Scuba Diving

Technical terms

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Contents
Articles
Breathing gas Decompression sickness Deep diving Equivalent air depth Equivalent narcotic depth High-pressure nervous syndrome List of diving hazards and precautions Maximum operating depth Nitrogen narcosis Nitrox Oxygen toxicity Partial pressure Rebreather Technical diving Trimix (breathing gas) 1 8 23 28 29 30 32 38 40 49 56 72 77 91 97

References
Article Sources and Contributors Image Sources, Licenses and Contributors 102 104

Article Licenses
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Breathing gas

Breathing gas
Breathing gas is a mixture of gaseous chemical elements and compounds used for respiration. Air is the most common and only natural breathing gas. Other artificial gases, either pure gases or mixtures of gases, are used in breathing equipment and enclosed habitats such as SCUBA equipment, surface supplied diving equipment, recompression chambers, submarines, space suits, spacecraft and anaesthetic machines.[1] [2] [3] Most breathing gases are a mixture of oxygen and one or more inert gases.[1] [3] Other breathing gases have been developed to improve on the performance of air by reducing the risk of decompression sickness, reducing the duration of decompression stops, reducing nitrogen narcosis or allowing safer deep diving.[1] [3] A safe breathing gas has three essential features: it must contain sufficient oxygen to support the life, consciousness and work rate of the breather.[1] [2] [3] it must not contain harmful gases. Carbon monoxide and carbon dioxide are common poisons in breathing gases. There are many others.[1] [2] [3] it must not become toxic when being breathed at high pressure such as when underwater. Oxygen and nitrogen are examples of gases that become toxic under pressure.[1] [2] [3] The techniques used to fill diving cylinders with gases other than air are called gas blending.[4] [5]

Common diving breathing gases

Common diving breathing gases are: Air is a mixture of 21% oxygen, 78% nitrogen, and approximately 1% other trace gases; to simplify calculations this last 1% is usually treated as if it were nitrogen. Being cheap and simple to use, it is the most common diving gas.[1] [2] [3] As its nitrogen component causes nitrogen narcosis it is considered to have a safe depth limit of about 40 metres (130feet) for most divers, although the maximum operating depth of air is 66.2 metres (218feet).[1] [3]
[6]

Pure oxygen is mainly used to speed the shallow decompression stops at the end of a military, commercial or technical dive and is only safe down to a depth of 6 meters (maximum operating depth) before oxygen toxicity steps in.[1] [2] [3] [6] It was much used in frogmen's rebreathers.[2] [6] [7] [8] Nitrox is a mixture of oxygen and air, and generally refers to mixtures which are more than 21% oxygen. It can be used as a tool to accelerate in-water decompression stops or to decrease the risk of decompression sickness and thus prolong a dive (a common misconception is that the diver can go deeper, this is not true owing to a shallower maximum operating depth than on conventional air).[1] [2] [3] [9] Trimix is a mixture of oxygen, nitrogen and helium and is often used at depth in technical diving and commercial diving instead of air to reduce nitrogen narcosis and to avoid the dangers of oxygen toxicity.[1] [2] [3] Heliox is a mixture of oxygen and helium and is often used in the deep phase of a commercial deep dive to eliminate nitrogen narcosis.[1] [2] [3] [10] Heliair is a form of trimix that is easily blended from helium and air without using pure oxygen. It always has a 21:79 ratio of oxygen to nitrogen; the balance of the mix is helium.[3] [11] Hydreliox is a mixture of oxygen, helium, and hydrogen and is used for dives below 130 metres in commercial diving.[1] [3] [10] [12] [13] Hydrox, a gas mixture of hydrogen and oxygen is used as a breathing gas in very deep diving.[1] [3] [10] [12] [14] Neox (also called neonox) is a mixture of oxygen and neon sometimes employed for in deep commercial diving. It is rarely used due to its cost. Also, DCS symptoms produced by neon ("neox bends") have a poor reputation, being widely reported to be more severe than those produced by an exactly equivalent dive-table and mix with helium.[1] [3] [10] [15]

Breathing gas

Individual component gases

Oxygen
Oxygen (O2) must be present in every breathing gas.[1] [2] [3] This is because it is essential to the human body's metabolic process, which sustains life. The human body cannot store oxygen for later use as it does with food. If the body is deprived of oxygen for more than a few minutes, unconsciousness and death result. The tissues and organs within the body (notably the heart and brain) are damaged if deprived of oxygen for much longer than four minutes.

NEDU gas analysis lab

Filling a diving cylinder with pure oxygen costs around five times more than filling it with compressed air. As oxygen supports combustion and causes rust in diving cylinders, it should be handled with caution when gas blending.[4] [5] Oxygen has historically been obtained by fractional distillation of liquid air, but is increasingly obtained by non cryogenic technologies such as pressure swing adsorption (PSA) and vacuum-pressure swing adsorption (VPSA) technologies.[16] Fraction of oxygen The fraction of the oxygen component of a breathing gas mixture is sometimes used when naming the mix: hypoxic mixes, strictly, contain less than 21% oxygen, although often a boundary of 16% is used, and are designed only to be breathed at depth as a "bottom gas" where the higher pressure increases the partial pressure of oxygen to a safe level.[1] [2] [3] Trimix, Heliox and Heliair create typical hypoxic mixes and are used in technical diving as deep breathing gases.[1] [3] normoxic mixes have the same proportion of oxygen as air, 21%.[1] [3] The maximum operating depth of a normoxic mix could be as shallow as 47 metres (155feet). Trimix with between 17% and 21% oxygen is often described as normoxic because it contains a high enough proportion of oxygen to be safe to breathe at the surface. hyperoxic mixes have more than 21% oxygen. Enriched Air Nitrox (EANx) is a typical hyperoxic breathing gas.[1] [3] [9] Hyperoxic mixtures, when compared to air, cause oxygen toxicity at shallower depths but can be used to shorten decompression stops by drawing dissolved inert gases out of the body more quickly.[6] [9] The fraction of the oxygen determines the deepest the mixture gas can safely be used to avoid oxygen toxicity. This depth is called the maximum operating depth.[1] [3] [6] [9] Partial pressure of oxygen The concentration of oxygen in a gas mix depends on both the fraction and the pressure of the mixture. It is expressed by the partial pressure of oxygen (ppO2).[1] [3] [6] [9] The partial pressure of any component gas in a mixture is calculated as: partial pressure = total absolute pressure x volume fraction of gas component For the oxygen component: ppO2 = P x FO2

Breathing gas

where: ppO2 P FO2 = partial pressure of oxygen = total pressure = volume fraction of oxygen

The minimum safe partial pressure of oxygen in a breathing gas is commonly held to be 16 kPa (0.16 bar). Below this partial pressure the diver may be at risk of unconsciousness and death due to hypoxia, depending on factors including individual physiology and level of exertion. When a hypoxic mix is breathed in shallow water it may not have a high enough ppO2 to keep the diver conscious. For this reason normoxic or hyperoxic "travel gases" are used at medium depth between the "bottom" and "decompression" phases of the dive. The maximum safe ppO2 in a breathing gas depends on exposure time, the level of exercise and the security of the breathing equipment being used. It is typically between 100 kPa (1 bar) and 160 kPa (1.6 bar) but for dives of less than three hours is commonly considered to be 140 kPa (1.4 bar), although the U.S. Navy has been known to authorize dives with a ppO2 of as much as 180 kPa (1.8 bar).[1] [2] [3] [6] [9] At high ppO2 or longer exposures, the diver risks oxygen toxicity including a seizure.[1] [2] Each breathing gas has a maximum operating depth that is determined by its oxygen content.[1] [2] [3] [6] [9] Oxygen analysers measure the ppO2 in the gas mix.[4] Divox "Divox" is oxygen. In the Netherlands, pure oxygen for breathing purposes is regarded as medicinal as opposed to industrial oxygen, such as that used in welding, and is only available on medical prescription. The diving industry "created" Divox and registered it as a trademark to circumvent the strict rules concerning medicinal oxygen thus making it easier for (recreational) scuba divers to obtain oxygen for blending their breathing gas. In most countries, there is no difference in purity in medical oxygen and industrial oxygen, as they are produced by exactly the same methods and manufacturers, but labeled and tanked differently. The chief difference between them is that the paper record-keeping trail is much more extensive for medical oxygen, in order to more easily identify the exact manufacturing trail of a "lot" of oxygen, in case problems are later found with its purity.

Nitrogen
Nitrogen (N2) is a diatomic gas and the main component of air, the cheapest and most common breathing gas used for diving. It causes nitrogen narcosis in the diver, so its use is limited to shallower dives. Nitrogen can cause decompression sickness.[1] [2] [3] [17] Equivalent air depth is used to estimate the decompression requirements of a nitrox (oxygen/nitrogen) mixture. Equivalent narcotic depth is used to estimate the narcotic potency of trimix (oxygen/helium/nitrogen mixture). Many divers find that the level of narcosis caused by a 30m (100ft) dive, whilst breathing air, is a comfortable maximum.[1] [2] [3] [18] [19] Nitrogen in a gas mix is almost always obtained by adding air to the mix.

Breathing gas

Helium
Helium (He) is an inert gas that is less narcotic than nitrogen at equivalent pressure (in fact there is no evidence for any narcosis from helium at all), so it is more suitable for deeper dives than nitrogen.[1] [3] Helium is equally able to cause decompression sickness. At high pressures, helium also causes High Pressure Nervous Syndrome, which is a CNS irritation syndrome which is in some ways opposite to narcosis.[1] [2] [3] [20] Helium fills typically cost ten times more than an equivalent air fill. Helium is not very suitable for dry suit inflation due to its poor thermal insulation properties helium is a very good conductor of heat (compared to air which is a rather poor, making it more of an insulator).[1] [3] Helium's low molecular weight (monatomic MW=4, compared with diatomic nitrogen MW=28) increases the timbre of the breather's voice, which may impede communication.[1] [3] [21] This is because the speed of sound is faster in a lower molecular weight gas, which increases the resonance frequency of the vocal cords.[1] [21] Helium leaks from damaged or faulty valves more readily than other gases because atoms of helium are smaller allowing them to pass through smaller gaps in seals. Helium is found in significant amounts only in natural gas, from which it is extracted at low temperatures by fractional distillation.

Neon
Neon (Ne) is an inert gas sometimes used in deep commercial diving but is very expensive.[1] helium, it is less narcotic than nitrogen, but unlike helium, it does not distort the diver's voice.
[3] [10] [15]

Like

Hydrogen
Hydrogen (H2) has been used in deep diving gas mixes but is very explosive when mixed with more than about 4 to 5% oxygen (such as the oxygen found in breathing gas).[1] [3] [10] [12] This limits use of hydrogen to deep dives and imposes complicated protocols to ensure that oxygen is cleared from the lungs, the blood stream and the breathing equipment before breathing hydrogen starts. Like helium, it increases the timbre of the diver's voice. The hydrogen-oxygen mix when used as a diving gas is sometimes referred to as Hydrox.

Unwelcome components of breathing gases

Many gases are not suitable for use in diving breathing gases.[5] present in a diving environment:
[22]

Here is an incomplete list of gases commonly

Argon
Argon (Ar) is an inert gas that is more narcotic than nitrogen, so is not generally suitable as a diving breathing gas.[23] Argox is used for decompression research.[1] [3] [24] [25] It is sometimes used for dry suit inflation by divers whose primary breathing gas is helium-based, because of argon's good thermal insulation properties. Argon is more expensive than air or oxygen, but considerably less expensive than helium.

Breathing gas

Carbon dioxide
Carbon dioxide (CO2) is produced by the metabolism in the human body and can cause carbon dioxide poisoning.[22]
[26] [27]

Carbon monoxide
Carbon monoxide (CO) is produced by incomplete combustion.[1] common sources are:
[2] [5] [22]

See carbon monoxide poisoning. Four

Internal combustion engine exhaust gas containing CO in the air being drawn into a diving air compressor. CO in the intake air cannot be stopped by any filter. The exhausts of all internal combustion engines running on petroleum fuels contain some CO, and this is a particular problem on boats, where the intake of the compressor cannot be arbitrarily moved as far as desired from the engine and compressor exhausts. Heating of lubricants inside the compressor may vaporize them sufficiently to be available to a compressor intake or intake system line. In some cases hydrocarbon lubricating oil may be drawn into the compressor's cylinder directly through damaged or worn seals, and the oil may (and usually will) then undergo combustion, being ignited by the immense compression ratio and subsequent temperature rise. Since heavy oils don't burn well - especially when not atomized properly - incomplete combustion will result in carbon monoxide production. A similar process is thought to potentially happen to any particulate material, which contains "organic" (carbon-containing) matter, especially in cylinders which are used for hyperoxic gas mixtures. If the compressor air filter(s) fail, ordinary dust will be introduced to the cylinder, which contains organic matter (since it usually contains humus). A more severe danger is that air particulates on boats and industrial areas, where cylinders are filled, often contain carbon-particulate combustion products (these are what makes a dirt rag black), and these represent a more severe CO danger when introduced into a cylinder.

Hydrocarbons
Hydrocarbons (CxHy) are present in compressor lubricants and fuels. They can enter diving cylinders as a result of contamination, leaks, or due to incomplete combustion near the air intake.[2] [4] [5] [22] [28] They can act as a fuel in combustion increasing the risk of explosion, especially in high-oxygen gas mixtures. Inhaling oil mist can damage the lungs and ultimately cause the lungs to degenerate with severe lipid pneumonia or emphysema.

Moisture content
The process of compressing gas into a diving cylinder removes moisture from the gas.[5] [22] This is good for corrosion prevention in the cylinder but means that the diver inhales very dry gas. The dry gas extracts moisture from the diver's lungs while underwater contributing to dehydration, which is also thought to be a predisposing risk factor of decompression sickness. It is also uncomfortable, causing a dry mouth and throat and making the diver thirsty. This problem is reduced in rebreathers because the soda lime reaction to remove carbon dioxide puts moisture back into the breathing gas.[8] In hot climates, open circuit diving can accelerate heat exhaustion because of dehydration. Another concern with regard to moisture content is the tendency of moisture to condense as the gas is decompressed while passing through the regulator; this coupled with the extreme reduction in temperature, also due to the decompression can cause the moisture to solidify as ice. This icing up in a regulator can cause moving parts to seize and the regulator to fail or free flow. It is for this reason that SCUBA regulators are generally constructed from brass, and chrome plated (for protection). Brass, with its good thermal conductive properties, quickly conducts heat from the surrounding water to the cold, newly decompressed air, helping to prevent icing up.

Breathing gas

Gas detection and measurement

Divers find it difficult to detect most gases that are likely to be present in diving cylinders because they are colourless, odourless and tasteless. Electronic sensors exist for some gases, such as oxygen analysers, helium analyser, carbon monoxide detectors and carbon dioxide detectors.[2] [4] [5] Oxygen analysers are commonly found underwater in rebreathers.[8] Oxygen and helium analysers are often used on the surface during gas blending to determine the percentage of oxygen or helium in a breathing gas mix.[4] Chemical and other types of gas detection methods are not often used in recreational diving.

References
[1] Brubakk, A. O.; T. S. Neuman (2003). Bennett and Elliott's physiology and medicine of diving, 5th Rev ed.. United States: Saunders Ltd.. pp.800. ISBN0702025712. [2] US Navy Diving Manual, 6th revision (http:/ / www. supsalv. org/ 00c3_publications. asp?destPage=00c3& pageID=3. 9). United States: US Naval Sea Systems Command. 2006. . Retrieved 2008-08-29. [3] Tech Diver. "Exotic Gases" (http:/ / www. techdiver. ws/ exotic_gases. shtml). . Retrieved 2008-08-29. [4] Harlow, V (2002). Oxygen Hacker's Companion. Airspeed Press. ISBN0967887321. [5] Millar IL; Mouldey PG (2008). "Compressed breathing air the potential for evil from within." (http:/ / archive. rubicon-foundation. org/ 7964). Diving and Hyperbaric Medicine. (South Pacific Underwater Medicine Society) 38: 14551. . Retrieved 2009-02-28. [6] Acott, Chris (1999). "Oxygen toxicity: A brief history of oxygen in diving" (http:/ / archive. rubicon-foundation. org/ 6014). South Pacific Underwater Medicine Society Journal 29 (3). ISSN0813-1988. OCLC16986801. . Retrieved 2008-08-29. [7] Butler FK (2004). "Closed-circuit oxygen diving in the U.S. Navy" (http:/ / archive. rubicon-foundation. org/ 3986). Undersea Hyperb Med 31 (1): 320. PMID15233156. . Retrieved 2008-08-29. [8] Richardson, Drew; Menduno, Michael; Shreeves, Karl. (eds). (1996). "Proceedings of Rebreather Forum 2.0." (http:/ / archive. rubicon-foundation. org/ 7555). Diving Science and Technology Workshop.: 286. . Retrieved 2008-08-29. [9] Lang, M.A. (2001). DAN Nitrox Workshop Proceedings (http:/ / archive. rubicon-foundation. org/ 4855). Durham, NC: Divers Alert Network. pp.197. . Retrieved 2008-08-29. [10] Hamilton Jr Robert W, Schreiner Hans R (eds) (1975). Development of Decompression Procedures for Depths in Excess of 400 feet (http:/ / archive. rubicon-foundation. org/ 4498). 9th Undersea and Hyperbaric Medical Society Workshop. Bethesda, MD: Undersea and Hyperbaric Medical Society. pp.272. . Retrieved 2008-08-29. [11] Bowen, Curt. "Heliair: Poor man's mix" (http:/ / www. advanceddivermagazine. com/ ezinefreearticles/ HeliairPoorMansMix. pdf). DeepTech. . Retrieved 2010-01-13. [12] Fife, William P (1979). "The use of Non-Explosive mixtures of hydrogen and oxygen for diving". Texas A&M University Sea Grant TAMU-SG-79-201. [13] Rostain, J. C.; M. C. Gardette-Chauffour; C. Lemaire; R. Naquet. (1988). "Effects of a H2-He-O2 mixture on the HPNS up to 450 msw." (http:/ / archive. rubicon-foundation. org/ 2487). Undersea Biomed. Res. 15 (4): 25770. ISSN0093-5387. OCLC2068005. PMID3212843. . Retrieved 2008-08-29. [14] Brauer RW (ed). (1985). "Hydrogen as a Diving Gas." (http:/ / archive. rubicon-foundation. org/ 4862). 33rd Undersea and Hyperbaric Medical Society Workshop. (Undersea and Hyperbaric Medical Society) (UHMS Publication Number 69(WS-HYD)3-1-87): 336 pages. . Retrieved 2008-09-16. [15] Hamilton Jr, Robert W; Powell, Michael R; Kenyon, David J; Freitag, M (1974). "Neon Decompression" (http:/ / archive. rubicon-foundation. org/ 3778). Tarrytown Labs LTD NY CRL-T-797. . Retrieved 2008-08-29. [16] Universal Industrial Gases, Inc. (2003). "Non-Cryogenic Air Separation Processes" (http:/ / www. uigi. com/ noncryo. html). . Retrieved 2008-08-29. [17] Fowler, B; Ackles, KN; Porlier, G (1985). "Effects of inert gas narcosis on behavior--a critical review." (http:/ / archive. rubicon-foundation. org/ 3019). Undersea Biomed. Res. 12 (4): 369402. ISSN0093-5387. OCLC2068005. PMID4082343. . Retrieved 2008-08-29. [18] Logan, JA (1961). "An evaluation of the equivalent air depth theory" (http:/ / archive. rubicon-foundation. org/ 3835). United States Navy Experimental Diving Unit Technical Report NEDU-RR-01-61. . Retrieved 2008-08-29. [19] Berghage TE, McCraken TM (December 1979). "Equivalent air depth: fact or fiction" (http:/ / archive. rubicon-foundation. org/ 2835). Undersea Biomed Res 6 (4): 37984. PMID538866. . Retrieved 2008-08-29. [20] Hunger Jr, W. L.; P. B. Bennett. (1974). "The causes, mechanisms and prevention of the high pressure nervous syndrome" (http:/ / archive. rubicon-foundation. org/ 2661). Undersea Biomed. Res. 1 (1): 128. ISSN0093-5387. OCLC2068005. PMID4619860. . Retrieved 2008-08-29. [21] Ackerman MJ, Maitland G (December 1975). "Calculation of the relative speed of sound in a gas mixture" (http:/ / archive. rubicon-foundation. org/ 2738). Undersea Biomed Res 2 (4): 30510. PMID1226588. . Retrieved 2008-08-29. [22] NAVSEA (2005). "Cleaning and gas analysis for diving applications handbook." (http:/ / archive. rubicon-foundation. org/ 7563). NAVSEA Technical Manual (NAVAL SEA SYSTEMS COMMAND) SS521-AK-HBK-010. . Retrieved 2008-08-29.

Breathing gas
[23] Rahn H, Rokitka MA (March 1976). "Narcotic potency of N2, A, and N2O evaluated by the physical performance of mouse colonies at simulated depths" (http:/ / archive. rubicon-foundation. org/ 2768). Undersea Biomed Res 3 (1): 2534. PMID1273982. . Retrieved 2008-08-28. [24] D'Aoust BG, Stayton L, Smith LS (September 1980). "Separation of basic parameters of decompression using fingerling salmon" (http:/ / archive. rubicon-foundation. org/ 2869). Undersea Biomed Res 7 (3): 199209. PMID7423658. . Retrieved 2008-08-29. [25] Pilmanis AA, Balldin UI, Webb JT, Krause KM (December 2003). "Staged decompression to 3.5 psi using argon-oxygen and 100% oxygen breathing mixtures" (http:/ / www. ingentaconnect. com/ content/ asma/ asem/ 2003/ 00000074/ 00000012/ art00004). Aviat Space Environ Med 74 (12): 124350. PMID14692466. . Retrieved 2008-08-29. [26] Lambertsen, C. J. (1971). "Carbon Dioxide Tolerance and Toxicity" (http:/ / archive. rubicon-foundation. org/ 3861). Environmental Biomedical Stress Data Center, Institute for Environmental Medicine, University of Pennsylvania Medical Center (Philadelphia, PA) IFEM Report No. 2-71. . Retrieved 2008-08-29. [27] Glatte Jr H. A., Motsay G. J., Welch B. E. (1967). "Carbon Dioxide Tolerance Studies" (http:/ / archive. rubicon-foundation. org/ 6045). Brooks AFB, TX School of Aerospace Medicine Technical Report SAM-TR-67-77. . Retrieved 2008-08-29. [28] Rosales, KR; Shoffstall, MS; Stoltzfus, JM (2007). "Guide for Oxygen Compatibility Assessments on Oxygen Components and Systems." (http:/ / archive. rubicon-foundation. org/ 4861). NASA, Johnson Space Center Technical Report NASA/TM-2007-213740. . Retrieved 2008-08-29.

External links
altitude.org. "Altitude oxygen calculator" (http://www.altitude.org/oxgyen_levels.php). altitude.org. Retrieved 2008-08-29. Westfalen (2004). "Fact sheet on Divox" (http://www.westfalengassen.nl/technischegassen/divox/divox.pdf) (in Dutch). Westfalen. Retrieved 2008-08-29. Taylor, L. "A Brief History Of Mixed Gas Diving" (http://www-personal.umich.edu/~lpt/mixhistory.htm). Retrieved 2008-08-29. OSHA. "Commercial Diving Regulations (Standards - 29 CFR) - Mixed-gas diving. - 1910.426" (http://www. osha.gov/pls/oshaweb/owadisp.show_document?p_id=9986&p_table=STANDARDS). U.S. Department of Labor, Occupational Safety & Health Administration. Retrieved 2008-08-29.

Decompression sickness

Decompression sickness
Caisson disease [decompression sickness]
Classification and external resources

Two United States Navy sailors prepare for training inside a decompression chamber. ICD-10 ICD-9 DiseasesDB eMedicine MeSH T70.3 993.3 3491 [1] [2] [3] [4] [5]

emerg/121

C21.866.120.248

Decompression sickness (DCS; also known as divers' disease, the bends or caisson disease) describes a condition arising from dissolved gases coming out of solution into bubbles inside the body on depressurization. DCS most commonly refers to a specific type of scuba diving hazard but may be experienced in other depressurisation events such as caisson working, flying in unpressurised aircraft, and extra-vehicular activity from spacecraft. Since bubbles can form in or migrate to any part of the body, DCS can produce many symptoms, and its effects may vary from joint pain and rashes to paralysis and death. Individual susceptibility can vary from day to day, and different individuals under the same conditions may be affected differently or not at all. The classification of types of DCS by its symptoms has evolved since its original description over a hundred years ago. Although DCS is not a common event, its potential severity is such that much research has gone into preventing it, and scuba divers use dive tables or dive computers to set limits on their exposure to pressure and their ascent speed. Treatment is by hyperbaric oxygen therapy in a recompression chamber. If treated early, there is a significantly higher chance of successful recovery.

Classification
DCS is classified by symptoms. The earliest descriptions of DCS used the terms: "bends" for joint or skeletal pain; "chokes" for breathing problems; and "staggers" for neurological problems.[6] In 1960, Golding et al. introduced a simpler classification using the term "Type I ('simple')" for symptoms involving only the skin, musculoskeletal system, or lymphatic system, and "Type II ('serious')" for symptoms where other organs (such as the central nervous system) are involved.[6] Type II DCS is considered more serious and usually has worse outcomes.[7] This system, with minor modifications, may still be used today.[8] Following changes to treatment methods, this classification is now much less useful in diagnosis,[9] since neurological symptoms may develop after the initial presentation, and both Type I and Type II DCS have the same initial management.[10]

Decompression sickness

Decompression illness and dysbarism

The term dysbarism encompasses decompression sickness, arterial gas embolism, and barotrauma, whereas decompression sickness and arterial gas embolism are commonly classified together as decompression illness when a precise diagnosis cannot be made.[11] DCS and arterial gas embolism are treated very similarly because they are both the result of gas bubbles in the body.[10] The U.S. Navy prescribes identical treatment for Type II DCS and arterial gas embolism.[12] Their spectra of symptoms also overlap, although those from arterial gas embolism are generally more severe because they often arise from an infarction (blockage of blood supply and tissue death).

Signs and symptoms

While bubbles can form anywhere in the body, DCS is most frequently observed in the shoulders, elbows, knees, and ankles. Joint pain ("the bends") accounts for about 60% to 70% of all altitude DCS cases, with the shoulder being the most common site. Neurological symptoms are present in 10% to 15% of DCS cases with headache and visual disturbances the most common symptom. Skin manifestations are present in about 10% to 15% of cases. Pulmonary DCS ("the chokes") is very rare in divers and has been observed much less frequently in aviators since the introduction of oxygen pre-breathing protocols.[13] The table below shows symptoms for different DCS types.[14]

Signs and symptoms of decompression sickness

DCS type Bubble location Signs & symptoms (clinical manifestations) Localized deep pain, ranging from mild to excruciating. Sometimes a dull ache, but rarely a sharp pain. Active and passive motion of the joint aggravates the pain. The pain may be reduced by bending the joint to find a more comfortable position. If caused by altitude, pain can occur immediately or up to many hours later. Itching, usually around the ears, face, neck, arms, and upper torso Sensation of tiny insects crawling over the skin (formication) Mottled or marbled skin usually around the shoulders, upper chest and abdomen, with itching Swelling of the skin, accompanied by tiny scar-like skin depressions (pitting edema) Altered sensation, tingling or numbness paresthesia, increased sensitivity hyperesthesia Confusion or memory loss (amnesia) Visual abnormalities Unexplained mood or behaviour changes Seizures, unconsciousness Ascending weakness or paralysis in the legs Girdling abdominal or chest pain Urinary incontinence and fecal incontinence Headache Unexplained fatigue Generalised malaise, poorly localised aches Loss of balance Dizziness, vertigo, nausea, vomiting Hearing loss Dry persistent cough Burning chest pain under the sternum, aggravated by breathing Shortness of breath

Musculoskeletal Mostly large joints

(elbows, shoulders, hip, wrists, knees, ankles) Cutaneous Skin Neurologic Brain Neurologic Spinal cord

Constitutional

Whole body

Audiovestibular Inner ear [15] [16]

Pulmonary

Lungs

Decompression sickness

10

Frequency
Symptoms local joint pain arm symptoms leg symptoms dizziness paralysis shortness of breath extreme fatigue collapse/unconsciousness Frequency 89% 70% 30% 5.3% 2.3% 1.6% 1.3% 0.5%

Onset
Time to onset within 1 hour within 3 hours within 8 hours within 24 hours within 48 hours Percentage of cases 42% 60% 83% 98% 100%

The distribution of symptoms of DCS observed by the U.S. Navy are as [17] follows:

Although onset of DCS can occur rapidly after a dive, in extreme cases even before a dive has been completed, in more than half of all cases symptoms do not begin to present until over an hour following the dive. The U.S. Navy and Technical Diving International, a leading technical diver training organization, have published a table that indicates onset of first symptoms. The table does not differentiate between types of DCS, [18] [19] or types of symptom.

Causes
DCS is caused by a reduction in ambient pressure that results in the formation of bubbles of inert gases within tissues of the body. It may happen when leaving a high-pressure environment, ascending from depth, or ascending to altitude.

Ascent from depth

DCS is best known as a diving disorder that affects divers having breathed gas that is at a higher pressure than the surface pressure, owing to the pressure of the surrounding water. The risk of DCS increases when diving for extended periods or at greater depth, without ascending gradually and making the decompression stops needed to slowly reduce the excess pressure of inert gases dissolved in the body. The specific risk factors are not well understood and some divers may be more susceptible than others under identical conditions.[20] [21] DCS has been confirmed in rare cases of breath-holding divers who have made a sequence of many deep dives with short surface intervals; and it may be the cause of the disease called taravana by South Pacific island natives who for centuries have dived by breath-holding for food and pearls.[22] Two principal factors control the risk of a diver suffering DCS: 1. the rate and duration of gas absorption under pressure the deeper or longer the dive the more gas is absorbed into body tissue in higher concentrations than normal (Henry's Law); 2. the rate and duration of outgassing on depressurization the faster the ascent and the shorter the interval between dives the less time there is for absorbed gas to be offloaded safely through the lungs, causing these gases to come out of solution and form "micro bubbles" in the blood.[23] Even when the change in pressure causes no immediate symptoms, rapid pressure change can cause permanent bone injury called dysbaric osteonecrosis (DON). DON can develop from a single exposure to rapid decompression.[24]

Decompression sickness

11

Leaving a high-pressure environment

When a worker comes out of a pressurized caisson or out of a mine that has been pressurized to keep water out, they will experience a significant reduction in ambient pressure.[20] [25] A similar pressure reduction occurs when an astronaut exits a space vehicle to perform a space-walk or extra-vehicular activity, where the pressure in his spacesuit is lower than the pressure in the vehicle.[20] [26] [27] [28] The original name for DCS was "caisson disease"; this term was used in the 19th century, in large engineering excavations below the water table, such as bridge supports and tunnels, where caissons under pressure were used to keep water from The principal features of a caisson are the workspace, pressurised by an external air flooding the excavations. Workers spending supply, and the access tube with an airlock time in high-pressure atmospheric pressure conditions are at risk when they return to the lower pressure outside the caisson if the pressure surrounding them was not reduced slowly. DCS was a major factor during construction of Eads Bridge, when 15 workers died from what was then a mysterious illness, and later during construction of the Brooklyn Bridge, where it incapacitated the project leader Washington Roebling.[29]

Ascent to altitude
Passengers may be at risk of DCS when an unpressurized aircraft ascends to high altitude.[20] [26] [27] [30] Likewise, there is increased risk for divers flying in any aircraft shortly after diving, since even in a pressurized aircraft the cabin pressure is not maintained at sea-level pressure but may drop to as low as 73% of sea level pressure.[20] [26] [31] Altitude DCS became a common problem in the 1930s with the development of high-altitude balloon and aircraft flights. Today, cabin pressurization systems maintain commercial aircraft cabin pressure at the equivalent altitude of 2400m (7900ft) or less, allowing safe flights at 12000m (39000 ft) or more. DCS is very rare in healthy individuals who experience pressures equivalent to this altitude. However, since the pressure in the cabin is not actually maintained at sea-level pressure, there is still a risk of DCS in individuals having dived recently. Also, cabin pressurization systems still fail occasionally, and some people may be predisposed to the drop in pressure that occurs even in pressurized aircraft.[32] [33] There is no specific altitude threshold that can be considered safe for everyone and below which no one will develop altitude DCS. Nevertheless, there is very little evidence of altitude DCS occurring among healthy individuals who have not been scuba diving at pressure altitudes below 5500m (18000ft). The higher the altitude of exposure the greater is the risk of developing altitude DCS. Although exposures to incremental altitudes above 5500m (18000ft) show an incremental risk of altitude DCS, they do not show a direct relationship with the severity of the various types of DCS. Individual exposures to pressure altitudes between 5500m (18000ft) and 7500m (24600 ft) have shown a low occurrence of altitude DCS. A US Air Force study of altitude DCS cases reported that 87% of incidents occurred at 7500m (24600 ft) or higher.[34] High altitude parachutists performing a HALO jump may develop altitude DCS if they do not flush nitrogen from the body by pre-breathing pure oxygen.[35]

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Predisposing factors
Although the occurrence of DCS is not easily predictable, many predisposing factors are known. They may be considered as either environmental or individual.

