntary immersed breath-holds. Eur J Appl Physiol 2009; 105 (05) 673-678
    CrossrefPubMedGoogle Scholar
  • 21 Ferrigno M, Grassi B, Ferretti G. et al. Electrocardiogram during deep breath-hold dives by elite divers. Undersea Biomed Res 1991; 18 (02) 81-91
    PubMedGoogle Scholar
  • 22 Ferrigno M, Ferretti G, Ellis A. et al. Cardiovascular changes during deep breath-hold dives in a pressure chamber. J Appl Physiol 1997; 83 (04) 1282-1290
    CrossrefPubMedGoogle Scholar
  • 23 Lindholm P, Lundgren CEG. The physiology and pathophysiology of human breath-hold diving. J Appl Physiol 2009; 106 (01) 284-292
    CrossrefPubMedGoogle Scholar
  • 24 AIDA official World Records History. World Records. Accessed April 20, 2023 at: https://www.aidainternational.org/WorldRecords/History
    PubMed
  • 25 Agostoni E. Limitation to depths of diving mechanics of chest wall. In: Rahn H, Yokoyama T, eds. Physiology of Breath-Hold Diving and the Ama of Japan. Washington, DC: National Academy of Sciences; 1965: 139-145
  • 26 Craig Jr AB. Depth limits of breath hold diving (an example of Fennology). Respir Physiol 1968; 5 (01) 14-22
    CrossrefPubMedGoogle Scholar
  • 27 Schaefer KE, Allison RD, Dougherty Jr JHJ. et al. Pulmonary and circulatory adjustments determining the limits of depths in breathhold diving. Science 1968; 162 (3857): 1020-1023
    CrossrefPubMedGoogle Scholar
  • 28 Dail CW. “Glossopharyngeal breathing” by paralyzed patients; a preliminary report. Calif Med 1951; 75 (03) 217-218
    PubMedGoogle Scholar
  • 29 Bach JR, Bianchi C, Vidigal-Lopes M, Turi S, Felisari G. Lung inflation by glossopharyngeal breathing and “air stacking” in Duchenne muscular dystrophy. Am J Phys Med Rehabil 2007; 86 (04) 295-300
    CrossrefPubMedGoogle Scholar
  • 30 Bach JR, Tewfik G. Air doping: an exposé on “frog” insufflation in competitive sports. Am J Phys Med Rehabil 2007; 86 (04) 301-303
    CrossrefPubMedGoogle Scholar
  • 31 Muth CM, Radermacher P, Pittner A. et al. Arterial blood gases during diving in elite apnea divers. Int J Sports Med 2003; 24 (02) 104-107
    Article in Thieme ConnectPubMedGoogle Scholar
  • 32 Nygren-Bonnier M, Gullstrand L, Klefbeck B, Lindholm P. Effects of glossopharyngeal pistoning for lung insufflation in elite swimmers. Med Sci Sports Exerc 2007; 39 (05) 836-841
    CrossrefPubMedGoogle Scholar
  • 33 Tetzlaff K, Scholz T, Walterspacher S. et al. Characteristics of the respiratory mechanical and muscle function of competitive breath-hold divers. Eur J Appl Physiol 2008; 103 (04) 469-475
    CrossrefPubMedGoogle Scholar
  • 34 Eichinger M, Walterspacher S, Scholz T. et al; Breath-hold Diving Study Group of Baden-Württemberg. Lung hyperinflation: foe or friend?. Eur Respir J 2008; 32 (04) 1113-1116
    CrossrefPubMedGoogle Scholar
  • 35 Lindholm P, Nyrén S. Studies on inspiratory and expiratory glossopharyngeal breathing in breath-hold divers employing magnetic resonance imaging and spirometry. Eur J Appl Physiol 2005; 94 (5–6): 646-651
    CrossrefPubMedGoogle Scholar
