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利用者:JAlone/圧外傷2

曖昧さ回避 この項目では、the medical conditionについて説明しています。the video gameについては「Barotrauma (video game)」をご覧ください。
圧外傷(Barotrauma)
別称 Squeeze, decompression illness, lung overpressure injury, volutrauma
マスクの圧迫によりダイバーに軽度の圧外傷が発生。目と周囲の皮膚には点状出血と結膜下出血が見られる。
概要
症状 場所による
原因 生体組織とそれ以外(環境、体腔)の間の圧力差
合併症 動脈ガス塞栓, 気胸, 縦隔気腫
分類および外部参照情報

圧外傷とは、生体組織とそれ以外(環境、体腔)の間の圧力差による物理的損傷である。[1][2]通常、最初の損傷は、閉じた空間内のガスの膨張または組織を静水圧的に伝わる圧力差によって直接的に引き起こされる張力またはせん断力による組織の過度の伸張によるものである。組織の破裂は、局所組織へのガスの侵入や最初の外傷部位を通る循環によって複雑になる可能性があり、遠隔部位での循環不全を引き起こしたり、ガスの存在により臓器の正常な機能が妨げられたりする可能性がある。この用語は通常、関係する気泡が減圧前にすでに存在している場合に適用される。圧外傷は、圧迫事象と減圧事象の両方で発生する可能性がある。[1][2]

圧外傷は一般に、副鼻腔または中耳の影響、肺の過圧損傷、および外部からの圧迫による損傷として現れる。減圧症(decompression sickness)は周囲の圧力低下によって間接的に引き起こされ、組織の損傷は気泡によって直接的および間接的に引き起こされる。ただし、これらの泡は溶解ガスの過飽和溶液から形成されるため、一般に圧外傷とは呼ばれない。減圧病(decompression illness)とは、減圧症(decompression sickness)と肺の過膨張圧外傷によって引き起こされる動脈ガス塞栓症の2つの病態からなる。[3]これは、周囲気圧の変化に起因するすべての病状を含む、より広い用語の不快感にも分類される。[4]

圧外傷は通常、スキューバダイバー、フリーダイバー、飛行機の乗客が上昇または下降するとき、または潜水チャンバーや与圧航空機などの圧力容器が制御されていない減圧中に、生物が周囲圧力の重大な変化にさらされたときに発生する。衝撃波によって引き起こされることもある。人工呼吸器誘発性肺損傷 (VILI) は、身体が自力で呼吸できないときに使用される機械換気による肺の過剰拡張および拡張収縮の繰り返しによって引き起こされる症状であり、比較的大きな一回換気量と比較的高いピーク圧力を伴う。内部のガスで満たされた空間の過剰膨張による圧外傷は、容量外傷(volutrauma)とも呼ばれる。

代表例

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圧外傷によって損傷を受けやすい臓器や組織の例に以下のものがある

原因

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ダイビング時に気圧外傷を引き起こす圧力差は静水圧の変化である。ダイバーに作用する周囲の圧力には、大気圧と水圧の 2 つの要素がある。水中で 10 メートル (33 フィート) 降下すると、1圧とほぼ同じ量だけ増加する。したがって、水面から水深 10 メートル (33 フィート) まで降下すると、ダイバーにかかる圧力は 2 倍になる。この圧力変化により、ガスが満たされた柔軟な空間の体積が約半分に減る。ボイルの法則は、ガス空間の体積とガス内の圧力との関係を説明する。[1][22]

Barotraumas of descent, also known as compression barotrauma, and squeezes, are caused by preventing the free change of volume of the gas in a closed space in contact with the diver, resulting in a pressure difference between the tissues and the gas space, and the unbalanced force due to this pressure difference causes deformation of the tissues resulting in cell rupture.[2] Barotraumas of ascent, also called decompression barotrauma, are also caused when the free change of volume of the gas in a closed space in contact with the diver is prevented. In this case the pressure difference causes a resultant tension in the surrounding tissues which exceeds their tensile strength.[2]

Patients undergoing hyperbaric oxygen therapy must equalize their ears to avoid barotrauma. High risk of otic barotrauma is associated with unconscious patients.[23] Explosive decompression of a hyperbaric environment can produce severe barotrauma, followed by severe decompression bubble formation and other related injury. The Byford Dolphin incident is an example. Rapid uncontrolled decompression from caissons, airlocks, pressurised aircraft, spacecraft, and pressure suits can have similar effects of decompression barotrauma.