Environmental
The following environmental factors have been shown to increase the risk of DCS: the magnitude of the pressure reduction ratio a large pressure reduction ratio is more likely to cause DCS than a small one.[26] [31] [36] repetitive exposures repetitive dives within a short period of time (a few hours) increase the risk of developing DCS. Repetitive ascents to altitudes above 5500 metres (18000ft) within similar short periods increase the risk of developing altitude DCS.[26] [36] the rate of ascent the faster the ascent the greater the risk of developing DCS. The US Navy Dive Manual indicates that ascent rates greater than about 20m/min (66ft/min) when diving increase the chance of DCS, while recreational dive tables such as the Bhlmann tables require an ascent rate of 10m/min (33ft/min) with the last 6m (20ft) taking at least one minute.[37] An individual exposed to a rapid decompression (high rate of ascent) above 5500 metres (18000ft) has a greater risk of altitude DCS than being exposed to the same altitude but at a lower rate of ascent.[26] [36] the duration of exposure the longer the duration of the dive, the greater is the risk of DCS. Longer flights, especially to altitudes of 5500m (18000ft) and above, carry a greater risk of altitude DCS.[26] scuba diving before flying divers who ascend to altitude soon after a dive increase their risk of developing DCS even if the dive itself was within the dive table safe limits. Dive tables make provisions for post-dive time at surface level before flying to allow any residual excess nitrogen to outgas. However, the pressure maintained inside even a pressurized aircraft may be as low as the pressure equivalent to an altitude of 2400m (7900ft) above sea level. Therefore, the assumption that the dive table surface interval occurs at normal atmospheric pressure is invalidated by flying during that surface interval, and an otherwise-safe dive may then exceed the dive table limits.[38] [39] [40] diving before travelling to altitude DCS can occur without flying if the person moves to a high-altitude location on land immediately after scuba diving, for example, scuba divers in Eritrea who drive from the coast to the Asmara plateau at 2400m (7900ft) increase their risk of DCS.[41] diving at altitude diving in water whose surface altitude is above 300m (980ft) for example, Lake Titicaca is at 3800m (12500ft) without using versions of decompression tables or dive computers that are modified for high-altitude.[38] [42]

Individual

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The following individual factors have been identified as possibly contributing to increased risk of DCS: a person's age there are some reports indicating a higher risk of altitude DCS with increasing age.[20] [36] previous injury there is some indication that recent joint or limb injuries may predispose individuals to developing decompression-related bubbles.[20] [43] ambient temperature there is some evidence suggesting that individual exposure to very cold ambient temperatures may increase the risk of altitude DCS.[20] [36] Decompression sickness risk can be reduced by increased ambient temperature during decompression following dives in cold water.[44]

Atrial septal defect (PFO) showing left-to-right shunt. A right-to-left shunt may allow bubbles to pass into the arterial circulation.

body type typically, a person who has a high body fat content is at greater risk of DCS.[20] [36] This is due to nitrogen's five times greater solubility in fat than in water, leading to greater amounts of total body dissolved nitrogen during time at pressure. Fat represents about 1525 percent of a healthy adult's body, but stores about half of the total amount of nitrogen (about 1 litre) at normal pressures.[45] alcohol consumption and dehydration although alcohol consumption increases dehydration and therefore may increase susceptibility to DCS,[36] a 2005 study concluded that alcohol consumption did not increase the risk of DCS.[46] Studies by Walder concluded that decompression sickness could be reduced in aviators when the serum surface tension was raised by drinking isotonic saline,[47] and the high surface tension of water is generally regarded as helpful in controlling bubble size.[36] Maintaining proper hydration is recommended.[48] patent foramen ovale a hole between the atrial chambers of the heart in the fetus is normally closed by a flap with the first breaths at birth. In about 20% of adults the flap does not completely seal, however, allowing blood through the hole when coughing or during activities that raise chest pressure. In diving, this can allow venous blood with microbubbles of inert gas to bypass the lungs, where the bubbles would otherwise be filtered out by the lung capillary system, and return directly to the arterial system (including arteries to the brain, spinal cord and heart).[49] In the arterial system, bubbles (arterial gas embolism) are far more dangerous because they block circulation and cause infarction (tissue death, due to local loss of blood flow). In the brain, infarction results in stroke, and in the spinal cord it may result in paralysis.[50]

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Mechanism
Depressurisation causes inert gases, which were dissolved under higher pressure, to come out of physical solution and form gas bubbles within the body. These bubbles produce the symptoms of decompression sickness.[20] [51] Bubbles may form whenever the body experiences a reduction in pressure, but not all bubbles result in DCS.[52] The amount of gas dissolved in a liquid is described by Henry's Law, which indicates that, when the pressure of a gas in contact with a liquid is decreased, the amount of that gas dissolved in the liquid will also decrease proportionately. On ascent from a dive, inert gas comes out of solution in a process called "outgassing" or "offgassing". Under normal conditions, most offgassing occurs by gas exchange in the lungs.[53] [54] If inert gas comes out of solution too quickly to allow outgassing in the lungs then bubbles may form in the blood or within the solid tissues of the body. The formation of bubbles in the skin or joints results in milder symptoms, while large numbers of bubbles in the venous blood can cause lung damage. The most severe types of DCS interrupt and This surfacing diver must enter a decompression ultimately damage spinal cord function, leading to paralysis, chamber to avoid decompression sickness. sensory dysfunction, or death. In the presence of a right-to-left shunt of the heart, such as a patent foramen ovale, venous bubbles may enter the arterial system, resulting in an arterial gas embolism.[10] [55] A similar effect, known as ebullism, may occur during explosive decompression, when water vapour forms bubbles in body fluids due to a dramatic reduction in environmental pressure.[56]

Inert gases
The main inert gas in air is nitrogen, but nitrogen is not the only gas that can cause DCS. Breathing gas mixtures such as trimix and heliox include helium, which can also cause decompression sickness. Helium both enters and leaves the body faster than nitrogen, so different decompression schedules are required, but, since helium does not cause narcosis, it is preferred over nitrogen in gas mixtures for deep diving.[57] There is some debate as to the decompression requirements for helium during short-duration dives. Most divers do longer decompressions, however some groups like the WKPP have been pioneering the use of shorter decompression times by including deep stops.[58] Any inert gas that is breathed under pressure can form bubbles when the ambient pressure decreases. Very deep dives have been made using hydrogen-oxygen mixtures (hydrox),[59] but controlled decompression is still required to avoid DCS.[60]

Isobaric counterdiffusion
Further information: Isobaric counterdiffusion DCS can also be caused at a constant ambient pressure when switching between gas mixtures containing different proportions of inert gas. This is known as isobaric counterdiffusion, and presents a problem for very deep dives.[61] For example, after using a very helium-rich trimix at the deepest part of the dive, a diver will switch to mixtures containing progressively less helium and more oxygen and nitrogen during the ascent. Nitrogen diffuses into tissues 2.65 times slower than helium, but is about 4.5 times more soluble. Switching between gas mixtures that have very different fractions of nitrogen and helium can result in "fast" tissues (those tissues that have a good blood supply) actually increasing their total inert gas loading. This is often found to provoke inner ear decompression sickness, as

Decompression sickness the ear seems particularly sensitive to this effect.[62]

15

Diagnosis
Decompression sickness should be suspected if any of the symptoms associated with the condition occurs following a drop in pressure, in particular, within 24 hours of diving.[63] In 1995, 95% of all cases reported to Divers Alert Network had shown symptoms within 24 hours.[64] An alternative diagnosis should be suspected if severe symptoms begin more than six hours following decompression without an altitude exposure or if any symptom occurs more than 24 hours after surfacing.[65] The diagnosis is confirmed if the symptoms are relieved by recompression.[65] [66] Although MRI or CT can frequently identify bubbles in DCS, they are not as good at determining the diagnosis as a proper history of the event and description of the symptoms.[8]

Prevention
Underwater diving
To prevent the excess formation of bubbles that can lead to decompression sickness, divers limit their ascent rate to about 10 metres (33ft) per minute, and carry out a decompression schedule as necessary.[67] This schedule requires the diver to ascend to a particular depth, and remain at that depth until sufficient gas has been eliminated from the body to allow further ascent.[68] Each of these is termed a "decompression stop", and a schedule for a given bottom time and depth may contain one or more stops, or none at all. Dives that contain no decompression stops are called "no-stop dives", but divers usually schedule a short "safety stop" at 3 metres (10ft), 4.6 metres (15ft), or 6 metres (20ft), depending on the training agency.[67] [69] The decompression schedule may be derived from decompression tables, decompression software, or from dive computers, and these are The display of a basic personal dive computer commonly based upon a mathematical model of the body's uptake and shows depth, dive time, and decompression information. release of inert gas as pressure changes. These models, such as the Bhlmann decompression algorithm, are designed to fit empirical data and provide a decompression schedule for a given depth and dive duration.[70] Since divers on the surface after a dive still have excess inert gas in their bodies, any subsequent dive before this excess is fully eliminated needs to modify the schedule to take account of the residual gas load from the previous dive. This will result in a shorter available time under water or an increased decompression time during the subsequent dive. The total elimination of excess gas may take many hours, and tables will indicate the time at normal pressures that is required, which may be up to 18 hours.[71] Decompression time can be significantly shortened by breathing mixtures containing much less inert gas during the decompression phase of the dive (or pure oxygen at stops in 6 metres (20ft) of water or less). The reason is that the inert gas outgases at a rate proportional to the difference between the partial pressure of inert gas in the diver's body and its partial pressure in the breathing gas; whereas the likelihood of bubble formation depends on the difference between the inert gas partial pressure in the diver's body and the ambient pressure. Reduction in decompression requirements can also be gained by breathing a nitrox mix during the dive, since less nitrogen will be taken into the body than during the same dive done on air.[72] Following a decompression schedule does not completely protect against DCS. The algorithms used are designed to reduce the probability of DCS to a very low level, but do not reduce it to zero.[73]

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Exposure to altitude
One of the most significant breakthroughs in the prevention of altitude DCS is oxygen pre-breathing. Breathing pure oxygen significantly reduces the nitrogen loads in body tissues and, if continued without interruption, provides effective protection upon exposure to low-barometric pressure environments.[26] [27] However, breathing pure oxygen during flight alone (ascent, en route, descent) does not decrease the risk of altitude DCS.[26] [27] Although pure oxygen pre-breathing is an effective method to protect against altitude DCS, it is logistically complicated and expensive for the protection of civil aviation flyers, either commercial or private. Therefore, it is currently used only by military flight crews and astronauts for protection during high-altitude and space operations. It is also used by flight test crews involved with certifying aircraft. Astronauts aboard the International Space Station preparing for extra-vehicular activity (EVA) "camp out" at low atmospheric pressure, 10.2psi (0.70bar), spending eight sleeping hours in the Quest airlock chamber before their spacewalk. During the EVA they breathe 100% oxygen in their spacesuits, which operate at 4.3psi (0.30bar),[74] although research has examined the possibility of using 100% O2 at 9.5psi (0.66bar) in the suits to lessen the pressure reduction, and hence the risk of DCS.[75]

Treatment
Further information: Hyperbaric medicine All cases of decompression sickness should be treated initially with 100% oxygen until hyperbaric oxygen therapy (100% oxygen delivered in a high-pressure chamber) can be provided.[76] Mild cases of the "bends" and some skin symptoms may disappear during descent from high altitude; however, it is recommended that these cases still be evaluated. Neurological symptoms, pulmonary symptoms, and mottled or marbled skin lesions should be treated with hyperbaric oxygen therapy if seen within 10 to 14 days of development.[77]

The recompression chamber at the Neutral Buoyancy Lab.

Recompression on room air was shown to be an effective treatment for minor DCS symptoms by Keays in 1909.[78] Evidence of the effectiveness of recompression therapy utilizing oxygen was first shown by Yarbrough and Behnke,[79] and has since become the standard of care for treatment of DCS.[80] Recompression is normally carried out in a recompression chamber. At a dive site, a riskier alternative is in-water recompression.[81] [82] [83] Oxygen first aid has been used as an emergency treatment for diving injuries for years.[84] If given within the first four hours of surfacing, it increases the success of recompression therapy as well as a decrease the number of recompression treatments required.[85] Most fully closed-circuit rebreathers can deliver sustained high concentrations of oxygen-rich breathing gas and could be used as a means of supplying oxygen if dedicated equipment is not available.[86] It is beneficial to give fluids, as this helps reduce dehydration. It is no longer recommended to administer aspirin, unless advised to do so by medical personnel, as analgesics may mask symptoms. People should be made comfortable and placed in the supine position (horizontal), or the recovery position if vomiting occurs.[63] In the past, both the Trendelenburg position and the left lateral decubitus position (Durant's maneuver) have been suggested as beneficial where air emboli are suspected,[87] but are no longer recommended for extended periods, owing to concerns regarding cerebral edema.[84] [88]

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Prognosis
Immediate treatment with 100% oxygen, followed by recompression in a hyperbaric chamber, will in most cases result in no long term effects. However, permanent long-term injury from DCS is possible. Three-month follow-ups on diving accidents reported to DAN in 1987 showed 14.3% of the 268 divers surveyed "still had residual signs and symptoms from Type II DCS and 7% from Type I DCS".[89] [90] Long-term follow-ups showed similar results, with 16% having permanent neurological sequelae.[91]

Epidemiology
The incidence of decompression sickness is rare, estimated at 2.8 cases per 10,000 dives, with the risk 2.6 times greater for males than females.[8] DCS affects approximately 1,000 U.S. scuba divers per year.[63] In 1999, the Divers Alert Network (DAN) created "Project Dive Exploration" to collect data on dive profiles and incidents. From 1998 to 2002, they recorded 50,150 dives, from which 28 recompressions were required although these will almost certainly contain incidents of arterial gas embolism (AGE) a rate of about 0.05%.[7] [92]

History
1670: Robert Boyle demonstrated that a reduction in ambient pressure could lead to bubble formation in living tissue. This description of a viper in a vacuum was the first recorded description of decompression sickness.[93] 1769: Giovanni Morgagni described the post mortem findings of air in cerebral circulation and surmised that this was the cause of death.[94] 1840: Colonel William Pasley, who was involved in the recovery of the sunken warship HMS Royal George, commented that, of those having made frequent dives, "not a man escaped the repeated attacks of rheumatism and cold".[95] 1841: First documented case of decompression sickness, reported by a mining engineer who observed pain and muscle cramps among coal miners working in mine shafts air-pressurized to keep water out. 1870: Bauer published outcomes of 25 paralyzed caisson workers. From 1870 to 1910, all prominent features were established. Explanations at the time included: cold or exhaustion causing reflex spinal cord damage; electricity cause by friction on compression; or organ congestion; and vascular stasis caused by decompression.[94] 1871: The Eads Bridge in St Louis employed 352 compressed air workers including Dr. Alphonse Jaminet as the physician in charge. There were 30 seriously injured and 12 fatalities. Dr. Jaminet developed decompression sickness and his personal description was the first such recorded.[29]

The Eads Bridge where 42 workers were injured by caisson disease

1872: The similarity between decompression sickness and iatrogenic air embolism as well as the relationship between inadequate decompression and decompression sickness was noted by Friedburg. He suggested that intravascular gas was released by rapid decompression and recommended: slow compression and decompression; four-hour working shifts; limit to maximum depth 44.1 psig (4 ATA); using only healthy workers; and recompression treatment for severe cases. 1873: Dr. Andrew Smith first utilized the term "caisson disease" describing 110 cases of decompression sickness as the physician in charge during construction of the Brooklyn Bridge.[29] [96] The project employed 600 compressed air workers. Recompression treatment was not used. The project chief engineer Washington Roebling suffered from caisson disease.[29] (He took charge after his father John Augustus Roebling died of tetanus.) Washington's wife, Emily, helped manage the construction of the bridge after his sickness confined him to his home in Brooklyn. He battled the after-effects of the disease for the rest of his life. During this project, decompression sickness became known as "The [Grecian] Bends" because afflicted individuals characteristically

Decompression sickness arched their backs: this is possibly reminiscent of a then fashionable women's dance maneuver known as the Grecian Bend, or as historian David McCullough asserts in The Great Bridge it was a crude reference to "Greek" or anal sex.[97] 1900: Leonard Hill used a frog model to prove that decompression causes bubbles and that recompression resolves them.[94] [98] Hill advocated linear or uniform decompression profiles.[94] [98] This type of decompression is used today by saturation divers. His work was financed by Augustus Siebe and the Siebe Gorman Company.[94] 1908: "The Prevention of Compressed Air Illness" was published by JS Haldane, Boycott and Damant recommending staged decompression.[99] These tables were accepted for use by the Royal Navy.[94] 1924: The US Navy published the first standardized recompression procedure.[100] 1930s: Albert R Behnke separated the symptoms of Arterial Gas Embolism (AGE) from those of DCS.[94] 1935: Behnke et al. experimented with oxygen for recompression therapy.[94] [100] [101]

18

An early recompression chamber

1937: Behnke introduced the no-stop decompression tables.[94] 1941: Altitude DCS is treated with hyperbaric oxygen for the first time.[102] 1957: Robert Workman established a new method for calculation of decompression requirements (M-values).[103] 1959: The "SOS Decompression Meter", a submersible mechanical device that simulated nitrogen uptake and release, was introduced.[104] 1960: FC Golding et al. split the classification of DCS into Type 1 and 2.[105] 1982: Paul K Weathersby, Louis D Homer and Edward T Flynn introduce survival analysis into the study of decompression sickness.[106] 1983: Orca produced the "EDGE", a personal dive computer, using a microprocessor to calculate nitrogen absorption for twelve tissue compartments.[104] 1984: Albert A Bhlmann released his book "Decompression-Decompression Sickness," which detailed his deterministic model for calculation of decompression schedules.[107]

Society and culture

Economics
In the United States, it is common for medical insurance not to cover treatment for the bends that is the result of recreational diving. This is because scuba diving is considered an elective and "high-risk" activity and treatment for decompression sickness is expensive. A typical stay in a recompression chamber will easily cost several thousand dollars, even before emergency transportation is included. As a result, groups such as Divers Alert Network (DAN) offer medical insurance policies that specifically cover all aspects of treatment for decompression sickness at rates of less than $100 per year.[108] In the United Kingdom, treatment of DCS is provided by the National Health Service, either at a specialised facility or at a Hyperbaric Centre based within a general hospital.[109]

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Footnotes
[1] [2] [3] [4] [5] [6] [7] http:/ / apps. who. int/ classifications/ apps/ icd/ icd10online/ ?gt66. htm+ t703 http:/ / www. icd9data. com/ getICD9Code. ashx?icd9=993. 3 http:/ / www. diseasesdatabase. com/ ddb3491. htm http:/ / www. emedicine. com/ emerg/ topic121. htm http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2011/ MB_cgi?mode=& term=Decompression+ Sickness& field=entry#TreeC21. 866. 120. 248 Francis & Mitchell p.578 Pulley, Stephen A (27 November 2007). "Decompression Sickness" (http:/ / emedicine. medscape. com/ article/ 769717-overview). Medscape. . Retrieved 15 May 2010. [8] Marx p.1908 [9] Francis & Mitchell p.579 [10] Francis, T James R; Smith, DJ (1991). "Describing Decompression Illness" (http:/ / archive. rubicon-foundation. org/ 4499). 42nd Undersea and Hyperbaric Medical Society Workshop 79(DECO)5-15-91. . Retrieved 23 May 2010. [11] Francis & Mitchell p.580 [12] U.S. Navy Supervisor of Diving (2008). "Chapter20: Diagnosis and Treatment of Decompression Sickness and Arterial Gas Embolism" (http:/ / supsalv. org/ pdf/ DiveMan_rev6. pdf) (PDF). U.S. Navy Diving Manual. SS521-AG-PRO-010, revision 6. volume5. U.S. Naval Sea Systems Command. p.37. . Retrieved 15 May 2010. [13] Powell p.71 [14] Francis & Mitchell pp.578584 [15] Doolette, David J; Mitchell, Simon J (2003). "Biophysical basis for inner ear decompression sickness" (http:/ / jap. physiology. org/ cgi/ content/ full/ 94/ 6/ 2145). Journal of Applied Physiology 94 (6): 214550. doi:10.1152/japplphysiol.01090.2002 (inactive 7 January 2010). PMID12562679. . Retrieved 15 May 2010. [16] Inner ear counter diffusion is a rare form of DCS sometimes experienced by divers engaged in extreme deep diving, caused by helium being released from the tissues but blocked by heavier nitrogen molecules. Two of the best-recorded instances of it both occurred at Boesmansgat, South Africa once to Nuno Gomes in an early world record attempt, and later to Don Shirley when he tried to rescue David Shaw on his fateful dive trying to recover the body of Deon Dreyer, who had been one of Gomes's support divers. [17] Powell p.70 [18] U.S. Navy Supervisor of Diving (2008) (PDF). U.S. Navy Diving Manual (http:/ / supsalv. org/ pdf/ DiveMan_rev6. pdf). SS521-AG-PRO-010, revision 6. vol.5. U.S. Naval Sea Systems Command. pp.2025. . Retrieved 18 May 2010. [19] TDI Decompression Procedures Manual (Rev 1c), page 38 [20] Vann, Richard D, ed (1989). "The Physiological Basis of Decompression" (http:/ / archive. rubicon-foundation. org/ 6853). 38th Undersea and Hyperbaric Medical Society Workshop. 75(Phys)6-1-89: 437. . Retrieved 15 May 2010. [21] Benton, BJ (2001). "Acute Decompression Illness (DCI): the Significance of Provocative Dive Profiles" (http:/ / archive. rubicon-foundation. org/ 1002). Undersea and Hyperbaric Medicine Abstract 28 (Supplement). ISSN1066-2936. OCLC26915585. . Retrieved 18 May 2010. [22] Wong, RM (1999). "Taravana revisited: Decompression illness after breath-hold diving" (http:/ / archive. rubicon-foundation. org/ 6010). South Pacific Underwater Medicine Society Journal 29 (3). ISSN0813-1988. OCLC16986801. . Retrieved 18 May 2010. [23] Lippmann & Mitchell pp.6566 [24] Ohta, Yoshimi; Matsunaga, Hitoshi (February 1974). "Bone lesions in divers" (http:/ / www. jbjs. org. uk/ cgi/ content/ abstract/ 56-B/ 1/ 3). Journal of Bone and Joint Surgery (British Editorial Society of Bone and Joint Surgery) 56B (1): 315. . Retrieved 18 May 2010. [25] Elliott, David H (1999). "Early Decompression experience: Compressed air work" (http:/ / archive. rubicon-foundation. org/ 5988). South Pacific Underwater Medicine Society Journal 29 (1). ISSN0813-1988. OCLC16986801. . Retrieved 18 May 2010. [26] Dehart, RL; Davis, JR (2002). Fundamentals Of Aerospace Medicine: Translating Research Into Clinical Applications (3rd Rev ed.). United States: Lippincott Williams And Wilkins. p.720. ISBN978-0-7817-2898-0. [27] Pilmanis, Andrew A (1990). "The Proceedings of the Hypobaric Decompression Sickness Workshop" (http:/ / archive. rubicon-foundation. org/ 5892). US Air Force Technical Report AL-SR-1992-0005. . Retrieved 18 May 2010. [28] Vann, Richard D; Torre-Bueno, JR (1984). "A theoretical method for selecting space craft and space suit atmospheres". Aviation, Space, and Environmental Medicine 55 (12): 10971102. ISSN0095-6562. PMID6151391. [29] Butler, WP (2004). "Caisson disease during the construction of the Eads and Brooklyn Bridges: A review" (http:/ / archive. rubicon-foundation. org/ 4028). Undersea and Hyperbaric Medicine 31 (4): 44559. PMID15686275. . Retrieved 30 May 2010. [30] Gerth, Wayne A; Vann, Richard D (1995). "Statistical Bubble Dynamics Algorithms for Assessment of Altitude Decompression Sickness Incidence" (http:/ / archive. rubicon-foundation. org/ 4102). US Air Force Technical Report TR-1995-0037. . Retrieved 18 May 2010. [31] Vann, Richard D; Gerth, Wayne A; DeNoble, Petar J; Pieper, Carl F; Thalmann, Edward D (2004). "Experimental trials to assess the risks of decompression sickness in flying after diving" (http:/ / archive. rubicon-foundation. org/ 4027). Undersea and Hyperbaric Medicine 31 (4): 43144. ISSN1066-2936. OCLC26915585. PMID15686274. . Retrieved 18 May 2010. [32] Robinson, RR; Dervay, JP; Conkin, Johnny. "An Evidenced-Based Approach for Estimating Decompression Sickness Risk in Aircraft Operations" (http:/ / ston. jsc. nasa. gov/ collections/ TRS/ _techrep/ TM-1999-209374. pdf) (PDF). NASA STI Report Series NASA/TM1999209374. . Retrieved 18 May 2010.

Decompression sickness
[33] Powell, Michael R (2002). "Decompression limits in commercial aircraft cabins with forced descent" (http:/ / archive. rubicon-foundation. org/ 1181). Undersea and Hyperbaric Medicine Supplement (abstract). . Retrieved 18 May 2010. [34] Brown, JR; Antuano, Melchor J (14 July 2005). "Altitude-Induced Decompression Sickness" (http:/ / www. faa. gov/ pilots/ safety/ pilotsafetybrochures/ media/ dcs. pdf). AM-400-95/2. Federal Aviation Administration. . Retrieved 27 June 2010. [35] Pollock, Neal W; Natoli, Michael J; Gerth, Wayne A; Thalmann, Edward D; Vann, Richard D (November 2003). "Risk of decompression sickness during exposure to high cabin altitude after diving" (http:/ / www. ingentaconnect. com/ content/ asma/ asem/ 2003/ 00000074/ 00000011/ art00006). Aviation, Space, and Environmental Medicine 74 (11): 116368. PMID14620473. . Retrieved 18 May 2010. [36] Fryer, DI (1969). Subatmospheric decompression sickness in man. England: Technivision Services. p.343. ISBN978-0-85102-023-5. [37] Lippmann & Mitchell p.232 [38] Bassett, Bruce E (1982). "Decompression Procedures for Flying After Diving, and Diving at Altitudes above Sea Level" (http:/ / archive. rubicon-foundation. org/ 4531). US Air Force School of Aerospace Medicine Technical Report SAM-TR-82-47. . Retrieved 18 May 2010. [39] Sheffield, Paul J; Vann, Richard D (2002). Flying After Diving Workshop. Proceedings of the DAN 2002 Workshop (http:/ / archive. rubicon-foundation. org/ 5611). United States: Divers Alert Network. p.127. ISBN0-9673066-4-7. . Retrieved 18 May 2010. [40] Vann, Richard D; Pollock, Neal W; Freiberger, John J; Natoli, Michael J; Denoble, Petar J; Pieper, Carl F (2007). "Influence of bottom time on preflight surface intervals before flying after diving" (http:/ / archive. rubicon-foundation. org/ 7343). Undersea and Hyperbaric Medicine 34 (3): 21120. PMID17672177. . Retrieved 18 May 2010. [41] Lippmann & Mitchell p.79 [42] Egi, SM; Brubakk, Alf O (1995). "Diving at altitude: a review of decompression strategies" (http:/ / archive. rubicon-foundation. org/ 2194). Undersea and Hyperbaric Medicine 22 (3): 281300. ISSN1066-2936. OCLC26915585. PMID7580768. . Retrieved 18 May 2010. [43] Karlsson, L; Linnarson, D; Gennser, M; Blogg, SL; Lindholm, Peter (2007). "A case of high doppler scores during altitude decompression in a subject with a fractured arm" (http:/ / archive. rubicon-foundation. org/ 5136). Undersea Hyperbaric Medicine 34 (Supplement). ISSN1066-2936. OCLC26915585. . Retrieved 18 May 2010. [44] Gerth, Wayne A; Ruterbusch, VL; Long, Edward T (2007). "The Influence of Thermal Exposure on Diver Susceptibility to Decompression Sickness" (http:/ / archive. rubicon-foundation. org/ 5063). United States Navy Experimental Diving Unit Technical Report NEDU-TR-06-07. . Retrieved 18 May 2010. [45] Boycott, AE; Damant, JCC (1908). "Experiments on the influence of fatness on susceptibility to caisson disease". Journal of Hygiene (Cambridge University Press) 8 (4): 44556. doi:10.1017/S0022172400015862. PMC2167151. PMID20474366. [46] Leigh, BC; Dunford, Richard G (2005). "Alcohol use in scuba divers treated for diving injuries: A comparison of decompression sickness and arterial gas embolism" (http:/ / depts. washington. edu/ adai/ pubs/ pres/ LeighRSAPoster. pdf). Alcoholism: Clinical and Experimental Research (29 (Suppl.), 157A). . Presented at the Annual Meeting of the Research Society on Alcoholism, Santa Barbara, California, June 2005. [47] Walder, Dennis N (1945). "The Surface Tension of the Blood Serum in 'Bends'". Royal Air Force Technical Report. [48] Lippmann & Mitchell p.71 [49] Moon, Richard E; Kisslo, Joseph (1998). "PFO and decompression illness: An update" (http:/ / archive. rubicon-foundation. org/ 5949). South Pacific Underwater Medicine Society Journal 28 (3). ISSN0813-1988. OCLC16986801. . Retrieved 18 May 2010. [50] Lippmann & Mitchell p.70 [51] Ackles, KN (1973). "Blood-Bubble Interaction in Decompression Sickness" (http:/ / archive. rubicon-foundation. org/ 3867). Defence R&D Canada (DRDC) Technical Report DCIEM-73-CP-960. . Retrieved 23 May 2010. [52] Nishi, Ron Y; Brubakk, Alf O; Eftedal, Olav S (2003). "10.3: Bubble Detection". In Brubakk, Alf O; Neuman, Tom S. Bennett and Elliott's physiology and medicine of diving, 5th Revised edition. United States: Saunders Ltd. p.501. ISBN0-7020-2571-2. OCLC51607923. [53] Kindwall, Eric P; Baz, A; Lightfoot, EN; Lanphier, Edward H; Seireg, A (1975). "Nitrogen elimination in man during decompression" (http:/ / archive. rubicon-foundation. org/ 2741). Undersea Biomedical Research 2 (4): 285297. ISSN0093-5387. OCLC2068005. PMID1226586. . Retrieved 23 May 2010. [54] Kindwall, Eric P (1975). "Measurement of helium elimination from man during decompression breathing air or oxygen" (http:/ / archive. rubicon-foundation. org/ 2742). Undersea Biomedical Research 2 (4): 277284. ISSN0093-5387. OCLC2068005. PMID1226585. . Retrieved 23 May 2010. [55] Francis & Mitchell pp.58041 [56] Landis, Geoffrey A (19 March 2009). "Explosive Decompression and Vacuum Exposure" (http:/ / www. geoffreylandis. com/ vacuum. html). . Retrieved 30 July 2010. [57] Hamilton & Thalmann p.475 [58] Wienke, Bruce R; O'Leary, Timothy R (10 October 2002). "Deep stops and deep helium" (http:/ / www. tek-dive. com/ portal/ upload/ deep. pdf). RGBM Technical Series 9. Tampa, Florida: NAUI Technical Diving Operations. . Retrieved 27 June 2010. [59] Fife, William P (1979). "The use of Non-Explosive mixtures of hydrogen and oxygen for diving". Texas A&M University Sea Grant TAMU-SG-79-201. [60] Brauer, RW, ed (1985). "Hydrogen as a Diving Gas" (http:/ / archive. rubicon-foundation. org/ 4862). 33rd Undersea and Hyperbaric Medical Society Workshop (Undersea and Hyperbaric Medical Society) (UHMS Publication Number 69(WSHYD)3187). . Retrieved 23 May 2010. [61] Hamilton & Thalmann p.477

20

Decompression sickness
[62] Burton, Steve (December 2004). "Isobaric Counter Diffusion" (http:/ / www. scubaengineer. com/ isobaric_counter_diffusion. htm). ScubaEngineer. . Retrieved 10 January 2010. [63] Thalmann, Edward D (March/April 2004). "Decompression Illness: What Is It and What Is The Treatment?" (http:/ / www. diversalertnetwork. org/ medical/ articles/ article. asp?articleid=65). Divers Alert Network. . Retrieved 3 August 2010. [64] Divers Alert Network (1997). Report on Diving Accidents and Fatalities in 1995 (http:/ / archive. rubicon-foundation. org/ 4269). Divers Alert Network. . Retrieved 23 May 2010. [65] Moon, Richard E (1998). "Assessment of patients with decompression illness" (http:/ / archive. rubicon-foundation. org/ 5919). South Pacific Underwater Medicine Society Journal 28 (1). . Retrieved 23 May 2010. [66] Moon, Richard E; Sheffield, Paul J, eds (1996). "Treatment of Decompression Illness. 45th Undersea and Hyperbaric Medical Society Workshop" (http:/ / archive. rubicon-foundation. org/ 7999). UHMS Publication Number WD712 (Undersea and Hyperbaric Medical Society): 426. . Retrieved 25 May 2010. [67] Hamilton & Thalmann p.471 [68] Hamilton & Thalmann p.455 [69] Tables based on US Navy tables have a safety stop at 15 feet (4.6m); BSAC tables have a safety stop at 6 metres (20ft); Bhlmann tables have a safety stop at 3 metres (9.8ft) [70] Hamilton & Thalmann pp.45657 [71] Hamilton & Thalmann pp.47173 [72] Hamilton & Thalmann pp.47475 [73] Hamilton & Thalmann p.456 [74] Nevills, Amiko (2006). "Preflight Interview: Joe Tanner" (http:/ / www. nasa. gov/ mission_pages/ shuttle/ shuttlemissions/ sts115/ interview_tanner. html). NASA. . Retrieved 26 June 2010. [75] Webb, James T; Olson, RM; Krutz, RW; Dixon, G; Barnicott, PT (1989). "Human tolerance to 100% oxygen at 9.5 psia during five daily simulated 8-hour EVA exposures". Aviation Space and Environmental Medicine 60 (5): 41521. PMID2730484. [76] Marx p.1912 [77] Marx p.1813 [78] Keays, FJ (1909). "Compressed air illness, with a report of 3,692 cases". Department of Medicine Publications of Cornell University Medical College 2: 155. [79] Yarbrough, OD; Behnke, Albert R (1939). "The treatment of compressed air illness using oxygen". Journal of industrial hygiene and toxicology 21: 21318. ISSN0095-9030. [80] Berghage, Thomas E; Vorosmarti Jr, James; Barnard, EEP (1978). "Recompression treatment tables used throughout the world by government and industry" (http:/ / archive. rubicon-foundation. org/ 3414). US Naval Medical Research Center Technical Report NMRI-78-16. . Retrieved 25 May 2010. [81] Edmonds, Carl (1998). "Underwater oxygen for treatment of decompression sickness: A review" (http:/ / archive. rubicon-foundation. org/ 6428). South Pacific Underwater Medicine Society Journal 25 (3). ISSN0813-1988. OCLC16986801. . Retrieved 2008-04-05. [82] Pyle, Richard L; Youngblood, David A (1995). "In-water Recompression as an emergency field treatment of decompression illness" (http:/ / archive. rubicon-foundation. org/ 6083). AquaCorp 11. . Retrieved 25 May 2010. [83] Kay, Edmond; Spencer, Merrill P (1999). In water recompression. 48th Undersea and Hyperbaric Medical Society Workshop (http:/ / archive. rubicon-foundation. org/ 5629). United States: Undersea and Hyperbaric Medical Society. p.108. . Retrieved 25 May 2010. [84] Moon & Gorman p.616 [85] Longphre, John M; DeNoble, Petar J; Moon, Richard E; Vann, Richard D; Freiberger, John J (2007). "First aid normobaric oxygen for the treatment of recreational diving injuries" (http:/ / archive. rubicon-foundation. org/ 5514). Undersea and Hyperbaric Medicine 34 (1): 4349. ISSN1066-2936. OCLC26915585. PMID17393938. . Retrieved 25 May 2010. [86] Goble, Steve (2003). "Rebreathers" (http:/ / archive. rubicon-foundation. org/ 7782). Journal of the South Pacific Underwater Medicine Society 33 (2): 98102. . Retrieved 25 July 2010. [87] O'Dowd, Liza C; Kelley, Mark A (October 2000). "Air embolism" (http:/ / cmbi. bjmu. edu. cn/ uptodate/ critical care/ embolic disease/ air embolism. htm). Chinese Medical Biotechnology Information Network. Peking University. . Retrieved 8 August 2010. [88] Bove, Alfred A (April 2009). "Arterial Gas Embolism: Injury During Diving or Work in Compressed Air" (http:/ / www. merck. com/ mmpe/ sec21/ ch323/ ch323c. html). Merck Manual Professional. Merk Sharp and Dohme. . Retrieved 8 August 2010. [89] Bennett, Peter B; Dovenbarger, Joel A; Corson, Karen (1991). Epidemiology of Bends (http:/ / archive. rubicon-foundation. org/ 7997). In Nashimoto, I; Lanphier, EH. "What is Bends?". 43rd Undersea and Hyperbaric Medical Society Workshop (Undersea and Hyperbaric Medical Society) 80(BENDS)6-1-91: 1320. . Retrieved 30 May 2010. [90] Dovenbarger, Joel A (1988). Report on Decompression Illness and Diving Fatalities (1988) (http:/ / archive. rubicon-foundation. org/ 4261). Divers Alert Network. . Retrieved 30 May 2010. [91] Desola, J (1989). "Epidemiological review of 276 dysbaric diving accidents". Proceedings XV Meeting European Undersea Biomedical Society: 209. [92] "Project Dive Exploration: Project Overview" (http:/ / www. diversalertnetwork. org/ research/ projects/ pde/ overview. asp). Divers Alert Network. 2010. . Retrieved 30 May 2010. [93] Acott, Chris (1999). "The diving "Law-ers": A brief resume of their lives" (http:/ / archive. rubicon-foundation. org/ 5990). South Pacific Underwater Medicine Society Journal (South Pacific Underwater Medicine Society) 29 (1). ISSN0813-1988. OCLC16986801. . Retrieved

21

Decompression sickness
30 May 2010. [94] Acott, Chris (1999). "A brief history of diving and decompression illness" (http:/ / archive. rubicon-foundation. org/ 6004). South Pacific Underwater Medicine Society Journal (South Pacific Underwater Medicine Society) 29 (2). ISSN0813-1988. OCLC16986801. . Retrieved 30 May 2010. [95] Marx p.1903 [96] Smith, Andrew Heermance (1886). The Physiological, Pathological and Therapeutical Effects of Compressed Air (http:/ / books. google. com/ ?id=hLq981_A5bMC& printsec=frontcover& dq=Diving). George S. Davis. . Retrieved 30 May 2010. [97] McCullough, David (June 2001). The Great Bridge: The Epic Story of the Building of the Brooklyn Bridge (http:/ / www. simonsays. com/ content/ book. cfm?tab=1& pid=414117& er=9780743217378). Simon & Schuster. ISBN0-7432-1737-3. . Retrieved 30 May 2010. [98] Hill, Leonard Erskine (1912). Caisson sickness, and the physiology of work in compressed air (http:/ / books. google. com/ ?id=FTC0AAAAIAAJ& dq=Leonard+ Erskine+ Hill& printsec=frontcover). London: Arnold. ISBN1-113-96529-0. . Retrieved 30 May 2010. [99] Boycott, AE; Damant, GCC; Haldane, John Scott (1908). "Prevention of compressed air illness" (http:/ / archive. rubicon-foundation. org/ 7489). Journal of Hygiene 8 (3): 342443. doi:10.1017/S0022172400003399. PMC2167126. PMID20474365. . Retrieved 30 May 2010. [100] Thalmann, Edward D (1990). Principles of U.S Navy recompression treatments for decompression sickness (http:/ / archive. rubicon-foundation. org/ 7996). In Bennett, Peter B; Moon, Richard E. "Diving Accident Management". 41st Undersea and Hyperbaric Medical Society Workshop (Undersea and Hyperbaric Medical Society) 78(DIVACC)12-1-90. . Retrieved 30 May 2010. [101] Behnke, Albert R; Shaw, Louis A; Messer, Anne C; Thomson, Robert M; Motley, E Preble (January 31, 1936). "The circulatory and respiratory disturbances of acute compressed-air illness and the administration of oxygen as a therapeutic measure" (http:/ / ajplegacy. physiology. org/ cgi/ content/ citation/ 114/ 3/ 526). Americal Journal of Physiology 114 (3): 526533. . Retrieved 30 May 2010. [102] Davis Jefferson C, Sheffield Paul J, Schuknecht L, Heimbach RD, Dunn JM, Douglas G, Anderson GK (August 1977). "Altitude decompression sickness: hyperbaric therapy results in 145 cases". Aviation, Space, and Environmental Medicine 48 (8): 72230. PMID889546. [103] Workman, Robert D (1957). "Calculation of air saturation decompression tables" (http:/ / archive. rubicon-foundation. org/ 3458). Navy Experimental Diving Unit Technical Report NEDU-RR-11-57. . Retrieved 30 May 2010. [104] Carson, Daryl. "Dive Computer Evolution" (http:/ / www. skin-diver. com/ departments/ gearingup/ accessories/ may00_computer. asp?theid=1212). Skin-Diver.com. . Retrieved 30 May 2010. [105] Golding, F Campbell; Griffiths, P; Hempleman, HV; Paton, WDM; Walder, DN (July 1960). "Decompression sickness during construction of the Dartford Tunnel". British Journal of Industrial Medicine 17 (3): 16780. PMC1038052. PMID13850667. [106] Weathersby, Paul K; Homer, Louis D; Flynn, Edward T (September 1984). "On the likelihood of decompression sickness" (http:/ / jap. physiology. org/ cgi/ pmidlookup?view=long& pmid=6490468). Journal of Applied Physiology 57 (3): 81525. PMID6490468. . Retrieved 2009-04-27. [107] Bhlmann, Albert A (1984). Decompression-Decompression Sickness. Berlin New York: Springer-Verlag. ISBN0-387-13308-9. [108] "DAN Insurance" (http:/ / www. diversalertnetwork. org/ insurance/ index. asp). Divers Alert Network. 2003. . Retrieved 25 July 2010. [109] "NHS Funded Treatment" (http:/ / www. londonhyperbaric. com/ decompression-illness/ nhs-funded-treatment). London Hyperbaric Ltd. . Retrieved 22 August 2011.