  • 36 Overgaard K, Friis S, Pedersen RB, Lykkeboe G. Influence of lung volume, glossopharyngeal inhalation and P(ET) O2 and P(ET) CO2 on apnea performance in trained breath-hold divers. Eur J Appl Physiol 2006; 97 (02) 158-164
    CrossrefPubMedGoogle Scholar
  • 37 Seccombe LM, Rogers PG, Mai N, Wong CK, Kritharides L, Jenkins CR. Features of glossopharyngeal breathing in breath-hold divers. J Appl Physiol 2006; 101 (03) 799-801
    CrossrefPubMedGoogle Scholar
  • 38 Loring SH, O'Donnell CR, Butler JP, Lindholm P, Jacobson F, Ferrigno M. Transpulmonary pressures and lung mechanics with glossopharyngeal insufflation and exsufflation beyond normal lung volumes in competitive breath-hold divers. J Appl Physiol 2007; 102 (03) 841-846
    CrossrefPubMedGoogle Scholar
  • 39 Seccombe LM, Chung SCS, Jenkins CR. et al. Lung perfusion and chest wall configuration is altered by glossopharyngeal breathing. Eur Respir J 2010; 36 (01) 151-156
    CrossrefPubMedGoogle Scholar
  • 40 Nygren-Bonnier M, Lindholm P, Markström A, Skedinger M, Mattsson E, Klefbeck B. Effects of glossopharyngeal pistoning for lung insufflation on vital capacity in healthy women. Am J Phys Med Rehabil 2007; 86 (04) 290-294
    CrossrefPubMedGoogle Scholar
  • 41 Schaefer KE, Carey CR. Alveolar pathways during 90-foot, breath-hold dives. Science 1962; 137 (3535): 1051-1052
    CrossrefPubMedGoogle Scholar
  • 42 Linér MH, Linnarsson D. Intrapulmonary distribution of alveolar gas exchange during breath-hold diving in humans. J Appl Physiol 1995; 78 (02) 410-416
    CrossrefPubMedGoogle Scholar
  • 43 Lindholm P. Loss of motor control and/or loss of consciousness during breath-hold competitions. Int J Sports Med 2007; 28 (04) 295-299
    Article in Thieme ConnectPubMedGoogle Scholar
  • 44 Fitz-Clarke JR. Adverse events in competitive breath-hold diving. Undersea Hyperb Med 2006; 33 (01) 55-62
    PubMedGoogle Scholar
  • 45 Schagatay E, Andersson J. Diving response and apneic time in humans. Undersea Hyperb Med 1998; 25 (01) 13-19
    PubMedGoogle Scholar
  • 46 Schagatay E, van Kampen M, Emanuelsson S, Holm B. Effects of physical and apnea training on apneic time and the diving response in humans. Eur J Appl Physiol 2000; 82 (03) 161-169
    CrossrefPubMedGoogle Scholar
  • 47 Boyd C, Levy A, McProud T, Huang L, Raneses E, Olson C. Centers for Disease Control and Prevention (CDC). Fatal and nonfatal drowning outcomes related to dangerous underwater breath-holding behaviors - New York State, 1988-2011. MMWR Morb Mortal Wkly Rep 2015; 64 (19) 518-521
    PubMedGoogle Scholar
  • 48 Paulev P. Decompression sickness following repeated breath-hold dives. J Appl Physiol 1965; 20 (05) 1028-1031
    CrossrefPubMedGoogle Scholar
  • 49 Kohshi K, Wong RM, Abe H, Katoh T, Okudera T, Mano Y. Neurological manifestations in Japanese Ama divers. Undersea Hyperb Med 2005; 32 (01) 11-20
    PubMedGoogle Scholar
  • 50 Schagatay E. Predicting performance in competitive apnea diving. Part III: deep diving. Diving Hyperb Med 2011; 41 (04) 216-228
    PubMedGoogle Scholar
  • 51 Fitz-Clarke JR. Mechanics of airway and alveolar collapse in human breath-hold diving. Respir Physiol Neurobiol 2007; 159 (02) 202-210