Collapse of a pressure resistant structure such as a submarine, submersible, or atmospheric diving suit can cause rapid compression barotrauma. A rapid change of altitude can cause barotrauma when internal air spaces cannot be equalised. Excessively strenuous efforts to equalise the ears using the Valsalva manoeuvre can overpressurise the middle ear, and can cause middle ear and/or inner ear barotrauma. An explosive blast and explosive decompression create a pressure wave that can induce barotrauma. The difference in pressure between internal organs and the outer surface of the body causes injuries to internal organs that contain gas, such as the lungs, gastrointestinal tract, and ear.[24] Lung injuries can also occur during rapid decompression, although the risk of injury is lower than with explosive decompression.[25][26]

機械換気は肺の圧外傷を引き起こす可能性がある。これは次のいずれかの原因が考えられる[27]

  • 肺コンプライアンスが低下した肺を無理に換気しようとする絶対圧力
  • せん断力ː特にガス速度の急速な変化に関連するもの

その結果生じる肺胞破裂は、気胸、肺間質性気腫（pulmonary interstitial emphysema,PIE）、縦隔気腫を引き起こす可能性がある。[28]

Barotrauma is a recognised complication of mechanical ventilation that can occur in any patient receiving mechanical ventilation, but is most commonly associated with acute respiratory distress syndrome. It used to be the most common complication of mechanical ventilation but can usually be avoided by limiting tidal volume and plateau pressure to less than 30 to 50 cm water column (30 to 50 mb). As an indicator of transalveolar pressure, which predicts alveolar distention, plateau pressure or peak airway pressure (PAP) may be the most effective predictor of risk, but there is no generally accepted safe pressure at which there is no risk.

圧外傷は人工呼吸器の合併症として知られており、人工呼吸器を受けているすべての患者に発生する可能性があるが、最も一般的には急性呼吸窮迫症候群に関連している。以前は人工呼吸器の最も一般的な合併症だったが、、通常は一回換気量とプラトー圧を30 ～ 50 cmH2O (30 ～ 50 mb) 未満に制限することで回避できる。肺胞の膨張を予測する肺胞内圧の指標として、プラトー圧またはピーク気道内圧 (peak airway pressure,PAP) がリスクを予測する最も効果的な指標である可能性があるが、リスクが存在しない一般に受け入れられている安全な圧力は存在しない。

[28][29] また、胃内容物の誤嚥や、壊死性肺炎や慢性肺疾患などの既存疾患によってもリスクが高まるらしい。喘息重積発作は、気管​​支閉塞を克服するために比較的高い圧力を必要とするため、特に問題となる。[29]

肺組織が肺胞の過膨張によって損傷を受けると、その損傷は容量外傷(volutrauma)と呼ばれることがあるが、容積と経肺圧は密接に関係している。人工呼吸器による肺損傷は、多くの場合、一回換気量(Vt)の増加と関連している。[30]

同様の原因による他の傷害には、減圧症やアームストロング限界を超えた気圧高度で起きる体液沸騰がある。[31]

病態生理学

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肺過圧損傷

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フリーダイバーは息を吐き出さずに潜水し、安全に上昇することができる。これは、肺内のガスが大気圧で吸入されており、降下中に圧縮され、上昇中に元の体積に戻るためである。スキューバまたは水面から供給されたダイバーが深海で水中呼吸装置からガスを呼吸すると、大気圧よりも高い周囲圧力で肺がガスで満たされる。 10 メートルの肺には、大気圧で含まれるガスの 2 倍の量のガスが含まれている。息を吐き出さずに上昇すると、肺が弾性限界に達して裂け始めるまで、ガスは圧力の低下に合わせて膨張し、生命を脅かす肺損傷を受ける可能性がある。[2][22] 組織の破裂に加えて、過剰な圧力により、破裂部を通って組織内にガスが侵入し、さらに循環系を通ってガスが侵入する可能性がある。[2] 上昇性の肺の圧外傷（Pulmonary barotrauma,PBt）は、肺過膨張症候群（pulmonary over-inflation syndrome,POIS）、肺過圧損傷（lung over-pressure injury,LOP）、肺破裂としても知られている。[22]