22

References Bibliography
Hamilton, Robert W; Thalmann, Edward D (2003). "10.2: Decompression Practice". In Brubakk, Alf O; Neuman, Tom S. Bennett and Elliott's physiology and medicine of diving (5th Revised ed.). United States: Saunders Ltd. pp.455500. ISBN0-7020-2571-2. OCLC51607923. Francis, T James R; Mitchell, Simon J (2003). "10.4: Pathophysiology of Decompression Sickness". In Brubakk, Alf O; Neuman, Tom S. Bennett and Elliott's physiology and medicine of diving (5th Revised ed.). United States: Saunders Ltd. pp.53056. ISBN0-7020-2571-2. OCLC51607923. Francis, T James R; Mitchell, Simon J (2003). "10.6: Manifestations of Decompression Disorders". In Brubakk, Alf O; Neuman, Tom S. Bennett and Elliott's physiology and medicine of diving (5th Revised ed.). United States: Saunders Ltd. pp.57899. ISBN0-7020-2571-2. OCLC51607923. Moon, Richard E; Gorman, Des F (2003). "10.7: Treatment of the Decompression Disorders". In Brubakk, Alf O; Neuman, Tom S. Bennett and Elliott's physiology and medicine of diving (5th Revised ed.). United States: Saunders Ltd. pp.600650. ISBN0-7020-2571-2. OCLC51607923. Lippmann, John; Mitchell, Simon (2005). Deeper into Diving (2nd ed.). Melbourne, Australia: J L Publications. ISBN0-9752290-1-X.

Decompression sickness Marx, John (2010). Rosen's emergency medicine: concepts and clinical practice (7th ed.). Philadelphia, PA: Mosby/Elsevier. ISBN978-0-323-05472-0. Powell, Mark (2008). Deco for Divers. Southend-on-Sea: Aquapress. ISBN1-905492-07-3.

23

External links
Environmental Physiology Medical Literature (http://archive.rubicon-foundation.org) Divers Alert Network: diving medicine articles (http://www.diversalertnetwork.org/medical/articles/index. asp) Dive Tables from the NOAA (http://www.ndc.noaa.gov/dp_forms.html)

Deep diving
The meaning of the term deep diving is a form of technical diving.[1] It is defined by the level of the diver's diver training, diving equipment, breathing gas, and surface support: in recreational diving, PADI define anything from 18 metres / 60 feet - 30 metres / 100 feet as a "deep dive" (other diving organisations vary) in technical diving, 60 metres / 200 feet may be a "deep dive" in surface supplied diving, 100 metres / 330 feet may be a "deep dive" This definition essentially relates to recreational diving. Deep diving may have quite a different meaning in the commercial diving field. For instance the early experiments carried out by Comex S.A. (Compagnie maritime d'expertises) using hydrox and also nitrogen trimix attained far greater depths than any recreational technical diving. One example being the Comex Janus IV open-sea dive to 500 metres, in 1977.[2] The open-sea diving depth record was achieved in 1988 by a team of Comex divers who performed pipe line connection exercises at a depth of 534 metres in the Mediterranean Sea as part of the Hydra 8 programme.[3] These divers needed to breathe special gas mixtures because they were exposed to very high ambient pressure (more than 50 times atmospheric pressure). An atmospheric diving suit allows very deep dives of up to 700 metres. These suits are capable of withstanding the pressure at great depth permitting the diver to remain at normal atmospheric pressure. This eliminates the problems associated with breathing high pressure gases.

Diver returning from a 600ft/180 metres dive

Deep diving

24

Deep Diving
Depth [4] Comments Recreational diving limit for divers aged under 12 years old and beginner divers. Recreational diving limit for divers with Open Water certification but without greater training and experience. Recommended recreational diving limit for divers. adults. [1] Average depth at which nitrogen narcosis symptoms begin to appear in

40 feet/12 meters 60 feet/18 meters 100 feet/30 meters

130 feet/40 meters 180 feet/55 meters 218 feet/65 meters

Absolute recreational diving limit for divers specified by Recreational Scuba Training Council (RSTC). Technical diving limit for "extended range" dives breathing air to a maximum ppO2 of 1.4 ATA. Depth at which compressed air results in an unacceptable risk of oxygen toxicity. [5]

[1]

330 feet/100 meters Technical diving training limit for divers breathing trimix. Recommended technical diving limit. 509 feet/155 meters Record depth for scuba dive on compressed air.[6] 660 feet/200 meters Absolute limit for surface light penetration sufficient for plant growth, though minimal visibility possible farther down.[7] 1,083 feet/330 meters 2,000 feet/610 meters World record for deepest dive on SCUBA. [8]

Navy diver in Atmospheric Diving System (ADS) suit .

[9]

Particular problems associated with deep dives

Deep diving has more consequences and dangers than basic open water diving.[10] Nitrogen narcosis, the narks or rapture of the deep, starts with feelings of euphoria and over-confidence but then leads to numbness and memory impairment similar to alcohol intoxication. Decompression sickness, or the bends, can happen if a diver ascends too fast, when excess inert gas leaves solution in the blood and tissues and forms bubbles. These bubbles produce mechanical and biochemical effects that lead to the condition. The effects tend to be delayed until reaching the surface. Bone degeneration (dysbaric osteonecrosis) is caused by the bubbles forming inside the bones; most commonly the upper arm and the thighs. Air embolism causes loss of consciousness and speech and visual problems. This tends to be life threatening, and requires a recompression chamber for treatment. Deep diving involves a much greater danger of all of these, and presents the additional risk of oxygen toxicity, which may lead to a convulsion underwater. Very deep diving using a heliumoxygen mixture (heliox) carries a risk of high pressure nervous syndrome. Coping with the physical and physiological stresses of deep diving requires good physical conditioning.[11] Using normal scuba equipment, breathing gas consumption is proportional to ambient pressure - so at 50 metres (160ft), where the pressure is 6 bar, a diver breathes 6 times as much as on the surface (1 bar). Heavy physical exertion causes even more gas to be breathed, and gas becomes denser requiring increased effort to breathe with depth, leading to increasing risk of hypercapnia, an excess of carbon dioxide in the blood. The need to do decompression stops increases with depth. A diver at 6 metres (20ft) may be able to dive for many hours without needing to do decompression stops. At depths greater than 40 metres (130ft), a diver may have only a few minutes at the deepest part of the dive before decompression stops are needed. In the event of an emergency the diver cannot make an immediate ascent to the surface without risking decompression sickness. All of these considerations result in the amount of breathing gas required for deep diving being much greater than for shallow open water diving. The diver needs a disciplined approach to planning and conducting dives to minimise these additional risks.

Deep diving

25

Dealing with depth

Divers carry larger volumes of breathing gas to compensate for the increased gas consumption and decompression stops. Rebreathers manage gas much more efficiently than open circuit scuba, but are inherently more complex than open circuit scuba. Use of helium-based breathing gases such as trimix reduces nitrogen narcosis and stays below the limits of oxygen toxicity. A diving shot, a decompression trapeze or a decompression buoy can help divers return to their surface safety cover at the end of a dive.

Technical divers preparing for a mixed-gas decompression dive in Bohol, Philippines. Note the backplate and wing setup with sidemounted stage tanks containing EAN50 (left side) and pure oxygen (right side).

Ultra-deep diving
Verified SCUBA dives below 800 feet
Name Nuno Gomes Location Red Sea Red Sea South Africa South Africa Depth 1044 feet (318m) 890 feet (270m) 927 feet (283m) 826 feet (252m) Year 2005 2004 1996 1994

Pascal Bernab

Mediterranean Mediterranean

1083 feet 2005 (330m) 2005 873 feet (266m) 888 feet (271m) 2004 898 feet (274m) 2002 1010 feet 2001 (310m) 2001 833 feet (254m) 925 feet (282m) 825 feet (251m) 1994 1993

David Shaw

[12]

South Africa

Gilberto M de Oliveira Brazil John Bennett [12] Philippines Philippines

Jim Bowden

Mexico Mexico South Africa Mexico South Africa Andaman Sea Thailand

Sheck Exley Don Shirley

[12]

863 feet (263m) 1993 867 feet (264m) 1989 820 feet (250m) 2005 1026 feet 2003 (313m) 2003 850 feet (260m)

Mark Ellyatt

Amongst technical divers, there are certain elite divers who participate in ultra-deep diving on SCUBA (using closed circuit rebreathers and heliox) below 660 feet (200m). Ultra-deep diving requires extraordinarily high levels of training, experience, fitness and surface support. Only eight (or possibly nine) persons are known to have ever dived below a depth of 800 feet (240m) on self contained breathing apparatus recreationally.[13] [14] [15] [16] That is fewer

Deep diving than the number of people who have walked on the surface of the moon. The Holy Grail of deep SCUBA diving was the 1000ft (300m) mark, first achieved by John Bennett in 2001, and has only been achieved five times since. Dives of this nature have been impossible to verify - proof being as tangible as faith more often than not. Since the recent introduction of depth gauges capable of reading to 330m it is unlikely that such records will be attempted in the future. In 2003 Mark Ellyatt claimed dives to depths of 260m and 313m. Besides scuba, there is a small group of divers who have reached depths below 200 meters on closed-circuit rebreathers. Some examples are David Shaw, Don Shirley, Alessandro Scuotto, Marco Reis, Mario Marconi, Paul Raymeakers and Pim van der Horst.

26

Ultra deep air

While extreme deep diving on air is extremely dangerous, before the popularity of Trimix attempts were made to set world record depths using conventional air. This created an extreme risk of both narcosis and oxygen toxicity in the divers and, perhaps unsurprisingly, contributed to an astonishingly high fatality rate amongst those attempting records. In his book, Deep Diving, Bret Gilliam chronicles the various fatal attempts to set records as well as the smaller number of successes.[17] From the comparatively few who survived extremely deep air dives: 1947 Frdric Dumas, a colleague of Jacques Cousteau, dived to 307 feet (94m) on air 1959 Ennie Falco reported having reached a depth of 435 feet (133m) on air, but had no means to record it 1965 Tom Mount and Frank Martz dive to a depth of 360 feet (110m) on air 1967 Hal Watts and AJ Muns dive to a depth of 390 feet (120m) on air 1968 Neil Watson and John Gruener dived to 437 feet (133m) on air in the Bahamas. Watson reported that he had no recollection at all of what transpired at the bottom of the descent due to narcosis. 1990 Bret Gilliam dived to a depth of 452 feet (138m) on air. Unusually, Gilliam remained largely functional at depth and was able to complete basic maths problems and answer simple questions written on a slate by his crew beforehand. 1993 Bret Gilliam extended his own world record to 475 feet (145m), again reporting no ill effects from narcosis or oxygen toxicity. 1994 Dan Manion set the current record for a deep dive on air at 509 feet (155m). Manion reported he was almost completely incapacitated by narcosis and has no recollection of time at depth. In deference to the high death rate, the Guinness World Records ceased to publish records on deep air dives.

References
[1] Brylske, A. (2006). Encyclopedia of Recreational Diving, 3rd edition. United States: PADI. ISBN1878663011. [2] Hydra 8: Pre-commercial Hydrogen Diving Project (http:/ / www. onepetro. org/ mslib/ servlet/ onepetropreview?id=SUT-AUTOE-v14-107& soc=SUT& speAppNameCookie=ONEPETRO) [3] Comex S.A. HYDRA 8 and HYDRA 10 test projects (http:/ / www. comex. fr/ suite/ ceh/ histo/ histo anglais. html) [4] All depths specified for sea water. Fractionally deeper depths may apply in relation to freshwater due to its lower density [5] Oxygen toxicity depends upon a combination of partial pressure and time of exposure, individual physiology, and other factors not fully understood. NOAA recommends that divers do not expose themselves to breathing oxygen at greater than 1.6 bar ppO2, which occurs at 218 feet breathing air. [6] Set by Dr Dan Marion on March 18, 1994. The record is not officially recognised anywhere, and it should be noted that Dr Marion's second dive computer only registered a depth of 490 feet. See generally Deep Diving by Bret Gilliam, ISBN 0-922769-31-1, at pages 35 and following. (http:/ / books. google. vg/ books?id=HVbjgdorRXAC& lpg=PA35& ots=TjUeuuvLmB& dq="bret gilliam" record air& pg=PA35#v=onepage& q="bret gilliam" record air& f=false) [7] Assuming crystal clear water; surface light may disappear completely at much shallower depths in murky conditions. Minimal visibility is still possible far deeper. Deep sea explorer William Beebe reported seeing blueness, not blackness, at 1400 feet (424 meters). "I peered down and again I felt the old longing to go farther, although it looked like the black pit-mouth of hell itself---yet still showed blue." (William Beebe, "A Round Trip to Davey Jones's Locker," The National Geographic Magazine, June 1931, p. 660.)

Deep diving
[8] 1,083 feet was the depth reportedly achieved by Pascal Bernab in 2005. However, the Guinness World Records still recognises the 1,044 feet dive by Nuno Gomes earlier in the same year as the current official world record. [9] Navy diver sets world record (http:/ / www. military. com/ features/ 0,15240,108883,00. html) [10] Egstrom GH (2006). "Historic Perspective: Scientific Deep Diving and the Management of the Risk" (http:/ / archive. rubicon-foundation. org/ 4653). In: Lang, MA and Smith, NE (eds). Proceedings of Advanced Scientific Diving Workshop (Washington, DC). . Retrieved 2008-07-05. [11] Southerland, DG (2006). "Medical Fitness at 300 FSW" (http:/ / archive. rubicon-foundation. org/ 4659). In: Lang, MA and Smith, NE (eds). Proceedings of Advanced Scientific Diving Workshop (Washington, DC). . Retrieved 2008-07-05. [12] Subsequently died during diving accidents. [13] Gomes, N. "Verified dives below 200 metres" (http:/ / www. nunogomes. co. za/ rec. htm). . Retrieved 2008-06-14. [14] Scubarecords.com. "Recorded Deep Dives Below 200m" (http:/ / www. scubarecords. com/ DeepRecords. htm). . Retrieved 2008-06-14. [15] Statistics exclude military divers (classified), and commercial divers (although commercial diving to that depth is unknown on SCUBA). In 1989 the US Navy experimental diving unit published a paper entitled EX19 [a type of experimental rebreather] Performance Testing at 850 and 450 FSW which included a section on results from tests on the use of rebreathers at 850 feet. --Knafelc, ME (1989). "EX 19 Performance Testing at 850 and 450 FSW (Feet of Seawater)" (http:/ / archive. rubicon-foundation. org/ 7423). US Naval Experimental Diving Unit Technical Report NEDU-8-89. . Retrieved 2008-07-24. [16] In 2007 Erdogan Bayburt, a former Turkish Navy diver, dived to a depth of 998 feet (304m) off the coast of Cyprus, but that dive has not been independently verified. He used a closed-circuit rebreather. His dive was aborted due to equipment failure. It was a Turkish Navy experimental dive. [17] Deep Diving, an advanced guide to physiology, procedures and systems (http:/ / books. google. com/ ?id=HVbjgdorRXAC& pg=PT1& lpg=PT1& dq=Bret+ Gilliam+ deep+ diving#v=onepage& q=& f=false). Bret Gilliam. 1995-01-25. ISBN9780922769315. . Retrieved 2009-11-19.

27

Footnotes Further reading

Dent, W (2006). "AAUS Deep Diving Standards" (http://archive.rubicon-foundation.org/4669). In: Lang, MA and Smith, NE (eds). Proceedings of Advanced Scientific Diving Workshop (Washington, DC). Retrieved 2008-07-05.

External links
Recreational Deep Diving (http://www.divinglore.com/RecreationalDeepDiving.htm)

Equivalent air depth

28

Equivalent air depth

The equivalent air depth (EAD) is a way of approximating the decompression requirements of breathing gas mixtures that contain nitrogen and oxygen in different proportions to those in air, known as nitrox.[1] [2] [3] The equivalent air depth, for a given nitrox mix and depth, is the depth of a dive when breathing air that would have the same partial pressure of nitrogen. So, for example, a gas mix containing 36% oxygen (EAN36) being used at 27 metres (89ft) has an EAD of 20 metres (66ft).

Calculations in metres
The equivalent air depth can be calculated for depths in metres as follows: EAD = (Depth + 10) Fraction of N2 / 0.79 10 Working the earlier example, for a nitrox mix containing 64% nitrogen (EAN36) being used at 27 metres, the EAD is: EAD = (27 + 10) 0.64 / 0.79 10 EAD = 37 0.81 10 EAD = 30 10 EAD = 20 metres So at 27 metres on this mix, the diver would calculate their decompression requirements as if on air at 20 metres.

Calculations in feet
The equivalent air depth can be calculated for depths in feet as follows: EAD = (Depth + 33) Fraction of N2 / 0.79 33 Working the earlier example, for a nitrox mix containing 64% nitrogen (EAN36) being used at 90 feet, the EAD is: EAD = (90 + 33) 0.64 / 0.79 33 EAD = 123 0.81 33 EAD = 100 33 EAD = 67 feet So at 90 feet on this mix, the diver would calculate their decompression requirements as if on air at 67 feet.

Dive tables
Although not all dive tables are recommended for use in this way, the Bhlmann tables are suitable for use with these kind of calculations. At 27 metres the Bhlmann 1986 table (0700 m) allows 20 minutes bottom time without requiring a decompression stop. While at 20 metres the no-stop time is 35 minutes. This shows that using EAN36 for a 27 metre dive can give a 75% increase in bottom time over using air.

References
[1] Logan, JA (1961). "An evaluation of the equivalent air depth theory" (http:/ / archive. rubicon-foundation. org/ 3835). United States Navy Experimental Diving Unit Technical Report NEDU-RR-01-61. . Retrieved 2008-05-01. [2] Berghage Thomas E, McCraken TM (December 1979). "Equivalent air depth: fact or fiction" (http:/ / archive. rubicon-foundation. org/ 2835). Undersea Biomedical Research 6 (4): 37984. PMID538866. . Retrieved 2008-05-01. [3] Lang, Michael A. (2001). DAN Nitrox Workshop Proceedings (http:/ / archive. rubicon-foundation. org/ 4855). Durham, NC: Divers Alert Network. p.197. . Retrieved 2008-05-02.

Equivalent narcotic depth

29

Equivalent narcotic depth

Equivalent narcotic depth (END) is used in technical diving as a way of estimating the narcotic effect of a breathing gas mixture, such as heliox and trimix. The method is, for a given mix and depth, to calculate the depth which would produce the same narcotic effect when breathing air. The equivalent narcotic depth of a breathing gas mix at a particular depth is calculated by finding the depth of a dive when breathing air that would have the same total partial pressure of nitrogen and oxygen as the breathing gas in question. For example, a trimix containing 20% oxygen, 40% helium, 40% nitrogen (trimix 20/40) being used at 60 metres (200ft) has an END of 32 metres (105ft).

Calculations
Metres
The equivalent narcotic depth can be calculated for depths in metres as follows: END = (Depth + 10) (1 Fraction of helium) 10 Working the earlier example, for a gas mix containing 40% helium being used at 60 metres, the END is: END = (60 + 10) (1 0.4) 10 END = 70 0.6 10 END = 42 10 END = 32 metres So at 60 metres on this mix, the diver would feel the same narcotic effect as a dive on air to 32 metres.

Feet
The equivalent narcotic depth can be calculated for depths in feet as follows: END = (Depth + 33) (1 Fraction of helium) 33 Working the earlier example, for a gas mix containing 40% helium being used at 200 feet, the END is: END = (200 + 33) (1 0.4) 33 END = 233 0.6 33 END = 140 33 END = 107 feet So at 200 feet on this mix, the diver would feel the same narcotic effect as a dive on air to 107 feet.

Oxygen Narcosis
Since there is evidence that oxygen plays a part in the narcotic effects of a gas mixture,[1] the NOAA diving manual recommends treating oxygen and nitrogen as equally narcotic.[2] This is now preferred to the previous method of considering only nitrogen as narcotic, since it is more conservative. In this analysis, it is assumed that the narcotic potentials of nitrogen and oxygen are similar. Although oxygen has greater lipid solubility than nitrogen and therefore should be more narcotic (Meyer-Overton correlation), it is likely that some of the oxygen is metabolised, thus reducing its effect to a level similar to that of nitrogen.

Equivalent narcotic depth

30

References
[1] Hesser CM, Fagraeus L, Adolfson J (December 1978). "Roles of nitrogen, oxygen, and carbon dioxide in compressed-air narcosis" (http:/ / archive. rubicon-foundation. org/ 2810). Undersea Biomed Res 5 (4): 391400. PMID734806. . Retrieved 2008-05-01. [2] "Mixed-Gas & Oxygen". NOAA Diving Manual, Diving for Science and Technology. 4th. National Oceanic and Atmospheric Administration. 2002. "[16.3.1.2.4] ... since oxygen has some narcotic properties, it is appropriate to include the oxygen in the END calculation when using trimixes (Lambersten et al. 1977,1978). The non-helium portion (i.e., the sum of the oxygen and the nitrogen) is to be regarded as having the same narcotic potency as an equivalent partial pressure of nitrogen in air, regardless of the proportions of oxygen and nitrogen."

High-pressure nervous syndrome

High-pressure nervous syndrome (HPNS also known as high-pressure neurological syndrome) is a neurological and physiological diving disorder that results when a commercial diver or scuba diver descends below about 500 feet (150m) while breathing a heliumoxygen mixture. The effects depend on the rate of descent and the depth.[1] HPNS is a limiting factor in future deep diving. "Helium tremors" were first widely described in 1965 by Royal Navy physiologist Peter B. Bennett, who also founded the Divers Alert Network.[1] [2] Russian scientist G. L. Zal'tsman also reported on helium tremors in his experiments from 1961. Unfortunately these reports were not available in the West until 1967.[3] The term high pressure nervous syndrome was first used by Brauer to describe the combined symptoms of tremor, electroencephalography (EEG) changes, and somnolence that appeared during a 1189-foot (362m) chamber dive in Marseilles.[4]

Symptoms
Symptoms of HPNS include tremors, myoclonic jerking, somnolence, EEG changes,[5] visual disturbance, nausea, dizziness, and decreased mental performance.[1] [2]

Causes
HPNS has two components, one resulting from the speed of compression and the other from the absolute pressure. The compression effects may occur when descending below 500 feet (150m) at rates greater than a few metres per minute, but reduce within a few hours once the pressure has stabilised. The effects from depth become significant at depths exceeding 1000 feet (300m) and remain regardless of the time spent at that depth.[1] The susceptibility of divers and animals to HPNS varies over a wide range depending on the individual, but has little variation between different dives by the same diver.[1]

Prevention
It is likely that HPNS can not be entirely prevented but there are effective methods to delay or change the development of the symptoms.[1] [6]

Rate of Compression
Utilizing slow rates of compression or adding stops to the compression have been found to prevent large initial decrements in performance.[1] [7]

Breathing Mixture
Including other gases in the mix, such as nitrogen (creating trimix) or hydrogen (hydreliox) suppresses the neurological effects.[8] [9] [10]

High-pressure nervous syndrome

31

Drugs
Alcohol, anesthetics and anticonvulsant drugs have had varying results in suppressing HPNS with animals.[1] None are currently in use for humans.

References
[1] Bennett, Peter B; Rostain, Jean Claude (2003). "The High Pressure Nervous Syndrome". In Brubakk, Alf O; Neuman, Tom S. Bennett and Elliott's physiology and medicine of diving, 5th Rev ed. United States: Saunders. pp.32357. ISBN0702025712. [2] Bennett, P. B. (1965). "Psychometric impairment in men breathing oxygen-helium at increased pressures". Royal Navy Personnel Research Committee, Underwater Physiology Subcommittee Report No. 251 (London). [3] Zal'tsman, G. L. (1967). "Psychological principles of a sojourn of a human in conditions of raised pressure of the gaseous medium (in Russian, 1961)". English translation, Foreign Technology Division. AD655 360 (Wright Patterson Air Force Base, Ohio). [4] Brauer, R. W. (1968). "Seeking man's depth level". Ocean Industry (London) 3: 2833. [5] Brauer, R. W.; S. Dimov; X. Fructus; P. Fructus; A. Gosset; R. Naquet. (1968). "Syndrome neurologique et electrographique des hautes pressions". Rev Neurol (Paris) 121 (3): 2645. PMID5378824. [6] Hunger Jr, W. L.; P. B. Bennett. (1974). "The causes, mechanisms and prevention of the high pressure nervous syndrome" (http:/ / archive. rubicon-foundation. org/ 2661). Undersea Biomed. Res. 1 (1): 128. ISSN0093-5387. OCLC2068005. PMID4619860. . Retrieved 2008-04-07. [7] Bennett, P. B.; R. Coggin; M. McLeod. (1982). "Effect of compression rate on use of trimix to ameliorate HPNS in man to 686 m (2250 ft)" (http:/ / archive. rubicon-foundation. org/ 2920). Undersea Biomed. Res. 9 (4): 33551. ISSN0093-5387. OCLC2068005. PMID7168098. . Retrieved 2008-04-07. [8] Vigreux, J. (1970). "Contribution to the study of the neurological and mental reactions of the organism of the higher mammal to gaseous mixtures under pressure". MD Thesis (Toulouse University). [9] Fife, W. P. (1979). "The use of Non-Explosive mixtures of hydrogen and oxygen for diving". Texas A&M University Sea Grant TAMU-SG-79-201. [10] Rostain, J. C.; Gardette-Chauffour, M. C.; Lemaire, C.; Naquet, R. (1988). "Effects of a H2-He-O2 mixture on the HPNS up to 450 msw" (http:/ / archive. rubicon-foundation. org/ 2487). Undersea Biomedical Research 15 (4): 25770. ISSN0093-5387. OCLC2068005. PMID3212843. . Retrieved 2008-04-07.

External links
Select publications about HPNS (http://archive.rubicon-foundation.org/dspace/simple-search?query=high+ pressure+nervous+syndrome) hosted by the Rubicon Foundation

List of diving hazards and precautions

32

List of diving hazards and precautions

Divers face specific physical and health risks when they go underwater (e.g. with scuba or other diving equipment) or use high pressure breathing gases. Some of these conditions also affect people who work in raised pressure environments out of water, e.g. in caissons. According to a North American 1970 study, diving was (on a man-hours based criteria) 96 times more dangerous than driving an automobile.[1] According to a 2000 Japanese study, every hour of recreational diving is 36 to 62 times riskier than automobile driving.[2]

Effects of relying on breathing equipment while underwater

Being unable to breathe fresh air naturally whilst submerged and relying on limited breathing gas supplies and fallible breathing equipment can have these effects. Click on the boldface links to find symptoms and more information for each topic.

Types of this sort of diving disorder, and how to avoid them

Type Drowning Secondary drowning Cause Being unable to inhale anything but water Can occur hours after a near drowning How to avoid it See under "anoxia" hereinunder Prompt medical treatment after near drowning Proper training before using a rebreather or oxygen enriched gases such as nitrox.

Oxygen toxicity

Breathing gas at too high a partial pressure of oxygen; partial pressure depends upon proportion of oxygen and depth

Hypoxia or anoxia occurs while having gas to breathe, but where the oxygen partial pressure is too low to sustain normal activity or consciousness.

A faulty or misused rebreather can provide the diver with Keep rebreathers properly maintained. hypoxic gas Proper training before using a rebreather. Some deep diving breathing gases such as trimix and heliox can be hypoxic at shallow depths Don't breathe hypoxic gas in shallow water. Proper training before using mixed gases. Corerect identification of cylinder gases and safe procedures for gas changes. Keep cylinders routinely checked and tested. If a cylinder has stood full for months, empty it and refill it. Keep equipment routinely checked and in good condition Better training of divers. More disciplined attitude when underwater. Better awareness underwater. Carry a diver's net cutter, or dive tool/knife. Specific training and leadership for such types of diving. See cave diving and wreck diving. Better training and leadership, including in using a compass underwater Keep equipment routinely checked and in good condition

A full cylinder standing for a long time while the inside of the cylinder rusts, using up oxygen in the contained air, before the diver uses the cylinder Anoxia due to having no air or gas to breathe Equipment failure - particularly in rebreathers that monitor and maintain oxygen content Running out of air due to a number of factors, including poor dive discipline Running out of air due to getting trapped by nets

Running out of air due to getting trapped or lost in enclosed spaces underwater (e.g. caves and shipwrecks)

Running out of air due to getting lost in open water

Salt water aspiration syndrome

Inhaling a mist of sea water from a faulty demand valve causing a reaction in the lungs

List of diving hazards and precautions

33
Air cylinder filled by a compressor which sucked in products of combustion, often its own engine's exhaust gas Oil getting into the air feed and firing in the air compression cylinder, like in a diesel engine Proper precautions when filling cylinders

Carbon monoxide poisoning

Proper servicing of the compressor

Emphysema caused by inhaling oil mist

This happens gradually over a long time. This is a particular risk with a pumped surface air feed. Re-inhaling carbon dioxide-laden exhaled gas

Use proper filters in the air pump or air compressor. Minimise the volume of any enclosed spaces which the diver breathes through. For example, this hazard can happen with diving with a large "bubblehead" helmet. British naval divers called it shallow water blackout. Keep rebreathers properly maintained. Proper training before using a rebreather. Check conditions where you have your cylinders refilled. Put the proper gas identification markings on cylinders.

Carbon dioxide poisoning: hypercapnia

With a rebreather, the diver re-inhales carbon dioxide because the soda lime scrubber cannot absorb the exhaled carbon dioxide as fast as the diver produces it. See Rebreather#Carbon dioxide scrubber. Various effects of breathing a wrong gas A wrong gas was put in a cylinder

Effects of barotrauma or pressure damage

See barotrauma and pressure for more information.

On descent
Air spaces within the body provide no support against greater outside pressure. This can happen from losing control of buoyancy causing excessive vertical speed during descent. Click on the boldface links to find symptoms and more information for each topic.

Types of this sort of diving disorder, and how to avoid them

Type Eardrum damage. Cold water in the middle ear chills the inner ear, causing dizziness and disorientation etc. Cause Failing to equalize the pressure in the middle ear with surrounding pressure. How to avoid it Do not dive if the eustachian tube is congested, e.g. with the common cold. Proper diver training in clearing the ears. Make sure that your hood does not make an airtight seal over the outside ear hole; never wear earplugs. Do not dive with conditions such as the common cold Let air into the mask through the nose. Do not dive with eyes-only goggles.

The pressure in the outer ear not equalizing with surrounding pressure

Damage to other body air spaces, such as the paranasal sinuses. Squeeze damage to blood vessels around the eyes

Obstruction to the sinus ducts

Caused by suction from the air space inside a mask ("mask squeeze") which is not a fullface mask

List of diving hazards and precautions

34
Modern drysuits have a tube connection to inflate the drysuit from the cylinder Use an underwater breathing set Keep equipment in good order and inspected. Proper training in its use.

Squeeze damage to skin under Suction into the space inside the fold folds in a drysuit

Lung squeeze: blood in lungs

Extreme depth when snorkelling

Helmet squeeze, with the old standard diving dress. This does not happen with scuba where there is no solid pressure-tight helmet

A non-return valve in the helmet failing, accompanied by a failure of the air compressor (on the surface) to pump enough air into the suit for the gas pressure inside the suit remaining equal to the outside pressure of the water. In severe cases much of the diver's body could be mangled and compacted inside the helmet, however, this requires substantial pressure difference caused by aforementioned failures in the air supply and the non-return valve (which was absent from the earliest models of this type of diving suit).

On ascent
Air spaces within the body expand when the outside pressure decreases. This can happen from holding the breath on ascent, or from losing control of buoyancy causing excessive vertical speed during ascent. Click on the boldface links to find symptoms and more information for each topic.

Types of this sort of diving disorder, and how to avoid them

Type Cause How to avoid it Never hold your breath while diving with breathing apparatus

Pulmonary barotrauma: "burst lung" Holding the breath while ascending This can cause: Pneumothorax Interstitial emphysema Subcutaneous emphysema Gas embolism Collapsed lung, air loose in the pleural cavity Gas trapped in the chest after burst lung Gas loose under the skin. Air or other gas in the blood stream. Its effects can be very similar to decompression sickness. Blockage of the sinus's duct Blocked Eustachian tube

Pain in a sinus Eardrum bursting outwards

Do not dive with nasal congestion, e.g. the common cold.