    CrossrefPubMedGoogle Scholar
  • 52 Tetzlaff K, Schöppenthau H, Schipke JD. Risk of neurological insult in competitive deep breath-hold diving. Int J Sports Physiol Perform 2017; 12 (02) 268-271
    CrossrefPubMedGoogle Scholar
  • 53 Schipke JD, Tetzlaff K. Why predominantly neurological decompression sickness in breath-hold divers?. J Appl Physiol 2016; 120 (12) 1474-1477
    CrossrefPubMedGoogle Scholar
  • 54 Laitila M, Eskola V. Spontaneous pneumomediastinum in an 11-year-old boy after a shallow breath-hold dive. Diving Hyperb Med 2013; 43 (04) 235-236
    PubMedGoogle Scholar
  • 55 Jacobson FL, Loring SH, Ferrigno M. Pneumomediastinum after lung packing. Undersea Hyperb Med 2006; 33 (05) 313-316
    PubMedGoogle Scholar
  • 56 Chung SC, Seccombe LM, Jenkins CR, Frater CJ, Ridley LJ, Peters MJ. Glossopharyngeal insufflation causes lung injury in trained breath-hold divers. Respirology 2010; 15 (05) 813-817
    CrossrefPubMedGoogle Scholar
  • 57 Cialoni D, Sponsiello N, Marabotti C. et al. Prevalence of acute respiratory symptoms in breath-hold divers. Undersea Hyperb Med 2012; 39 (04) 837-844
    PubMedGoogle Scholar
  • 58 Lindholm P, Ekborn A, Oberg D, Gennser M. Pulmonary edema and hemoptysis after breath-hold diving at residual volume. J Appl Physiol 2008; 104 (04) 912-917
    CrossrefPubMedGoogle Scholar
  • 59 Strauss MB, Wright PW. Thoracic squeeze diving casualty. Aerosp Med 1971; 42 (06) 673-675
    PubMedGoogle Scholar
  • 60 Boussuges A, Pinet C, Thomas P, Bergmann E, Sainty JM, Vervloet D. Haemoptysis after breath-hold diving. Eur Respir J 1999; 13 (03) 697-699
    CrossrefPubMedGoogle Scholar
  • 61 Kiyan E, Aktas S, Toklu AS. Hemoptysis provoked by voluntary diaphragmatic contractions in breath-hold divers. Chest 2001; 120 (06) 2098-2100
    CrossrefPubMedGoogle Scholar
  • 62 Training fundamentals: following recommended dive limits. Accessed April 20, 2023 at: https://scubadiverlife.com/training-fundamentals-following-recommended-dive-limits/
    PubMed
  • 63 Butler BD, Hills BA. The lung as a filter for microbubbles. J Appl Physiol 1979; 47 (03) 537-543
    CrossrefPubMedGoogle Scholar
  • 64 Gerriets T, Tetzlaff K, Liceni T. et al. Arteriovenous bubbles following cold water sport dives: relation to right-to-left shunting. Neurology 2000; 55 (11) 1741-1743
    CrossrefPubMedGoogle Scholar
  • 65 Carturan D, Boussuges A, Vanuxem P, Bar-Hen A, Burnet H, Gardette B. Ascent rate, age, maximal oxygen uptake, adiposity, and circulating venous bubbles after diving. J Appl Physiol 2002; 93 (04) 1349-1356
    CrossrefPubMedGoogle Scholar
  • 66 Dujić Z, Eterović D, Denoble P, Krstacić G, Tocilj J, Gosović S. Effect of a single air dive on pulmonary diffusing capacity in professional divers. J Appl Physiol 1993; 74 (01) 55-61
    CrossrefPubMedGoogle Scholar
  • 67 Thorsen E, Risberg J, Segadal K, Hope A. Effects of venous gas microemboli on pulmonary gas transfer function. Undersea Hyperb Med 1995; 22 (04) 347-353
    PubMedGoogle Scholar
  • 68 Eckenhoff RG, Olstad CS, Carrod G. Human dose-response relationship for decompression and endogenous bubble formation. J Appl Physiol 1990; 69 (03) 914-918