結果として起こる損傷には、ガスが到達する場所に応じて、動脈ガス塞栓症、気胸、縦隔気腫、間質気腫、皮下気腫などが含まれる可能性があるが、通常はすべて同時に発生するわけではない。

肺過膨張症候群(POIS)は機械換気で生じることもある。

動脈ガス塞栓症

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→詳細は「Arterial gas embolism」を参照

Gas in the arterial system can be carried to the blood vessels of the brain and other vital organs. It typically causes transient embolism similar to thromboembolism but of shorter duration. Where damage occurs to the endothelium inflammation develops and symptoms resembling stroke may follow. The bubbles are generally distributed and of various sizes, and usually affect several areas, resulting in an unpredictable variety of neurological deficits. Unconsciousness or other major changes to the state of consciousness within about 10 minutes of surfacing are generally assumed to be gas embolism until proven otherwise. The belief that the gas bubbles themselves formed static emboli which remain in place until recompression has been superseded by the knowledge that the gas emboli are normally transient, and the damage is due to inflammation following endothelial damage and secondary injury from inflammatory mediator upregulation.[32]

Hyperbaric oxygen can cause downregulation of the inflammatory response and resolution of oedema by causing hyperoxic arterial vasoconstriction of the supply to capillary beds. High concentration normobaric oxygen is appropriate as first aid but is not considered definitive treatment even when the symptoms appear to resolve. Relapses are common after discontinuing oxygen without recompression.[32]

気胸

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→詳細は「気胸」を参照

A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall.[33] Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath.[34] In a minority of cases, a one-way valve is formed by an area of damaged tissue, and the amount of air in the space between chest wall and lungs increases; this is called a tension pneumothorax.[33] This can cause a steadily worsening oxygen shortage and low blood pressure. This leads to a type of shock called obstructive shock, which can be fatal unless reversed.[33] Very rarely, both lungs may be affected by a pneumothorax.[35] It is often called a "collapsed lung", although that term may also refer to atelectasis.[36]

Divers who breathe from an underwater apparatus are supplied with breathing gas at ambient pressure, which results in their lungs containing gas at higher than atmospheric pressure. Divers breathing compressed air (such as when scuba diving) may develop a pneumothorax as a result of barotrauma from ascending just 1メートル (3 ft) while breath-holding with their lungs fully inflated.[37] An additional problem in these cases is that those with other features of decompression sickness are typically treated in a diving chamber with hyperbaric therapy; this can lead to a small pneumothorax rapidly enlarging and causing features of tension.[37]

Diagnosis of a pneumothorax by physical examination alone can be difficult (particularly in smaller pneumothoraces).[38] A chest X-ray, computed tomography (CT) scan, or ultrasound is usually used to confirm its presence.[39] Other conditions that can result in similar symptoms include a hemothorax (buildup of blood in the pleural space), pulmonary embolism, and heart attack.[34][40] A large bulla may look similar on a chest X-ray.[33]

縦隔気腫

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→詳細は「Pneumomediastinum」を参照

Also known as mediastinal emphysema to divers, pneumomediastinum is a volume of gas inside the mediastinum, the central cavity in the chest between the lungs and surrounding the heart and central blood vessels, usually formed by gas escaping from the lungs as a result of lung rupture.[41]

Gas bubbles escaping from a ruptured lung can travel along the outside of bronchioles and blood vessels until they reach the mediastinal cavity round the heart, major blood vessels, oesophagus and trachea. Gas trapped in the mediastinum expands as the diver continues to rise. The pressure of the trapped gas may cause intense pain inside the rib cage and in the shoulders, and the gas may compress the respiratory passageways, making breathing difficult, and collapse blood vessels. Symptoms range from pain under the sternum, shock, shallow breathing, unconsciousness, respiratory failure, and associated cyanosis. The gas will usually be absorbed by the body over time, and when the symptoms are mild, no treatment may be necessary. Otherwise it may be vented through a hypodermic needle inserted into the mediastinum.[41] Recompression is not usually indicated.

