Lung issues and DCI

[h20_kat]

Unbelievably I write this from a hospital bed in Singapore after suffering a pneumothorax while on a diving holiday in Indonesia. As there isn't much to do besides surf the internet I have been doing a fair bit of that and read (not for the first time) an article on the DAN website Decompression Illness: What Is It and What Is The Treatment? which mentions pulmonary disease as a possible risk factor for DCI. This makes sense, but I hadn't considered that it might be relevant to me until after I had the pneumothorax.

In October 2013 I suffered decompression sickness. I am unsure to this date why exactly it happened but contributing factors could have been: short surface intervals, fatigue and possibly being cold.

I had about a 48 hour delay getting to the chamber and it took 6 months for my symptoms to completely resolve. In August 2014 I was cleared by a diving physician to return to diving, however, with increased conservatism advised.

I did about 20 dives in September-October and was fine. I planned an extended dive holiday for December-January. I was nearly at the end of my amazing trip, having done probably 75 dives when I suffered the pneumothorax.

The incident happened while I was diving in Sulawesi, Indonesia and there was a pretty huge language barrier between myself and the doctor. However, it seems from the CT scan that I had there that there is some issue with my lung. I don't know if the doctor knew what it was exactly or if he was even able to tell because at that point there was a fair bit of trapped air in my thoracic cavity.

After the first chest tube was removed in Indonesia my chest cavity again filled with air. The doctor said I was going to need a thorocotomy. My insurer decided to evacuate me to a better hospital thankfully. The hospital in Indo was a scary place. I had another chest tube inserted when I arrived in Singapore. It was removed yesterday and all seems okay so far. I will have another x-ray tomorrow to confirm. They haven't done a CT scan here and don't intend to. I will have to follow up on this after I get home.

My point in writing this is two-fold.

1. Does anyone have any information or links to articles that discuss how lung issues can contribute to DCI?
2. If indeed I do have a lung issue that was a contributing factor in both dive incidents then I am concerned that the diving physician did not investigate this when he did my medical. He did not do a chest x-ray as part of the examination. I did disclose to him that I had previously had pneumonia (25 years ago) and that I had been a smoker for many years. There is obviously nothing that can be done about this now, but perhaps it can serve as a lesson to other divers to ensure they have complete medicals in order to evaluate their fitness to dive. Even if something doesn't seem obvious as a problem (I am not aware of any lung issues) it could potentially be.

Thanks for listening. I am devastated that I will no longer be able to be a part of the scuba community. That year off from diving was difficult and I was so happy to be back in the water. I am gutted that I won't be able to dive anymore.

 

[Stoo]

Kat, I am sorry to read about your trials. I'm sure everyone is saying this to you, but "be happy" it wasn't worth...

I can't really contribute to the DCI/lung problem issue. However, I can tell you that both of my sons suffered several "spontaneous" pneumothoraxes when they were in their late teens/and twenties. One of them had started to dive, and to that end, he too stopped diving. The eldest boy had surgery ultimately, while the younger did not.

While all of this was going on, their Mom and I struggled to understand what was going on. As best we can determine, in their cases, it was most likely related to their build. Both of them are tall (over 6') and very lean. The ruptures happened spontaneously, sometimes when they were just sitting quietly. There is likely a genetic component and while I have never had one, my Mom seems to recall that my Dad had had a similar problem before she new him. He was also very tall and thin. The theory is that in "tall skinny" folks, the top of the lungs fail to grow properly, leaving "blebs" or small blisters on them, which are subject to bursting. These were apparent on x-rays.

Anyway, my point is only that your "problem" may not be diving related at all. I see you are a female person and I understand that this alone reduces the odds of this just falling into the "sh!t happens" category.

Hopefully you will have a full recovery, although in my experience, re-occurrences were common for several years, but with decreasing severity. You are wise to hang up your fins. As a "hardcore" diving enthusiast, I'd hate to have to do that, but I'd also hate to be dead. A lung burst on the surface is one thing. At depth, you're going to have a REALLY bad day!

 

[h20_kat]

A lung burst on the surface is one thing. At depth, you're going to have a REALLY bad day!

It did happen at depth or at least below the surface. I felt fine until I surfaced at the end of the dive. I felt a sharp pain in my right side and back and had difficulty breathing.

I am happy to be alive. I know it could have been worse.

I know pneumothorax can occur amongst people with a tall/thin build, particularly young males. One of my tall/thin friends (female) had one as a teenager. Sadly I don't fit that build! Pneumothoraxes due to the tall/thin build tend to happen at a younger age than I am (nearly 40) as well. I think it is more likely that if I have blebs or scarring that it is due to something else. Thanks for sharing the info about your sons. Glad they are both okay.

