Blood Gas Analyses in Hyperbaric and Underwater Environments: A Systematic Review

Background: Pulmonary gas exchange during diving or in a dry hyperbaric environment is affected by increased breathing gas density and possibly water immersion. During free diving there is also the effect of apnea. Few studies have published blood gas data in underwater or hyperbaric environments: this review summarizes the available literature and was used to test the hypothesis that arterial PO2 under hyperbaric conditions can be predicted from blood gas measurement at 1 atmosphere assuming a constant arterial/alveolar PO2 ratio (a:A). Methods: A systematic search was performed on traditional sources including arterial blood gases obtained on humans in hyperbaric or underwater environments. The a:A was calculated at 1 atmosphere absolute (ATA). For each condition, predicted PaO2 at pressure was calculated using the 1 ATA a:A, and the measured PaO2 was plotted against the predicted value with Spearman correlation coefficients. Results: Of 3640 records reviewed, 30 studies were included: 25 were reports describing values obtained in hyperbaric chambers, and the remaining were collected while underwater. Increased inspired O2 at pressure resulted in increased PaO2, although underlying lung disease in patients treated with hyperbaric oxygen attenuated the rise. PaCO2 generally increased only slightly. In breath-hold divers, hyperoxemia generally occurred at maximum depth, with hypoxemia after surfacing. The a:A adequately predicted the PaO2 under various conditions: dry (r=0.993, p< 0.0001); rest vs. exercise (r=0.999, p< 0.0001); and breathing mixtures (r=0.995, p< 0.0001). Conclusion: Pulmonary oxygenation under hyperbaric conditions can be reliably and accurately predicted from 1 ATA a:A measurements.

Evaluation and Characteristic of Modified Ventilator Under Hyperbaric Conditions During Volume-controlled Ventilation

Purpose：The stability of the modified ventilator (Shangrila590, Beijing Aeonmed Company, Beijing, China) was evaluated under hyperbaric conditions during volume-controlled ventilation in this study by Michigan test lung (5601i, Grand Rapids, MI, US).Methods：Experiments were performed inside the multiplace hyperbaric chamber at 1.0, 1.5 and 2.0 atmospheres absolute (ATA). The modified ventilator placed inside the hyperbaric chamber was connected to the test lung. During volume-controlled ventilation (VCV), data for the test lung were collected by a personal computer outside the hyperbaric chamber. The preset tide volume (VTset) of the ventilator (400-1000 ml) and the resistance and compliance of the testing lung were adjusted before the experiments at every ambient pressure. With every test setting, the tide volume (VT), inspiratory airway peak pressure (Ppeak) and minute volume (MV) displayed by the ventilator and the test lung were recorded by the computer. We compared the ventilator and test lung data under 1.0, 1.5 and 2.0 ATA to evaluate the stability of the modified ventilator.Results：The variation in VT in the test lung and the ventilator at different ambient pressures changed within a narrow range, and the differences were statistically significant. In every test setting, changes in the MV of the ventilator were limited and acceptable, with significant differences at different ambient pressures. However, Ppeak increased obviously, as detected by the ventilator and test lung at higher ambient pressure during VCV.Conclusions：The modified Shangrila590 ventilator can work well in a hyperbaric chamber. It can provide relatively stable VT and MV during VCV with VTset from 400 ml to 1000 ml when the ambient pressure increases from 1.0 ATA to 2.0 ATA. The raised ambient pressure will lead to increased gas density, which may result in more airway resistance and higher Ppeak during VCV.

Dopamine-dependent biphasic behaviour under ‘deep diving’ conditions in Caenorhabditis elegans

Underwater divers are susceptible to neurological risks due to their exposure to increased pressure. Absorption of elevated partial pressure of inert gases such as helium and nitrogen may lead to nitrogen narcosis. Although the symptoms of nitrogen narcosis are known, the molecular mechanisms underlying these symptoms have not been elucidated. Here, we examined the behaviour of the soil nematode Caenorhabditis elegans under scuba diving conditions. We analysed wild-type animals and mutants in the dopamine pathway under hyperbaric conditions, using several gas compositions and under varying pressure levels. We found that the animals changed their speed on a flat bacterial surface in response to pressure in a biphasic mode that depended on dopamine. Dopamine-deficient cat-2 mutant animals did not exhibit a biphasic response in high pressure, while the extracellular accumulation of dopamine in dat-1 mutant animals mildly influenced this response. Our data demonstrate that in C. elegans , similarly to mammalian systems, dopamine signalling is involved in the response to high pressure. This study establishes C. elegans as a powerful system to elucidate the molecular mechanisms that underly nitrogen toxicity in response to high pressure.