Diagnosis

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Blood gas analyser

Diagnosis of barotrauma generally involves a history of exposure to a source of pressure which could cause the injury suggested by the symptoms. This can vary from the immediately obvious if exposed to explosive blast, or mask squeeze, to rather complex discrimination between possibilities of inner ear decompression sickness and inner ear barotrauma, which may have nearly identical symptoms but different causative mechanism and mutually incompatible treatments. The detailed dive history may be necessary in these cases.[42]

In terms of barotrauma the diagnostic workup for the affected individual could include the following:

Laboratory:[43]

Imaging:[43]

  • Chest radiography can show pneumothorax, and is indicated if there is chest discomfort or breathing difficulty
  • Computed tomography (CT) scans and magnetic resonance imaging (MRI) may be indicated when there is severe headache or severe back pain after diving.
  • CT is the most sensitive method to evaluate for pneumothorax. It can be used where barotrauma-related pneumothorax is suspected and chest radiograph findings are negative.
  • Echocardiography can be used to detect the number and size of gas bubbles in the right side of the heart.

Ear barotrauma

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Barotrauma can affect the external, middle, or inner ear. Middle ear barotrauma (MEBT) is the most common diving injury,[44] being experienced by between 10% and 30% of divers and is due to insufficient equilibration of the middle ear. External ear barotrauma may occur if air is trapped in the external auditory canal. Diagnosis of middle and external ear barotrauma is relatively simple, as the damage is usually visible if severe enough to require intervention.

External auditory canal

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Barotrauma can occur in the external auditory canal if it is blocked by cerumen, exostoses, a tight-fitting diving suit hood or earplugs, which create an airtight, air-filled space between the eardrum and the blockage. On descent, a pressure differential develops between the ambient water and the interior of this space, and this can cause swelling and haemorrhagic blistering of the canal. Treatment is usually analgesics and topical steroid eardrops. Complications may include local infection. This form of barotrauma is usually easily avoided.[44]

Middle ear

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→詳細は「Middle ear barotrauma」を参照

Middle ear barotrauma (MEBT) is an injury caused by a difference in pressure between the external ear canal and the middle ear. It is common in underwater divers and usually occurs when the diver does not equalise sufficiently during descent or, less commonly, on ascent. Failure to equalise may be due to inexperience or eustachian tube dysfunction, which can have many possible causes.[44] Unequalised ambient pressure increase during descent causes a pressure imbalance between the middle ear air space and the external auiditory canal over the eardrum, referred to by divers as ear squeeze, causing inward stretching, serous effusion and haemorrhage, and eventual rupture. During ascent internal over-pressure is normally passively released through the eustachian tube, but if this does not happen the volume expansion of middle ear gas will cause outward bulging, stretching and eventual rupture of the eardrum known to divers as Template:Diving term. This damage causes local pain and hearing loss. Tympanic rupture during a dive can allow water into the middle ear, which can cause severe vertigo from caloric stimulation. This may cause nausea and vomiting underwater, which has a high risk of aspiration of vomit or water, with possible fatal consequences.[44]

Inner ear

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→「Inner ear decompression sickness § Diagnosis」も参照

Inner ear barotrauma (IEBt), though much less common than MEBT, shares a similar external cause. Mechanical trauma to the inner ear can lead to varying degrees of conductive and sensorineural hearing loss as well as vertigo. It is also common for conditions affecting the inner ear to result in auditory hypersensitivity.[45] Two possible mechanisms are associated with forced Valsalva manoeuvre. In the one, the Eustachian tube opens in response to the pressure, and a sudden rush of high pressure air into the middle ear causes stapes footplate dislocation and inward rupture of the oval or round window. In the other, the tube remains closed and increased cerebrospinal fluid pressure is transmitted through the cochlea and causes outward rupture of the round window.[44]

Inner ear barotrauma can be difficult to distinguish from Inner ear decompression sickness. Both conditions manifest as cochleovestibular symptoms. The similarity of symptoms makes differential diagnosis difficult, which can delay appropriate treatment or lead to inappropriate treatment.[42]

Nitrogen narcosis, oxygen toxicity, hypercarbia, and hypoxia can cause disturbances in balance or vertigo, but these appear to be central nervous system effects, not directly related to effects on the vestibular organs. High-pressure nervous syndrome during heliox compression is also a central nervous system dysfunction. Inner ear injuries with lasting effects are usually due to round window ruptures, often associated with Valsalva maneuver or inadequate middle ear equalisation.[46] Inner ear barotrauma is often concurrent with middle ear barotrauma as the external causes are generally the same. A variety of injuries may be present, which may include inner ear haemorrhage, intralabyrinthine membrane tear, perilymph fistula, and other pathologies.[47]