Effects of breathing gas at high pressure

Click on the boldface links to find symptoms and more information for each topic.

List of diving hazards and precautions

35

Types of this sort of diving disorder, and how to avoid them

Type Decompression sickness ("the bends") Cause Gas dissolves in tissues under pressure according to Henry's Law over time. After dive, ascending too quickly will cause gas to supersaturate and form bubbles in tissues depending on time and depth of the dive. Many deep dives in succession. See taravana. How to avoid it Plan your dive. Know how long you can stay at the planned depth and still make a normal ascent. If stops are necessary, do not miss or cut short decompression stops. Training in using diving tables and a dive computer. See decompression sickness for a detailed list of the symptoms. Use breathing gas mixtures with reduced inert gas fraction, eg Nitrox. Provide something for the diver to hold onto while ascending and decompressing to maintain accurate depth during stops and correct ascent rate. Avoid dehydration and hypothermia. Maintain cardiovascular fitness. Reduce the number of deep dives, increase surface interval or reduce dive depth. Use an underwater breathing apparatus and ascend at a rate determined by decompression tables or computer. Dont dive deep on air. Limit the depth of the dive to limit the partial pressures of gases with narcotic effects to a level that you can safely manage. With mixed gas diving, use the correct breathing gas mixture to limit the equivalent narcotic depth to an acceptable level for the planned depth. This hazard is well known with closed circuit rebreathers when the control of the mixture fails. This can also happen when diving with open-circuit scuba and semi-closed circuit rebreathers if the maximum operating depth for the breathing gas is exceeded. Use another diving technique, such as an ROV; or add a little nitrogen as described at HPNS.

Bends in snorkellers. Uncommon but known. Nitrogen narcosis

Breathing a high partial pressure of nitrogen (or other gas, to varying degrees)

Oxygen toxicity

Breathing a high partial pressure of oxygen

HPNS: High Pressure Nervous Syndrome or Helium Tremors

Breathing a high partial pressure of helium

The term dysbarism describes Decompression sickness, arterial gas embolism, and barotrauma. Divers face specific physical and health risks when they go underwater (e.g. with scuba) or use high pressure breathing gases. Some of these conditions also affect people who work in raised pressure environments out of water, e.g. in caissons.

Other risks encountered by people in water

Types of this class of diving disorder, and how to avoid them. Click on the boldface links to find symptoms and more information for each topic. Where it says "Avoid diving with bare skin", a boilersuit could be worn in very warm water.
Type Hypothermia Cause Losing body heat to the water. Water carries heat away far better than air. How to avoid it In cool or cold water, wear an adequately warm diving suit for the conditions. Also, much heat can be lost from a head without a hood. Do not get too close to coral. Avoid diving with bare skin.

Cuts, sometimes with Coral coral tissue left in them Cuts Rock, metal, etc.

Avoid diving in bare skin, particularly in caves or shipwrecks. It is yellow. Learn to identify it. Learn about the dangerous species. Avoid diving with bare skin.

Stings Stings, some dangerous

Fire coral Some jellyfish

List of diving hazards and precautions

36
Do not poke about in sand where they live. Care when wading.

A deep cut which leaves poison in the wound Reef rash

sting ray (its self-defence reaction)

A generic catch-all term that refers to the various cuts, scrapes, bruises and skin conditions that result from diving in tropical waters. This includes sunburn, jellyfish stings, sea lice bites, fire coral inflammation and other skin injuries that a diver may gain from using a shorty wetsuit or no diving suit. lionfish, stonefish, crown of thorns starfish, some sea urchins in warm seas Blue ringed octopus, in parts of the Pacific Ocean Sharks, likelihood of risk is location dependent

Wear a full-body exposure suit to prevent direct skin to environment contact.

Poison-injecting spines Poison injection Shark bites

Learn to identify them. Keep away from them. Care when wading.

Consult location-specific information to determine risk; never molest even seemingly-tame sharks underwater. Get proper information on them. Avoid waters known to be inhabited by crocodiles. Keep a lookout for the fish and move away if they act aggressively

Crocodile attack

Crocodiles, in some tropical waters

Attack by Titan Triggerfish Attack by an unusually large grouper.

This tropical Indo-Pacific fish is very territorial during breeding season and will attack and bite divers

Epinephelus lanceolatus can grow very big in tropical waters, Get proper information on them. where protected from attack by sharks. There have been cases [3] [4] [5] of very large groupers trying to swallow humans. [6] [7] Electric eel, in some South American fresh water Electric ray, in some warm seas It is said that some naval anti-frogman defences use electric shock Keep out of armed forces areas Get proper information on them

Electrocution

Powerful ultrasound

It is said that some naval anti-frogman defences use powerful ultrasound. Also used for long-range communication with submarines Weil's disease (in rat's urine) Bilharzia (in some warm fresh water) Various bacteria found in sewage May be found in water polluted by industrial waste outfalls or by natural sources. For example hydrogen sulfide in some lakes and caves can be absorbed through the skin. Colliding with a boat or its propeller. Wave action on the shore.

Keep out of armed forces areas. Avoid large ships' ordinary sonar. See Underwater Port Security System. In affected water, dive in watertight drysuit and full face diving mask

Exposure to disease carried by in-water organisms Exposure to harmful chemicals in the water Broken bones, bleeding wounds and other trauma

Use Surface detection aids or a diving shot to mark surfacing position and aid searchers. Plan a safe exit point and check weather and tidal conditions. Ensure that boat uses a positive check system to identify each diver is on board after a dive. Carry a yellow flag or surface marker buoy to attract attention. Carry a personal submersible EPIRB or submersible vhf radio. Carry a signalling mirror and/or sound signalling device. Local knowledge, good weather forecasts, plan alternative exits

Diver lost at sea after Separated from boat cover due to poor visibility at surface or a boat dive strong underwater currents. Left behind due to inaccurate check by boat crew

Diver lost at sea after Big waves made it unsafe to leave the water; currents moved a shore dive the diver away from a safe exit; surface weather on the shore make the sea too rough to safely exit. Sudden loss of underwater visibility Silt out: stirring up silt or other light loose material

Training in diving in zero visibility. Learn the frog kick.

List of diving hazards and precautions

37
Carry at least one line cutting implement. Dive with a buddy who is capable of helping to free you and will stay close enough to notice, Train in wreck diving and cave diving techniques, Use low snag equipment configurations (avoid dangling gear and snap hooks that can snag on lines)

Entrapment

Snagging on lines, nets, wrecks, debris or caves

Getting lost under an overhead

Losing your way in wrecks and caves where there is no direct Proper training and dive planning, Correct use of reels and route to the surface lines, directional markers. Backup lights.

References
[1] Lansche, James M (1972). "Deaths During Skin and Scuba Diving in California in 1970". California Medicine 116 (6): 1822. PMC1518314. PMID5031739. [2] Ikeda, T; Ashida, H (2000). "Is recreational diving safe?" (http:/ / archive. rubicon-foundation. org/ 6770). Undersea and Hyperbaric Medical Society. . Retrieved 2009-08-08. [3] Alevizon, Bill (July 2000). "A Case for Regulation of the Feeding of Fishes and Other Marine Wildlife by Divers and Snorkelers" (http:/ / www. reefrelief. org/ science_body4. shtml). Reef Relief. . Retrieved 2009-08-08. [4] Allard, Evan T (2002-01-04). "Did fish feeding cause recent shark, grouper attacks?" (http:/ / www. cdnn. info/ eco/ e020104/ e020104. html). Cyber Diver News Network. . Retrieved 2009-08-08. [5] "Goliath grouper attacks" (http:/ / www. jacksonville. com/ tu-online/ stories/ 061905/ spo_19030958. shtml). Jacksonville.com (Florida Times-Union). 2005-06-19. . Retrieved 2009-08-08. [6] Sargent, Bill (2005-06-26). "Big Grouper Grabs Diver On Keys Reef" (http:/ / www. flmnh. ufl. edu/ fish/ InNews/ grouperattack2005. html). FloridaToday.com. Florida Museum of Natural History. . Retrieved 2009-08-08. [7] Arthur C. Clarke, Reefs of Taprobane, ISBN 0-7434-4502-3, page 138: 15 feet long, 4 feet side side to side. in the sunken Admiralty floating dock in Trincomalee, Sri Lanka

External links
Diving Diseases Research Centre (http://www.DDRC.org)

Maximum operating depth

38

Maximum operating depth

In technical diving and nitrox diving, the maximum operating depth (MOD) of a breathing gas is the depth at which the partial pressure of oxygen (ppO2) of the gas mix exceeds a safe limit. This safe limit varies depending on the diver training agency, the level of underwater exertion planned and the planned duration of the dive, but is normally in the range of 1.2 to 1.6 bar.[1] The MOD is significant when planning dives using gases such as nitrox and trimix because the proportion of oxygen in the mix determines the maximum safe depth for breathing that gas. There is a risk of oxygen toxicity if the MOD is exceeded.[1] The tables below show MODs for a selection of oxygen mixes. Note that 21% is the concentration of oxygen in normal air.

Safe limit of partial pressure of oxygen

The maximum single exposure limits recommended in the NOAA Diving Manual are 45 minutes at 1.6 bar, 120 minutes at 1.5 bar, 150 minutes at 1.4 bar, 180 minutes at 1.3 bar and 210 minutes at 1.2 bar.[1]

Formulas
To calculate the MOD for a specific ppO2 and percentage of oxygen, the following formulas are used:

In feet

In which ppO2 is the desired partial pressure in oxygen and the FO2 is the decimal value of the fraction of oxygen in the mixture. For example, if a gas contains 36% oxygen and the maximum ppO2 is 1.4 bar, the MOD (fsw) is 33 feet (10m) x [(1.4 / 0.36) - 1] = 95.3 feet (29.0m). Note that the formula simply divides the total partial pressure of PURE oxygen which can be tolerated (expressed in bar or atmospheres) by the fraction of oxygen in the nitrox, to calculate to total atmospheres pressure this mix can be breathed at (obviously 50% nitrox can be breathed at twice the pressure of 100% oxygen, so divide by 0.5, etc.). Of this total pressure which can be tolerated by the diver, 1 atmosphere is due to the Earth's air, and the rest is due to depth in water. So the 1 atm for the air is subtracted out, to give the rest of the pressure added by water (in atmospheres). The remaining part in each formula merely converts pressure in atm produced by depth in water, to the depth. It does this by multiplying by the appropriate amount of depth to produce an atmosphere of pressure: 33 feet (10m) of salt water (fsw) or 10 meters of salt water.

In metres

In which ppO2 is the desired partial pressure in oxygen and the FO2 is the decimal value of the fraction of oxygen in the mixture. For example, if a gas contains 36% oxygen and the maximum ppO2 is 1.4 bar, the MOD (m) is 10 metres x [(1.4 / 0.36) - 1] = 28.9 metres.

Maximum operating depth

39

MOD table in feet

Maximum Operating Depth (MOD) in feet of sea water for ppO2 1.2 to 1.6
MOD (fsw) 3 6 9 12 15 18 21 24 27 30 % oxygen 33 36 39 42 45 50 55 60 65 70 75 80 85 90 100

Maximum ppO2 (bar) 1.6 1727 847 553 407 319 260 218 187 162 143 127 113 102 92 84 72 63 54 48 42 37 33 29 25 93 1.5 1617 792 517 379 297 242 202 173 150 132 117 104 95 1.4 1507 737 480 352 275 223 187 159 138 121 107 97 1.3 1397 682 443 324 253 205 171 145 125 110 99 1.2 1287 627 407 297 231 187 155 132 113 87 77 68 61 55 46 39 33 27 23 19 16 13 11 86 77 69 62 52 45 38 33 28 24 20 17 14 85 77 69 59 51 44 38 33 28 24 21 18 84 77 66 57 49 43 37 33 28 25 22

19

16

13

These depths are rounded down to the nearest foot.

MOD table in metres

Maximum Operating Depth (MOD) in metres of sea water for ppO2 1.2 to 1.6
MOD (msw) 3 6 9 12 15 18 21 24 27 30 33 % oxygen 36 39 42 45 50 55 60 65 70 75 80 85 90 100

Maximum ppO2 1.6 523.3 256.7 167.8 123.3 96.7 78.9 66.2 56.7 49.3 43.3 38.5 34.4 31.0 28.1 25.6 22.0 19.1 16.7 14.6 12.9 11.3 10.0 8.8 7.8 6.0 (bar) 8.8 1.5 490.0 240.0 156.7 115.0 90.0 73.3 61.4 52.5 45.6 40.0 35.5 31.7 28.5 25.7 23.3 20.0 17.3 15.0 13.1 11.4 10.0 7.6 6.7 5.0

8.7 1.4 456.7 223.3 145.6 106.7 83.3 67.8 56.7 48.3 41.9 36.7 32.4 28.9 25.9 23.3 21.1 18.0 15.5 13.3 11.5 10.0

7.5 6.5 5.6 4.0

98.3 1.3 423.3 206.7 134.4 76.7 62.2 51.9 44.2 38.1 33.3 29.4 26.1 23.3 21.0 18.9 16.0 13.6 11.7 10.0

8.6

7.3

6.3 5.3 4.4 3.0

90.0 1.2 390.0 190.0 123.3 70.0 56.7 47.1 40.0 34.4 30.0 26.4 23.3 20.8 18.6 16.7 14.0 11.8 10.0

8.5

7.1

6.0

5.0 4.1 3.3 2.0

Maximum operating depth

40

References
[1] Lang, M.A. (2001). DAN Nitrox Workshop Proceedings (http:/ / archive. rubicon-foundation. org/ 4855). Durham, NC: Divers Alert Network. p.197. . Retrieved 2008-06-24.

Nitrogen narcosis
Inert gas narcosis [Nitrogen narcosis]
Classification and external resources

Divers breathe a mixture of oxygen, helium and nitrogen for deep dives to avoid the effects of narcosis. A cylinder label shows the maximum operating depth and mixture (oxygen/helium). DiseasesDB MeSH 30088 [1] [2]

C21.613.455.571

Some components of breathing gases, and their relative narcotic potentcies

[3]

Gas Ne H2 N2 O2 Ar Kr CO2 Xe

Relative narcotic potency 0.3 0.6 1.0 1.7 2.3 7.1 20.0 25.6

Narcosis while diving (also known as nitrogen narcosis, inert gas narcosis, raptures of the deep, Martini effect), is a reversible alteration in consciousness that occurs while scuba diving at depth. The Greek word (narcosis) is derived from narke, "temporary decline or loss of senses and movement, numbness", a term used by Homer and Hippocrates.[4] Narcosis produces a state similar to alcohol intoxication or nitrous oxide inhalation, and can occur during shallow dives, but usually does not become noticeable until greater depths, beyond 30 meters (100ft). Apart from helium, and probably neon, all gases that can be breathed have a narcotic effect, which is greater as the lipid solubility of the gas increases.[5] As depth increases, the effects may become hazardous as the diver is increasingly impaired. Although divers can learn to cope with the effects, it is not possible to develop a tolerance. While narcosis affects all divers, predicting the depth at which narcosis will affect a diver is difficult, as susceptibility varies widely from dive to dive and amongst individuals.

Nitrogen narcosis The condition is completely reversed by ascending to a shallower depth with no long-term effects. For this reason, narcosis while diving in open water rarely develops into a serious problem as long as the divers are aware of its symptoms and ascend to manage it. Diving beyond 40m (130ft) is considered outside the scope of recreational diving: as narcosis and oxygen toxicity become critical factors, specialist training is required in the use of various gas mixtures such as trimix or heliox.

41

Classification
Narcosis results from breathing gases under elevated pressure and may be classified by the principal gas involved. The noble gases, except helium and probably neon,[5] as well as nitrogen, oxygen and hydrogen cause a decrement in mental function, but their effect on psychomotor function (processes affecting the coordination of sensory or cognitive processes and motor activity) varies widely. The effects of carbon dioxide consistently result in a decrease of both mental and psychomotor function.[6] The noble gases argon, krypton, and xenon are more narcotic than nitrogen at a given pressure, and xenon has so much anesthetic activity that it is actually a usable anesthetic at 80% concentration and normal atmospheric pressure. Xenon has historically been too expensive to be used very much in practice, but it has been successfully used for surgical operations, and xenon anesthesia systems are still being proposed and designed.[7]

Signs and symptoms

Due to its perception-altering effects, the onset of narcosis may be hard to recognize.[8] [9] At its most benign, narcosis results in relief of anxiety - a feeling of tranquility and mastery of the environment. These effects are essentially identical to various concentrations of nitrous oxide. They also resemble (though not as closely) the effects of alcohol and the familiar benzodiazepine drugs such as diazepam and alprazolam.[10] Such effects are not harmful unless they cause some immediate danger not to be recognized and addressed. Once stabilized, the effects generally remain the same at a given depth, only worsening if the diver ventures deeper.[11]

Narcosis can produce tunnel vision, making it difficult to read multiple gauges

The most dangerous aspects of narcosis are the loss of decision-making ability and focus, and impaired judgement, multi-tasking and coordination. Other effects include vertigo, and visual or auditory disturbances. The syndrome may cause exhilaration, giddiness, extreme anxiety, depression, or paranoia, depending on the individual diver and the diver's medical or personal history. When more serious, the diver may feel overconfident, disregarding normal safe diving practices.[12] The relation of depth to narcosis is sometimes informally known as "Martini's law". This is the idea that narcosis results in the feeling of one martini for every 10m (33ft) below 20m (66ft) depth. This is a very rough guide, and not a substitute for an individual diver's known susceptibility, or for standard diving safety guides. Professional divers use such a calculation only as a rough guide to give new divers a metaphor, comparing a situation they may be more familiar with.[13] Reported signs and symptoms are summarized against typical depths in meters and feet of sea water in the following table:[12]

Nitrogen narcosis

42

Signs and symptoms of narcosis (breathing air)

Pressure (bar) 12 24 Depth (m) 010 1030 Depth (ft) 0-33 33100 Comments

Unnoticeable small symptoms, or no symptoms at all. Mild impairment of performance of unpracticed tasks. Mildly impaired reasoning. Mild euphoria possible. Delayed response to visual and auditory stimuli. Reasoning and immediate memory affected more than motor coordination. Calculation errors and wrong choices. Idea fixation. Over-confidence and sense of well-being. Laughter and loquacity (in chambers) which may be overcome by self control. Anxiety (common in cold murky water). Sleepiness, impaired judgment, confusion. Hallucinations. Severe delay in response to signals, instructions and other stimuli. Occasional dizziness. Uncontrolled laughter, hysteria (in chamber). Terror in some. Poor concentration and mental confusion. Stupefaction with some decrease in dexterity and judgment. Loss of memory, increased excitability. Hallucinations. Increased intensity of vision and hearing. Sense of impending blackout, euphoria, dizziness, manic or depressive states, a sense of levitation, disorganization of the sense of time, changes in facial appearance. Unconsciousness. Death.

46

3050

100165

68

5070

165230

810

7090

230300

10+

90+

300+

Causes
The cause of narcosis is related to the increased solubility of gases in body tissues, as a result of the elevated pressures at depth (Henry's law).[14] Modern theories have suggested that inert gases dissolving in the lipid bilayer of cell membranes cause narcosis.[15] More recently, researchers have been looking at neurotransmitter receptor protein mechanisms as a possible cause of the narcosis.[16] The breathing gas mix entering the diver's lungs will have the same pressure as the surrounding water, known as the ambient pressure. For any given depth, the pressure of gases in the blood passing through the brain catches up with ambient pressure within a minute or two and this produces a delay in narcotic effect after coming to a new depth.[14] [17] Rapid compression potentiates narcosis, owing to carbon dioxide retention.[18] [19] A divers' cognition may be affected on dives as shallow as 10m (33ft), but the changes are not usually noticeable.[20] However there is no reliable method to predict the depth at which narcosis becomes noticeable, or the severity of the effect on an individual diver, as the effect may vary from dive to dive (even on the same day).[14] [19] Significant impairment due to narcosis is an increasing risk below depths of about 30m (100ft), corresponding to an ambient pressure of about 4bar (400kPa).[14] Most sport scuba training organizations recommend depths of no more than 40m (130ft) because of risk of narcosis.[13] When breathing air at depths of 90m (300ft)an ambient pressure of about 10bar (1000kPa)narcosis in most divers leads to hallucinations, loss of memory, and unconsciousness.[14] [21] A number of divers have died in attempts to set air depth records below 120m (400ft). Because of these incidents, the Guinness Book of World Records no longer reports on this figure.[22]

Nitrogen narcosis Narcosis has been compared with altitude sickness insofar as its variability (though not its symptoms); its effects depend on many factors, with variations between individuals. Thermal cold, stress, heavy work, fatigue, and carbon dioxide retention all increase the risk and severity of narcosis.[6] [14] Carbon dioxide has a high narcotic potential and also causes increased blood flood to the brain, increasing the effects of other gases.[23] Increased risk of narcosis results from increasing the amount of carbon dioxide retained through heavy exercise, shallow or skip breathing, or because of poor gas exchange in the lungs.[24] Narcosis is known to be additive to even minimal alcohol intoxication,[25] [26] and also to the effects of other drugs such as marijuana (which is more likely than alcohol to have effects which last into a day of abstinence from use).[27] Other sedative and analgesic drugs, such as opiate narcotics and benzodiazepines, add to narcosis.[25]

43

Mechanism
The precise mechanism is not well understood, but it appears to be the direct effect of gas dissolving into nerve membranes and causing temporary disruption in nerve transmissions. While the effect was first observed with air, other gases including argon, krypton and hydrogen cause very similar effects at higher than atmospheric pressure.[28] Some of these effects may be due to antagonism at NMDA receptors and potentiation of GABAA receptors,[29] similar to the mechanism of nonpolar anesthetics such diethyl ether or ethylene.[30] However, their Illustration of a lipid bilayer, typical of a cell reproduction by the very chemically inactive gas argon makes them membrane, showing the hydrophilic heads on the unlikely to be a strictly chemical bonding to receptors in the usual outside and hydrophobic tails inside sense of a chemical bond. An indirect physical effectsuch as a change in membrane volumewould therefore be needed to affect the ligand-gated ion channels of nerve cells.[31] Trudell et al. have suggested non-chemical binding due to the attractive van der Waals force between proteins and inert gases.[32] Similar to the mechanism of ethanol's effect, the increase of gas dissolved in nerve cell membranes may cause altered ion permeability properties of the neural cells' lipid bilayers. The partial pressure of a gas required to cause a measured degree of impairment correlates well with the lipid solubility of the gas: the greater the solubility, the less partial pressure is needed.[31] An early theory, the Meyer-Overton hypothesis suggested that narcosis happens when the gas penetrates the lipids of the brain's nerve cells, causing direct mechanical interference with the transmission of signals from one nerve cell to another.[14] [15] [19] More recently, specific types of chemically-gated receptors in nerve cells have been identified as being involved with anesthesia and narcosis. However, the basic and most general underlying idea, that nerve transmission is altered in many diffuse areas of the brain as a result of gas molecules dissolved in the nerve cells' fatty membranes, remains largely unchallenged.[16] [33]

Diagnosis and management

The symptoms described may be caused by other factors during a dive: ear problems causing disorientation or nausea;[34] early signs of oxygen toxicity causing visual disturbances;[35] or hypothermia causing rapid breathing and shivering.[36] Nevertheless the presence of any of these symptoms should imply narcosis. Alleviation of the effects upon ascending to a shallower depth will confirm the diagnosis. Given the setting, other likely conditions do not produce reversible effects. In the rare event of misdiagnosis when another condition is causing the symptoms, the initial managementascending closer to the surfaceis still essential.[9] The management of narcosis is simply to ascend to shallower depths; the effects then disappear within minutes.[37] In the event of complications or other conditions being present, ascending is always the correct initial response.

Nitrogen narcosis Should problems remain, then it is necessary to abort the dive. The decompression schedule can still be followed unless other conditions require emergency assistance.[38]

44

Prevention
The most straightforward way to avoid nitrogen narcosis is for a diver to limit the depth of dives. If narcosis does occur, the effects disappear almost immediately upon ascending to a shallower depth. Since narcosis becomes more severe as depth increases, a diver keeping to shallower depths can avoid serious narcosis. Most recreational dive schools will only certify basic divers to depths of 18m (60ft), and at these depths narcosis does not present a large risk. Further training is normally required for certification up to 30m (100ft) on air, and this training should include a discussion of narcosis, its effects, and cure. Some diver training agencies offer specialty training to prepare recreational divers to go to depths of 40m (130ft), often consisting of further theory and some practice in deep dives with close supervision.[39] [40] Scuba organizations which train for diving beyond Narcosis while deep diving is prevented by filling recreational depths,[41] may forbid diving with gases that cause too dive cylinders with a gas mixture containing much narcosis at depth in the average diver, and strongly encourage helium. Helium is stored in brown cylinders. the use of other breathing gas mixes containing helium in place of some or all of the nitrogen in airsuch as trimix and helioxbecause helium has no narcotic potential.[5] [42] The use of these gases forms part of technical diving and requires further training and certification.[13] While the individual diver cannot predict exactly at what depth the onset of narcosis will occur on a given day, the first symptoms of narcosis for any given diver are often more predictable and personal. For example, one diver may have trouble with eye focus (close accommodation for middle-aged divers), another may experience feelings of euphoria, and another feelings of claustrophobia. Some divers report that they have hearing changes, and that the sound which their exhaled bubbles make becomes different. Specialist training may help divers in identifying these personal onset signs, and these may then be used as a signal to ascend to shallower depths. Although severe narcosis may interfere with the judgment necessary to take preventive action, a diver who remains calm and is alert to the danger will be capable of resolving these problems at an earlier stage.[37] Deep dives should be made only after a gradual training to gradually test the individual diver's sensitivity to increasing depths, with careful supervision and logging of reactions. Diving organizations such as Global Underwater Explorers (GUE) emphasize that such sessions are for the purpose of gaining experience in recognizing the onset symptoms of narcosis for an individual, which are somewhat more repeatable than for the average group of divers. Scientific evidence does not show that a diver can train to overcome any measure of narcosis at a given depth or become tolerant of it.[43] Equivalent narcotic depth (END) is a commonly used way of expressing the narcotic effect of different breathing gases.[44] The National Oceanic and Atmospheric Administration (NOAA) Diving Manual now states that both oxygen and nitrogen should be considered equally narcotic.[45] Standard tables, based on relative lipid solubilities, list conversion factors for narcotic effect of other gases.[46] For example, neon at a given pressure has a narcotic effect equivalent to nitrogen at 0.28 times that pressure, so in principle it should be usable at nearly four times the depth. Argon, however, has 2.33 times the narcotic effect of nitrogen, and is not suitable as a breathing gas for diving (it is used as a drysuit inflation gas, owing to its low thermal conductivity). Some gases have other dangerous effects when breathed at pressure; for example, high-pressure oxygen can lead to oxygen toxicity. Although helium is the

Nitrogen narcosis least intoxicating of the breathing gases, at greater depths it can cause high pressure nervous syndrome, a still-mysterious but apparently unrelated phenomenon.[47] Inert gas narcosis is only one factor which influences the choice of gas mixture; the risks of decompression sickness and oxygen toxicity, cost, and other factors are also important.[48] Because of similar and additive effects, divers should avoid sedating medications and drugs, such as marijuana and alcohol before any dive. A hangover, combined with the reduced physical capacity that goes with it, makes nitrogen narcosis more likely.[25] Experts recommend total abstinence from alcohol at least 12hours before diving, and longer for other drugs.[49] Abstinence time needed for marijuana is unknown, but due to the much longer half-life of the active agent of this drug in the body, it is likely to be longer than for alcohol.[27]

45

Prognosis and epidemiology

Narcosis is potentially one of the most dangerous conditions to affect the scuba diver below about 30m (100ft). Except for occasional amnesia of events at depth, the effects of narcosis are entirely reversible by ascending and therefore pose no problem in themselves, even for repeated, chronic or acute exposure.[14] [19] Nevertheless, the severity of narcosis is unpredictable and it can be fatal while diving, as the result of illogical behavior in a dangerous environment.[19] Tests have shown that all divers are affected by nitrogen narcosis, though some are less affected than others. Even though it is possible that some divers can manage better than others because of learning to cope with the subjective impairment, the underlying behavioral effects remain.[30] [50] [51] These effects are particularly dangerous because a diver may feel they are not experiencing narcosis, yet still be affected by it.[14]

History
French researcher Victor T. Junod was the first to describe symptoms of narcosis in 1834, noting "the functions of the brain are activated, imagination is lively, thoughts have a peculiar charm and, in some persons, symptoms of intoxication are present."[52] [53] Junod suggested that narcosis resulted from pressure causing increased blood flow and hence stimulating nerve centers.[54] Walter Moxon (18361886), a prominent Victorian physician, hypothesized in 1881 that pressure forced blood to inaccessible parts of the body and the stagnant blood then resulted in emotional changes.[55] The first report of anesthetic potency being related to Both Meyer and Overton discovered that the narcotic potency of an anesthetic can lipid solubility was published by Hans generally be predicted from its solubility in oil H. Meyer in 1899, entitled Zur Theorie der Alkoholnarkose. Two years later a similar theory was published independently by Charles Ernest Overton.[56] What became known as the Meyer-Overton Hypothesis is illustrated in the diagram to the right.

Nitrogen narcosis In 1939, Albert R. Behnke and O. D. Yarborough demonstrated that gases other than nitrogen also could cause narcosis.[57] For an inert gas the narcotic potency was found to be proportional to its lipid solubility. As hydrogen has only 0.55 the solubility of nitrogen, deep diving experiments using hydrox were conducted by Arne Zetterstrm between 1943 and 1945.[58] Jacques-Yves Cousteau in 1953 famously described it as "livresse des grandes profondeurs" or the "rapture of the deep".[59] Further research into the possible mechanisms of narcosis by anesthetic action led to the "minimum alveolar concentration" concept in 1965. This measures the relative concentration of different gases required to prevent motor response in 50% of subjects in response to stimulus, and shows similar results for anesthetic potency as the measurements of lipid solubility.[60] The (NOAA) Diving Manual was revised to recommend treating oxygen as if it were as narcotic as nitrogen, following research by Christian J. Lambertsen et al. in 1977 and 1978.[61]

46

Footnotes
[1] http:/ / www. diseasesdatabase. com/ ddb30088. htm [2] http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2011/ MB_cgi?mode=& term=Nitrogen+ Narcosis& field=entry#TreeC21. 613. 455. 571 [3] Bennett, Peter; Rostain, Jean Claude (2003). "Inert Gas Narcosis". In Brubakk, Alf O; Neuman, Tom S. Bennett and Elliott's physiology and medicine of diving (5th ed.). United States: Saunders Ltd. p.304. ISBN0702025712. OCLC51607923. (Value for Krypton from 4th Edition, p.176). [4] Askitopoulou, Helen; Ramoutsaki, Ioanna A; Konsolaki, Eleni (April 12, 2000). "Etymology and Literary History of Related Greek Words" (http:/ / www. anesthesiaanalgesia. org/ content/ 91/ 2/ 486. full). Analgesia and Anesthesia. International Anesthesia Research Society. . Retrieved June 9, 2010. [5] Brubakk & Neuman 2003, p.305 [6] Hesser, CM; Fagraeus, L; Adolfson, J (1978). "Roles of nitrogen, oxygen, and carbon dioxide in compressed-air narcosis" (http:/ / archive. rubicon-foundation. org/ 2810). Undersea and Hyperbaric Medicine (Undersea and Hyperbaric Medical Society, Inc) 5 (4): 391400. ISSN0093-5387. OCLC2068005. PMID734806. . Retrieved 2009-07-29. [7] Burov, NE; Kornienko, Liu; Makeev, GN; Potapov, VN (NovemberDecember 1999). "Clinical and experimental study of xenon anesthesia" (http:/ / www. general-anaesthesia. com/ xenon-anaesthesia. html). Anesteziol Reanimatol (6): 5660. . Retrieved 2008-11-03. [8] Brubakk & Neuman 2003, p.301 [9] U.S. Navy Supervisor of Diving (2008) (PDF). U.S. Navy Diving Manual (http:/ / supsalv. org/ pdf/ DiveMan_rev6. pdf). SS521-AG-PRO-010, revision 6. U.S. Naval Sea Systems Command. . Retrieved 2009-06-29. [10] Hobbs M (2008). "Subjective and behavioural responses to nitrogen narcosis and alcohol" (http:/ / archive. rubicon-foundation. org/ 8101). Undersea & Hyperbaric Medicine : Journal of the Undersea and Hyperbaric Medical Society, Inc 35 (3): 17584. PMID18619113. . Retrieved 2009-08-07. [11] Lippmann, John; Mitchell, Simon J (2005). "Nitrogen narcosis". Deeper into Diving (2nd ed.). Victoria, Australia: J.L. Publications. p.103. ISBN097522901X. OCLC66524750. [12] Lippmann & Mitchell 2005, p.105 [13] Brylske, A (2006). Encyclopedia of Recreational Diving (3rd ed.). United States: Professional Association of Diving Instructors. ISBN1878663011. [14] Brubakk & Neuman 2003, p.308 [15] Paton, William (1975). "Diver narcosis, from man to cell membrane" (http:/ / archive. rubicon-foundation. org/ 5897). Journal of the South Pacific Underwater Medicine Society (first published at Oceans 2000 Conference) 5 (2). . Retrieved 2008-12-23. [16] Rostain, Jean C; Balon N (2006). "Recent neurochemical basis of inert gas narcosis and pressure effects" (http:/ / archive. rubicon-foundation. org/ 5060). Undersea and Hyperbaric Medicine 33 (3): 197204. PMID16869533. . Retrieved 2008-12-23. [17] Case, EM; Haldane, John Burdon Sanderson (1941). "Human physiology under high pressure". Journal of Hygiene 41 (3): 22549. doi:10.1017/S0022172400012432. PMC2199778. PMID20475589. [18] Brubakk & Neuman 2003, p.303 [19] Hamilton, RW; Kizer, KW (eds) (1985). "Nitrogen Narcosis" (http:/ / archive. rubicon-foundation. org/ 4496). 29th Undersea and Hyperbaric Medical Society Workshop (Bethesda, MD: Undersea and Hyperbaric Medical Society) (UHMS Publication Number 64WS(NN)4-26-85). . Retrieved 2008-12-23. [20] Petri, NM (2003). "Change in strategy of solving psychological tests: evidence of nitrogen narcosis in shallow air-diving" (http:/ / archive. rubicon-foundation. org/ 3976). Undersea and Hyperbaric Medicine (Undersea and Hyperbaric Medical Society, Inc) 30 (4): 293303. PMID14756232. . Retrieved 2008-12-23. [21] Hill, Leonard; David, RH; Selby, RP; et al. (1933). "Deep diving and ordinary diving". Report of a Committee Appointed by the British Admiralty. [22] PSAI Philippines. "Professional Scuba Association International History" (http:/ / www. psai-philippines. com/ history. html). Professional Scuba Association International - Philippines. . Retrieved 2008-10-31.