    CrossrefPubMedGoogle Scholar
  • 69 Bove AA, Hallenbeck JM, Elliott DH. Circulatory responses to venous air embolism and decompression sickness in dogs. Undersea Biomed Res 1974; 1 (03) 207-220
    PubMedGoogle Scholar
  • 70 Neuman TS, Spragg RG, Wagner PD, Moser KM. Cardiopulmonary consequences of decompression stress. Respir Physiol 1980; 41 (02) 143-153
    CrossrefPubMedGoogle Scholar
  • 71 Peterson BT, Grauer SE, Hyde RW, Ortiz C, Moosavi H, Utell MJ. Response of pulmonary veins to increased intracranial pressure and pulmonary air embolization. J Appl Physiol 1980; 48 (06) 957-964
    CrossrefPubMedGoogle Scholar
  • 72 Levin LL, Stewart GJ, Lynch PR, Bove AA. Blood and blood vessel wall changes induced by decompression sickness in dogs. J Appl Physiol 1981; 50 (05) 944-949
    CrossrefPubMedGoogle Scholar
  • 73 Ward CA, McCullough D, Fraser WD. Relation between complement activation and susceptibility to decompression sickness. J Appl Physiol 1987; 62 (03) 1160-1166
    CrossrefPubMedGoogle Scholar
  • 74 Ohkuda K, Nakahara K, Binder A, Staub NC. Venous air emboli in sheep: reversible increase in lung microvascular permeability. J Appl Physiol 1981; 51 (04) 887-894
    CrossrefPubMedGoogle Scholar
  • 75 Buttolph TB, Dick Jr EJ, Toner CB. et al. Cutaneous lesions in swine after decompression: histopathology and ultrastructure. Undersea Hyperb Med 1998; 25 (02) 115-121
    PubMedGoogle Scholar
  • 76 Hartig F, Reider N, Sojer M. et al. Livedo racemosa - the pathophysiology of decompression-associated cutis marmorata and right/left shunt. Front Physiol 2020; 11: 994
    CrossrefPubMedGoogle Scholar
  • 77 Butler BD, Hills BA. Transpulmonary passage of venous air emboli. J Appl Physiol 1985; 59 (02) 543-547
    CrossrefPubMedGoogle Scholar
  • 78 Catron PW, Flynn Jr ET, Yaffe L. et al. Morphological and physiological responses of the lungs of dogs to acute decompression. J Appl Physiol 1984; 57 (02) 467-474
    CrossrefPubMedGoogle Scholar
  • 79 Vik A, Brubakk AO, Hennessy TR, Jenssen BM, Ekker M, Slørdahl SA. Venous air embolism in swine: transport of gas bubbles through the pulmonary circulation. J Appl Physiol 1990; 69 (01) 237-244
    CrossrefPubMedGoogle Scholar
  • 80 Atkins CE, Lehner CE, Beck KA, Dubielzig RR, Nordheim EV, Lanphier EH. Experimental respiratory decompression sickness in sheep. J Appl Physiol 1988; 65 (03) 1163-1171
    CrossrefPubMedGoogle Scholar
  • 81 Wirjosemito SA, Touhey JE, Workman WT. Type II altitude decompression sickness (DCS): U.S. Air Force experience with 133 cases. Aviat Space Environ Med 1989; 60 (03) 256-262
    PubMedGoogle Scholar
  • 82 Muth CM, Shank ES. Gas embolism. N Engl J Med 2000; 342 (07) 476-482
    CrossrefPubMedGoogle Scholar
  • 83 Butler BD, Luehr S, Katz J. Venous gas embolism: time course of residual pulmonary intravascular bubbles. Undersea Biomed Res 1989; 16 (01) 21-29
    PubMedGoogle Scholar
  • 84 Butler BD, Katz J. Vascular pressures and passage of gas emboli through the pulmonary circulation. Undersea Biomed Res 1988; 15 (03) 203-209
