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Respiratory Problems - Pneumothorax (Traumatic)

Dr Jules Eden, dive medicine specialist and founder of e-med, answers divers' questions - as published in Sport Diver magazine:
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Q - Hello. As part of an investigation into abnormal levels of iron in my liver my consultant wishes to perform a liver biopsy. This involves a 1 in 1000 risk of a punctured lung. I am a very active diver and would therefore not like to jeopardise this. What advice would you give? Does an "accidentally" punctured lung heal? Thank you.

A - Hi. As a kid I remember games of Risk that went on for days over Christmas. I realise now that it was a tactic to keep the aunts and uncles from each other throats while they deployed their armies and biscuit crumbs across the globe. But dealing with medical risk is an altogether more interesting concept. What does “1 in 1000” mean to you? If I told you that the chance of needing emergency treatment in the next year after being injured by a bed mattress or pillow is 1 in 2000, would that make you more or less likely to take this 1 in 1000 risk?

Oodles of stuff has been written about “risk perception” – how an individual understands and judges risk (and how that influences behaviour). People are much more willing to accept voluntary risks (such as driving a car, where the lifetime risk of dying in a crash is 1 in 100) than risks where they have no control. The risk of lung cancer from a pack a day habit is about 1 in 125 over a lifetime; for skin cancer from sun exposure it’s a staggering 1 in 3 (although most are non-fatal). 1 in 1000 is about the same probability as a 4-4 draw in a football match. A 5-5 score would be 1 in 10,000 and winning the Lottery about 1 in 3,000,000 so get down to William Hill rather than buying scratchcards. According to the HSE, the average annual risk of death from SCUBA diving is 1 in 200,000 dives. Pretty safe really.

Ultimately then, each individual has their own perception of risk, which is shaped by their personality, previous experiences and probably hundreds of other factors yet to be determined. On this aspect it’s therefore difficult to give black and white answers.

Punctured lungs I’ve covered in some depth in previous articles. The bottom line is that we are talking here about a so-called “traumatic” pneumothorax, where the cause of the lung injury is known (in this case an errant biopsy needle). So there is no reason to suspect that the underlying lung tissue is more susceptible to barotrauma or another puncture. Most of these types of injuries heal up and all that is required is some confirmation that the repair is complete, usually a CT scan and some lung function tests.

Word of advice for the New Year - take care in the bath. There’s a 1 in 685,000 chance you’ll drown in it before 2010.

Q - I'm hoping you will give me some information over a problem I've had for some time. About 15 years ago I was attacked with a baseball bat and a machete, I was on life support and in a coma with multiple injuries. When I eventually got out of hospital I started going to a gym and got myself fit again, a few years ago I started diving, I'm now an AOWD and I love it. The problem is, one of my injuries was a collapsed lung, the hospital drained all the tar which had accumulated over the years being a heavy smoker and cleaned me up I haven't smoked since, I don't have any problems healthwise but I do use Seretide 500 once a day for asthma which doesn't effect me in any way. I've had numerous health medicals all proved good but I've never told anyone about the lung problem. It is now starting to worry me before each dive as I am ignorant to the fact of what might happen, my wife keeps going on at me to write to you. Please explain to me doctor, what's the consequences, can I keep diving or am I just being an idiot aged 55 but fit.

A - I don't think you're being an idiot at all, but there are some issues here. Firstly, a word or two about collapsed lung, or "pneumothorax". The lung normally sits happily in the chest cavity, like a balloon, but if the surface is damaged then air leaks out into the chest. As the air accumulates, the increasing pressure crushes the lung down, until eventually it collapses – a pneumothorax. These are generally split into 2 types, spontaneous (out of the blue) and traumatic (due to an injury of some sort). Spontaneous ones can occur in young people, skinny tall smokers being particularly prone, or in older individuals with underlying lung disease (again most common in heavy smokers). Sometimes even a hiccup is enough to rupture a wee portion and allow air to escape. Traumatic ones are due to an injury, which can leave scars on the lung. Both types can predispose you to air trapping, with consequent over-expansion injury when you ascend from a dive. If the incident is 15 years in the past then it is very unlikely to cause a problem, but a CT scan of the lungs may be needed to be 100% certain. You should keep an eye on the lung function too, particularly with the asthma. Yearly spirometry (where you blow into a tube which estimates your lung capacity and elasticity) is a good idea. So I would pop down to your local dive doc and get the tests done for full peace of mind.