 

[Saturation]

Sorry to read. Any article on pneumothorax can help. DCI typically means DCS and barotrauma. Pneumothorax isn't related to the physiology of DCS, DCI as a term is used when both types of injuries occur to an individual from the same dive.

en.wikipedia.org/wiki/Pneumothorax

In the stated case, it may not even be physiologic at all, given we do not have details of the dive profile, which could explain the prior DCS and the current pneumothorax.

A pneumothorax is primary when no cause can be found to initiate it, or the same act would do nothing to a healthy lung e.g. sneezing or coughing. It happens anytime during a lifetime, its typically a congenital defect, or it could have come from weakening of the lungs from smoking or lung diseases one develops even without smoking [e.g. scarring from post-pneumonia].

Secondary types are from physical injuries [ e.g. car accidents, puncture wounds,blast injury].

Smoking alone is not an indication to do even a chest x-ray for sport divers, unless there is something gross found on physical exam. Further any abnormality cannot be predicted to prelude a pneumothorax either, even by the preferred test, a high resolution CT scan. Commercial divers require a baseline chest-ray and periodic repeats only because of regulatory agencies. But in the end, the only proof some issue causes a pneumothorax is if the patient gets a primary type in their lifetime.

There is a surgical treatment to prevent future pneumothoraxes, but even afterwards, clearance for diving is unlikely as it has ~ 1% recurrence rate.

..
My point in writing this is two-fold.

1. Does anyone have any information or links to articles that discuss how lung issues can contribute to DCI?
2. If indeed I do have a lung issue that was a contributing factor in both dive incidents then I am concerned that the diving physician did not investigate this when he did my medical. He did not do a chest x-ray as part of the examination. I did disclose to him that I had previously had pneumonia (25 years ago) and that I had been a smoker for many years. There is obviously nothing that can be done about this now, but perhaps it can serve as a lesson to other divers to ensure they have complete medicals in order to evaluate their fitness to dive. Even if something doesn't seem obvious as a problem (I am not aware of any lung issues) it could potentially be.

Thanks for listening. I am devastated that I will no longer be able to be a part of the scuba community. That year off from diving was difficult and I was so happy to be back in the water. I am gutted that I won't be able to dive anymore.

 

[TSandM]

I am assuming that your first incident was a case of the bends, related to nitrogen loading. There really is no correlation between this type of diving injury and pulmonary barotrauma, unless you developed pulmonary fibrosis as a result of the high oxygen tensions of multiple chamber rides. I'm not sure that has ever been described, and I also think you would have known it, having noticed a significant decrease in exercise tolerance as a result of poor pulmonary function.

What is more worrisome is the etiology of your pneumothorax. If it was due to ascending while holding your breath, that is traumatic; if it was not, it was spontaneous, and spontaneous pneumothorax is one of the strong contraindications to diving. Spontaneous pneumothorax is generally due to some abnormality of the underlying lung. Some people have "blebs", or little blisters on the surface of their lungs, which are weak points and rupture easily with any increase in pressure. Sometimes just coughing is enough! Other people have cystic abnormalities in the lung, which is common in smokers and people with emphysema. Some of these abnormalities can be seen with a high-resolution CT scan of the chest, but I cannot think of any reason why someone would have been moved to do one after a case of simple, nitrogen-loading DCS.

 

[h20_kat]

Smoking alone is not an indication to do even a chest x-ray for sport divers, unless there is something gross found on physical exam. Further any abnormality cannot be predicted to prelude a pneumothorax either, even by the preferred test, a high resolution CT scan. Commercial divers require a baseline chest-ray and periodic repeats only because of regulatory agencies. But in the end, the only proof some issue causes a pneumothorax is if the patient gets a primary type in their lifetime.

There is a surgical treatment to prevent future pneumothoraxes, but even afterwards, clearance for diving is unlikely as it has ~ 1% recurrence rate.

I realise that they cannot predict whether a pneumothorax will or will not happen. Is a history of pneumonia an indication to do a chest x-ray? I did have pneumonia about 25 years ago. I understand that could have left scarring on the lung. Would that even show up on an x-ray or would it require a high res CT scan? What about the blebs? Is it worth seeking a high res CT scan when I return home? I really would like to know why this happened to me.

I'm quite sure diving is off the table. Even if a high resolution scan showed perfect lungs I don't think I would be comfortable with the risk.