Divers who develop cochlear and/or vestibular symptoms during descent to any depth, or during shallow diving in which decompression sickness is unlikely, should be treated with bed rest with head elevation, and should avoid any activity which could cause raised cerebrospinal fluid and intralabyrinthine pressure.[要説明] If there is no improvement in symptoms after 48 hours, exploratory tympanotomy may be considered to investigate possible repair of a labyrinthine window fistula. Recompression therapy is contraindicated in these cases, but is the definitive treatment for inner ear decompression sickness, making an early and accurate differential diagnosis important for deciding on appropriate treatment. IEBt in divers may be difficult to distinguish from inner ear decompression sickness (IEDCS), and as a dive profile alone cannot always eliminate either of the possibilities, the detailed dive history may be necessary to diagnose the more likely injury.[42][47] It is also possible for both to occur at the same time, and IEDCS is more likely to affect the semicircular canals, causing severe vertigo, while IEBt is more likely to affect the cochlea, causing hearing loss, but these are just statistical probabilities, and in reality it can go either way or both.[48] It is accepted practice to assume that if any symptom typical of DCS is present, that the diver has DCS and will be treated accordingly with recompression.[48] Limited case data suggest that recompression does not usually cause harm if the differential diagnosis between IEBt vs IEDCS is doubtful.[47]

Symptom comparison between inner ear barotrauma and inner ear decompression sickness[44]
Barotrauma Decompression sickness
Conductive or mixed hearing loss Sensorineural hearing loss
Occurs during descent or ascent Onset during ascent or after surfacing
Cochlear symptoms (i.e. hearing loss) predominate Vestibular symptoms (vertigo) predominant; right sided
History of difficult ear clearing or forced Valsalva manoeuvre No history of eustachian tube dysfunction
Low-risk dive profile Depth >15 m, helium mixtures, helium to nitrogen gas switches, repetitive dives
Isolated inner ear symptoms, or inner and middle ear on the same sides Other neurological or dermatological symptoms suggestive of DCS

Barosinusitis

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→詳細は「Aerosinusitis」を参照

The sinuses, like other air-filled cavities, are susceptible to barotrauma if their openings become obstructed. This can result in pain as well as epistaxis (nosebleed). Diagnosis is usually simple provided the history of pressure exposure is mentioned.[49] Barosinusitis, is also called aerosinusitis, sinus squeeze or sinus barotrauma. Sinus barotrauma can be caused by external or internal overpressure. External over-pressure is called sinus squeeze by divers, while internal over-pressure is usually referred to as reverse block or reverse squeeze.

Mask squeeze

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If a diver's mask is not equalized during descent the relative negative internal pressure can produce petechial hemorrhages in the area covered by the mask along with subconjunctival hemorrhages.[49]

Helmet squeeze

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→「Standard diving dress § Specific hazards」も参照

A problem mostly of historical interest, but still relevant to surface supplied divers who dive with the helmet sealed to the dry suit. If the air supply hose is ruptured near or above the surface, the pressure difference between the water around the diver and the air in the hose can be several bar. The non-return valve at the connection to the helmet will prevent backflow if it is working correctly, but if absent, as in the early days of helmet diving, or if it fails, the pressure difference will tend to squeeze the diver into the rigid helmet, which can result in severe trauma. The same effect can result from a large and rapid increase in depth if the air supply is insufficient to keep up with the increase in ambient pressure.[50] On a helmet with a neck dam, the neck dam will allow water to flood the helmet before serious barotrauma can occur. This can happen with helium reclaim helmets if the reclaim regulator system fails, so there is a manual bypass valve, which allows the helmet to be purged so breathing can continue on open circuit.

Pulmonary barotrauma

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→詳細は「List of signs and symptoms of diving disorders § Arterial gas embolism and pulmonary barotrauma」を参照

Lung over-pressure injury in ambient pressure divers using underwater breathing apparatus is usually caused by breath-holding on ascent. The compressed gas in the lungs expands as the ambient pressure decreases causing the lungs to over-expand and rupture unless the diver allows the gas to escape by maintaining an open airway, as in normal breathing. The lungs do not sense pain when over-expanded giving the diver little warning to prevent the injury. This does not affect breath-hold divers as they bring a lungful of air with them from the surface, which merely re-expands safely to near its original volume on ascent.[2] The problem only arises if a breath of ambient pressure gas is taken at depth, which may then expand on ascent to more than the lung volume. Pulmonary barotrauma may also be caused by explosive decompression of a pressurised aircraft,[51] as occurred on 1 February 2003 to the crew in the Space Shuttle Columbia disaster.