Performance characteristics of high-frequency percussive ventilation under hyperbaric conditions

Introduction: Safe administration of critical care hyperbaric medicine requires specialized equipment and advanced training. Equipment must be tested in order to evaluate function in the hyperbaric environment. High-frequency percussive ventilation (HFPV) has been used in intensive care settings effectively, but it has never been tested in a hyperbaric chamber. Methods: Following a modified U.S. Navy testing protocol used to evaluate hyperbaric ventilators, we evaluated an HFPV transport ventilator in a multiplace hyperbaric chamber at 1.0, 1.9, and 2.8 atmospheres absolute (ATA). We used a test lung with analytical software for data collection. The ventilator uses simultaneous cyclic pressure-controlled ventilation at a pulsatile flow rate (PFR)/oscillatory continuous positive airway pressure (oCPAP) ratio of 30/10 with a high-frequency oscillation percussive rate of 500 beats per minute. Inspiratory and expiratory times were maintained at two seconds throughout each breathing cycle. Results: During manned studies, the PFR/oCPAP ratios were 26/6, 22/7, and 22.5/8 at an airway resistance of 20cm H2O/L/second and 18/9, 15.2/8.5, and 13.6/7 at an airway resistance of 50 cm/H2O/L/second at 1, 1.9, and 2.8 ATA. The resulting release volumes were 800, 547, and 513 mL at airway resistance of 20 cm H2O/L/sec and 400, 253, and 180 mL at airway resistance of 50 cm/H2O/L/sec at 1, 1.9, and 2.8 ATA. Unmanned testing showed similar changes. The mean airway pressure (MAP) remained stable throughout all test conditions; theoretically, supporting adequate lung recruitment and gas exchange. A case where HFPV was used to treat a patient for CO poisoning was presented to illustrate that HFPV worked well under HBO2 conditions and no complications occurred during HBO2 treatment. Conclusion: The HFPV transport ventilator performed adequately under hyperbaric conditions and should be considered a viable option for hyperbaric critical care. This ventilator has atypical terminology and produces unique pulmonary physiology, thus requiring specialized training prior to use.

Non-invasive monitoring of carboxyhemoglobin during hyperbaric oxygen therapy

Introduction: This study aimed to assess the capability of a pulse CO-oximeter to continuously monitor carboxyhemoglobin (COHb) during hyperbaric oxygen (HBO2) therapy. We estimated limits of agreement (LOA) between blood gas analysis and pulse CO-oximeter for COHb during HBO2 therapy in patients suffering from acute CO poisoning. Furthermore, we did a medicotechnical evaluation of the pulse CO-oximeter in hyperbaric conditions. Method: We conducted a prospective, non-clinical, observational study in which we included n=10 patients with acute CO poisoning referred for HBO2 therapy. We did five repeated measurements of COHb for each patient during the HBO2 therapy. Bland-Altman analysis for multiple observations per individual was used to assess the agreement. The a priori LOA was ±6% for COHb. For the medicotechnical evaluation continuous measurements were obtained throughout each complete HBO2 therapy. The measurements were visually inspected and evaluated. Results: The Bland-Altman analysis showed that the pulse CO-oximeter overestimated COHb by 2.9 % [±1.0%] and the LOA was ±7.3% [±1.8%]. The continuous measurements by pulse CO-oximetry showed fluctuating levels of COHb and summarized saturations reached levels above 100%. Measurements were not affected by changes in pressure. Conclusion: To our knowledge, this study is the first to asses LOA and demonstrate use of a non-invasive method to measure COHb during HBO2 therapy. The pulse CO-oximeter performed within the manufactures reported LOA (±6%) despite hyperbaric conditions and was unaffected by changes in pressure. However, summarized saturations reached levels above 100%.