    PubMedGoogle Scholar
  • 85 Vik A, Jenssen BM, Eftedal O, Brubakk AO. Relationship between venous bubbles and hemodynamic responses after decompression in pigs. Undersea Hyperb Med 1993; 20 (03) 233-248
    PubMedGoogle Scholar
  • 86 Wilmshurst PT, Byrne JC, Webb-Peploe MM. Relation between interatrial shunts and decompression sickness in divers. Lancet 1989; 2 (8675): 1302-1306
    CrossrefPubMedGoogle Scholar
  • 87 Moon RE, Camporesi EM, Kisslo JA. Patent foramen ovale and decompression sickness in divers. Lancet 1989; 1 (8637): 513-514
    CrossrefPubMedGoogle Scholar
  • 88 Ries S, Knauth M, Kern R. et al. Arterial gas embolism after decompression: correlation with right-to-left shunting. Neurology 1999; 52 (02) 401-404
    CrossrefPubMedGoogle Scholar
  • 89 Glen SK, Georgiadis D, Grosset DG, Douglas JDM, Lees KR. Transcranial Doppler ultrasound in commercial air divers: a field study including cases with right-to-left shunting. Undersea Hyperb Med 1995; 22 (02) 129-135
    PubMedGoogle Scholar
  • 90 Germonpré P, Lafère P, Portier W, Germonpré F-L, Marroni A, Balestra C. Increased risk of decompression sickness when diving with a right-to-left shunt: results of a prospective single-blinded observational study (the “Carotid Doppler” Study). Front Physiol 2021; 12: 763408
    CrossrefPubMedGoogle Scholar
  • 91 Bove AA. Risk of decompression sickness with patent foramen ovale. Undersea Hyperb Med 1998; 25 (03) 175-178
    PubMedGoogle Scholar
  • 92 Torti SR, Billinger M, Schwerzmann M. et al. Risk of decompression illness among 230 divers in relation to the presence and size of patent foramen ovale. Eur Heart J 2004; 25 (12) 1014-1020
    CrossrefPubMedGoogle Scholar
  • 93 Honěk J, Šrámek M, Honěk T. et al. Patent foramen ovale closure is effective in divers: long-term results from the DIVE-PFO registry. J Am Coll Cardiol 2020; 76 (09) 1149-1150
    CrossrefPubMedGoogle Scholar
  • 94 Reul J, Weis J, Jung A, Willmes K, Thron A. Central nervous system lesions and cervical disc herniations in amateur divers. Lancet 1995; 345 (8962): 1403-1405
    CrossrefPubMedGoogle Scholar
  • 95 Knauth M, Ries S, Pohimann S. et al. Cohort study of multiple brain lesions in sport divers: role of a patent foramen ovale. BMJ 1997; 314 (7082): 701-705
    CrossrefPubMedGoogle Scholar
  • 96 Schwerzmann M, Seiler C, Lipp E. et al. Relation between directly detected patent foramen ovale and ischemic brain lesions in sport divers. Ann Intern Med 2001; 134 (01) 21-24
    CrossrefPubMedGoogle Scholar
  • 97 Cordes P, Keil R, Bartsch T. et al. Neurologic outcome of controlled compressed-air diving. Neurology 2000; 55 (11) 1743-1745
    CrossrefPubMedGoogle Scholar
  • 98 Gerriets T, Tetzlaff K, Hutzelmann A. et al. Association between right-to-left shunts and brain lesions in sport divers. Aviat Space Environ Med 2003; 74 (10) 1058-1060
    PubMedGoogle Scholar
  • 99 Balestra C, Germonpré P. Correlation between patent foramen ovale, cerebral “lesions” and neuropsychometric testing in experienced sports divers: does diving damage the brain?. Front Psychol 2016; 7: 696
    PubMedGoogle Scholar