---------- Post added February 3rd, 2015 at 07:07 PM ----------

I am assuming that your first incident was a case of the bends, related to nitrogen loading. There really is no correlation between this type of diving injury and pulmonary barotrauma, unless you developed pulmonary fibrosis as a result of the high oxygen tensions of multiple chamber rides. I'm not sure that has ever been described, and I also think you would have known it, having noticed a significant decrease in exercise tolerance as a result of poor pulmonary function.

What is more worrisome is the etiology of your pneumothorax. If it was due to ascending while holding your breath, that is traumatic; if it was not, it was spontaneous, and spontaneous pneumothorax is one of the strong contraindications to diving. Spontaneous pneumothorax is generally due to some abnormality of the underlying lung. Some people have "blebs", or little blisters on the surface of their lungs, which are weak points and rupture easily with any increase in pressure. Sometimes just coughing is enough! Other people have cystic abnormalities in the lung, which is common in smokers and people with emphysema. Some of these abnormalities can be seen with a high-resolution CT scan of the chest, but I cannot think of any reason why someone would have been moved to do one after a case of simple, nitrogen-loading DCS.

My first incident was nitrogen related. It was neurological DCS. Good to know there is no relation between the two.

I don't believe I was holding my breath. The entire dive was very easy and relaxed. I think it's likely there is some abnormality of the lung as indicated by the doctor in Indonesia. It's unfortunate I have not had a CT scan here in Singapore where I can actually have a conversation with the doctor.

Thanks for the info TSandM.

 

[Duke Dive Medicine]

Kat,

If your lungs come out clear on CT then it's possible that you suffered from barotrauma but didn't realize it at the time. The classic history for pulmonary barotrauma in diving is a panic ascent with a breath-hold, but it can also happen inadvertently if you're holding your breath at the wrong time (especially in shallow water) and a reasonably good-sized wave goes over the top of you, or you're hanging onto a dive ladder in heavy seas. The resultant depth change can be enough to lead to barotrauma. I'd recommend you go see Dr. Simon Mitchell in Auckland once you're home.

Best regards,
DDM

 

[chillyinCanada]

Back the way Kat, how long will you remain in hospital here in Singapore? Do you have anywhere ne with you? How are you to be repatriated?

 

[Akimbo]

... The classic history for pulmonary barotrauma in diving is a panic ascent with a breath-hold, but it can also happen inadvertently if you're holding your breath at the wrong time (especially in shallow water) and a reasonably good-sized wave goes over the top of you, or you're hanging onto a dive ladder in heavy seas. The resultant depth change can be enough to lead to barotrauma...

For sure, it's not just a newbie problem. Joachim Wendler died from a massive embolism on the Helgoland habitat. Anytime you are on a stop or just ascending a fairly taught downline in heavy swells you have to be extra careful keeping your airway open at all times. No panic necessary, even an ill-timed gulp "could" do it. You are better off hanging from a line on the boat that is rising and lowering with the swell.

 

[h20_kat]

Kat,

If your lungs come out clear on CT then it's possible that you suffered from barotrauma but didn't realize it at the time. The classic history for pulmonary barotrauma in diving is a panic ascent with a breath-hold, but it can also happen inadvertently if you're holding your breath at the wrong time (especially in shallow water) and a reasonably good-sized wave goes over the top of you, or you're hanging onto a dive ladder in heavy seas. The resultant depth change can be enough to lead to barotrauma. I'd recommend you go see Dr. Simon Mitchell in Auckland once you're home.

Best regards,
DDM

I have a friend who already phoned Dr Simon Mitchell to consult about my situation when I was in Indonesia receiving questionable care. I think it's a very good idea to see him when I get back to Auckland. Thanks for the info.

---------- Post added February 4th, 2015 at 05:44 PM ----------

Back the way Kat, how long will you remain in hospital here in Singapore? Do you have anywhere ne with you? How are you to be repatriated?

I am getting out of the hospital today. As of yesterday's x-ray my lung is fully inflated. I need to stay for a week before I can fly back to Auckland. I am not sure about what the deal is with flying home yet. One step at a time. Once I am out and into a hotel then my insurance can start working on getting me a flight. When I was in Indonesia, before the reoccurence of the pneumothorax, they were talking about getting me a medical escort for the flight home. I am travelling on my own but do have a friend in Singapore who has been visiting me and bringing me treats, doing my laundry, getting me a SIM card, lending me money, etc.

Regarding your status - have you been to Lembeh? That's where I was diving when this happened. It was my 4th time there. It is the BEST diving in the world if you like muck diving. GO! Just don't wind up in the hospital in Manado.