Nitrogen narcosis
[23] Kety, Seymour S; Schmidt, Carl F (1948). "The effects of altered arterial tensions of carbon dioxide and oxygen on cerebral blood flow ans cerebral oxygen consumption of normal young men". Journal of Clinical Investigation 27 (4): 484492. doi:10.1172/JCI101995. ISSN0021-9738. PMC439519. PMID16695569. [24] Lippmann & Mitchell 2005, pp.1103 [25] Fowler, B; Hamilton, K; Porlier, G (1986). "Effects of ethanol and amphetamine on inert gas narcosis in humans" (http:/ / archive. rubicon-foundation. org/ 3050). Undersea Biomedical Research 13 (3): 34554. PMID3775969. . Retrieved 2008-12-23. [26] Michalodimitrakis, E; Patsalis, A (1987). "Nitrogen narcosis and alcohol consumption--a scuba diving fatality". Journal of Forensic Sciences 32 (4): 10957. PMID3612064. [27] Pope, Harrison G; Gruber, Amanda J; Hudson, James I; Huestis, Marilyn A; Yurgelun-Todd, Deborah (2001). "Neuropsychological performance in long-term cannabis users" (http:/ / archpsyc. ama-assn. org/ cgi/ content/ full/ 58/ 10/ 909). Archives of General Psychiatry (American Medical Association) 58 (10): 90915. doi:10.1001/archpsyc.58.10.909. PMID11576028. . Retrieved 2008-10-31. [28] Brubakk & Neuman 2003, p.304 [29] Hapfelmeier, Gerhard; Zieglgnsberger, Walter; Haseneder, Rainer; Schneck, Hajo; Kochs, Eberhard (December 2000). "Nitrous oxide and xenon increase the efficacy of GABA at recombinant mammalian GABA(A) receptors" (http:/ / www. anesthesia-analgesia. org/ cgi/ content/ full/ 91/ 6/ 1542). Anesthesia and Analgesia 91 (6): 15429. doi:10.1097/00000539-200012000-00045. PMID11094015. . Retrieved 2009-07-29. [30] Hamilton, K; Lalibert, MF; Fowler, B (1995). "Dissociation of the behavioral and subjective components of nitrogen narcosis and diver adaptation" (http:/ / archive. rubicon-foundation. org/ 2199). Undersea and Hyperbaric Medicine : Journal of the Undersea and Hyperbaric Medical Society 22 (1): 419. ISSN1066-2936. OCLC26915585. PMID7742709. . Retrieved 2009-07-29. [31] Franks, NP; Lieb, WR (1994). "Molecular and cellular mechanisms of general anaesthesia". Nature 367 (6464): 60714. doi:10.1038/367607a0. PMID7509043. [32] Trudell, JR; Koblin, DD; Eger, EI (1998). "A molecular description of how noble gases and nitrogen bind to a model site of anesthetic action" (http:/ / www. anesthesia-analgesia. org/ cgi/ content/ abstract/ 87/ 2/ 411). Anesthesia and Analgesia 87 (2): 4118. doi:10.1097/00000539-199808000-00034. PMID9706942. . Retrieved 2008-12-01. [33] Smith, EB (July 1987). "Priestley lecture 1986. On the science of deep-sea diving--observations on the respiration of different kinds of air" (http:/ / archive. rubicon-foundation. org/ 2720). Undersea & hyperbaric medicine : journal of the Undersea and Hyperbaric Medical Society, Inc 14 (4): 34769. PMID3307084. . Retrieved 2009-07-29. [34] Molvaer, Otto I (2003). "Otorhinolaryngological aspects of diving". In Brubakk, Alf O; Neuman, Tom S. Bennett and Elliott's physiology and medicine of diving (5th ed.). United States: Saunders Ltd. p.234. ISBN0702025712. OCLC51607923. [35] Clark, James M; Thom, Stephen R (2003). "Oxygen under pressure". In Brubakk, Alf O; Neuman, Tom S. Bennett and Elliott's physiology and medicine of diving (5th ed.). United States: Saunders Ltd. p.374. ISBN0702025712. OCLC51607923. [36] Mekjavic, Igor B; Tipton, Michael J; Eiken, Ola (2003). "Thermal considerations in diving". In Brubakk, Alf O; Neuman, Tom S. Bennett and Elliott's physiology and medicine of diving (5th ed.). United States: Saunders Ltd. p.129. ISBN0702025712. OCLC51607923. [37] Lippmann & Mitchell 2005, p.106 [38] U.S. Navy Diving Manual 2008, vol.2, ch.9, p.3546 [39] "Extended Range Diver" (http:/ / www. tdisdi. com/ index. php?did=80& site=2). International Training. 2009. . Retrieved 2009-07-02. [40] A number of technical diving agencies, such as TDI and IANTD teach "extended range" or "deep air" courses which teach diving to depths of up to 55m (180ft) without helium. [41] BSAC, SAA and other European training agencies teach recreational diving to a depth limit of 50m (160ft). [42] Hamilton Jr, RW; Schreiner, HR (eds) (1975). "Development of Decompression Procedures for Depths in Excess of 400feet" (http:/ / archive. rubicon-foundation. org/ 4498). 9th Undersea and Hyperbaric Medical Society Workshop (Bethesda, MD: Undersea and Hyperbaric Medical Society) (UHMS Publication Number WS2-28-76): 272. . Retrieved 2008-12-23. [43] Hamilton, K; Lalibert, MF; Heslegrave, R (1992). "Subjective and behavioral effects associated with repeated exposure to narcosis". Aviation, space, and environmental medicine 63 (10): 8659. PMID1417647. [44] IANTD (1 January 2009). "IANTD Scuba & CCR, PSCR & SCR Rebreather Diver Programs (Recreational Trimix Diver)" (http:/ / www. iantd. com/ iantd3. html). IANTD/IAND, Inc. . Retrieved 2009-03-22. [45] "Mixed-Gas & Oxygen". NOAA Diving Manual, Diving for Science and Technology. 4th. National Oceanic and Atmospheric Administration. 2002. "[16.3.1.2.4] ... since oxygen has some narcotic properties, it is appropriate to include the oxygen in the END calculation when using trimixes (Lambersten et al. 1977,1978). The non-helium portion (i.e., the sum of the oxygen and the nitrogen) is to be regarded as having the same narcotic potency as an equivalent partial pressure of nitrogen in air, regardless of the proportions of oxygen and nitrogen." [46] Anttila, Matti. "Narcotic factors of gases" (http:/ / www. techdiver. ws/ exotic_gases. shtml#6). . Retrieved 2008-06-10. [47] Bennett, Peter; Rostain, Jean Claude (2003). "The High Pressure Nervous Syndrome". In Brubakk, Alf O; Neuman, Tom S. Bennett and Elliott's physiology and medicine of diving (5th ed.). United States: Saunders Ltd.. pp.32357. ISBN0702025712. OCLC51607923. [48] Lippmann & Mitchell 2005, pp.4301 [49] St Leger Dowse, Marguerite (2008). "Diving Officer's Conference presentations" (http:/ / www. bsac. com/ page. asp?section=2595& sectionTitle=DOC+ presentation+ summaries& preview=1). British Sub-Aqua Club. . Retrieved 2009-08-16. [50] Fowler, B; Ackles, KN; Porlier, G (1985). "Effects of inert gas narcosis on behavior--a critical review." (http:/ / archive. rubicon-foundation. org/ 3019). Undersea and Hyperbaric Medicine : Journal of the Undersea and Hyperbaric Medical Society 12 (4): 369402.

47

Nitrogen narcosis
ISSN0093-5387. OCLC2068005. PMID4082343. . Retrieved 2009-07-29. [51] Rogers, WH; Moeller, G (1989). "Effect of brief, repeated hyperbaric exposures on susceptibility to nitrogen narcosis" (http:/ / archive. rubicon-foundation. org/ 2522). Undersea and Hyperbaric Medicine : Journal of the Undersea and Hyperbaric Medical Society 16 (3): 22732. ISSN0093-5387. OCLC2068005. PMID2741255. . Retrieved 2009-07-29. [52] Brubakk & Neuman 2003, p.300 [53] Junod, Victor T (1834). "Recherches physiologiques et thrapeutiques sur les effets de la compression et de la rarfaction de l'air" (http:/ / books. google. com/ ?id=K5XREXyDSQoC). Revue mdicale franaise et trangre: journal des progrs de la mdecine hippocratique (Chez Gabon et compagnie): 350368. . Retrieved 2009-06-04. [54] Brubakk & Neuman 2003, p.306 [55] Moxon, Walter (1881). "Croonian lectures on the influence of the circulation on the nervous system" (http:/ / www. informaworld. com/ smpp/ content~content=a789031692~db=all). British Medical Journal 1: 4917, 5835. doi:10.1136/bmj.1.1057.491. PMID20749857. . Retrieved 2009-03-22. [56] Overton, Charles Ernest (1901). "Studien ber Die Narkose" (in German). Allgemeiner Pharmakologie (Institut fr Pharmakologie). [57] Behnke, AR; Yarborough, OD (1939). "Respiratory resistance, oil-water solubility and mental effects of argon compared with helium and nitrogen". American Journal of Physiology (126): 40915. [58] Ornhagen, H (1984). "Hydrogen-Oxygen (Hydrox) breathing at 1.3 MPa". FOA Rapport C58015-H1 (Stockholm: National Defence Research Institute). ISSN0347-7665. [59] Cousteau, Jacques-Yves; Dumas, Frdric (1953). The Silent World: A Story of Undersea Discovery and Adventure. Harper & Brothers Publishers. pp.266. ISBN0792267966. [60] Eger, EI; Saidman, LJ; Brandstater, B (1965). "Minimum alveolar anesthetic concentration: a standard of anesthetic potency". Anesthesiology 26 (6): 75663. doi:10.1097/00000542-196511000-00010. PMID5844267. [61] Lambertsen, Christian J; Gelfand, R; Clark, JM (1978). "University of Pennsylvania Institute for Environmental Medicine report, 1978" (http:/ / archives. mc. duke. edu/ uhmsupiemr. html). University of Pennsylvania. Institute for Environmental Medicine. . Retrieved 2009-03-22.

48

References External links

Undersea and Hyperbaric Medical Society (http://www.uhms.org) Scientific body, publications about nitrogen narcosis. Rubicon Research Repository (http://archive.rubicon-foundation.org/) Searchable repository of Diving and Environmental Physiology Research. Diving Diseases Research Centre (DDRC) (http://www.ddrc.org/) UK charity dedicated to treatment of diving diseases. Campbell, Ernest S. (2009-06-25). "Diving While Using Marijuana" (http://scuba-doc.com/marij.html). Retrieved 2009-08-25. ScubaDoc's overview of marijuana and diving. Campbell, Ernest S. (2009-05-03). "Alcohol and Diving" (http://scuba-doc.com/alch.htm). Retrieved 2009-08-25. ScubaDoc's overview of alcohol and diving. Campbell, George D. (2009-02-01). "Nitrogen Narcosis" (http://www.deep-six.com/page74.htm). Diving with Deep-Six. Retrieved 2009-08-25.

Nitrox

49

Nitrox
Nitrox refers to any gas mixture composed (excluding trace gases) of nitrogen and oxygen; this includes normal air which is approximately 78% nitrogen, 21% oxygen, and 1% other gases, primarily argon.[1] [2] [3] However, in scuba diving, nitrox is normally Typical Nitrox cylinder marking differentiated and handled differently from air.[3] The most common use of nitrox mixtures containing higher than normal levels of oxygen is in scuba, where the reduced percentage of nitrogen is advantageous in reducing nitrogen uptake in the body's tissues and so extending the possible dive time, and/or reducing the risk of decompression sickness (also known as the bends).

Purpose
Enriched Air Nitrox, nitrox with an oxygen content above 21%, is mainly used in scuba diving to reduce the proportion of nitrogen in the breathing gas mixture. Reducing the proportion of nitrogen by increasing the proportion of oxygen reduces the risk of decompression sickness for the same dive profile, or allows extended dive times without increasing the need for decompression stops for the same risk. Nitrox is not a safer gas than compressed air in all respects; although its use can reduce the risk of decompression sickness, it increases the risk of oxygen toxicity and fire, which are further discussed below.

Enriched Air Nitrox diving tables, showing adjusted no-decompression times.

Breathing nitrox is not thought to reduce the effects of narcosis, as oxygen seems to have equally narcotic properties under pressure as nitrogen; thus one should not expect a reduction in narcotic effects due only to the use of nitrox.[4] [5] [6] Nonetheless, there are people in the diving community who insist that they feel reduced narcotic effects at depths breathing nitrox.[7] This may be due to a dissociation of the subjective and behavioural effects of narcosis.[8] However, it should be noted that because of risks associated with oxygen toxicity, divers tend not to utilize nitrox at greater depths where more pronounced narcosis symptoms are more likely to occur. For a reduction in narcotic effects trimix or heliox, gases which also contain helium, are generally used by divers. There is anecdotal evidence that the use of nitrox reduces post-dive fatigue,[9] particularly in older and or obese divers; however a double-blind study to test this found no statistically significant reduction in reported fatigue.[1] [10] There was, however, some suggestion that post dive fatigue is due to sub-clinical decompression sickness (DCS) (i.e. micro bubbles in the blood insufficient to cause symptoms of DCS); the fact that the study mentioned was conducted in a dry chamber with an ideal decompression profile may have been sufficient to reduce sub-clinical DCS and prevent fatigue in both nitrox and air divers. In 2008, a study was published using wet divers at the same depth and confirmed that no statistically significant reduction in reported fatigue is seen.[11] Further studies with a number of different dive profiles, and also different levels of exertion, would be necessary to fully investigate this issue. For example, there is much better scientific evidence that breathing high-oxygen gases

Nitrox increase exercise tolerance, during aerobic exertion.[12] Though even moderate exertion while breathing from the regulator is a relatively uncommon occurrence in scuba, as divers usually try to minimize it in order to conserve gas, episodes of exertion while regulator-breathing do occasionally occur in sport diving. Examples are surface-swimming a distance to a boat or beach after surfacing, where residual "safety" cylinder gas is often used freely, since the remainder will be wasted anyway when the dive is completed. It is possible that these so-far un-studied situations have contributed to some of the positive reputation of nitrox.

50

Naming
Nitrox is known by many names: EnhancedAirNitrox, OxygenEnrichedAir, Nitrox, EANx or SafeAir.[3] [13] The name "nitrox" may be capitalized when referring to specific mixtures such as Nitrox32, which contains 68% nitrogen and 32% oxygen. When one figure is stated, it refers to the oxygen percentage, not the nitrogen percentage. The original convention, Nitrox68/32 became shortened as the first figure is redundant. Although "nitrox" usually refers to a mixture of nitrogen and oxygen with more than 21% oxygen, it can refer to mixtures that are leaner in oxygen than air.[3] "Enriched Air Nitrox", "Enriched Air" or "EAN" are used to emphasise richer than air mixtures.[3] In "EANx", the "x" indicates the percentage of oxygen in the mix and is replaced by a number when the percentage is known; for example a 40% oxygen mix is called EAN40. The two most popular blends are EAN32 and EAN36 (also named Nitrox I and Nitrox II, respectively, or Nitrox68/32 and Nitrox64/36).[2]
[3]

In its early days of introduction to non-technical divers, nitrox has occasionally also been known by detractors by less complimentary terms, such as "devil gas" or "voodoo gas" (a term now sometimes used with pride). These percentages are what the gas blender aims for in partial-pressure blending, but the final actual mix in such cases will be unique, and so a small flow of gas from the cylinder must be measured with a handheld oxygen analyzer, before the diver breathes from the cylinder underwater.[14]

Richness of mix
The two most common recreational diving nitrox mixes contain 32% and 36% oxygen, which have maximum operating depths (MODs) of 34 metres (112ft) and 29 metres (95ft) respectively when limited to a maximum partial pressure of oxygen of 1.4bar (140kPa). Divers may calculate an equivalent air depth to determine their decompression requirements or may use nitrox tables or a nitrox-capable dive computer.[2] [3] [15] [16] Nitrox with more than 40% oxygen is uncommon within recreational diving. There are two main reasons for this: the first is that Technical divers preparing for a mixed-gas decompression dive in Bohol, Philippines. Note the backplate and wing setup with sidemounted stage tanks all pieces of diving equipment that come containing EAN50 (left side) and pure oxygen (right side). into contact with mixes containing higher proportions of oxygen, particularly at high pressure, need special cleaning and servicing to reduce the risk of fire.[2] [3] The second reason is that richer mixes extend the time the diver can stay underwater without needing decompression stops far further than the duration of typical diving cylinders. For example, based on the PADI nitrox recommendations, the maximum operating depth

Nitrox for EAN45 would be 21 metres (69ft) and the maximum dive time available at this depth even with EAN36 is nearly 1 hour 15 minutes: a diver with a breathing rate of 20 litres per minute using twin 10 litre, 230 bar (about double 85 cu. ft.) cylinders would have completely emptied the cylinders after 1 hour 14 minutes at this depth. Usage of nitrox mixtures containing 50% to 80% oxygen is common in technical diving as a decompression gas, which by virtue of its lower partial pressure of inert gases such as nitrogen and helium, allows for more efficient (faster) elimination of these gases from the tissues than leaner oxygen mixtures. In deep open circuit technical diving, where hypoxic gases are breathed during the bottom portion of the dive, a Nitrox mix with 50% or less oxygen called a "travel mix" is sometimes breathed during the beginning of the descent in order to avoid hypoxia. Normally, however, the most oxygen-lean of the diver's decompression gases would be used for this purpose, since descent time spent reaching a depth where bottom mix is no longer hypoxic is normally small, and the distance between this depth and the MOD of any nitrox decompression gas is likely to be very short, if it occurs at all.

51

Cylinder markings
Any cylinder containing any blend of gas other than the standard air content is required by most diving training organizations to be clearly marked. Some organizations, e.g. GUE, argue that it does not make sense to have a permanent marking on a gas tank that can be filled with any gas. The standard nitrox cylinder is yellow in color and marked with a green band around the shoulder of the tank, with Nitrox or "Enriched air" marked in white or yellow letters inside. Tanks of any other color are generally marked with six inch band around the shoulder, with a one inch yellow band on the top and bottom, with four inches of green in the middle. This green band will also have the designation of "NITROX" or something similar inside, in yellow or white letters. Every nitrox cylinder should also have a sticker stating whether or not the cylinder is oxygen clean and suitable for partial pressure blending. Any oxygen clean cylinder may have any mix up to 100% oxygen inside. If by some accident an oxygen clean cylinder is filled at a station which does not supply gas to oxygen-clean standards it is then considered contaminated and must be re-cleaned before a gas containing more than 40% oxygen may again be added.[17] Cylinders marked as not-oxygen clean may only be filled with enriched oxygen mixtures from membrane or stick blending systems where the gas is mixed before being added to the cylinder. Finally, all nitrox cylinders should have a tag that, at minimum, states the oxygen content of the cylinder, the date it was blended, the gas blender's name, and the maximum operating depth along with the partial pressure this depth was calculated with. Other requirements Cylinder showing Nitrox band and sticker marked with MOD and O2% may be made as to what is marked on the cylinder, but these markings are considered standard and safe by the diving community, and any cylinders lacking these markings should be considered possibly unsafe. Training for nitrox certification suggests this tag be verified by the diver himself by using an oxygen analyzer.

Nitrox

52

Dangers
Oxygen toxicity
Diving and handling nitrox raises a number of potentially fatal dangers due to the high partial pressure of oxygen (ppO2).[2] [3] Nitrox is not a deep-diving gas mixture owing to the increased proportion of oxygen, which becomes toxic when breathed at high pressure. For example, the maximum operating depth of nitrox with 36% oxygen, a popular recreational diving mix, is 29 metres (95ft) to ensure a maximum ppO2 of no more than 1.4bar (140kPa). The exact value of the maximum allowed ppO2 and maximum operating depth varies depending on factors such as the training agency, the type of dive, the breathing equipment and the level of surface support, with professional divers sometimes being allowed to breath higher ppO2 than those recommended to recreational divers. To dive safely with nitrox, the diver must learn good buoyancy control, a vital part of scuba diving in its own right, and a disciplined approach to preparing, planning and executing a dive to ensure that the ppO2 is known, and the maximum operating depth is not exceeded. Most dive shops, dive operators, and gas blenders require the diver to have a nitrox certification card before selling nitrox to divers. Some training agencies, such as Technical Diving International, teach the use of two depth limits to protect against oxygen toxicity. The shallower depth is called the "maximum operating depth" and is reached when the partial pressure of oxygen in the breathing gas reaches 1.4bar (140kPa). The deeper depth, called the "contingency depth", is reached when the partial pressure reaches 1.6bar (160kPa). Diving at or beyond this level exposes the diver to the risk of central nervous system (CNS) oxygen toxicity. This can be extremely dangerous since its onset is often without warning and can lead to drowning, as the regulator may be spat out during convulsions, which occur in conjunction with sudden unconsciousness (general seizure induced by oxygen toxicity). Divers trained to use nitrox memorise the acronym VENTID-C (which stands for Vision (blurriness), Ears (ringing sound), Nausea, Twitching, Irritability, Dizziness, and Convulsions). However, evidence from non-fatal oxygen convulsions indicates that most convulsions are not preceded by any warning symptoms at all.[18] Further, many of the suggested warning signs are also symptoms of nitrogen narcosis, and so may lead to misdiagnosis by a diver. A solution to either is to ascend to a shallower depth.

Precautionary procedures at the fill station

Many training agencies such as PADI,[19] CMAS, SSI and NAUI train their divers to personally check the oxygen percentage content of each nitrox cylinder before every dive. If the oxygen percentage deviates by more than 1% from the value written on the cylinder by the gas blender, the scuba diver must either recalculate his or her bottom times with the new mix, or else abort the dive to remain safe and avoid oxygen toxicity or decompression sickness. Under IANTD and ANDI rules for use of nitrox,[20] which are followed by most dive resorts around the world, filled nitrox cylinders are signed out personally in a gas blender log book, which contains, for each cylinder and fill, the cylinder number, the measured oxygen percent composition, the signature of the receiving diver (who should have personally measured the oxygen percent with an instrument at the fill-shop), and finally a calculation of the maximum operating depth for that fill/cylinder. All of these steps minimize danger but increase complexity of operations (for example, personalized cylinders for each diver must generally be kept track of on dive boats with nitrox, which is not the case with generic compressed air cylinders).

Nitrox

53

Fire and toxic cylinder contamination from oxygen reactions

Diving cylinders are usually filled with nitrox by a gas blending technique such as partial pressure blending or premix decanting (in which a nitrox mix is supplied to the filler in pressurized larger cylinders). A few facilities have begun to fill cylinders with air which has been enriched with oxygen by a pre-mixing process, so that it is pressurized as nitrox for the first time in the diving cylinder. The pre-mixing is accomplished either by a membrane system which removes nitrogen from the air during compression or by a 'stick' blending technique where pure oxygen is mixed with air in a baffled chamber attached to the compressor intake. With the use of pure oxygen during "partial pressure blending" (where pure oxygen is added from a large oxygen cylinder to the nearly empty dive cylinder until it reaches 300500 psi (2030 bar) before air is added by compressor) there is an especially increased risk of fire. Partial blending using pure oxygen is often used to provide nitrox for multiple dives on live-aboard dive boats, but it is also used in some smaller diver shops. However, any gas which contains a significantly larger percentage of oxygen than air is a fire hazard. Furthermore, such gases can also react with hydrocarbons or incorrect lubricants inside a dive cylinder to produce carbon monoxide, even if a recognized fire does not happen. At present, there is some discussion over whether or not mixtures of gas which contain less than 40% oxygen may sometimes be exempt from oxygen clean standards.[21] Some of the controversy comes from a single U.S. regulation intended for commercial divers (not recreational divers) years ago.[3] However, the U.S. Compressed Gas Association (CGA) and two international nitrox teaching agencies (IANTD and ANDI) now support the standard that any gas containing more than 23.5% oxygen should be treated as nitrox (which is to say, no differently from pure oxygen) for purposes of oxygen cleanliness and oxygen compatibility (i.e., oxygen "servicability"). However, the largest training agency - PADI - is still teaching that pre-mixed nitrox (i.e. nitrox which is mixed before being put into the cylinder) below 40% oxygen does not require a specially cleaned cylinder or other equipment.[2] [3] [19] Most nitrox fill stations which supply pre-mixed nitrox will fill non-oxygen clean cylinders with mixtures below 40%. For a history of this controversy[3] see Luxfer cylinders [22] .

History
In the 1920s or 1930s Draeger of Germany made a nitrox backpack independent air supply for a standard diving suit. In World War II or soon after, British commando frogmen and work divers started sometimes diving with oxygen rebreathers adapted for semi-closed-circuit nitrox (which they called "mixture") diving by fitting larger cylinders and carefully setting the gas flow rate using a flow meter. These developments were kept secret until independently duplicated by civilians in the 1960s. In the 1950s the United States Navy (USN) documented enriched oxygen gas procedures for military use of what we today call nitrox, in the USN Diving Manual.[23] In 1970, Dr. Morgan Wells, who was the first director of the National Oceanographic and Atmospheric Administration (NOAA) Diving Center, began instituting diving procedures for oxygen-enriched air. He also developed a process for mixing oxygen and air which he called a continuous blending system. For many years Dr. Wells' invention was the only practical alternative to partial pressure blending. In 1979 NOAA published Wells' procedures for the scientific use of nitrox in the NOAA Diving Manual.[2] [3] In 1985 Dick Rutkowski, a former NOAA diving safety officer, formed IAND (International Association of Nitrox Divers) and began teaching nitrox use for recreational diving. This was considered dangerous by some, and met with heavy skepticism by the diving community. In 1991, in a watershed moment, the annual DEMA show (held in Houston, Texas that year) banned nitrox training providers from the show. This created a backlash, and when DEMA relented, a number of organisations took the opportunity to present nitrox workshops outside the show. In 1992 BSAC banned its members from using nitrox.

Nitrox In 1992 the name was changed to the International Association of Nitrox and Technical Divers (IANTD), the T being added when the European Association of Technical Divers (EATD) merged with IAND. In the early 1990s, the agencies teaching nitrox were not the main scuba agencies. New organizations, including Ed Betts' American Nitrox Divers International (ANDI) - which invented the term "Safe Air" for marketing purposes - and Bret Gilliam's Technical Diving International (TDI) gave scientific credence to nitrox. Meanwhile, diving stores were finding a purely economic reason to offer nitrox: not only was an entire new course and certification needed to use it, but instead of cheap or free tank fills with compressed air, dive shops found they could charge premium amounts of money for custom-gas blending of nitrox to their ordinary moderately experienced divers. With the new dive computers which could be programmed to allow for the longer bottom-times and shorter residual nitrogen times which nitrox gave, the incentive for the sport diver to use the gas increased. An intersection of economics and scientific validity had occurred. In 1993 Skin Diver magazine, the leading recreational diving publication at the time, published a three part series arguing that nitrox was unsafe for sport divers.[24] Against this trend, in 1992 NAUI became the first existing major sport diver training agency to sanction nitrox. In 1993 Dive Rite manufactured the first nitrox compatible dive computer, called the Bridge.[25] In 1996, the Professional Association of Diving Instructors (PADI) announced full educational support for nitrox.[19] While other main line scuba organizations had announced their support of nitrox earlier,[26] it was PADI's endorsement that put nitrox over the top as a standard sport diving "option."[27]

54

Nitrox in nature
Sometimes in the geologic past the Earth's atmosphere contained much more than 20% oxygen: e.g. up to 35% in the Upper Carboniferous. This let animals absorb oxygen more easily and influenced evolution.[28] [29]

References
[1] Brubakk, A. O.; T. S. Neuman (2003). Bennett and Elliott's physiology and medicine of diving, 5th Rev ed.. United States: Saunders Ltd.. pp.800. ISBN0702025712. [2] Joiner, J. T. (2001). NOAA Diving Manual: Diving for Science and Technology, Fourth Edition. United States: Best Publishing. pp.660. ISBN0941332705. [3] Lang, M.A. (2001). DAN Nitrox Workshop Proceedings (http:/ / archive. rubicon-foundation. org/ 4855). Durham, NC: Divers Alert Network. pp.197. . Retrieved 2008-05-02. [4] Hesser, CM; Fagraeus, L; Adolfson, J (1978). "Roles of nitrogen, oxygen, and carbon dioxide in compressed-air narcosis." (http:/ / archive. rubicon-foundation. org/ 2810). Undersea Biomedical Research (Bethesda, Md: Undersea and Hyperbaric Medical Society) 5 (4): 391400. ISSN0093-5387. OCLC2068005. PMID734806. . Retrieved 2008-04-08. [5] Brubakk, Alf O; Neuman, Tom S (2003). Bennett and Elliott's physiology and medicine of diving, 5th Rev ed. United States: Saunders Ltd. p.304. ISBN0702025712. [6] Oxygen has the potential to be 1.7 times more narcotic than nitrogen - see relevant narcotic potency of gases [7] Although oxygen appears chemically more narcotic at the surface, relative narcotic effects at depth have never been studied in detail. It is clear that different gases result in different narcotic effects at depth. Helium is considered to have very little narcotic effect, but results in HPNS when breathed at high pressures, which does not happen with gases with have greater narcotic qualities. [8] Hamilton K, Lalibert MF, Fowler B (March 1995). "Dissociation of the behavioral and subjective components of nitrogen narcosis and diver adaptation" (http:/ / archive. rubicon-foundation. org/ 2199). Undersea and Hyperbaric Medicine (Undersea and Hyperbaric Medical Society) 22 (1): 419. PMID7742709. . Retrieved 2009-01-27. [9] "How does nitrox make you feel?" (http:/ / www. scubaboard. com/ forums/ basic-scuba-discussions/ poll-1630-a. html). ScubaBoard. 2007. . Retrieved 2009-05-21. [10] Harris RJ, Doolette DJ, Wilkinson DC, Williams DJ (2003). "Measurement of fatigue following 18 msw dry chamber dives breathing air or enriched air nitrox" (http:/ / archive. rubicon-foundation. org/ 3975). Undersea and Hyperbaric Medicine (Undersea and Hyperbaric Medical Society) 30 (4): 28591. PMID14756231. . Retrieved 2008-05-02. [11] Chapman SD, Plato PA. Measurement of Fatigue following 18 msw Open Water Dives Breathing Air or EAN36.. In: Brueggeman P, Pollock NW, eds. Diving for Science 2008. Proceedings of the American Academy of Underwater Sciences 27th Symposium.. http:/ / archive. rubicon-foundation. org/ 8005. Retrieved 2009-05-21. [12] Ergogenic Aids (http:/ / www. pponline. co. uk/ encyc/ 1008. htm)

Nitrox
[13] Elliott, D (1996). "Nitrox" (http:/ / archive. rubicon-foundation. org/ 6309). South Pacific Underwater Medicine Society Journal 26 (3). ISSN0813-1988. OCLC16986801. . Retrieved 2008-05-02. [14] Lippmann, John; Mitchell, Simon J (October 2005). "28". Deeper into Diving (2 ed.). Victoria, Australia: J.L. Publications. pp.4034. ISBN097522901X. OCLC66524750. [15] Logan, JA (1961). "An evaluation of the equivalent air depth theory" (http:/ / archive. rubicon-foundation. org/ 3835). United States Navy Experimental Diving Unit Technical Report NEDU-RR-01-61. . Retrieved 2008-05-01. [16] Berghage Thomas E, McCraken TM (December 1979). "Equivalent air depth: fact or fiction" (http:/ / archive. rubicon-foundation. org/ 2835). Undersea Biomedical Research 6 (4): 37984. PMID538866. . Retrieved 2008-05-01. [17] Butler, Glen L; Mastro, Steven J; Hulbert, Alan W; Hamilton Jr, Robert W. (1992). "Oxygen safety in the production of enriched air nitrox breathing mixtures." (http:/ / archive. rubicon-foundation. org/ 9033). In: Cahoon, LB. (ed.) Proceedings of the American Academy of Underwater Sciences Twelfth Annual Scientific Diving Symposium "Diving for Science 1992". Held September 24-27, 1992 at the University of North Carolina at Wilmington, Wilmington, NC. (American Academy of Underwater Sciences). . Retrieved 2011-01-11. [18] Clark, James M; Thom, Stephen R (2003). "Oxygen under pressure". In Brubakk, Alf O; Neuman, Tom S. Bennett and Elliott's physiology and medicine of diving (5th ed.). United States: Saunders. p.375. ISBN0702025712. OCLC51607923. [19] Richardson, D and Shreeves, K (1996). "The PADI Enriched Air Diver course and DSAT oxygen exposure limits." (http:/ / archive. rubicon-foundation. org/ 6310). South Pacific Underwater Medicine Society Journal 26 (3). ISSN0813-1988. OCLC16986801. . Retrieved 2008-05-02. [20] http:/ / www. andihq. com/ pages/ mainpage. html [21] Rosales KR, Shoffstall MS, Stoltzfus JM (2007). "Guide for Oxygen Compatibility Assessments on Oxygen Components and Systems." (http:/ / archive. rubicon-foundation. org/ 4861). NASA Johnson Space Center Technical Report NASA/TM-2007-213740. . Retrieved 2008-06-05. [22] http:/ / www. luxfercylinders. com/ support/ faq/ aluminumoxygen. shtml [23] US Navy Diving Manual, 6th revision (http:/ / www. supsalv. org/ 00c3_publications. asp?destPage=00c3& pageID=3. 9). United States: US Naval Sea Systems Command. 2006. . Retrieved 2008-04-24. [24] A position which it would formally maintain until in 1995 magazine editor Bill Gleason was reported to say that nitrox was "all right". Skin Diver would later go into bankruptcy. [25] TDI, Nitrox Gas Blending Manual, at pages 9-11 [26] Allen, C (1996). "BSAC gives the OK to nitrox." (http:/ / archive. rubicon-foundation. org/ 6275). Diver 1995; 40(5) May: 35-36. reprinted in South Pacific Underwater Medicine Society Journal 26 (3). ISSN0813-1988. OCLC16986801. . Retrieved 2008-05-02. [27] http:/ / www. americandivecenter. com/ nitrox/ preview_p03. htm [28] R.A.BERNER AND D.E.CANFIELD (1989. A NEW MODEL FOR ATMOSPHERIC OXYGEN OVER PHANEROZOIC TIME. AMERICAN JOURNAL OF SCIENCE 289, pp.333-361. [29] ATMOSPHERIC OXYGEN, GIANT PALEOZOIC INSECTS AND THE EVOLUTION OF AERIAL LOCOMOTOR PERFORMANCE. ROBERT DUDLEY* Department of Zoology, University of Texas, Austin, TX 78712, USA and Smithsonian Tropical Research Institute, PO Box 2072, Balboa, Republic of Panama Accepted 28 October 1997; published on WWW 24 March 1998.

55

Footnotes External links

Nitrox - frequently asked questions (http://www.gasdiving.co.uk/pages/misc/Nitrox.htm) Useful Luxfer FAQ on the CGA and "40% rule" controversy (http://www.luxfercylinders.com/support/faq/ aluminumoxygen.shtml) Online Nitrox calculator for EAD, MOD and PPO2; warns if a critical limit is reached (http://www.dive-hive. com/nitrox_calc.php?lang=en) Diving Nitrox (http://dive-center.org/diving-nitrox.html)

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Oxygen toxicity
Oxygen toxicity
Classification and external resources

In 194243 the UK Government carried out extensive testing for oxygen toxicity in divers. The chamber is pressurised with air to 3.7bar. The [1] subject in the centre is breathing 100% oxygen from a mask. ICD-10 ICD-9 MeSH T59.8 987.8 [2] [3] [4]

D018496

Oxygen toxicity is a condition resulting from the harmful effects of breathing molecular oxygen (O2) at elevated partial pressures. It is also known as oxygen toxicity syndrome, oxygen intoxication, and oxygen poisoning. Historically, the central nervous system condition was called the Paul Bert effect, and the pulmonary condition the Lorrain Smith effect, after the researchers who pioneered its discovery and description in the late 19th century. Severe cases can result in cell damage and death, with effects most often seen in the central nervous system, lungs and eyes. Oxygen toxicity is a concern for scuba divers, those on high concentrations of supplemental oxygen (particularly premature babies), and those undergoing hyperbaric oxygen therapy. The result of breathing elevated concentrations of oxygen is hyperoxia, an excess of oxygen in body tissues. The body is affected in different ways depending on the type of exposure. Central nervous system toxicity is caused by short exposure to high concentrations of oxygen at greater than atmospheric pressure. Pulmonary and ocular toxicity result from longer exposure to elevated oxygen levels at normal pressure. Symptoms may include disorientation, breathing problems, and vision changes such as myopia. Prolonged or very high oxygen concentrations can cause oxidative damage to cell membranes, the collapse of the alveoli in the lungs, retinal detachment, and seizures. Oxygen toxicity is managed by reducing the exposure to elevated oxygen levels. Studies show that, in the long term, a robust recovery from most types of oxygen toxicity is possible. Protocols for avoidance of hyperoxia exist in fields where oxygen is breathed at higher-than-normal partial pressures, including underwater diving using compressed breathing gases, hyperbaric medicine, neonatal care and human spaceflight. These protocols have resulted in the increasing rarity of seizures due to oxygen toxicity, with pulmonary and ocular damage being mainly confined to the problems of managing premature infants. In recent years, oxygen has become available for recreational use in oxygen bars. The US Food and Drug Administration has warned those suffering from problems such as heart or lung disease not to use oxygen bars. Scuba divers use breathing gases containing up to 100% oxygen, and should have specific training in using such gases.