  • 100 Slosman DO, De Ribaupierre S, Chicherio C. et al. Negative neurofunctional effects of frequency, depth and environment in recreational scuba diving: the Geneva “memory dive” study. Br J Sports Med 2004; 38 (02) 108-114
    CrossrefPubMedGoogle Scholar
  • 101 Tetzlaff K, Friege L, Hutzelmann A, Reuter M, Höll D, Leplow B. Magnetic resonance signal abnormalities and neuropsychological deficits in elderly compressed-air divers. Eur Neurol 1999; 42 (04) 194-199
    CrossrefPubMedGoogle Scholar
  • 102 Russi EW. Diving and the risk of barotrauma. Thorax 1998; 53 ( suppl 2): S20-S24
    CrossrefPubMedGoogle Scholar
  • 103 Schaffer KE, McNULTY Jr WP, Carey C, Liebow AA. Mechanisms in development of interstitial emphysema and air embolism on decompression from depth. J Appl Physiol 1958; 13 (01) 15-29
    CrossrefPubMedGoogle Scholar
  • 104 Malhotra MS, Wright HC. The effects of a raised intrapulmonary pressure on the lungs of fresh unchilled cadavers. J Pathol Bacteriol 1961; 82: 198-202
    CrossrefPubMedGoogle Scholar
  • 105 Liebow AA, Stark JE, Vogel J, Schaefer KE. Intrapulmonary air trapping in submarine escape training casualties. U S Armed Forces Med J 1959; 10 (03) 265-289
    PubMedGoogle Scholar
  • 106 Broome CR, Jarvis LJ, Clark RJ. Pulmonary barotrauma in submarine escape training. Thorax 1994; 49 (02) 186-187
    CrossrefPubMedGoogle Scholar
  • 107 Lafère P, Germonpré P, Balestra C. Pulmonary barotrauma in divers during emergency free ascent training: review of 124 cases. Aviat Space Environ Med 2009; 80 (04) 371-375
    CrossrefPubMedGoogle Scholar
  • 108 Zaugg M, Kaplan V, Widmer U, Baumann PC, Russi EW. Fatal air embolism in an airplane passenger with a giant intrapulmonary bronchogenic cyst. Am J Respir Crit Care Med 1998; 157 (5, Pt 1): 1686-1689
    CrossrefPubMedGoogle Scholar
  • 109 Rudge FW. Altitude-induced arterial gas embolism: a case report. Aviat Space Environ Med 1992; 63 (03) 203-205
    PubMedGoogle Scholar
  • 110 Rios-Tejada F, Azofra-Garcia J, Valle-Garrido J, Pujante Escudero A. Neurological manifestation of arterial gas embolism following standard altitude chamber flight: a case report. Aviat Space Environ Med 1997; 68 (11) 1025-1028
    PubMedGoogle Scholar
  • 111 Cable GG, Keeble T, Wilson G. Pulmonary cyst and cerebral arterial gas embolism in a hypobaric chamber: a case report. Aviat Space Environ Med 2000; 71 (02) 172-176
    PubMedGoogle Scholar
  • 112 Lee CT. Cerebral arterial gas embolism in air force ground maintenance crew–a report of two cases. Aviat Space Environ Med 1999; 70 (07) 698-700
    PubMedGoogle Scholar
  • 113 Hickey MJ, Zanetti CL. Delayed-onset cerebral arterial gas embolism in a commercial airline mechanic. Aviat Space Environ Med 2003; 74 (09) 977-980
    PubMedGoogle Scholar
  • 114 Zwillich CW, Pierson DJ, Creagh CE, Sutton FD, Schatz E, Petty TL. Complications of assisted ventilation. A prospective study of 354 consecutive episodes. Am J Med 1974; 57 (02) 161-170
    CrossrefPubMedGoogle Scholar
  • 115 Benton PJ, Woodfine JD, Westwood PR. Arterial gas embolism following a 1-meter ascent during helicopter escape training: a case report. Aviat Space Environ Med 1996; 67 (01) 63-64