予防

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Diving

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Barotrauma may be caused when diving, either from being crushed, or squeezed, on descent or by stretching and bursting on ascent; both can be avoided by equalising the pressures. A negative, unbalanced pressure is known as a squeeze, crushing eardrums, dry suit, lungs or mask inwards and can be equalised by putting air into the squeezed space. A positive unbalanced pressure expands internal spaces rupturing tissue and can be equalised by letting air out, for example by exhaling. Both may cause barotrauma. There are a variety of techniques depending on the affected area and whether the pressure inequality is a squeeze or an expansion:

  • Ears and sinuses: There is a risk of stretched or burst eardrums, usually crushed inwards during descent but sometimes stretched outwards on ascent. The diver can use a variety of methods to let air into or out of the middle ears via the Eustachian tubes. Sometimes swallowing will open the Eustachian tubes and equalise the ears.[52]
  • Lungs: There is a risk of pneumothorax, arterial gas embolism, and mediastinal and subcutaneous emphysema during ascent, which are commonly called burst lung or lung overpressure injury by divers. To equalise the lungs, all that is necessary is not to hold the breath during ascent. This risk does not occur when breath-hold diving from the surface, unless the diver breathes from an ambient pressure gas source underwater; breath-hold divers do suffer squeezed lungs on descent, crushing in the chest cavity, but, while uncomfortable, this rarely causes lung injury and returns to normal at the surface. Some people have pathology of the lung which prevent rapid flow of excess air through the passages, which can lead to lung barotrauma even if the breath is not held during rapid depressurisation. These people should not dive as the risk is unacceptably high. Most commercial or military diving medical examinations will look specifically for signs of this pathology.[53]
  • Diving mask squeeze enclosing the eyes and nose: The main risk is rupture of the capillaries of the eyes and facial skin because of the negative pressure difference between the gas space and blood pressure,[11] or orbital emphysema from higher pressures.[54][要説明] This can be avoided by breathing air into the mask through the nose. Goggles covering only the eyes are not suitable for deep diving as they cannot be equalised.
  • Dry suit squeeze. The main risk is skin getting pinched and bruised by folds of the dry suit when squeezed on descent. Most dry suits can be equalised against squeeze via a manually operated valve fed from a low pressure gas supply. Air must be manually injected during the descent to avoid squeeze and is manually or automatically vented on the ascent to maintain buoyancy control.[55]
  • Diving helmet squeeze: Helmet squeeze will occur if the gas supply hose is severed above the diver and the non-return valve at the helmet gas inlet fails or is not fitted. Severity will depend on the hydrostatic pressure difference.[56] A very rapid descent, usually by accident, may exceed the rate at which the breathing gas supply can equalise the pressure causing a temporary squeeze. The introduction of the non-return valve and high maximum gas supply flow rates have all but eliminated both these risks. In helmets fitted with a neck dam, the dam will admit water into the helmet if the internal pressure gets too low; this is less of a problem than helmet squeeze but the diver may drown if the gas supply is not reinstated quickly.[50]:90 This form of barotrauma is avoidable by controlled descent rate, which is standard practice for commercial divers, who will use shotlines, diving stages and wet bells to control descent and ascent rates.

Medical screening

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→詳細は「Fitness to dive」を参照

Professional divers are screened for risk factors during initial and periodical medical examination for fitness to dive.[57] In most cases recreational divers are not medically screened, but are required to provide a medical statement before acceptance for training in which the most common and easy to identify risk factors must be declared. If these factors are declared, the diver may be required to be examined by a medical practitioner, and may be disqualified from diving if the conditions indicate.[58]

Asthma, Marfan syndrome, and COPD pose a very high risk of pneumothorax.[要説明] In some countries these may be considered absolute contraindications, while in others the severity may be taken into consideration. Asthmatics with a mild and well controlled condition may be permitted to dive under restricted circumstances.[59]

Training

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→「Recreational diver training」、「Scuba skills」、および「Surface supplied diving skills」も参照