Q - I have been given you name from the London Diving School. I am looking to go diving at Easter but just wanted to check some medical details with you first. I had a car crash 16 years ago and my lungs collapsed and I was on a life support machine for 10 days. Unfortunately the crash happened out in Saudi and so I was not allowed to take any of the medical records out of the country. I was 14 when it happened - now 30 and fighting fit with no conditions at all. Could you advise me if it's ok to dive this Easter?

A - The chances are good for you. The reason for this is because although you had bilateral pneumothoraces. Punctured lungs in effect, it is more allowable to have had these if they were caused by a traumatic event, than if they were spontaneous and occurred as you were ambling down the street. In such a serious accident as this, often the ribs will break, puncture the lining of the lungs, the pleura, and cause air to enter around the lung on each breath, which then crushes the lungs slowly. Life threatening stuff, and in need of a great big tube in through the chest to decompress the lungs. But once resolved, as your lungs were in good nick before, they should be fine after. So all you need is this checked with a test called spirometry. Contact your local dive doctor for this.

A spontaneous pneumothorax means there is underlying disease, and one which can occur again at any time where there is exertion. These people need to jump through a lot more hoops to be able to dive than you.

Bit odd, though, them not letting you take your medical records with you. They would be useful, so call the British Embassy out there, drag the ambassador away from his Ferrero Rocher and tell him to go get 'em.

Q - I am proposing to go on a diving holiday, but wanted to ensure that I am medically fit enough to go, and wondered if you can help? I had a pneumothorax as the result of a fractured rib, two years ago. I am fully recovered now. Do you foresee any problems?

I had a seizure, also at this time, due to a head trauma. This seizure occurred whilst unconscious. I have had none since, and have been declared medically fit to drive. I do not take any medication. Are there any problems with this too?

Finally, I sustained some fractures in my pelvis and upper left arm. Both have healed and I have no problems.

Am I medically fit enough to go diving?????
Thank you very much for your time.

A - There are 3 issues here to deal with. As your punctured lung or pneumothorax was as a result of injury, rather than being spontaneous, it is more likely that you will be fit enough to dive.

You still need to have your chest examined by a qualified diving physician, and our regulations also call for a CT scan of your chest to make sure that all is well now before we can recommend you dive again.

Your seizure is less of a problem. In normal cases of head injury the length of any amnesia or presence of a seizure will decide the lay off from diving time. You have been fine for the last 2 years with no problems , so I think that this shouldn't be a problem to you.

Finally the fractures you sustained are of relevance only if they stop you from kitting up on a RIB, or mean that you would not be able to look after your buddy if they had a problem. The other thing to have checked by your diving doc is if there is any residual problems left by the injury which could be mistaken for a bend, by this I mean areas of numbness or joint pain in your pelvis or upper left arm .It's best to have these documented now, so you are not incorrectly diagnosed as bent in the future. So, if the chest CT is fine look forward to getting wet!

Q - Recently my boyfriend and I went an a rescue diver course in Looe. We finished our course on the Friday doing our last dive on the Friday morning. We returned home both feeling fine. On the Monday my boyfriend went for a run and ended up in hospital. The doctors diagnosed him with a pneumothorax (although the lung did not completely collapse it just had a hole in it). Do you think that this could have been diving related? Also do you think that it would be safe to dive again? The doctors at the hospital he was at said he should consult a diving specialist doctor.

A - To answer your question... Yes. There is a chance that it could be diving related.

If for some reason he had had some pulmonary barotraumas i.e. lung damage , mainly due to breath holding during ascent then this may have only gotten worse when he was exercising fully i.e. during his run. But we have to assume that it was a spontaneous pneumothorax which can happen in tall skinny people when they are exercising. They have something called "bullae" which are large blown out lung bubbles. During exercise these can burst spontaneously with a sudden onset shortness of breath and chest pain on the side of the problem. Now the problem with diving is that if these fill with compressed air at depth they then have the air expand on ascent which causes these lung ruptures, which can be fatal.

I actually think your boyfriend was very lucky not to have had this happen to him underwater, which could have happened if he had had a very exhausting dive. But whatever the cause, the fact remains that after such an event he should avoid diving for 5 years, and after that he needs a CT scan of his chest to make sure all is well afterwards If he smokes he should stop immediately as this increases the risk of recurrence dramatically.

Sorry to bring the bad news, but it's snorkelling now until 2005.

(other dive medical questions)



   


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