    PubMedGoogle Scholar
  • 116 Raymond LW. Pulmonary barotrauma and related events in divers. Chest 1995; 107 (06) 1648-1652
    CrossrefPubMedGoogle Scholar
  • 117 Weiss LD, Van Meter KW. Cerebral air embolism in asthmatic scuba divers in a swimming pool. Chest 1995; 107 (06) 1653-1654
    CrossrefPubMedGoogle Scholar
  • 118 Mellem H, Emhjellen S, Horgen O. Pulmonary barotrauma and arterial gas embolism caused by an emphysematous bulla in a SCUBA diver. Aviat Space Environ Med 1990; 61 (06) 559-562
    PubMedGoogle Scholar
  • 119 Reuter M, Tetzlaff K, Warninghoff V, Steffens JC, Bettinghausen E, Heller M. Computed tomography of the chest in diving-related pulmonary barotrauma. Br J Radiol 1997; 70 (833) 440-445
    CrossrefPubMedGoogle Scholar
  • 120 Toklu AS, Kiyan E, Aktas S, Cimsit M. Should computed chest tomography be recommended in the medical certification of professional divers? A report of three cases with pulmonary air cysts. Occup Environ Med 2003; 60 (08) 606-608
    CrossrefPubMedGoogle Scholar
  • 121 Germonpré P, Balestra C, Pieters T. Influence of scuba diving on asymptomatic isolated pulmonary bullae. Diving Hyperb Med 2008; 38 (04) 206-211
    PubMedGoogle Scholar
  • 122 Tetzlaff K, Reuter M, Leplow B, Heller M, Bettinghausen E. Risk factors for pulmonary barotrauma in divers. Chest 1997; 112 (03) 654-659
    CrossrefPubMedGoogle Scholar
  • 123 Calder IM. Autopsy and experimental observations on factors leading to barotrauma in man. Undersea Biomed Res 1985; 12 (02) 165-182
    PubMedGoogle Scholar
  • 124 Colebatch HJ, Ng CK. Decreased pulmonary distensibility and pulmonary barotrauma in divers. Respir Physiol 1991; 86 (03) 293-303
    CrossrefPubMedGoogle Scholar
  • 125 Benton PJ, Francis TJR, Pethybridge RJ. Spirometric indices and the risk of pulmonary barotrauma in submarine escape training. Undersea Hyperb Med 1999; 26 (04) 213-217
    PubMedGoogle Scholar
  • 126 Wilmshurst PT, Nuri M, Crowther A, Webb-Peploe MM. Cold-induced pulmonary oedema in scuba divers and swimmers and subsequent development of hypertension. Lancet 1989; 1 (8629): 62-65
    CrossrefPubMedGoogle Scholar
  • 127 Pons M, Blickenstorfer D, Oechslin E. et al. Pulmonary oedema in healthy persons during scuba-diving and swimming. Eur Respir J 1995; 8 (05) 762-767
    CrossrefPubMedGoogle Scholar
  • 128 Weiler-Ravell D, Shupak A, Goldenberg I. et al. Pulmonary oedema and haemoptysis induced by strenuous swimming. BMJ 1995; 311 (7001): 361-362
    CrossrefPubMedGoogle Scholar
  • 129 Miller III CC, Calder-Becker K, Modave F. Swimming-induced pulmonary edema in triathletes. Am J Emerg Med 2010; 28 (08) 941-946
    CrossrefPubMedGoogle Scholar
  • 130 Wenger M, Russi EW. Aqua jogging-induced pulmonary oedema. Eur Respir J 2007; 30 (06) 1231-1232
    CrossrefPubMedGoogle Scholar
  • 131 Marinovic J, Ljubkovic M, Obad A. et al. Assessment of extravascular lung water and cardiac function in trimix SCUBA diving. Med Sci Sports Exerc 2010; 42 (06) 1054-1061
    CrossrefPubMedGoogle Scholar