A significant part of entry level diver training is focused on understanding the risks and procedural avoidance of barotrauma.[60] Professional divers and recreational divers with rescue training are trained in the basic skills of recognizing and first aid management of diving barotrauma.[61][62]

機械換気

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単独の機械的力では、人工呼吸器誘発性肺損傷 (VILI,ventilator-induced lung injury）,人工呼吸器関連肺損傷( VALI,ventilator-associated lung injury）を適切に説明できない可能性がある。損傷は、これらの力と肺組織の既存の状態の相互作用によって影響を受け、肺胞構造の動的な変化が関与している可能性がある。

プラトー圧(機械換気時に肺にかかる最大圧力)や呼気終末陽圧(呼気が終わる時の圧力、つまり機械換気時に肺にかかる最低圧力)(positive end-expiratory pressureːPEEP) などの要因だけでは損傷を適切に予測できない。肺組織の周期的変形は VILI の原因に大きな役割を果たしている可能性があり、その寄与因子にはおそらく 1 回換気量、呼気終末陽圧、呼吸数が含まれる。すべてのアプリケーションですべてのリスクを回避することが保証されたプロトコルはない。[30]

胸郭の拡張を抑え、高い気道内圧であっても肺気量の増加を伴わないようにした動物実験モデルでは、肺傷害が生じないことが示され、容量外傷（volutrauma）の概念が提唱された。

さらに、高い PEEP と低い PEEP で換気を行った動物実験では，低 PEEP 群で肺傷害が生じることが示された。この機序として換気に伴って肺胞が拡張─虚脱を繰り返すことが原因と推定されatelectrauma(虚脱性肺損傷、無気肺損傷) の概念が提唱された。さらに、物理的刺激により肺局所での炎症性メディエーターの 産生が亢進して炎症性肺損傷(biotrauma)が生じる。[63][64]

これらの実験結果から、PEEPを高め、プラトー圧を下げ、一回換気量を減らせば肺損傷を防げるとわかったが、当然換気量は低下してしまい呼吸性アシドーシスを招きやすい。

材料力学の疲労と同様、応力振幅が肺損傷に影響する。応力振幅には駆動圧⊿P=プラトー圧 - PEEPが相当する。プラトー圧が上昇してもPEEPも上昇し駆動圧が普遍の場合、死亡率は増加しないことが過去のRCTにより示されている。[65]

Aviation and spaceflight

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Barotrauma caused during airplane journeys is also referred to as airplane ear.[66] The environmental pressure must be prevented from changing rapidly by large amounts.[31] One should include multiple redundant levels of protection against rapid decompression, and systems allowing non-catastrophic failure with sufficient time to allow comfortable equalization of relevant air spaces, particularly the inner ear. A low internal pressure reduces decompression rate and severity in a catastrophic decompression reduces the risk of barotrauma but can increase the risk of decompression sickness and hypoxia in normal operating conditions.

Some measures for protection against rapid decompression specific to airplanes include:[66]

  1. Yawn and swallow during ascent and descent
  2. Use the Valsalva maneuver during ascent and descent
  3. Avoid sleeping during takeoffs and landings
  4. Use an over the counter nasal spray
  5. Using filtered earplugs which slowly equalize the pressure against your eardrum during ascents and descents

Outside of a pressurized cabin environment at very high altitudes, a pressure suit is the usual protective measure and is the definitive protection in decompression and exposure to vacuum, but they are expensive, heavy, bulky, restrict mobility, cause thermal regulatory problems, and reduce comfort.[67] To prevent injury from unavoidable pressure changes, similar equalization techniques and relatively slow pressure changes are required, which in turn require patent Eustachian tubes and sinuses.

治療

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Treatment of diving barotrauma depends on the symptoms, which depend on the affected tissues. Lung over-pressure injury may require a chest drain to remove air from the pleura or mediastinum. Recompression with hyperbaric oxygen therapy is the definitive treatment for arterial gas embolism, as the raised pressure reduces bubble size, the reduced blood inert gas concentration may accelerate inert gas solution, and high oxygen partial pressure helps oxygenate tissues compromised by the emboli. Care must be taken when recompressing to avoid a tension pneumothorax.[68] Barotraumas that do not involve gas in the tissues are generally treated according to severity and symptoms for similar trauma from other causes.