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Classification

The effects of oxygen toxicity may be classified by the organs affected, producing three principal forms:[5] [6] [7] Central nervous system, characterised by convulsions followed by unconsciousness, occurring under hyperbaric conditions; Pulmonary (lungs), characterised by difficulty in breathing and pain within the chest, occurring when breathing elevated pressures of oxygen for extended periods; Ocular (retinopathic conditions), characterised by alterations to the eyes, occurring when breathing elevated pressures of oxygen for extended periods. Central nervous system oxygen toxicity can cause seizures, brief periods of rigidity followed by convulsions and unconsciousness, and is of concern to divers who encounter greater than atmospheric pressures. Pulmonary oxygen toxicity results in damage to the lungs, causing pain and difficulty in breathing. Oxidative damage to the eye may lead to myopia or partial detachment of the retina. Pulmonary and ocular damage are most likely to occur when supplemental oxygen is administered as part of a treatment, particularly to newborn infants, but are also a concern during hyperbaric oxygen therapy. Oxidative damage may occur in any cell in the body but the effects on the three most susceptible organs will be the primary concern. It may also be implicated in red blood cell destruction (hemolysis),[8] [9] damage to liver (hepatic),[10] heart (myocardial),[11] endocrine glands (adrenal, gonads, and thyroid),[12] [13] [14] or kidneys (renal),[15] and general damage to cells.[5] [16] In unusual circumstances, effects on other tissues may be observed: it is suspected that during spaceflight, high oxygen concentrations may contribute to bone damage.[17] Hyperoxia can also indirectly cause carbon dioxide narcosis in patients with lung ailments such as chronic obstructive pulmonary disease or with central respiratory depression.[17] Oxygen toxicity is not associated with hyperventilation, because breathing air at atmospheric pressure always has a partial pressure of oxygen (ppO2) of 0.21bar (21kPa) and the lower limit for toxicity is more than 0.3bar (30kPa).[18]

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Signs and symptoms

Oxygen Poisoning at 90ft (27m) in the Dry in 36 Subjects in Order of Performance K W Donald[1]
Exposure (mins.) 96 6069 5055 3135 2130 1620 1115 610 Num. of Subjects 1 3 4 4 6 8 4 6 Symptoms Prolonged dazzle; severe spasmodic vomiting Severe lip-twitching; Euphoria; Nausea and vertigo; arm twitch Severe lip-twitching; Dazzle; Blubbering of lips; fell asleep; Dazed Nausea, vertigo, lip-twitching; Convulsed Convulsed; Drowsiness; Severe lip-twitching; epigastric aura; twitch L arm; amnesia Convulsed; Vertigo and severe lip twitching; epigastric aura; spasmodic respiration; Inspiratory predominance; lip-twitching and syncope; Nausea and confusion Dazed and lip-twitching; paraesthesiae; vertigo; "Diaphragmatic spasm"; Severe nausea

Central nervous system

Central nervous system oxygen toxicity manifests as symptoms such as visual changes (especially tunnel vision), ringing in the ears (tinnitus), nausea, twitching (especially of the face), irritability (personality changes, anxiety, confusion, etc.), and dizziness. This may be followed by a tonicclonic seizure consisting of two phases: intense muscle contraction occurs for several seconds (tonic); followed by rapid spasms of alternate muscle relaxation and contraction producing convulsive jerking (clonic). The seizure ends with a period of unconsciousness (the postictal state).[19] [20] The onset of seizure depends upon the partial pressure of oxygen (ppO2) in the breathing gas and exposure duration. However, exposure time before onset is unpredictable, as tests have shown a wide variation, both amongst individuals, and in the same individual from day to day.[19] [21] [22] In addition, many external factors, such as underwater immersion, exposure to cold, and exercise will decrease the time to onset of central nervous system symptoms.[1] Decrease of tolerance is closely linked to retention of carbon dioxide.[23] [24] [25] Other factors, such as darkness and caffeine, increase tolerance in test animals, but these effects have not been proven in humans.[26] [27]

Pulmonary
Pulmonary toxicity symptoms result from an inflammation that starts in the airways leading to the lungs and then spreads into the lungs (tracheobronchial tree). The symptoms appear in the upper chest region (substernal and carinal regions).[28] [29] [30] This begins as a mild tickle on inhalation and progresses to frequent coughing.[28] If breathing elevated partial pressures of oxygen is not discontinued, patients experience a mild burning on inhalation along with uncontrollable coughing and occasional shortness of breath (dyspnea).[28] Physical findings related to pulmonary toxicity have included bubbling sounds heard through a stethoscope (bubbling rales), fever, and increased blood flow to the lining of the nose (hyperemia of the nasal mucosa).[30] The radiological finding from the lungs shows inflammation and swelling (pulmonary edema).[28] [29] Pulmonary function measurements are reduced, as noted by a reduction in the amount of air that the lungs can hold (vital capacity) and changes in expiratory function and lung elasticity.[30] [31] Tests in animals have indicated a variation in tolerance similar to that found in central nervous system toxicity, as well as significant variations between species. When the exposure to oxygen above 0.5bar (50kPa) is intermittent, it permits the lungs to recover and delays the onset of toxicity.[32]

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Ocular
In premature babies, signs of damage to the eye (retinopathy of prematurity, or ROP) are observed via an ophthalmoscope as a demarcation between the vascularized and non-vascularised regions of an infant's retina. The degree of this demarcation is used to designate four stages: (I) the demarcation is a line; (II) the demarcation becomes a ridge; (III) growth of new blood vessels occurs around the ridge; (IV) the retina begins to detach from the inner wall of the eye (choroid).[33]

Causes
Oxygen toxicity is caused by exposure to oxygen at partial pressures greater than those to which the body is normally exposed. This occurs in three principal settings: underwater diving, hyperbaric oxygen therapy and the provision of supplemental oxygen, particularly to premature infants. In each case, the risk factors are markedly different.

Central nervous system toxicity

Exposures, from minutes to a few hours, to partial pressures of oxygen above 1.6 bars (160kPa)about eight times the atmospheric concentrationare usually associated with central nervous system oxygen toxicity and are most likely to occur among patients undergoing hyperbaric oxygen therapy and divers. Since atmospheric pressure is about 1 bar (100kPa), central nervous system toxicity can only occur under hyperbaric conditions, where ambient pressure is above normal.[34] [35] Divers breathing air at depths greater than 60m (200ft) face an increasing risk of an oxygen toxicity "hit" (seizure). Divers breathing a gas mixture enriched with oxygen, such as nitrox, can similarly suffer a seizure at shallower depths, should they descend below the maximum depth allowed for the mixture.[36]

Pulmonary toxicity
The lungs, as well as the remainder of the respiratory tract, are exposed to the highest concentration of oxygen in the human body and are therefore the first organs to show toxicity. Pulmonary toxicity occurs with exposure to concentrations of oxygen greater than 0.5bar (50kPa), corresponding to an oxygen fraction of 50% at normal atmospheric pressure. Signs of pulmonary toxicity begins with evidence of tracheobronchitis, or inflammation of the upper airways, after an asymptomatic period between 4 and 22 hours at greater than 95% oxygen,[37] with some studies suggesting symptoms usually begin after approximately 14 hours at this level of oxygen.[38] At partial pressures of oxygen of 2 to 3 bar (200 to 300 kPa)100% oxygen at 2 to 3 times atmospheric pressurethese symptoms may begin as early as 3 hours after exposure to oxygen.[37] Experiments on rats show pulmonary manifestations of oxygen toxicity are not the same for normobaric conditions as they are for hyperbaric conditions.[39] Evidence of decline in lung function as measured by pulmonary function testing can occur as quickly as 24 hours of continuous exposure to 100% oxygen,[38] with evidence of diffuse alveolar damage and the onset of acute respiratory distress syndrome usually occurring after 48 hours on 100% oxygen.[37] Breathing 100% oxygen also eventually leads to collapse of the alveoli (atelectasis), whileat the same partial pressure of oxygenthe presence of significant partial pressures of inert gases, typically nitrogen, will prevent this effect.[40] Preterm newborns are known to be at higher risk for bronchopulmonary dysplasia with extended exposure to high concentrations of oxygen.[41] Other groups at higher risk for oxygen toxicity are patients on mechanical ventilation with exposure to levels of oxygen greater than 50%, and patients exposed to chemicals that increase risk for oxygen toxicity such the chemotherapeutic agent bleomycin.[38] Therefore, current guidelines for patients on mechanical ventilation in intensive care suggests keeping oxygen concentration less than 60%.[37] Likewise, divers who undergo treatment of decompression sickness are at increased risk of oxygen toxicity as treatment entails exposure to long periods of oxygen breathing under hyperbaric conditions, in addition to any oxygen exposure during the dive.[34]

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Ocular toxicity
Prolonged exposure to high inspired fractions of oxygen causes damage to the retina.[42] [43] [44] Damage to the developing eye of infants exposed to high oxygen fraction at normal pressure has a different mechanism and effect from the eye damage experienced by adult divers under hyperbaric conditions.[45] [46] Hyperoxia may be a contributing factor for the disorder called retrolental fibroplasia or retinopathy of prematurity (ROP) in infants.[45] [47] In preterm infants, the retina is often not fully vascularised. Retinopathy of prematurity occurs when the development of the retinal vasculature is arrested and then proceeds abnormally. Associated with the growth of these new vessels is fibrous tissue (scar tissue) that may contract to cause retinal detachment. Supplemental oxygen exposure, while a risk factor, is not the main risk factor for development of this disease. Restricting supplemental oxygen use does not necessarily reduce the rate of retinopathy of prematurity, and may raise the risk of hypoxia-related systemic complications.[45] Hyperoxic myopia has occurred in closed circuit oxygen rebreather divers with prolonged exposures.[46] [48] [49] It also occurs frequently in those undergoing repeated hyperbaric oxygen therapy.[43] [50] This is due to an increase in the refractive power of the lens, since axial length and keratometry readings do not reveal a corneal or length basis for a myopic shift.[50] [51] It is usually reversible with time.[43] [50]

Mechanism
The biochemical basis for the toxicity of oxygen is the partial reduction of oxygen by one or two electrons to form reactive oxygen species,[52] which are natural by-products of the normal metabolism of oxygen and have important roles in cell signalling.[53] One species produced by the body, the superoxide anion (O2),[54] is possibly involved in iron acquisition.[55] Higher than normal concentrations of oxygen lead to increased levels of reactive oxygen species.[56] Oxygen is necessary for cell metabolism, and the blood supplies it to all parts of the body. When oxygen is breathed at high partial pressures, a hyperoxic condition will rapidly spread, The lipid peroxidation mechanism shows a single radical initiating a chain reaction with the most vascularised tissues being which converts unsaturated lipids to lipid peroxides, most vulnerable. During times of environmental stress, levels of reactive oxygen species can increase dramatically, which can damage cell structures and produce oxidative stress.[22] [57] While all the reaction mechanisms of these species within the body are not yet fully understood,[58] one of the most reactive products of oxidative stress is the hydroxyl radical (OH), which can initiate a damaging chain reaction of lipid peroxidation in the unsaturated lipids within cell membranes.[59] High concentrations of oxygen also increase the formation of other free radicals, such as nitric oxide, peroxynitrite, and trioxidane, which harm DNA and other biomolecules.[22] [60] Although the body has many antioxidant systems such as glutathione that guard against oxidative stress, these systems are eventually overwhelmed at very high concentrations of free oxygen, and the rate of cell damage exceeds the capacity of the systems that prevent or repair it.[61] [62] [63] Cell damage and cell death then result.[64]

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Diagnosis
Diagnosis of central nervous system oxygen toxicity in divers prior to seizure is difficult as the symptoms of visual disturbance, ear problems, dizziness, confusion and nausea can be due to many factors common to the underwater environment such as narcosis, congestion and coldness. However, these symptoms may be helpful in diagnosing the first stages of oxygen toxicity in patients undergoing hyperbaric oxygen therapy. In either case, unless there is a prior history of epilepsy or tests indicate hypoglycemia, a seizure occurring in the setting of breathing oxygen at partial pressures greater than 1.4bar (140kPa) suggests a diagnosis of oxygen toxicity.[65] Diagnosis of bronchopulmonary dysplasia in new-born infants with breathing difficulties is difficult in the first few weeks. However, if the infant's breathing does not improve during this time, blood tests and x-rays may be used to confirm bronchopulmonary dysplasia. In addition, an echocardiogram can help to eliminate other possible causes such as congenital heart defects or pulmonary arterial hypertension.[66] The diagnosis of retinopathy of prematurity in infants is typically suggested by the clinical setting. Prematurity, low birth weight and a history of oxygen exposure are the principal indicators, while no hereditary factors have been shown to yield a pattern.[67]

Prevention
The prevention of oxygen toxicity depends entirely on the setting. Both underwater and in space, proper precautions can eliminate the most pernicious effects. Premature infants commonly require supplemental oxygen to treat complications of preterm birth. In this case prevention of bronchopulmonary dysplasia and retinopathy of prematurity must be carried out without compromising a supply of oxygen adequate to preserve the infant's life.

Underwater
A seizure caused by oxygen toxicity to the central nervous system is a deadly but avoidable event while diving.[36] The diver may experience no warning symptoms.[20] The effects are sudden convulsions and unconsciousness, during which victims can lose their regulator and The label on the diving cylinder shows that it drown.[68] One of the advantages of a full-face diving mask is contains oxygen-rich gas (36%) and is boldly prevention of regulator loss in the event of a seizure. As there is an marked with a maximum operating depth of increased risk of central nervous system oxygen toxicity on deep dives, 28metres. long dives and dives where oxygen-rich breathing gases are used, divers are taught to calculate a maximum operating depth for oxygen-rich breathing gases, and cylinders containing such mixtures must be clearly marked with that depth.[25] [69] In some diver training courses for these types of diving, divers are taught to plan and monitor what is called the oxygen clock of their dives.[69] This is a notional alarm clock, which ticks more quickly at increased ppO2 and is set to activate at the maximum single exposure limit recommended in the National Oceanic and Atmospheric Administration Diving Manual.[25] [69] For the following partial pressures of oxygen the limit is: 45minutes at 1.6bar (160kPa), 120minutes at 1.5bar (150kPa), 150minutes at 1.4bar (140kPa), 180minutes at 1.3bar (130kPa) and 210minutes at 1.2bar (120kPa), but is impossible to predict with any reliability whether or when toxicity symptoms will occur.[70] [71] Many Nitrox-capable dive computers calculate an oxygen loading and can track it across multiple dives. The aim is to avoid activating the alarm by reducing the ppO2 of the breathing gas or the length of time breathing gas of higher ppO2. As the ppO2 depends on the fraction of oxygen in the breathing gas and the depth of the dive, the diver obtains more time on the oxygen clock by diving at a shallower depth, by

Oxygen toxicity breathing a less oxygen-rich gas, or by shortening the duration of exposure to oxygen-rich gases.[72] [73] Diving below 60m (200ft) on air would expose a diver to increasing danger of oxygen toxicity as the partial pressure of oxygen exceeds 1.4bar (140kPa), so a gas mixture must be used which contains less than 21% oxygen (a hypoxic mixture). Increasing the proportion of nitrogen is not viable, since it would produce a strongly narcotic mixture. However, helium is not narcotic, and a usable mixture may be blended either by completely replacing nitrogen with helium (the resulting mix is called heliox), or by replacing part of the nitrogen with helium, producing a trimix.[74] Pulmonary oxygen toxicity is an entirely avoidable event while diving. The limited duration and naturally intermittent nature of most diving makes this a relatively rare (and even then, reversible) complication for divers.[18] Guidelines have been established that allow divers to calculate when they are at risk of pulmonary toxicity.[75] [76]
[77]

62

Hyperbaric setting
The presence of a fever or a history of seizure is a relative contraindication to hyperbaric oxygen treatment.[78] The schedules used for treatment of decompression illness allow for periods of breathing air rather than 100% oxygen (oxygen breaks) to reduce the chance of seizure or lung damage. The U.S. Navy uses treatment tables based on periods alternating between 100% oxygen and air. For example, U.S.N. table 6 requires 75minutes (three periods of 20minutes oxygen/5minutes air) at an ambient pressure of 2.8 standard atmospheres (280kPa), equivalent to a depth of 18 metres (60ft). This is followed by a slow reduction in pressure to 1.9atm (190kPa) over 30minutes on oxygen. The patient then remains at that pressure for a further 150minutes, consisting of two periods of 15minutes air/60minutes oxygen, before the pressure is reduced to atmospheric over 30minutes on oxygen.[79] Vitamin E and selenium were proposed and later rejected as a potential method of protection against pulmonary oxygen toxicity.[80] [81] [82] There is however some experimental evidence in rats that vitamin E and selenium aid in preventing in vivo lipid peroxidation and free radical damage, and therefore prevent retinal changes following repetitive hyperbaric oxygen exposures.[83]

Normobaric setting
Bronchopulmonary dysplasia is reversible in the early stages by use of break periods on lower pressures of oxygen, but it may eventually result in irreversible lung injury if allowed to progress to severe damage. One or two days of exposure without oxygen breaks are needed to cause such damage.[17] Retinopathy of prematurity is largely preventable by screening. Current guidelines require that all babies of less than 32weeks gestational age or having a birth weight less than 1.5kg (3.3lb) should be screened for retinopathy of prematurity at least every two weeks.[84] The National Cooperative Study in 1954 showed a causal link between supplemental oxygen and retinopathy of prematurity, but subsequent curtailment of supplemental oxygen caused an increase in infant mortality. To balance the risks of hypoxia and retinopathy of prematurity, modern protocols now require monitoring of blood oxygen levels in premature infants receiving oxygen.[85]

Hypobaric setting
In low-pressure environments oxygen toxicity may be avoided since the toxicity is caused by high partial pressure of oxygen, not merely by high oxygen fraction. This is illustrated by modern pure oxygen use in spacesuits, which must operate at low pressure (also historically, very high percentage oxygen and lower than normal atmospheric pressure was used in early spacecraft, for example, the Gemini and Apollo spacecraft).[86] In such applications as extra-vehicular activity, high-fraction oxygen is non-toxic, even at breathing mixture fractions approaching 100%, because the oxygen partial pressure is not allowed to chronically exceed 0.3bar (4.4psi).[86]

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Management
During hyperbaric oxygen therapy, the patient will usually breathe 100% oxygen from a mask, while inside a hyperbaric chamber pressurised with air to about 2.8bar (280kPa). Seizures during the therapy are managed by removing the mask from the patient, thereby dropping the partial pressure of oxygen inspired below 0.6bar (60kPa).[20] A seizure underwater requires that the diver is brought to the surface as soon as practicable. Although for many years the recommendation has been not to raise the diver during the seizure itself, owing to the danger of arterial gas embolism,[87] there is no evidence of expiratory obstruction during seizure and benefit may be gained by raising the diver during the seizure's clonic phase.[88] Rescuers need to ensure that their own safety is not compromised during the convulsive phase. They then ensure that the victim's air supply is established and maintained, and carry out a controlled buoyant lift. Lifting an unconscious body is taught by most diver training agencies. Upon reaching the surface, emergency services are always contacted as there is a possibility of further complications requiring medical attention.[89] The U.S. Navy has procedures for completing the decompression stops where a recompression chamber is not immediately available.[90]

The retina (red) is detached at the top of the eye.

The silicone band (scleral buckle, blue) is placed The occurrence of symptoms of bronchopulmonary dysplasia or acute around the eye. This brings the wall of the eye respiratory distress syndrome is treated by lowering the fraction of into contact with the detached retina, allowing the oxygen administered, along with a reduction in the periods of exposure retina to re-attach. and an increase in the break periods where normal air is supplied. Where supplemental oxygen is required for treatment of another disease (particularly in infants), a ventilator may be needed to ensure that the lung tissue remains inflated. Reductions in pressure and exposure will be made progressively and medications such as bronchodilators and pulmonary surfactants may be used.[91]

Retinopathy of prematurity may regress spontaneously, but should the disease progress beyond a threshold (defined as five contiguous or eight cumulative hours of stage 3 retinopathy of prematurity), both cryosurgery and laser surgery have been shown to reduce the risk of blindness as an outcome. Where the disease has progressed further, techniques such as scleral buckling and vitrectomy surgery may assist in re-attaching the retina.[92]

Prognosis
Although the convulsions caused by central nervous system oxygen toxicity may lead to incidental injury to the victim, it remained uncertain for many years whether damage to the nervous system following the seizure could occur and several studies searched for evidence of such damage. An overview of these studies by Bitterman in 2004 concluded that following removal of breathing gas containing high fractions of oxygen, no long-term neurological damage from the seizure remains.[22] [93] The majority of infants who have survived following an incidence of bronchopulmonary dysplasia will eventually recover near-normal lung function, since lungs continue to grow during the first 57 years and the damage caused by bronchopulmonary dysplasia is to some extent reversible (even in adults). However, they are likely be more susceptible to respiratory infections for the rest of their lives and the severity of later infections is often greater than that in their peers.[94] [95]

Oxygen toxicity Retinopathy of prematurity (ROP) in infants frequently regresses without intervention and eyesight may be normal in later years. Where the disease has progressed to the stages requiring surgery, the outcomes are generally good for the treatment of stage 3 ROP, but are much worse for the later stages. Although surgery is usually successful in restoring the anatomy of the eye, damage to the nervous system by the progression of the disease leads to comparatively poorer results in restoring vision. The presence of other complicating diseases also reduces the likelihood of a favourable outcome.[96]

64

Epidemiology
The incidence of central nervous system toxicity among divers has decreased since the Second World War, as protocols have developed to limit exposure and partial pressure of oxygen inspired. In 1947, Donald recommended limiting the depth allowed for breathing pure oxygen to 7.6m (25ft), or a ppO2 of 1.8bar (180kPa).[98] This limit has been reduced, until today a limit of 1.4bar (140kPa) during a recreational dive and 1.6bar (160kPa) during shallow decompression stops is accepted. Oxygen toxicity has now become a rare occurrence other than when caused by equipment malfunction and Retinopathy of prematurity (ROP) is more common in middle income countries where neonatal intensive care services are increasing; but greater awareness of the problem, human error. Historically, the U.S. [97] leading to preventive measures, has not yet occurred. Navy has refined its Navy Diving Manual Tables to reduce oxygen toxicity incidents. Between 1995 and 1999, reports showed 405 surface-supported dives using the heliumoxygen tables; of these, oxygen toxicity symptoms were observed on 6 dives (1.5%). As a result, the U.S. Navy in 2000 modified the schedules and conducted field tests of 150 dives, none of which produced symptoms of oxygen toxicity. Revised tables were published in 2001.[99] The variability in tolerance and other variable factors such as workload have resulted in the U.S. Navy abandoning screening for oxygen tolerance. Of the 6,250 oxygen-tolerance tests performed between 1976 and 1997, only 6 episodes of oxygen toxicity were observed (0.1%).[100] [101] Central nervous system oxygen toxicity among patients undergoing hyperbaric oxygen therapy is rare, and is influenced by a number of a factors: individual sensitivity and treatment protocol; and probably therapy indication and equipment used. A study by Welslau in 1996 reported 16 incidents out of a population of 107,264 patients (0.015%), while Hampson and Atik in 2003 found a rate of 0.03%.[102] [103] Yildiz, Ay and Qyrdedi, in a summary of 36,500 patient treatments between 1996 and 2003, reported only 3 oxygen toxicity incidents, giving a rate of 0.008%.[102] A later review of over 80,000 patient treatments revealed an even lower rate: 0.0024%. The reduction in incidence may be partly due to use of a mask (rather than a hood) to deliver oxygen.[104] Bronchopulmonary dysplasia is among the most common complications of prematurely born infants and its incidence has grown as the survival of extremely premature infants has increased. Nevertheless, the severity has decreased as better management of supplemental oxygen has resulted in the disease now being related mainly to

Oxygen toxicity factors other than hyperoxia.[41] In 1997 a summary of studies of neonatal intensive care units in industrialised countries showed that up to 60% of low birth weight babies developed retinopathy of prematurity, which rose to 72% in extremely low birth weight babies, defined as less than 1kg (2.2lb) at birth. However, severe outcomes are much less frequent: for very low birth weight babiesthose less than 1.5kg (3.3lb) at birththe incidence of blindness was found to be no more than 8%.[97]

65

History
Central nervous system toxicity was first described by Paul Bert in 1878.[105] [106] He showed that oxygen was toxic to insects, arachnids, myriapods, molluscs, earthworms, fungi, germinating seeds, birds, and other animals. Central nervous system toxicity may be referred to as the "Paul Bert effect".[17] Pulmonary oxygen toxicity was first described by J. Lorrain Smith in 1899 when he noted central nervous system toxicity and discovered in experiments in mice and birds that 0.43bar (43kPa) had no effect but 0.75bar (75kPa) of oxygen was a pulmonary irritant.[32] Pulmonary toxicity may be referred to as the "Lorrain Smith effect".[17] The first recorded human exposure was undertaken in 1910 by Bornstein when two men breathed oxygen at 2.8bar (280kPa) for 30minutes while he went on to 48minutes with no symptoms. In 1912, Bornstein developed cramps in his hands and legs while breathing oxygen at Paul Bert, a French physiologist, first described oxygen toxicity in 1878. 2.8bar (280kPa) for 51minutes.[6] Smith then went on to show that intermittent exposure to a breathing gas with less oxygen permitted the lungs to recover and delayed the onset of pulmonary toxicity.[32] Albert R. Behnke et al. in 1935 were the first to observe visual field contraction (tunnel vision) on dives between 1.0bar (100kPa) and 4.1bar (410kPa).[107] [108] During World War II, Donald and Yarbrough et al. performed over 2,000 experiments on oxygen toxicity to support the initial use of closed circuit oxygen rebreathers.[42] [109] Naval divers in the early years of oxygen rebreather diving developed a mythology about a monster called "Oxygen Pete", who lurked in the bottom of the Admiralty Experimental Diving Unit "wet pot" (a water-filled hyperbaric chamber) to catch unwary divers. They called having an oxygen toxicity attack "getting a Pete".[110] [111] In the decade following World War II, Lambertsen et al. made further discoveries on the effects of breathing oxygen under pressure as well as methods of prevention.[112] [113] Their work on intermittent exposures for extension of oxygen tolerance and on a model for prediction of pulmonary oxygen toxicity based on pulmonary function are key documents in the development of standard operating procedures when breathing elevated pressures of oxygen.[18] Lambertsen's work showing the effect of carbon dioxide in decreasing time to onset of central nervous system symptoms has influenced work from current exposure guidelines to future breathing apparatus design.[24] [25] [114] Retinopathy of prematurity was not observed prior to World War II, but with the availability of supplemental oxygen in the decade following, it rapidly became one of the principal causes of infant blindness in developed countries. By 1960 the use of oxygen had become identified as a risk factor and its administration restricted. The resulting fall in retinopathy of prematurity was accompanied by a rise in infant mortality and hypoxia-related complications. Since then, more sophisticated monitoring and diagnosis have established protocols for oxygen use which aim to balance between hypoxic conditions and problems of retinopathy of prematurity.[97] Bronchopulmonary dysplasia was first described by Northway in 1967, who outlined the conditions that would lead to the diagnosis.[115] This was later expanded by Bancalari and in 1988 by Shennan, who suggested the need for supplemental oxygen at 36weeks could predict long-term outcomes.[116] Nevertheless, Palta et al. in 1998 concluded that radiographic evidence was the most accurate predictor of long-term effects.[117]

Oxygen toxicity Bitterman et al. in 1986 and 1995 showed that darkness and caffeine would delay the onset of changes to brain electrical activity in rats.[26] [27] In the years since, research on central nervous system toxicity has centred on methods of prevention and safe extension of tolerance.[118] Sensitivity to central nervous system oxygen toxicity has been shown to be affected by factors such as circadian rhythm, drugs, age, and gender.[119] [120] [121] [122] In 1988, Hamilton et al. wrote procedures for the National Oceanic and Atmospheric Administration to establish oxygen exposure limits for habitat operations.[75] [76] [77] Even today, models for the prediction of pulmonary oxygen toxicity do not explain all the results of exposure to high partial pressures of oxygen.[123]

66

Society and culture

Recreational scuba divers commonly breathe nitrox containing up to 40% oxygen, while technical divers use pure oxygen or nitrox containing up to 80% oxygen. Divers who breathe oxygen fractions greater than in air (21%) need to be trained in the dangers of oxygen toxicity and how to prevent them.[69] In order to buy nitrox, a diver has to show evidence of such qualification.[124] Since the late 1990s the recreational use of oxygen has been promoted by oxygen bars, where customers breathe oxygen through a nasal cannula. Claims have been made that this reduces stress, increases energy, and lessens the effects of hangovers and headaches, despite the lack of any scientific evidence to support them.[125] There are also devices on sale that offer "oxygen massage" and "oxygen detoxification" with claims of removing body toxins and reducing body fat.[126] The American Lung Association has stated "there is no evidence that oxygen at the low flow levels used in bars can be dangerous to a normal person's health", but the U.S. Center for Drug Evaluation and Research cautions that people with heart or lung disease need their supplementary oxygen carefully regulated and should not use oxygen bars.[125] Victorian society had a fascination for the rapidly expanding field of science. In "Dr. Ox's Experiment", a short story written by Jules Verne in 1872, the eponymous doctor uses electrolysis of water to separate oxygen and hydrogen. He then pumps the pure oxygen throughout the town of Quiquendone, causing the normally tranquil inhabitants and their animals to become aggressive and plants to grow rapidly. An explosion of the hydrogen and oxygen in Dr Ox's factory brings his experiment to an end. Verne summarised his story by explaining that the effects of oxygen described in the tale were his own invention.[127] There is also a brief episode of oxygen intoxication in his "From the Earth to the Moon".[128]

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ISBN0-8089-1264-X. . [86] Webb, James T.; Olson, R.M.; Krutz, R.W.; Dixon, G.; Barnicott, P.T. (1989). "Human tolerance to 100% oxygen at 9.5 psia during five daily simulated 8-hour EVA exposures". Aviation Space and Environmental Medicine 60 (5): 41521. PMID2730484. [87] U.S. Navy Diving Manual 2008, vol.1, ch.3, p.45 [88] Mitchell, Simon J (2008-01-20). "Standardizing CCR rescue skills" (http:/ / www. rebreatherworld. com/ rebreather-accidents-incidents/ 16705-standardizing-ccr-rescue-skills-3. html#post163661). RebreatherWorld. . Retrieved 2009-05-26. This forum post's author chairs the diving committee of the Underwater and Hyperbaric Medical Society. [89] Thalmann, Edward D (2003-12-02). "OXTOX: If You Dive Nitrox You Should Know About OXTOX" (http:/ / www. diversalertnetwork. org/ medical/ articles/ article. asp?articleid=35). Divers Alert Network. . Retrieved 2008-10-20. - Section "What do you do if oxygen toxicity or a convulsion happens?" [90] U.S. Navy Diving Manual 2008, vol.2, ch.9, pp.3739 [91] "NIH MedlinePlus: Bronchopulmonary dysplasia" (http:/ / www. nlm. nih. gov/ medlineplus/ ency/ article/ 001088. htm). U.S. National Library of Medicine. . Retrieved 2008-10-02. [92] Regillo, Brown & Flynn 1998, p.184 [93] Lambertsen, Christian J. (1965). "Effects of oxygen at high partial pressure". In: Fenn, W.O.; Rahn, H. (eds.) Handbook of Physiology: Respiration (American Physiological Society) Sec3 Vol2: 102746. [94] "National Institutes of Health: What is bronchopulmonary dysplasia?" (http:/ / www. nhlbi. nih. gov/ health/ dci/ Diseases/ Bpd/ Bpd_WhatIs. html). U.S. Department of Health & Human Services. . Retrieved 2008-10-02. [95] Spear, Michael L. - reviewer, (June 2008). "Bronchopulmonary dysplasia (BPD)" (http:/ / kidshealth. org/ parent/ medical/ lungs/ bpd. html). Nemours Foundation. . Retrieved 2008-10-03. [96] Regillo, Brown & Flynn 1998, p.190 [97] Gilbert, Clare (1997). "Retinopathy of prematurity: epidemiology" (http:/ / www. cehjournal. org/ 0953-6833/ 10/ jceh_10_22_022. html). Journal of Community Eye Health (London: International Centre for Eye Health) 10 (22): 224. . [98] Donald 1947b [99] Gerth, Wayne A. (2006). "Decompression sickness and oxygen toxicity in U.S. Navy surface-supplied He-O2 diving" (http:/ / archive. rubicon-foundation. org/ 4654). Proceedings of Advanced Scientific Diving Workshop (Smithsonian Institution). ISBN20060725. . Retrieved 2008-10-02. [100] Walters, K.C.; Gould, M.T.; Bachrach, E.A.; Butler, Frank K. (2000). "Screening for oxygen sensitivity in U.S. Navy combat swimmers" (http:/ / archive. rubicon-foundation. org/ 2358). Undersea and Hyperbaric Medicine 27 (1): 216. PMID10813436. . Retrieved 2008-10-02. [101] Butler, Frank K.; Knafelc, M.E. (1986). "Screening for oxygen intolerance in U.S. Navy divers" (http:/ / archive. rubicon-foundation. org/ 3046). Undersea Biomedical Research 13 (1): 918. PMID3705251. . Retrieved 2008-10-02.