  • 132 Hampson NB, Dunford RG. Pulmonary edema of scuba divers. Undersea Hyperb Med 1997; 24 (01) 29-33
    PubMedGoogle Scholar
  • 133 Slade Jr JB, Hattori T, Ray CS, Bove AA, Cianci P. Pulmonary edema associated with scuba diving : case reports and review. Chest 2001; 120 (05) 1686-1694
    CrossrefPubMedGoogle Scholar
  • 134 Castagna O, de Maistre S, Schmid B, Caudal D, Regnard J. Immersion pulmonary oedema in a healthy diver not exposed to cold or strenuous exercise. Diving Hyperb Med 2018; 48 (01) 40-44
    CrossrefPubMedGoogle Scholar
  • 135 Castagna O, Gempp E, Poyet R. et al. Cardiovascular mechanisms of extravascular lung water accumulation in divers. Am J Cardiol 2017; 119 (06) 929-932
    CrossrefPubMedGoogle Scholar
  • 136 Castagna O, Regnard J, Gempp E. et al. The key roles of negative pressure breathing and exercise in the development of interstitial pulmonary edema in professional male SCUBA divers. Sports Med Open 2018; 4 (01) 1
    CrossrefPubMedGoogle Scholar
  • 137 Wester TE, Cherry AD, Pollock NW. et al. Effects of head and body cooling on hemodynamics during immersed prone exercise at 1 ATA. J Appl Physiol 2009; 106 (02) 691-700
    CrossrefPubMedGoogle Scholar
  • 138 Peacher DF, Pecorella SR, Freiberger JJ. et al. Effects of hyperoxia on ventilation and pulmonary hemodynamics during immersed prone exercise at 4.7 ATA: possible implications for immersion pulmonary edema. J Appl Physiol 2010; 109 (01) 68-78
    CrossrefPubMedGoogle Scholar
  • 139 Kovacs G, Berghold A, Scheidl S, Olschewski H. Pulmonary arterial pressure during rest and exercise in healthy subjects: a systematic review. Eur Respir J 2009; 34 (04) 888-894
    CrossrefPubMedGoogle Scholar
  • 140 Edmonds C, Lippmann J, Lockley S, Wolfers D. Scuba divers' pulmonary oedema: recurrences and fatalities. Diving Hyperb Med 2012; 42 (01) 40-44
    PubMedGoogle Scholar
  • 141 Moon RE, Martina SD, Peacher DF. et al. Swimming-induced pulmonary edema: pathophysiology and risk reduction with sildenafil. Circulation 2016; 133 (10) 988-996
    CrossrefPubMedGoogle Scholar
  • 142 Adir Y, Shupak A, Gil A. et al. Swimming-induced pulmonary edema: clinical presentation and serial lung function. Chest 2004; 126 (02) 394-399
    CrossrefPubMedGoogle Scholar
  • 143 Smith R, Ormerod JOM, Sabharwal N, Kipps C. Swimming-induced pulmonary edema: current perspectives. Open Access J Sports Med 2018; 9: 131-137
    CrossrefPubMedGoogle Scholar
  • 144 Hårdstedt M, Seiler C, Kristiansson L, Lundeqvist D, Klingberg C, Braman Eriksson A. Swimming-induced pulmonary edema: diagnostic criteria validated by lung ultrasound. Chest 2020; 158 (04) 1586-1595
    CrossrefPubMedGoogle Scholar
  • 145 Volk C, Spiro J, Boswell G. et al. Incidence and impact of swimming-induced pulmonary edema on navy seal candidates. Chest 2021; 159 (05) 1934-1941
    CrossrefPubMedGoogle Scholar
  • 146 Hårdstedt M, Kristiansson L, Seiler C, Braman Eriksson A, Sundh J. Incidence of swimming-induced pulmonary edema: a cohort study based on 47,600 open-water swimming distances. Chest 2021; 160 (05) 1789-1798
    CrossrefPubMedGoogle Scholar