First aid

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Pre-hospital care for lung barotrauma includes basic life support of maintaining adequate oxygenation and perfusion, assessment of airway, breathing and circulation, neurological assessment, and managing any immediate life-threatening conditions. High-flow oxygen up to 100% is considered appropriate for diving accidents. Large-bore venous access with isotonic fluid infusion is recommended to maintain blood pressure and pulse.[69]

Emergency treatment

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Pulmonary barotrauma:[70]

  • Endotracheal intubation may be required if the airway is unstable or hypoxia persists when breathing 100% oxygen.
  • Needle decompression or tube thoracostomy may be necessary to drain a pneumothorax or haemothorax
  • Foley catheterization may be necessary for spinal cord AGE if the person is unable to urinate.
  • Intravenous hydration may be required to maintain adequate blood pressure.
  • Therapeutic recompression is indicated for severe AGE. The diving medical practitioner will need to know the vital signs and relevant symptoms, along with the recent pressure exposure and breathing gas history of the patient. Air transport should be below 1,000フィート (300 m) if possible, or in a pressurized aircraft which should be pressurised to as low an altitude as reasonably possible.

Sinus squeeze and middle ear squeeze are generally treated with decongestants to reduce the pressure differential, with anti-inflammatory medications to treat the pain. For severe pain, narcotic analgesics may be appropriate.[70]

Suit, helmet and mask squeeze are treated as trauma according to symptoms and severity.

Medication

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The primary medications for lung barotrauma are hyperbaric and normobaric oxygen, hyperbaric heliox or nitrox, isotonic fluids, anti-inflammatory medications, decongestants, and analgesics.[71]

Outcomes

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Following barotrauma of the ears or lungs from diving the diver should not dive again until cleared by a diving doctor. After ear injury examination will include a hearing test and a demonstration that the middle ear can be autoinflated. Recovery can take weeks to months.[72]

Epidemiology

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An estimate of in the order of 1000 dive injuries per year occur in the United States and Canada. Many of these involve barotrauma, with nearly 50% of reported injuries involving middle ear barotrauma. Diving injuries tend to correlate with trait anxiety and a tendency to panic, lack of experience, advancing age and reduction in fitness, alcohol usage, obesity, asthma, chronic sinusitis and otitis.[73]

Barotrauma in other animals

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Whales and dolphins develop severely disabling barotrauma when exposed to excessive pressure changes induced by navy sonar, oil industry airguns, explosives, undersea earthquakes and volcanic eruptions.[要出典] Injury and mortality of fish, marine mammals, including sea otters, seals, dolphins and whales, and birds by underwater explosions has been recorded in several studies.[74]

It has been claimed that bats can suffer fatal barotrauma in the low pressure zones behind the blades of wind turbines due to their more fragile mammalian lung structure in comparison with the more robust avian lungs, which are less affected by pressure change.[75][76] The claims that have been made that bats can be killed by lung barotrauma when flying in low-pressure regions close to operating wind-turbine blades, have been supported by reports of measurements of the pressures around the turbine blades.[77] The diagnosis and contribution of barotrauma to bat deaths near wind turbine blades have been disputed by other research comparing dead bats found near wind turbines with bats killed by impact with buildings in areas with no turbines.[78]

浮き袋の過剰拡張

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タイガーエンゼルフィッシュの気圧外傷 - 頭端。膨張した浮き袋 (中央) と腹腔内のガス空間 (左) に注目
タイガーエンゼルフィッシュへの圧外傷による損傷 – 尾端

浮き袋が孤立した魚は、釣りで水面に上がったときに浮上時の気圧外傷を受けやすくなる。浮き袋は浮力を制御する器官であり、血液中の溶液から抽出されたガスで満たされており、通常は逆のプロセスによって除去される。ガスが吸収されるよりも早く魚が水柱内に引き上げられると、ガスは膀胱がその弾性限界まで伸びるまで膨張し、破裂する可能性がある。↵気圧外傷は直接的に致命傷となるか、魚を無力化して捕食されやすくなる可能性がある。浮上後すぐに引き上げたときと同じ深さに戻せば、岩礁魚は回復することができる。 NOAA の科学者は、岩礁魚を素早く深海に戻すSeaqualizerを開発した。[79] この装置は、キャッチアンドリリースされた岩礁魚の生存率を高める可能性がある


関連項目

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脚注

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[編集]
分類
外部リソース
（英語）

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