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Oxygen toxicity
[102] Yildiz, S.; Ay, H.; Qyrdedi, T. (2004). "Central nervous system oxygen toxicity during routine hyperbaric oxygen therapy" (http:/ / archive. rubicon-foundation. org/ 4007). Undersea and Hyperbaric Medicine (Undersea and Hyperbaric Medical Society, Inc) 31 (2): 18990. PMID15485078. . Retrieved 2008-10-03. [103] Hampson Neal, Atik D. (2003). "Central nervous system oxygen toxicity during routine hyperbaric oxygen therapy" (http:/ / archive. rubicon-foundation. org/ 3967). Undersea and Hyperbaric Medicine (Undersea and Hyperbaric Medical Society, Inc) 30 (2): 14753. PMID12964858. . Retrieved 2008-10-20. [104] Yildiz, S.; Aktas S, Cimsit M, Ay H, Torol E (2004). "Seizure incidence in 80,000 patient treatments with hyperbaric oxygen" (http:/ / www. ingentaconnect. com/ content/ asma/ asem/ 2004/ 00000075/ 00000011/ art00011). Aviation, Space and Environmental Medicine 75 (11): 9924. PMID15559001. . Retrieved 2009-07-01. [105] Bert, Paul (1943) [First published in French in 1878]. Barometric pressure: Researches in Experimental Physiology. Columbus, OH: College Book Company. Translated by: Hitchcock, Mary Alice; Hitchcock, Fred A. [106] British Sub-aqua Club (1985). Sport diving : the British Sub-Aqua Club diving manual. London: Stanley Paul. p.110. ISBN0-09-163831-3. OCLC12807848. [107] Behnke, Alfred R.; Johnson, F.S.; Poppen, J.R.; Motley, E.P. (1935). "The effect of oxygen on man at pressures from 1 to 4atmospheres". American Journal of Physiology 110: 56572. Note: 1atmosphere (atm) is 1.013bars. [108] Behnke, Alfred R.; Forbes, H.S.; Motley, E.P. (1935). "Circulatory and visual effects of oxygen at 3atmospheres pressure". American Journal of Physiology 114: 436442. Note: 1atmosphere (atm) is 1.013bars. [109] Donald 1992 [110] Taylor, Larry "Harris" (1993). "Oxygen Enriched Air: A New Breathing Mix?" (http:/ / www. mindspring. com/ ~divegeek/ eanx. htm). IANTD Journal. . Retrieved 2008-05-29. [111] Davis, Robert H. (1955). Deep Diving and Submarine Operations (6th ed.). Tolworth, Surbiton, Surrey: Siebe Gorman & Company Ltd. p.291. [112] Lambertsen, Christian J.; Clark, John M.; Gelfand, R. (2000). "The Oxygen research program, University of Pennsylvania: Physiologic interactions of oxygen and carbon dioxide effects and relations to hyperoxic toxicity, therapy, and decompression. Summation: 1940 to 1999". EBSDC-IFEM Report No. 3-1-2000 (Philadelphia, PA: Environmental Biomedical Stress Data Center, Institute for Environmental Medicine, University of Pennsylvania Medical Center). [113] Vann, Richard D. (2004). "Lambertsen and O2: Beginnings of operational physiology" (http:/ / archive. rubicon-foundation. org/ 3987). Undersea and Hyperbaric Medicine 31 (1): 2131. PMID15233157. . Retrieved 2008-04-29. [114] Lang 2001, pp.816 [115] Northway, W.H.; Rosan, R.C.; Porter, D.Y. (1967). "Pulmonary disease following respirator therapy of hyaline-membrane disease. Bronchopulmonary dysplasia". New England Journal of Medicine 276 (7): 35768. doi:10.1056/NEJM196702162760701. PMID5334613. [116] Shennan, A.T.; Dunn, M.S.; Ohlsson, A.; Lennox, K.; Hoskins, E.M. (1988). "Abnormal pulmonary outcomes in premature infants: prediction from oxygen requirement in the neonatal period". Pediatrics 82 (4): 52732. PMID3174313. [117] Palta, M.; Sadek, M.; Barnet, J.H.; et al. (1998). "Evaluation of criteria for chronic lung disease in surviving very low birth weight infants. Newborn Lung Project". Journal of Pediatrics 132 (1): 5763. doi:10.1016/S0022-3476(98)70485-8. PMID9470001. [118] Natoli, M.J.; Vann, Richard D. (1996). "Factors Affecting CNS Oxygen Toxicity in Humans" (http:/ / archive. rubicon-foundation. org/ 21). Report to the U.S. Office of Naval Research (Durham, NC: Duke University). . Retrieved 2008-04-29. [119] Hof, D.G.; Dexter, J.D.; Mengel, C.E. (1971). "Effect of circadian rhythm on CNS oxygen toxicity". Aerospace Medicine 42 (12): 12936. PMID5130131. [120] Torley, L.W.; Weiss, H.S. (1975). "Effects of age and magnesium ions on oxygen toxicity in the neonate chicken" (http:/ / archive. rubicon-foundation. org/ 2432). Undersea Biomedical Research 2 (3): 2237. PMID15622741. . Retrieved 2008-09-20. [121] Troy, S.S.; Ford, D.H. (1972). "Hormonal protection of rats breathing oxygen at high pressure". Acta Neurologica Scandinavica 48 (2): 23142. doi:10.1111/j.1600-0404.1972.tb07544.x. PMID5061633. [122] Hart, George B.; Strauss, Michael B. (2007). "Gender differences in human skeletal muscle and subcutaneous tissue gases under ambient and hyperbaric oxygen conditions" (http:/ / archive. rubicon-foundation. org/ 7346). Undersea and Hyperbaric Medicine 34 (3): 14761. PMID17672171. . Retrieved 2008-09-20. [123] Shykoff, Barbara E. (2007). "Performance of various models in predicting vital capacity changes caused by breathing high oxygen partial pressures" (http:/ / archive. rubicon-foundation. org/ 6867). NEDU-TR-07-13 (Panama City, FL: U.S. Naval Experimental Diving Unit Technical Report). . Retrieved 2008-06-06. [124] British Sub-Aqua Club (2006). "The Ocean Diver Nitrox Workshop" (http:/ / www. bsac. org/ uploads/ moved/ documents/ Resources/ Nitrox/ OD_Nitrox_Workshop_Student_Workbook_V00bh. pdf) (PDF). British Sub-Aqua Club. p. 6. . Retrieved 2010-09-15. [125] Bren, Linda (NovemberDecember 2002). "Oxygen Bars: Is a Breath of Fresh Air Worth It?" (http:/ / www. mamashealth. com/ doc/ oxygen. asp). FDA Consumer magazine. . Retrieved 2009-06-26. [126] O2Planet (2006). "O2 Planet - Exercise and Fitness Equipment" (http:/ / www. o2planet. com/ HTML/ fitness. html). O2Planet LLC. . Retrieved 2008-10-21. [127] Verne, Jules (2004) [1872]. A Fantasy of Dr Ox (http:/ / search. barnesandnoble. com/ A-Fantasy-of-Dr-Ox/ Jules-Verne/ e/ 9781843910671/ ?itm=1). Hesperus Press. ISBN978-1-84391-067-1. . Retrieved 2009-05-08. Translated from French. [128] Verne, Jules (1877) [1870]. "VIII [At seventy-eight thousand one hundred and fourteen leagues]" (http:/ / www. gutenberg. org/ etext/ 12901). Autour de la Lune [Round the Moon]. London: Ward Lock. ISBN2253005878. . Retrieved 2009-09-02. Translated from French.

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Oxygen toxicity

71

Sources
Clark, James M.; Thom, Stephen R. (2003). "Oxygen under pressure". In Brubakk, Alf O.; Neuman, Tom S. Bennett and Elliott's physiology and medicine of diving (5th ed.). United States: Saunders Ltd. pp.358418. ISBN0-7020-2571-2. OCLC51607923. Clark, John M.; Lambertsen, Christian J. (1970). "Pulmonary oxygen tolerance in man and derivation of pulmonary oxygen tolerance curves" (http://archive.rubicon-foundation.org/3863). IFEM Report No. 1-70 (Philadelphia, PA: Environmental Biomedical Stress Data Center, Institute for Environmental Medicine, University of Pennsylvania Medical Center). Retrieved 2008-04-29. Donald, Kenneth W. (1947). "Oxygen poisoning in manpart I". British Medical Journal 1 (4506): 66772. doi:10.1136/bmj.1.4506.667. PMC2053251. PMID20248086. Donald, Kenneth W. (1947). "Oxygen poisoning in manpart II". British Medical Journal 1 (4507): 7127. doi:10.1136/bmj.1.4507.712. PMC2053400. PMID20248096. Revised version of Donald's articles also available as: Donald, Kenneth W. (1992). Oxygen and the diver. UK: Harley Swan, 237 pages. ISBN1-85421-176-5. OCLC26894235. Lang, Michael A. (ed.) (2001). DAN nitrox workshop proceedings (http://archive.rubicon-foundation.org/ 4855). Durham, NC: Divers Alert Network, 197 pages. Retrieved 2008-09-20. Regillo, Carl D.; Brown, Gary C.; Flynn, Harry W. (1998). Vitreoretinal Disease: The Essentials. New York: Thieme, 693 pages. ISBN0-86577-761-6. OCLC39170393. U.S. Navy Supervisor of Diving (2008) (PDF). U.S. Navy Diving Manual (http://supsalv.org/pdf/ DiveMan_rev6.pdf). SS521-AG-PRO-010, revision 6. U.S. Naval Sea Systems Command. Retrieved 2009-06-29.

Further reading
Lamb, John S. (1999). The Practice of Oxygen Measurement for Divers. Flagstaff: Best Publishing, 120 pages. ISBN0-941332-68-3. OCLC44018369. Lippmann, John; Bugg, Stan (1993). The Diving Emergency Handbook. Teddington, UK: Underwater World Publications. ISBN0-946020-18-3. OCLC52056845. Lippmann, John; Mitchell, Simon (2005). "Oxygen". Deeper into Diving (2nd ed.). Victoria, Australia: J.L. Publications. pp.1214. ISBN0-9752290-1-X. OCLC66524750.

External links
General The following external site is a compendium of resources: Rubicon Research Repository (http://archive.rubicon-foundation.org/dspace/simple-search?query=oxygen+ toxicity&submit=Go). Online collection of the oxygen toxicity research Specialised The following external sites contain resources specific to particular topics: 2008 Divers Alert Network Technical Diving Conference (http://www.diversalertnetwork.org/FastAccess/ 2008TechnicalDiving.aspx). Video of "Oxygen Toxicity" lecture by Dr. Richard Vann (free download, mp4, 86MB). Physiology at MCG 4/4ch7/s4ch7_7 (http://www.lib.mcg.edu/edu/eshuphysio/program/section4/4ch7/ s4ch7_7.htm). Wide and detailed discussion of the effects of breathing oxygen on the respiratory system.

Oxygen toxicity Rajiah, Prabhakar (2009-03-11). "Bronchopulmonary Dysplasia" (http://emedicine.medscape.com/article/ 406564-overview). eMedicine. Retrieved 2009-06-29. Concise clinical overview with extensive references.

72

Partial pressure
In a mixture of ideal gases, each gas has a partial pressure which is the pressure which the gas would have if it alone occupied the volume.[1] The total pressure of a gas mixture is the sum of the partial pressures of each individual gas in the mixture. In chemistry, the partial pressure of a gas in a mixture of gases is defined as above. The partial pressure of a gas dissolved in a liquid is the partial pressure of that gas which would be generated in a gas phase in equilibrium with the liquid at the same temperature. The partial pressure of a gas is a measure of thermodynamic activity of the gas's molecules. Gases will always flow from a region of higher partial pressure to one of lower pressure; the larger this difference, the faster the flow. Gases dissolve, diffuse, and react according to their partial pressures, and not according to their concentrations in gas mixtures or liquids. This general property of gasses is also true of chemical reactions of gasses in biology. For example, the necessary amount of oxygen for human respiration, and the amount that is toxic, is set by the partial pressure of oxygen alone. This is true across a very wide range of different concentrations of oxygen present in various inhaled breathing gases, or dissolved in blood.

Dalton's law of partial pressures

The partial pressure of an ideal gas in a mixture is equal to the pressure it would exert if it occupied the same volume alone at the same temperature. This is because ideal gas molecules are so far apart that they don't interfere with each other at all. Actual real-world gases come very close to this ideal. A consequence of this is that the total pressure of a mixture of ideal gases is equal to the sum of the partial pressures of the individual gases in the mixture as stated by Dalton's law.[2] For example, given an ideal gas mixture of nitrogen (N2), hydrogen (H2) and ammonia (NH3):

where: = total pressure of the gas mixture = partial pressure of nitrogen (N2) = partial pressure of hydrogen (H2) = partial pressure of ammonia (NH3)

Partial pressure

73

Ideal gas mixtures

Ideally the ratio of partial pressures is the same as the ratio of molecules. That is, the mole fraction of an individual gas component in an ideal gas mixture can be expressed in terms of the component's partial pressure or the moles of the component:

and the partial pressure of an individual gas component in an ideal gas can be obtained using this expression:

where: = mole fraction of any individual gas component in a gas mixture = partial pressure of any individual gas component in a gas mixture = moles of any individual gas component in a gas mixture = total moles of the gas mixture = total pressure of the gas mixture

The mole fraction of a gas component in a gas mixture is equal to the volumetric fraction of that component in a gas mixture.[3]

Partial volume (Amagat's law of additive volume)

The partial volume of a particular gas is the volume which the gas would have if it alone occupied the volume, with unchanged pressure and temperature, and is useful in gas mixtures, e.g. air, to focus on one particular gas component, e.g. oxygen. It can be approximated both from partial pressure and molar fraction: [4]

Vx is the partial volume of any individual gas component (X) Vtot is the total volume in gas mixture Px is the partial pressure of gas X Ptot is the total pressure in gas mixture nx is the amount of substance of a gas (X) ntot is the total amount of substance in gas mixture

Partial pressure

74

Vapor pressure
Vapor pressure is the pressure of a vapor in equilibrium with its non-vapor phases (i.e., liquid or solid). Most often the term is used to describe a liquid's tendency to evaporate. It is a measure of the tendency of molecules and atoms to escape from a liquid or a solid. A liquid's atmospheric pressure boiling point corresponds to the temperature at which its vapor pressure is equal to the surrounding atmospheric pressure and it is often called the normal boiling point. The higher the vapor pressure of a liquid at a given temperature, the lower the normal boiling point of the liquid. The vapor pressure chart to the right has graphs of the vapor pressures versus temperatures for a variety of liquids.[5] As can be seen in the chart, the liquids with the highest vapor pressures have the lowest normal boiling points. For example, at any given temperature, propane has the highest vapor pressure of any of the liquids in the chart. It also has the lowest normal boiling point (-43.7 C), which is where the vapor pressure curve of propane (the purple line) intersects the horizontal pressure line of one atmosphere (atm) of absolute vapor pressure.

A typical vapor pressure chart for various liquids

Equilibrium constants of reactions involving gas mixtures

It is possible to work out the equilibrium constant for a chemical reaction involving a mixture of gases given the partial pressure of each gas and the overall reaction formula. For a reversible reaction involving gas reactants and gas products, such as:

the equilibrium constant of the reaction would be:

Partial pressure

75

where: = the equilibrium constant of the reaction = coefficient of reactant = coefficient of reactant = coefficient of product = coefficient of product = the partial pressure of = the partial pressure of = the partial pressure of = the partial pressure of raised to the power of raised to the power of raised to the power of raised to the power of

For reversible reactions, changes in the total pressure, temperature or reactant concentrations will shift the equilibrium so as to favor either the right or left side of the reaction in accordance with Le Chatelier's Principle. However, the reaction kinetics may either oppose or enhance the equilibrium shift. In some cases, the reaction kinetics may be the over-riding factor to consider.

Henry's Law and the solubility of gases

Gases will dissolve in liquids to an extent that is determined by the equilibrium between the undissolved gas and the gas that has dissolved in the liquid (called the solvent).[6] The equilibrium constant for that equilibrium is: (1)
where: = the equilibrium constant for the solvation process = partial pressure of gas = the concentration of gas in equilibrium with a solution containing some of the gas in the liquid solution

The form of the equilibrium constant shows that the concentration of a solute gas in a solution is directly proportional to the partial pressure of that gas above the solution. This statement is known as Henry's Law and the equilibrium constant is quite often referred to as the Henry's Law constant.[6] [7] [8] Henry's Law is sometimes written as:[9] (2) where above, is also referred to as the Henry's Law constant.[9] As can be seen by comparing equations (1) and (2) is the reciprocal of . Since both may be referred to as the Henry's Law constant, readers of the technical

literature must be quite careful to note which version of the Henry's Law equation is being used. Henry's Law is an approximation that only applies for dilute, ideal solutions and for solutions where the liquid solvent does not react chemically with the gas being dissolved.

Partial pressure

76

Partial pressure in diving breathing gases

In recreational diving and professional diving the richness of individual component gases of breathing gases is expressed by partial pressure. Using diving terms, partial pressure is calculated as: partial pressure = total absolute pressure x volume fraction of gas component For the component gas "i": ppi = P x Fi For example, at 50 metres (165 feet), the total absolute pressure is 6 bar (600 kPa) (i.e., 1 bar of atmospheric pressure + 5 bar of water pressure) and the partial pressures of the main components of air, oxygen 21% by volume and nitrogen 79% by volume are: ppN2 = 6 bar x 0.79 = 4.7 bar absolute ppO2 = 6 bar x 0.21 = 1.3 bar absolute
where: ppi P Fi ppN2 ppO2 = partial pressure of gas component i = = total pressure = in the terms used in this article

in the terms used in this article , in the terms used in this article

= volume fraction of gas component i = mole fraction, = partial pressure of nitrogen = = partial pressure of oxygen =

in the terms used in this article in the terms used in this article

The minimum safe lower limit for the partial pressures of oxygen in a gas mixture is 0.16 bar (16 kPa) absolute. Hypoxia and sudden unconsciousness becomes a problem with an oxygen partial pressure of less than 0.16 bar absolute. Oxygen toxicity, involving convulsions, becomes a problem when oxygen partial pressure is too high. The NOAA Diving Manual recommends a maximum single exposure of 45 minutes at 1.6 bar absolute, of 120 minutes at 1.5 bar absolute, of 150 minutes at 1.4 bar absolute, of 180 minutes at 1.3 bar absolute and of 210 minutes at 1.2 bar absolute. Oxygen toxicity becomes a risk when these oxygen partial pressures and exposures are exceeded. The partial pressure of oxygen determines the maximum operating depth of a gas mixture. Nitrogen narcosis is a problem when breathing gases at high pressure. Typically, the maximum total partial pressure of narcotic gases used when planning for technical diving is 4.5bar absolute, based on an equivalent narcotic depth of 35 metres (115ft).

References
[1] [2] [3] [4] [5] [6] [7] [8] [9] Charles Henrickson (2005). Chemistry. Cliffs Notes. ISBN0-764-57419-1. Dalton's Law of Partial Pressures (http:/ / dbhs. wvusd. k12. ca. us/ webdocs/ GasLaw/ Gas-Dalton. html) Pittsburgh University chemical engineering class notes (http:/ / granular. che. pitt. edu/ ~mccarthy/ che0035/ MB/ single/ ideal. html) Page 200 in: Medical biophysics. Flemming Cornelius. 6th Edition, 2008. Perry, R.H. and Green, D.W. (Editors) (1997). Perry's Chemical Engineers' Handbook (7th ed.). McGraw-Hill. ISBN0-07-049841-5. Intute University Introductory Chemistry (http:/ / www. intute. ac. uk/ sciences/ reference/ plambeck/ chem2/ p01182. htm) University of Delaware physical chemistry lecture (http:/ / www. udel. edu/ pchem/ C443/ Lectures/ Lecture33. pdf) Rice University chemistry class notes (http:/ / www. owlnet. rice. edu/ ~chem312/ Class Summaries/ Class12. html) University of Arizona chemistry class notes (http:/ / www. chem. arizona. edu/ ~salzmanr/ 103a004/ nts004/ l41/ l41. html)

Rebreather

77

Rebreather
A rebreather is a type of breathing set that provides a breathing gas containing oxygen and recycled exhaled gas. This recycling reduces the volume of breathing gas used, making a rebreather lighter and more compact than an open-circuit breathing set for the same duration in environments where humans cannot safely breathe from the atmosphere. In the armed forces it is sometimes called "CCUBA" (Closed Circuit Underwater Breathing Apparatus). Rebreather technology is used in many environments: Underwater where it is sometimes known as CCR = "closed circuit rebreather", "closed circuit scuba", "semi closed scuba", SCR = "semi closed rebreather", or CCUBA = "closed circuit underwater breathing apparatus", as opposed to Aqua-Lung-type equipment, which is known as "open circuit scuba".[1] Mine rescue and in industry where poisonous gases may be present or oxygen may be absent. Crewed spacecraft and space suits outer space is, for all intents and purposes, a vacuum where there is no oxygen to support life. Hospital anaesthesia breathing systems to supply controlled proportions of gases to patients without letting anaesthetic gas get into the atmosphere that the staff breathe.
A fully closed circuit electronic rebreather (Ambient Pressure Diving Inspiration)

Submarines and hyperbaric oxygen therapy chambers where the gas in the habitat must remain safe. Here the rebreather is big and is connected to the air in the habitat. Himalayan mountaineering. Both chemical and compressed oxygen has been used in experimental closed-circuit oxygen systemsthe first on Mt. Everest in 1938. A high rate of system failures due to extreme cold has not been solved.[2]

Theory
As a person breathes, the body consumes oxygen and makes carbon dioxide. At shallow depths, a person with an open-circuit breathing set typically only uses about a quarter of the oxygen in the air that is breathed in (4%5% of the inspired volume). The remaining oxygen is exhaled along with nitrogen and carbon dioxide. As the diver goes deeper, roughly the same quantity of oxygen is used, which represents an increasingly smaller fraction of the compressed air breathed in. Because exhaled air can contain as much as 79% nitrogen (which is not utilized in the body) and 16% (or more) unused oxygen, every exhaled breath from an open-circuit scuba set represents at least 95% wasted, potentially useful gas volume, which has to be replaced from the air supply. The rebreather recirculates the exhaled gas for re-use and does not discharge it to the atmosphere or water.[1] [3] It absorbs the carbon dioxide, which otherwise would accumulate and cause carbon dioxide poisoning. It removes the carbon dioxide by a process called scrubbing.[1] The rebreather adds oxygen, to replace the oxygen that was consumed.[1] Thus, the gas in the rebreather's circuit remains breathable and supports life and the diver needs only a fraction of the gas that would be required for an open-circuit system.

Rebreather

78

History of rebreathers
Around 1620 in England, Cornelius Drebbel made an early oar-powered submarine. Records show that, to re-oxygenate the air inside it, he likely generated oxygen by heating saltpetre (potassium nitrate) in a metal pan to make it emit oxygen. That would turn the saltpetre into potassium oxide or hydroxide, which would tend to absorb carbon dioxide from the air around. That may explain how Drebbel's men were not affected by carbon dioxide build-up as much as would be expected. If so, he accidentally made a crude rebreather more than two centuries before Saint Simon Sicard's patent.[4] The oldest known rebreather used an oxygen reservoir and relates to the 1849 patent from the Frenchman Pierre Aimable De Saint Simon Sicard.[5] In 1853 Professor T. Schwann designed a rebreather in Belgium; he exhibited it in Paris in 1878.[6] In 1878 Henry Fleuss invented a rebreather using stored oxygen and absorption of carbon dioxide by an absorbent (here rope yarn soaked in caustic potash solution), to rescue mineworkers who were trapped by water.[7] [8] The Davis Escape Set was the first rebreather which was practical for use and produced in quantity. It was designed about 1900 in Britain for escape from Royal Navy frogman in 1945 sunken submarines. Various industrial oxygen rebreathers (e.g. the Siebe Gorman Salvus and the Siebe Gorman Proto, both invented in the early 1900s) were descended from it; this link shows a Draeger rebreather used for mines rescue in 1907.

[9]

In 1903 to 1907 Professor Georges Jaubert, invented Oxylithe, which is a form of sodium peroxide (Na2O2) or sodium dioxide (NaO2). As it absorbs carbon dioxide it emits oxygen. In 1909 Captain S.S. Hall, R.N., and Dr. O. Rees, R.N., developed a submarine escape apparatus using Oxylithe; the Royal Navy accepted it. It was used for shallow water diving but never in a submarine escape;[8] it was used in the first filming (1907) of Twenty Thousand Leagues Under the Sea. The first recorded mass production of rebreathers started in 1912 with the Drger rebreathers, invented some years sooner by an engineer of the Drger company, Hermann Stelzner.[10] The Drger rebreathers, especially the DM40 model series, were those used by the German helmet divers during World War II. Another systematic use of rebreathers for diving was by Italian sport spearfishers in the 1930s. This practice came to the attention of the Italian Navy, which developed its frogman unit Decima Flottiglia MAS, which was used effectively in World War II.[8] In World War II captured Italian frogmen's rebreathers influenced design of British frogmen's rebreathers.[8] Many British frogmen's breathing sets' oxygen cylinders were German pilot's oxygen cylinders recovered from shot-down German Luftwaffe planes. Those first breathing sets may have been modified Davis Submarine Escape Sets; their fullface masks were the type intended for the Siebe Gorman Salvus. But in later operations different designs were used, leading to a fullface mask with one big face window, at first oval like in this image, and later rectangular (mostly flat, but the ends curved back to allow more vision sideways). Early British frogman's rebreathers had rectangular breathing bags on the chest like Italian frogman's rebreathers; later British frogman's rebreathers had a square recess in the top so they could extend further up onto his shoulders; in front they had a rubber collar that was clamped around the absorbent canister, as in the illustration below.[8] Some British armed forces divers used bulky thick diving suits called Sladen suits; one version of it had a flip-up single window for both eyes to let the user get binoculars to his eyes when on the surface.

Rebreather In the early 1940s US Navy rebreathers were developed by Dr. Christian J. Lambertsen for underwater warfare and is considered by the US Navy as "the father of the Frogmen".[11] [12] Lambertsen held the first closed-circuit oxygen rebreather course in the United States for the Office of Strategic Services maritime unit at the Naval Academy on 17 May 1943.[12] [13]

79

Advantages of rebreather diving

Efficiency advantages
The main advantage of the rebreather over other breathing equipment is the rebreather's economical use of gas. With open circuit scuba, the entire breath is expelled into the surrounding water when the diver exhales. A breath inhaled from an open circuit scuba system whose cylinders are filled with ordinary air is about 21%[14] oxygen. When that breath is exhaled back into the surrounding environment, it has an oxygen level in the range of 15 to 16% when the diver is at atmospheric pressure.[14] This leaves the available oxygen utilization at about 25%; the remaining 75% is lost. As the remaining 79% of the breathing gas (mostly nitrogen) is inert, the diver on open-circuit scuba only uses about 5% of his cylinders' contents. At depth, the advantage of a rebreather is even more marked. Since the generation of CO2 is directly related to the body's consumption of O2 (about ~99.5% of O2 is converted to CO2 on exhalation), the amount of O2 consumption doesn't change, therefore CO2 generation doesn't change. This means that at depth, the diver is not using any more of the O2 gas supply than when shallower. This is a marked difference from open circuit where the amount of gas used is directly proportional to the depth.

Feasibility advantages
Long or deep dives using open circuit equipment may not be feasible as there are limits to the number and weight of diving cylinders the diver can carry. The economy of gas consumption is also useful when the gas mix being breathed contains expensive gases, such as helium. In normal use, only oxygen is consumed: small volumes of expensive inert gases are reused during (only) one dive, due to venting of the gas on ascent. For example, a closed circuit rebreather diver effectively doesn't use any of their diluent gas once they've reached the bottom phase of the dive; they could turn off their diluent. On ascent, no diluent is added, however most of that in circuit is lost. A very small amount of trimix would then last for many dives. It is not uncommon for a 3litre (19cubicfoot) diluent cylinder to last for eight 40m (130ft) dives.

Other advantages
Except on ascent, closed circuit rebreathers produce no bubbles and make no bubble noise and much less gas hissing, unlike open-circuit scuba;[14] this can conceal military divers and allow divers engaged in marine biology and underwater photography to avoid alarming marine animals and thereby get closer to them.[15] This lack of exhale also allows shipwreck divers to enter enclosed areas on sunken ships and avoid slowly filling them with air, which then supports the growth of rust. The fully closed circuit rebreather is able to minimise the proportion of inert gases in the breathing mix, and therefore minimise the decompression requirements of the diver, by maintaining a specific and relatively high oxygen partial pressure (ppO2) at all depths. The breathing gas in a rebreather is warmer and more moist than the dry and cold gas from open circuit equipment making it more comfortable to breathe on long dives and causing less dehydration in the diver. Most modern rebreathers have a system of very sensitive oxygen sensors, which allow the diver to adjust the partial pressure of oxygen. This can offer a dramatic advantage at the end of deeper dives, where a diver can raise the partial pressure of oxygen somewhat at shallower depth, in order to shorten decompression times. Care must be taken that the ppO2 is not set to a level where it can become toxic though. Research has shown that a ppO2 of 1.6 bar is toxic

Rebreather with extended exposure[16] One major difference between rebreather diving and open-circuit scuba diving is in keeping neutral buoyancy. When an open-circuit scuba diver inhales, a quantity of highly compressed gas from his cylinder is reduced in pressure by a regulator, and enters the lungs at a much higher volume than it occupied in the cylinder. This means that the diver has a tendency to rise slightly with each inhalation, and lower slightly with each exhalation. This does not happen to a rebreather diver, because the diver is circulating a roughly constant volume of gas between his lungs and the breathing bag.

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Main rebreather design variants

Oxygen rebreather
This is the oldest type of rebreather and was commonly used by navies from the early twentieth century. Oxygen rebreathers can be remarkably simple designs, and their invention predates that of open-circuit scuba. The only gas that it supplies is oxygen.[17] As pure oxygen is toxic when inhaled at pressure, oxygen rebreathers are currently limited to a depth of 6 meters (20ft); some say 9 meters (30ft). In the past they have been used deeper (up to 20 meters) but such dives were more risky than what is now considered acceptable. Oxygen rebreathers are also sometimes used when decompressing from a deep open-circuit dive, as breathing pure oxygen makes the nitrogen diffuse out of the blood more rapidly.

Simplified diagram of the loop in an oxygen rebreather

The diving pioneer Hans Hass used Drger oxygen rebreathers in the early 1940s. In some rebreathers, e.g. the Siebe Gorman Salvus, the oxygen cylinder has two first stages in parallel. One is constant flow; the other is a plain on-off valve called a bypass; both feed into the same exit pipe which feeds the breathing bag.[7] In the Salvus there is no second stage and the gas is turned on and off at the cylinder. Some simple oxygen rebreathers had no constant-flow valve, but only the bypass, and the diver had to operate the valve at intervals to refill the breathing bag as he used the oxygen. Oxygen rebreathers are no longer commonly used in diving because of the depth limit imposed by oxygen toxicity. However, they are still the most commonly used for industrial applications on the surface, (SCBA) such as in mines, due to their simplicity and compact size.

Semi-closed circuit rebreather

Military and recreational divers use these because they provide better underwater duration than open circuit, have a deeper maximum operating depth than oxygen rebreathers and are fairly simple and cheap. Semi-closed circuit equipment generally supplies one breathing gas such as air or nitrox or trimix. The gas is injected into the loop at a constant rate to replenish oxygen consumed from the loop by the diver. Excess gas must be constantly vented from the loop in small volumes to make space for fresh, oxygen-rich gas. As the oxygen in the vented gas cannot be separated from the inert gas, semi-closed circuit is wasteful of oxygen.[18] The diver must fill the cylinders with gas mix that has a maximum operating depth that is safe for the depth of the dive being planned.

Simplified diagram of the loop in a semi-closed circuit rebreather

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As the amount of oxygen required by the diver increases with work rate, the gas injection rate must be carefully chosen and controlled to prevent unconsciousness in the diver due to hypoxia.[19] A higher gas injection rate reduces the likelihood of hypoxia but consumes more gas and wastes more oxygen.

Non-simplified diagram of the loop in a semi-closed circuit rebreather

Fully closed circuit rebreather

Military, photographic, and recreational divers use these because they allow long dives and produce no bubbles.[20] Closed circuit rebreathers generally supply two breathing gases to the loop: one is pure oxygen and the other is a diluent or diluting gas such as air or trimix. The major task of the fully closed circuit rebreather is to control the oxygen concentration, known as the oxygen partial pressure, in the loop and to warn the diver if it is becoming dangerously low or high. The concentration of oxygen in the loop depends on two factors: depth and the proportion of oxygen in the mix. Too low a concentration of oxygen results in hypoxia leading to sudden unconsciousness and ultimately death. Too high a concentration of oxygen results in hyperoxia, leading to oxygen toxicity, a condition causing convulsions which can make the diver lose the mouthpiece when they occur underwater, and can lead to drowning. In fully automatic closed-circuit systems, a mechanism injects oxygen into the loop when it detects that the partial pressure of oxygen in the loop has fallen below the required level. Often this mechanism is electrical and relies on oxygen sensitive electro-galvanic fuel cells called ppO2 meters to measure the concentration of oxygen in the loop. The diver may be able to manually control the mixture by adding diluent gas or oxygen. Adding diluent can prevent the loop's gas mixture becoming too oxygen rich. Manually adding oxygen is risky as additional small volumes of oxygen in the loop can easily raise the partial pressure of oxygen to dangerous levels.

Simplified diagram of the loop in a fully closed circuit rebreather

Non-simplified diagram of the loop in a fully closed circuit rebreather

Rebreathers using an absorbent that releases oxygen

There have been a few rebreather designs (e.g. the Oxylite) which had an absorbent canister filled with potassium superoxide, which gives off oxygen as it absorbs carbon dioxide: 4KO2 + 2CO2 = 2K2CO3 + 3O2; it had a very small oxygen cylinder to fill the loop at the start of the dive.[21] This system is dangerous because of the explosively hot reaction that happens if water gets on the potassium superoxide. The Russian IDA71 military and naval rebreather was designed to be run in this mode or as an ordinary rebreather. Tests on the IDA71 at the United States Navy Experimental Diving Unit in Panama City, Florida showed that the IDA71 could give significantly longer dive time with superoxide in one of the canisters than without.[21]

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Rebreathers which store liquid oxygen

If used underwater, the liquid-oxygen tank must be well insulated against heat coming in from the water. As a result, industrial sets of this type may not be suitable for diving, and diving sets of this type may not be suitable for use out of water. The set's liquid oxygen tank must be filled immediately before use. They include these types: Aerophor. Aerorlox [22] Cryogenic rebreather: see below. Cryogenic rebreather A cryogenic rebreather has a tank of liquid oxygen and no absorbent canister. The carbon dioxide is frozen out in a "snow box" by the cold produced as the liquid oxygen expands to gas as the oxygen is used and is replaced from the oxygen tank.
Aerorlox rebreather in a coal mining museum A cryogenic rebreather called the S-1000 was built around or soon after 1960 by Sub-Marine Systems Corporation. It had a duration of 6 hours and a maximum dive depth of 200 meters of salt water. Its ppO2 could be set to anything from 0.2 bar to 2 bar without electronics, by controlling the temperature of the liquid oxygen, thus controlling the equilibrium pressure of oxygen gas above the liquid. The diluent could be either liquid nitrogen or helium depending on the depth of the dive. The set could freeze out 230grams of carbon dioxide per hour from the loop, corresponding to an oxygen consumption of 2 liters per minute. If oxygen was consumed faster (high workload), a regular scrubber was needed.[23]

Cryogenic rebreathers were widely used in Soviet oceanography in the period 1980 to 1990.[24] [25]

Other designs
In the Siebe Gorman Proto the absorbent was in a flexible-walled compartment in the bottom of the breathing bag and not in a canister. This link [26] describes an experimental drysuit (with built-in hood and fullface mask) and rebreather combination where the drysuit acts as the breathing bag, like in an old Draeger standard diving suit variant which had a rebreather pack attached. Some British naval rebreathers (e.g. the Siebe Gorman CDBA) had a backpack weight pouch instead of the diver having a separate weight belt.

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Parts of a rebreather
The loop
Although there are several design variations of diving rebreather, all types have a gas-tight loop that the diver inhales from and exhales into. The loop consists of components sealed together. The diver breathes through a mouthpiece or a fullface mask (or with industrial breathing sets, sometimes a mouth-and-nose mask). This is connected to one or more tubes bringing inhaled gas and exhaled gas between the diver and a counterlung or breathing bag. This holds gas when it is not in the diver's lungs. The loop also includes a scrubber containing carbon dioxide absorbent to remove from the loop the carbon dioxide exhaled by the diver. Attached to the loop there will be at least one valve allowing injection of gases, such as oxygen and perhaps a diluting gas, from a gas source into the loop. There may be valves allowing venting of gas from the loop. Most modern rebreathers have a twin hose mouthpiece or breathing mask where the direction of flow of gas through the loop is controlled by one-way valves. Some have a single pendulum hose, where the inhaled and exhaled gas passes through the same tube in opposite directions. The mouthpiece often has a valve letting the diver take the mouthpiece from the mouth while underwater or floating on the surface without water getting into the loop. Many rebreathers have "water traps" in the counterlungs, to stop large volumes of water from entering the loop if the diver removes the mouthpiece underwater without closing the valve, or if the diver's lips get slack letting water leak in. Regardless of whether the rebreather in question has the facility to trap any ingress of water, any training on a rebreather will feature procedures for removing any excess water.

A simple naval-type diving oxygen rebreather with the parts labelled

Gas sources

A rebreather must have a source of oxygen to replenish that consumed by the diver. Nearly always, this oxygen is stored in a gas cylinder. Depending on the rebreather design variant, the oxygen source will either be pure or a breathing gas mixture.

Back of a closed circuit rebreather, with the casing opened

Pure oxygen is not considered to be safe for recreational diving deeper than 6 meters, so recreational rebreathers and many professional diving rebreathers also have a cylinder of diluent gas. This diluent cylinder may be filled with compressed air or another diving gas mix such as nitrox or trimix. The diluent reduces the percentage of oxygen breathed and increases the maximum operating depth of the rebreather. It is important that the diluent is not an oxygen-free gas, such as pure nitrogen or helium, and is breathable; it may be used in an emergency either to flush the loop with breathable gas or as a bailout.

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Carbon dioxide scrubber

The exhaled gases are directed through the chemical scrubber, a canister full of some suitable carbon dioxide absorbent such as a form of soda lime, which removes the carbon dioxide from the gas mixture and leaves the oxygen and other gases available for re-breathing.[14] Some absorbent chemical designed for diving applications are Sofnolime, Dragersorb, or Sodasorb. Some systems use a prepackaged Reactive Plastic Curtain (RPC)[27] based cartridge: Reactive Plastic Curtain (RPC) was first used between Micropore Inc. and the US Navy to describe Micropore's absorbent curtains for emergency submarine use, and then more recently RPC has been used on the web to describe their Reactive Plastic Cartridges ExtendAir [28]. The carbon dioxide passing through the scrubber absorbent is removed when it reacts with the absorbent in the canister; this chemical reaction is exothermic. This reaction occurs along a "front" which is a cross section of the canister, of the unreacted soda lime that is exposed to carbon dioxide-laden gas. This front moves through the scrubber canister, from the gas input end to the gas output end, as the reaction consumes the active ingredients. However, this front would be a wide zone, because the carbon dioxide in the gas going through the canister needs time to reach the surface of a grain of absorbent, and then time to penetrate to the middle of each grain of absorbent as the outside of the grain becomes exhausted. In larger environments, such as recompression chambers, a fan is used to pass gas through the canister. Scrubber failure The term "break through" means the failure of the "scrubber" to continue removing carbon dioxide from the exhaled gas mix. There are several ways that the scrubber may fail or become less efficient: Complete consumption of the active ingredient ("break through"). The scrubber canister has been incorrectly packed or configured. This allows the exhaled gas to bypass the absorbent. In a rebreather, the soda lime must be packed tightly so that all exhaled gas comes into close contact with the granules of soda lime and the loop is designed to avoid any spaces or gaps between the soda lime and the loop walls that would let gas avoid contact with the absorbent. If any of the seals, such as o rings, or spacers that prevent bypassing of the scrubber, are not cleaned or lubricated or fitted properly, the scrubber will be less efficient, or outside water or gas may get in circuit. When the gas mix is under pressure caused by depth, the inside of the canister is more crowded by other gas molecules (oxygen or diluent) and the carbon dioxide molecules are not so free to move around to reach the absorbent. In deep diving with a nitrox or other gas-mixture rebreather, the scrubber needs to be bigger than is needed for a shallow-water or industrial oxygen rebreather, because of this effect. Among British naval rebreather divers, this type of carbon dioxide poisoning was called shallow water blackout. A Caustic Cocktail Soda lime is caustic and can cause burns to the eyes and skin. A "caustic cocktail" is a mixture of water and soda lime that occurs when the "scrubber" floods. It gives rise to a chalky taste, which should prompt the diver to switch to an alternative source of breathing gas and rinse his or her mouth out with water. Many modern diving rebreather absorbents are designed not to produce "cocktail" if they get wet. in below-freezing operation (primarily mountain climbing) the wet scrubber chemicals can freeze when oxygen bottles are changed, thus preventing CO2 from reaching the scrubber material. Failure prevention An indicating dye in the soda lime. It changes the colour of the soda lime after the active ingredient is consumed. For example, a rebreather absorbent called "Protosorb" supplied by Siebe Gorman had a red dye, which was said to go white when the absorbent was exhausted. Color indicating dye was removed from US Navy fleet use in 1996 when it was suspected of releasing chemicals into the circuit.[29] With a transparent canister, this may be able to show the position of the reaction "front". This is useful in dry open environments, but is not useful on diving equipment, where:

Rebreather A transparent canister would likely be brittle and easily cracked by knocks. Opening the canister to look inside would flood it with water or let unbreathable external gas in. The canister is usually out of sight of the user, e.g. inside the breathing bag or inside a backpack box. Temperature monitoring. As the reaction between carbon dioxide and soda lime is exothermic, temperature sensors, most likely digital, along the length of the scrubber can be used to measure the position of the front and therefore the life of the scrubber.[30] [31] Diver training. Divers are trained to monitor and plan the exposure time of the soda lime in the scrubber and replace it within the recommended time limit. At present, there is no effective technology for detecting the end of the life of the scrubber or a dangerous increase in the concentration of carbon dioxide causing carbon dioxide poisoning. The diver must monitor the exposure of the scrubber and replace it when necessary. Carbon dioxide gas sensors exist, the first CO2 detector to be produced for rebreathers in a diving application was patented by Clive Wilcox of Amphilogic. Such systems are not useful as a tool for monitoring scrubber life when underwater as the onset of scrubber "break through" occurs quite rapidly. Such systems should be used as an essential safety device to warn divers to bail off the loop immediately. Effectiveness In rebreather diving, the typical effective duration of the scrubber will be half an hour to several hours of breathing, depending on the granularity and composition of the soda lime, the ambient temperature, the design of the rebreather, and the size of the canister. In some dry open environments, such as a recompression chamber or a hospital, it may be possible to put fresh absorbent in the canister when break through occurs.

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Controlling the mix

A basic need with a rebreather is to keep the partial pressure of oxygen (ppO2) in the mix from getting too low (causing hypoxia) or too high (causing oxygen toxicity). If not enough new oxygen is being added, the proportion of oxygen in the loop may be too low to support life. In humans, the urge to breathe is normally caused by a build-up of carbon dioxide in the blood, rather than lack of oxygen. The resulting serious hypoxia causes sudden blackout with little or no warning. This makes hypoxia a deadly problem for rebreather divers. In many rebreathers the diver can control the gas mix and volume in the loop manually by injecting each of the different available gases to the loop and by venting the loop. The loop often has a pressure relief valve to prevent over-pressure injuries caused by over-pressure of the loop. In some early rebreathers the diver had to manually open and close the valve to the oxygen cylinder to refill the counter-lung each time. In others the oxygen flow is kept constant by a pressure-reducing flow valve like the valves on blowtorch cylinders; the set also has a manual on/off valve called a bypass. In some modern rebreathers, the pressure in the breathing bag controls the oxygen flow like the demand valve in open-circuit scuba; for example, trying to breathe in from an empty bag makes the cylinder release more gas. Most modern closed-circuit rebreathers have electro-galvanic fuel cell sensors and onboard electronics, which monitor the ppO2, injecting more oxygen if necessary or issuing an audible warning to the diver if the ppO2 reaches dangerously high or low levels.
Narked at 90 Ltd Deep Pursuit Advanced electronic rebreather controller.

Counterlung

Rebreather The counterlung is a flexible part of the loop, which is designed to change in size by the same volume as the diver's lungs when breathing. Its purpose is to let the loop expand to hold the gas exhaled by the diver and to contract when the diver inhales letting the total volume of gas in the lungs and the loop remain constant throughout the diver's breathing cycle. Underwater, the position of the breathing bag, on the chest, over the shoulders, or on the back, has an effect on the ease of breathing. This is due to the pressure difference between the counterlung and the diver's lung caused by the vertical distance between the two. It is easier to inhale from a front mounted counterlung and exhale to a back mounted counterlung for diver swimming facedown and horizontally. The design of the rebreathers' counterlungs can also affect the swimming diver's streamlining due to location of the counterlungs themselves. Some are designed as over-the-shoulder lungs (e.g. Innerspace Systems Megalodon), while others incorporate the counter lungs into a solid case (e.g. The KISS Classic). For use out of water, this does not matter so much: for example, in an industrial version of the Siebe Gorman Salvus the breathing bag hangs down by the left hip. A rebreather whose counterlung is rubber and not in an enclosed casing, should be sheltered from sunlight when not in use, to prevent the rubber from perishing due to UV light.

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Bailout
While the diver is underwater, the rebreather may fail and be unable to provide a safe breathing mix for the duration of the ascent back to the surface. In this case the diver needs an alternative breathing source: the bailout. Although some rebreather diversreferred to as "alpinists"do not carry bailouts, bailout strategy becomes a crucial part of dive planning, particularly for long dives and deeper dives in technical diving. Often the planned dive is limited by the capacity of the bailout and not the capacity of the rebreather.
Rebreather diver with bailout and decompression cylinders

Several types of bailout are possible: An open-circuit demand valve connected to the rebreather's diluent cylinder. While this option has the advantages of being permanently mounted on the rebreather and not heavy, the quantity of gas held by the rebreather is small so the protection offered is low. An open-circuit demand valve connected to the rebreather's oxygen cylinder. This is similar to the open circuit diluent bailout except it can only safely be used in depths of 6 metres (20ft) or less because of the risk of oxygen toxicity.[32] An independent open-circuit system. The extra cylinders are heavy and cumbersome but larger cylinders let the diver carry more gas providing protection for the ascent from deeper and long dives. The breathing gas mix must be carefully chosen to be safe at all depths of the ascent. An independent closed-circuit system.

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Casing
Many rebreathers have their main parts in a hard backpack casing. This casing needs venting to let surrounding water or air in and out to allow for volume changes as the breathing bag inflates and deflates. In a diving rebreather this needs fairly large holes, including a hole at the bottom to drain the water out when the diver comes out of water. The SEFA, which is used for mine rescue, to keep grit and stones out of its working, is completely sealed, except for a large vent panel covered with metal mesh, and holes for the oxygen cylinder's on/off valve and the cylinder pressure gauge. Underwater the casing also serves for streamlining, e.g. in the IDA71 and Cis-Lunar.

Diffuser
Some military rebreathers have a diffuser over the blowoff valve, which helps to conceal the diver's presence by masking the release of bubbles.[33]

Disadvantages of rebreather diving

Risks
The percentage of deaths that involve the use of a rebreather among United States and Canadian residents increased from approximately 1 to 5% of the total diving fatalities collected by the Divers Alert Network from 1998 through 2004.[34] Investigations into rebreather deaths focus on three main areas: medical, equipment, and procedural.[34] In mountaineering, closed-circuit rebreathers are ideal to treat various altitude related illnesses as the user is brought back to sea level in terms of oxygen pp. The danger is that a sick climber using a rebreather might become unconscious. Because an absolute atmospheric seal is required for rebreathers to work correctly, such a seal could conceivably cause an unconscious user to suffocate when the oxygen ran out or the scrubber became exhausted. (Because there has been very little use of mountaineering rebreathers, this danger is still only theoretical.)

Closed circuit disorders

In addition to the other diving disorders suffered by divers, rebreather divers are also more susceptible to the following disorders (all of which are directly connected with the effectiveness of actual rebreather designs and construction, not with the theory of rebreathing): Sudden blackout due to hypoxia caused by too low a partial pressure of oxygen in the loop. A particular problem when using a closed circuit rebreather is the drop in ambient pressure caused by the ascent phase of the dive, which reduces the partial pressure of oxygen to hypoxic levels leading to what is sometimes called deep water blackout. Seizures due to oxygen toxicity caused by too high a partial pressure of oxygen in the loop. This can be caused by the rise in ambient pressure caused by the descent phase of the dive, which raises the partial pressure of oxygen to hyperoxic levels. In fully closed circuit equipment, aging oxygen sensors may become "current limited" and fail to measure high partial pressures of oxygen resulting in dangerously high oxygen levels. Disorientation, panic, headache, and hyperventilation due to excess of carbon dioxide caused by incorrect configuration, failure or inefficiency of the scrubber. The scrubber must be configured so that no exhaled gas can bypass it; it must be packed and sealed correctly. Another problem is the diver producing carbon dioxide faster than the absorbent can handle; for example, during hard work or fast swimming. The solution to this is to slow down and let the absorbent catch up. The scrubber efficiency may be reduced at depth where the increased concentration of other gas molecules, due to pressure, stops all the carbon dioxide molecules reaching the active ingredient of the scrubber. The rebreather diver must keep breathing in and out all the time, to keep the exhaled gas flowing over the carbon dioxide absorbent, so the absorbent can work all the time. Divers need to lose any air conservation habits that may have been developed while diving with open-circuit scuba. In closed circuit rebreathers, this also has the

Rebreather advantage of mixing the gases preventing oxygen-rich and oxygen-lean spaces developing within the loop, which may give inaccurate readings to the oxygen control system. "Caustic cocktail" in the loop if water comes into contact with the soda lime used in the carbon dioxide scrubber. The diver is normally alerted to this by a chalky taste in the mouth. A safe response is to bail out to "open circuit" and rinse the mouth out. Restoring the oxygen content of the loop Many diver training organizations teach the "diluent flush" technique as a safe way to restore the mix in the loop to a level of oxygen that is neither too high nor too low. It only works when partial pressure of oxygen in the diluent alone would not cause hypoxia or hyperoxia, such as when using a normoxic diluent and observing the diluent's maximum operating depth. The technique involves simultaneously venting the loop and injecting diluent. This flushes out the old mix and replaces it with a known proportion of oxygen

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Compared with open circuit

When compared with Aqua-Lungs, rebreathers have some disadvantages including expense, complexity of operation and maintenance, and fewer failsafes. A malfunctioning rebreather can supply a gas mixture which contains too little oxygen to sustain life, or it may allow carbon dioxide to build up to dangerous levels. Typically rebreathers try to solve these problems by monitoring the system with electronics, sensors and alarm systems. These are expensive and susceptible to failure, improper configuration and misuse. The bailout requirement of rebreather diving can sometimes also require a rebreather diver to carry almost as much bulk of cylinders as an open-circuit diver so the diver can complete the necessary decompression stops if the rebreather fails completely.[35] Some rebreather divers prefer not to carry enough bailout for a safe ascent breathing open circuit, but instead rely on the rebreather, believing that an irrecoverable rebreather failure is very unlikely. This practice is known as alpinism or alpinist diving and is generally maligned due to the perceived extremely high risk of death if the rebreather fails.[36]

Sport diving rebreather technology innovations

Over the past ten or fifteen years rebreather technology has advanced considerably, often driven by the growing market in recreational diving equipment. Innovations include: The electronic, fully closed circuit rebreather itself use of electronics and electro-galvanic fuel cells to monitor oxygen concentration within the loop and maintain a certain partial pressure of oxygen Automatic diluent valves these inject diluent gas into the loop when the loop pressure falls below the limit at which the diver can comfortably breathe. Dive/surface valves or bailout valves a device in the mouthpiece on the loop which connects to a bailout demand valve and can be switched to provide gas from either the loop or the demand valve without the diver taking the mouthpiece from his or her mouth. An important safety device when carbon dioxide poisoning occurs.[37] Integrated decompression computers these allow divers to take advantage of the content and generate a schedule of decompression stops. Carbon dioxide scrubber life monitoring systems temperature sensors monitor the progress of the reaction of the soda lime and provide an indication of when the scrubber will be exhausted.[38] Carbon dioxide monitoring systems Gas sensing cell and interpretive electronics which detect the presence of carbon dioxide in the unique environment of a rebreather loop. The first ever system that was proved to function correctly was patented by Clive Wilcox of Amphilogic.

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References
[1] Richardson, Drew; Menduno, Michael; Shreeves, Karl (eds). (1996). "Proceedings of Rebreather Forum 2.0." (http:/ / archive. rubicon-foundation. org/ 7555). Diving Science and Technology Workshop.: 286. . Retrieved 2008-08-20. [2] Holzel, Tom (2006). "Closed circuit oxygen system, high altitude oxygen" (http:/ / www. velocitypress. com/ closedcircuit. shtml). Velocity Press. . Retrieved 19 September 2010. [3] Goble, Steve (2003). "Rebreathers" (http:/ / archive. rubicon-foundation. org/ 7782). Journal of the South Pacific Underwater Medicine Society 33 (2): 98102. . Retrieved 2008-10-24. [4] "Cornelius Drebbel: inventor of the submarine" (http:/ / www. dutchsubmarines. com/ specials/ special_drebbel. htm). Dutch Submarines. . Retrieved 2008-02-23. [5] Saint Simon Sicard's invention as mentioned by the Muse du Scaphandre website (a diving museum in Espalion, south of France) (http:/ / www. espalion-12. com/ scaphandre/ autonomie/ autonomes_sans_detendeur. htm) [6] Bech, Janwillem. "Theodor Schwann" (http:/ / www. therebreathersite. nl/ Zuurstofrebreathers/ German/ theodore_schwann. htm). . Retrieved 2008-02-23. [7] Davis, RH (1955). Deep Diving and Submarine Operations (6th ed.). Tolworth, Surbiton, Surrey: Siebe Gorman & Company Ltd. p.693. [8] Quick, D. (1970). "A History Of Closed Circuit Oxygen Underwater Breathing Apparatus" (http:/ / archive. rubicon-foundation. org/ 4960). Royal Australian Navy, School of Underwater Medicine. RANSUM-1-70. . Retrieved 2008-04-25. [9] http:/ / www. therebreathersite. nl/ Zuurstofrebreathers/ German/ photos_draeger_1907_rescue_apparatus. htm [10] Drgerwerk page in Divingheritage.com, a specialised website. (http:/ / www. divingheritage. com/ drager. htm) [11] Vann RD (2004). "Lambertsen and O2: beginnings of operational physiology" (http:/ / archive. rubicon-foundation. org/ 3987). Undersea Hyperb Med 31 (1): 2131. PMID15233157. . Retrieved 2008-04-25. [12] Butler FK (2004). "Closed-circuit oxygen diving in the U.S. Navy" (http:/ / archive. rubicon-foundation. org/ 3986). Undersea Hyperb Med 31 (1): 320. PMID15233156. . Retrieved 2008-04-25. [13] Hawkins T (1st Quarter 2000). "OSS Maritime". The Blast 32 (1). [14] Reynolds, Glen Harlan (December 2006). "Seeking New Depths". Popular Mechanics 183 (12): 58. ISSN 0032-4558. [15] Lobel, Phillip S (2005). "Scuba Bubble Noise and Fish Behavior: A Rationale for Silent Diving Technology." (http:/ / archive. rubicon-foundation. org/ 9011). In: Godfrey, JM; Shumway, SE. Diving For Science 2005. Proceedings of the American Academy of Underwater Sciences Symposium on March 10-12, 2005 at the University of Connecticut at Avery Point, Groton, Connecticut. (American Academy of Underwater Sciences). . Retrieved 2011-01-09. [16] Manning AM. Oxygen therapy and toxicity. Vet Clin North Am Small Anim Pract 2002;32:1005-1020, v. [17] Older, P. (1969). "Theoretical Considerations in the Design of Closed Circuit Oxygen Rebreathing Equipment" (http:/ / archive. rubicon-foundation. org/ 4958). Royal Australian Navy, School of Underwater Medicine. RANSUM-4-69. . Retrieved 2008-06-14. [18] http:/ / www. bishopmuseum. org/ research/ treks/ palautz97/ rb. html [19] Elliott, D. (1997). "Some limitations of simi-closed rebreathers" (http:/ / archive. rubicon-foundation. org/ 6039). South Pacific Underwater Medicine Society Journal 27 (1). ISSN0813-1988. OCLC16986801. . Retrieved 2008-06-14. [20] Shreeves, K and Richardson, D (2006). "Mixed-Gas Closed-Circuit Rebreathers: An Overview of Use in Sport Diving and Application to Deep Scientific Diving" (http:/ / archive. rubicon-foundation. org/ 4667). In: Lang, MA and Smith, NE (eds.). Proceedings of Advanced Scientific Diving Workshop Smithsonian Institution, Washington, DC. ISBN20060725. . Retrieved 2008-06-14. [21] Kelley, JS; Herron, JM; Dean, WW; Sundstrom, EB (1968). "Mechanical and Operational Tests of a Russian 'Superoxide' Rebreather." (http:/ / archive. rubicon-foundation. org/ 3451). US Navy Experimental Diving Unit Technical Report NEDU-Evaluation-11-68. . Retrieved 2009-01-31. [22] http:/ / www. healeyhero. co. uk/ rescue/ glossary/ aerorlox. htm Fischel H., Closed circuit cryogenic SCUBA, "Equipment for the working diver" 1970 symposium, Washington, DC, USA. Marine Technology Society 1970:229-244. Cushman, L., Cryogenic Rebreather, Skin Diver magazine, June 1969, and reprinted in Aqua Corps magazine, N7, 28, 79. [24] "Popular mechanics (ru), 7(81) June 2009" (http:/ / www. popmech. ru/ article/ 5567-zhidkaya-voda-zhidkiy-vozduh/ ). . Retrieved 2009-07-17. [25] "Sportsmen-podvodnik journal, 1977" (http:/ / www. scubadiving. ru/ biblioteka/ Knigi/ sportsmen_podvodnik_046. pdf). . Retrieved 2008-07-17. [26] http:/ / www. therebreathersite. nl/ 06_Homebuilders/ secret_rebreather. htm [27] Norfleet, W and Horn, W (2003). "Carbon Dioxide Scrubbing Capabilities of Two New Non-Powered Technologies" (http:/ / archive. rubicon-foundation. org/ 4992). US Naval Submarine Medical Research Center Technical Report NSMRL-TR-1228. . Retrieved 2008-06-13. [28] http:/ / www. extendair. com/ productfrm. html [29] Lillo RS, Ruby A, Gummin DD, Porter WR, Caldwell JM (March 1996). "Chemical safety of U.S. Navy Fleet soda lime" (http:/ / archive. rubicon-foundation. org/ 2238). Undersea Hyperb Med 23 (1): 4353. PMID8653065. . Retrieved 2008-06-09. [30] Warkander, DE (2007). "DEVELOPMENT OF A SCRUBBER GAUGE FOR CLOSED-CIRCUIT DIVING. (abstract)" (http:/ / archive. rubicon-foundation. org/ 5110). Undersea Hyperb Med Society Annual Meeting. . Retrieved 2008-06-09. [31] http:/ / www. apdiving. com/ rebreathers/ vision/ scrubbermonitor/

Rebreather
[32] Lang, Michael A. (ed.) (2001). DAN nitrox workshop proceedings (http:/ / archive. rubicon-foundation. org/ 4855). Durham, NC: Divers Alert Network, 197 pages. . Retrieved 2011-07-30. [33] Chapple, JCB; Eaton, David J. "Development of the Canadian Underwater Mine Apparatus and the CUMA Mine Countermeasures dive system." (http:/ / archive. rubicon-foundation. org/ 7981). Defence R&D Canada Technical Report (Defence R&D Canada) (DCIEM 92-06). . Retrieved 2009-03-31. section 1.2.a [34] Vann RD, Pollock NW, and Denoble PJ (2007). "Rebreather Fatality Investigation" (http:/ / archive. rubicon-foundation. org/ 6997). In: NW Pollock and JM Godfrey (Eds.) the Diving for Science2007 (Dauphin Island, Ala.: American Academy of Underwater Sciences) Proceedings of the American Academy of Underwater Sciences (Twenty-sixth annual Scientific Diving Symposium). ISBN0-9800423-1-3. . Retrieved 2008-06-14. [35] Verdier C, Lee DA (2008). Motor skills learning and current bailout procedures in recreational rebreather diving. (http:/ / archive. rubicon-foundation. org/ 7282). Nitrox Rebreather Diving. DIRrebreather publishing. . Retrieved 2009-03-03. [36] Liddiard, John. "Bailout" (http:/ / www. jlunderwater. co. uk/ old_site/ photoix/ bailout/ bailout. htm). jlunderwater.co.uk. . Retrieved 2009-03-03. [37] "OC DSV BOV FFM page" (http:/ / www. therebreathersite. nl/ 01_Informative/ BOV_page/ BOV_page. html). www.therebreathersite.nl. 8 November 2010. . Retrieved 2010-12-29. [38] Warkander Dan E (2007). "Development of a scrubber gauge for closed-circuit diving" (http:/ / archive. rubicon-foundation. org/ 5110). Undersea and Hyperbaric Medicine Abstract 34. . Retrieved 2008-04-25.

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External links
RebreatherPro (http://www.rebreatherpro.com) Free searchable multimedia resource for rebreather divers Image gallery of LAR-6 and LAR-7 and FGT II and LAR V rebreathers, and other combat frogman's kit (http:// www.specwargear.com/dive&swim.html) In-depth explanation on how rebreathers work (http://www.bishopmuseum.org/research/treks/palautz97/rb. html) and many useful references in its "Further Reading" section A history of closed circuit oxygen underwater breathing apparatus (http://archive.rubicon-foundation.org/ 4960), published in 1970, plenty of images, including mountaineering rebreathers, may be slow to download Information on shallow water blackout (http://www.scuba-doc.com/latenthypoxia.html)

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Technical diving
Technical diving (sometimes referred to as Tec diving) is a form of scuba diving that exceeds the scope of recreational diving (although the vast majority of technical divers dive for recreation and nothing else). Technical divers require advanced training, extensive experience, specialized equipment and often breathe breathing gases other than air or standard nitrox.[1] The concept and term, technical diving, are both relatively recent Technical diver during a decompression stop. advents,[2] although divers have been engaging in what is now commonly referred to as technical diving for decades. The term technical diving has been credited to Michael Menduno, who was editor of the (now defunct) diving magazine AquaCorps in 1991.[3]

Definition of technical diving

There is some professional disagreement as to what the term should encompass.[4] [5] [6] Until recently, nitrox diving was considered technical, but this is no longer the case. Some say that technical diving is any type of scuba diving that is considered higher risk than conventional recreational diving. However, some advocate that this should include penetration diving (as opposed to open-water diving), whereas others contend that penetrating overhead environments should be regarded as a separate type of diving. Others seek to define technical diving solely by reference to the use of decompression.[7] Certain minority views contend that certain non-specific higher risk factors should cause diving to be classed as technical diving. Even those who agree on the broad definitions of technical diving may disagree on the precise boundaries between technical and recreational diving. PADI, the largest recreational diver training agency in North America, defines technical diving as "diving other than conventional commercial or recreational diving that takes divers beyond recreational diving limits. It is further defined as an activity that includes one or more of the following: diving beyond 40 meters/130 feet, required stage decompression, diving in an overhead environment beyond 130 linear feet from the surface, accelerated stage decompression and/or the use of multiple gas mixtures in a single dive."[8] NOAA defines technical diving in this way: "Technical diving is a term used to describe all diving methods that exceed the limits imposed on depth and/or immersion time for recreational scuba diving. Technical diving often involves the use of special gas mixtures (other than compressed air) for breathing. The type of gas mixture used is determined either by the maximum depth planned for the dive, or by the length of time that the diver intends to spend underwater. While the recommended maximum depth for conventional scuba diving is 130ft, technical divers may work in the range of 170ft to 350ft, sometimes even deeper. Technical diving almost always requires one or more mandatory decompression "stops" upon ascent, during which the diver may change breathing gas mixes at least once."[9] NOAA does not address issues relating to overhead environments in its definition. The following table tries to describe the differences between technical and recreational diving.

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Technical Diving
Activity Deep diving Decompression [11] diving Mixed gas diving Gas switching Recreational Maximum depth of 40 metres (130ft) No decompression [10] Technical Beyond 40 metres (130ft) Decompression diving

Air and Nitrox Single gas used

Trimix, Heliox, Heliair and Hydrox May switch between gases to accelerate decompression and/or "travel mixes" to permit descent carrying hypoxic gas mixes Deeper penetration

Wreck diving

Penetration limited to "light zone" or 30 metres (100ft) depth/penetration Penetration limited to "light zone" or 30 metres [12] (100ft) depth/penetration Some agencies regard ice diving as recreational diving; PADI [13]

Cave diving

Deeper penetration

Ice diving Rebreathers Solo diving

others as technical diving. NAUI [15]

[14] [14]

Some agencies regard use of semi-closed rebreathers as recreational diving; PADI Recreational diving requires buddy system

others as technical diving. NAUI [16]

Solo diving

Depth
Technical dives may be defined as being dives deeper than about 130 feet (40m) or dives in an overhead environment with no direct access to the surface or natural light.[17] Such environments may include fresh and saltwater caves and the interiors of shipwrecks. In many cases, technical dives also include planned decompression carried out over a number of stages during a controlled ascent to the surface at the end of the dive. The depth-based definition is derived from the fact that breathing regular air while experiencing pressures causes a Diver returning from a 600ft dive progressively increasing amount of impairment due to nitrogen narcosis that normally becomes serious at depths of 100 feet (30m) or greater. Increasing pressure at depth also increases the risk of oxygen toxicity based on the partial pressure of oxygen in the breathing mixture. For this reason, technical diving often includes the use of breathing mixtures other than air. These factors increase the level of risk and training required for technical diving far beyond that required for recreational diving. This is a fairly conservative definition of technical diving.

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Inability to ascend directly

Technical dives may alternatively be defined as dives where the diver cannot safely ascend directly to the surface either due to a mandatory decompression stop or a physical ceiling. This form of diving implies a much larger reliance on redundant equipment and training since the diver must stay underwater until it is safe to ascend or the diver has left the overhead environment. Decompression stops A diver at the end of a long or deep dive may need to do decompression stops to avoid decompression sickness, also known as the "bends". Metabolically inert gases in the diver's breathing gas, such as nitrogen and helium, are absorbed into body tissues when inhaled under high pressure during the deep phase of the dive. These dissolved gases must be released slowly from body tissues by pausing or "doing stops" at various depths during the ascent to the surface. In recent years, most technical divers have greatly increased the depth of the first stops to reduce the risk of bubble formation before the more traditional, long, Free floating decompression stop. shallow stops. Most technical divers breathe enriched oxygen breathing gas mixtures such as nitrox during the beginning and ending portion of the dive. To avoid nitrogen narcosis while at maximum depth, it is common to use trimix which adds helium to replace nitrogen in the diver's breathing mixture. Pure oxygen is then used during shallow decompression stops to reduce the time needed by divers to rid themselves of most of the remaining excess inert gas in their body tissues, reducing the risk of "the bends." Surface intervals (time spent on the surface between dives) are usually required to prevent the residual nitrogen from building up to dangerous levels on subsequent dives. Physical ceiling These types of overhead diving can prevent the diver surfacing directly: Cave diving - diving into a cave system. Deep diving - diving into greater depths. Ice diving - diving under ice. Wreck diving - diving inside a shipwreck.

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Extremely limited visibility

Technical dives in waters where the diver's vision is severely impeded by low-light conditions, caused by silt or depth, require greater knowledge and skill to operate in such an environment, and because vision is often reduced by water currents. The combination of low visibility and swift current make these technical dives extremely risky to all but the most skilled and well-equipped divers.

Gas mixes
Technical dives may also be characterised by the use of hypoxic breathing gas mixtures other than air, such as trimix, heliox, and heliair. Breathing normal air (with 21 percent oxygen) at depths greater than 180 feet (55m) creates a high risk of oxygen toxicity. The first sign of oxygen toxicity is usually a convulsion without warning which usually results in death, as the breathing regulator falls out and the victim drowns. Sometimes the diver may get warning symptoms prior to the convulsion. These can include visual and auditory hallucinations, nausea, twitching (especially Technical divers preparing for a mixed-gas decompression dive in Bohol, in the face and hands), irritability and mood Philippines. Note the backplate and wing setup with sidemounted stage tanks swings, and dizziness. Increasing pressure containing EAN50 (left side) and pure oxygen (right side). due to depth also causes nitrogen to become narcotic, resulting in a reduced ability to react or think clearly (see nitrogen narcosis). By adding helium to the breathing mix, divers can reduce these effects, as helium does not have the same narcotic properties at depth. These gas mixes can also lower the level of oxygen in the mix to reduce the danger of oxygen toxicity. Once the oxygen is reduced below 18 percent the mix is known as a hypoxic mix as it does not contain enough oxygen to be used safely at the surface. Nitrox is another common gas mix, and while it is not used for deep diving, it decreases the build up of nitrogen within the diver's body by increasing the percentage of oxygen. This reduces the nitrogen percentage, as well as allowing for a greater number of multiple dives compared to standard air. The depth limit of nitrox is governed by the percentage of oxygen used, as there are multiple oxygen percentages available in nitrox. Further training and knowledge is required in order to use safely and understand the effects of these gases on the body during a dive. Deep air/extended range diving One of the more divisive subjects in technical diving concerns using compressed air as a breathing gas on dives below 130 feet (40m).[18] While mainstream training agencies still promote and teach such courses (TDI,[19] IANTD and DSAT/PADI), a minority (NAUI Tec, GUE, UTD) argue that diving deeper on air is unacceptably risky, saying that helium mixes should be used for dives beyond a certain limit (100130 feet (3040 m), depending upon agency). Such courses used to be referred to as "deep air" courses, but are now commonly called "extended range" courses. Deep air proponents base the proper depth limit of air diving upon the risk of oxygen toxicity. Accordingly, they view the limit as being the depth at which partial pressure of oxygen reaches 1.4 ATA, which occurs at about 186 feet (57m). Helitrox/triox proponents argue that the defining risk should be nitrogen narcosis, and suggest that when

Technical diving the partial pressure of nitrogen reaches approximately 4.0 ATA, which occurs at about 130 feet (40m), helium is necessary to offset the effects of the narcosis. Both sides of the community tend to present self-supporting data. Divers trained and experienced in deep air diving report less problems with narcosis than those trained and experienced in mixed gas diving trimix/heliox, although scientific evidence does not show that a diver can train to overcome any measure of narcosis at a given depth, or become tolerant of it.[20] The Divers Alert Network does not formally reject deep air diving per se, but indicates the additional risks involved.[21]

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Equipment
Technical divers may use unusual diving equipment. Typically, technical dives last longer than average recreational scuba dives. Because required decompression stops act as an obstacle preventing a diver in difficulty from surfacing immediately, there is a need for redundant equipment. Technical divers usually carry at least two tanks, each with its own regulator. In the event of a failure, the second tank and regulator act as a back-up system. Technical divers therefore increase their supply of available breathing gas by either connecting multiple high capacity diving cylinders and/or by using a rebreather. The technical diver may also carry additional cylinders, known as stage bottles, to ensure adequate breathing gas supply for decompression, with a reserve for bail-out in case of failure of their primary breathing gas. The stage cylinders are normally carried using an adaptation of a sidemount configuration.

Training

Technical diving requires specialised equipment and training. There are many technical training organisations: see the Technical Diving section in the list of diver training organizations. Technical Diving International (TDI), Global Underwater Explorers (GUE), Profesional Scuba Association International(PSAI), International Association of Nitrox and Technical Divers (IANTD) and National Association of Underwater Instructors (NAUI) were popular as of 2009. Recent entries into the market include Unified Team Diving (UTD), and Diving Science and Technology (DSAT), the technical arm of Professional Association of Diving Instructors (PADI). The Scuba Schools International (SSI) Technical Diving Program (TechXR Technical eXtended Range) was launched in 2005.[22] British Sub-Aqua Club (BSAC) training has always had a technical element to its higher qualifications, however, it has recently begun to introduce more technical level Skill Development Courses into all its training schemes by introducing technical awareness into its lowest level qualification of Ocean Diver, for example, and nitrox training will become mandatory. It has also recently introduced trimix qualifications and continues to develop closed circuit training.

Technical diver with decompression gases in side mounted stage cylinders.

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References
[1] Richardson, Drew (2003). "Taking 'tec' to 'rec': the future of technical diving" (http:/ / archive. rubicon-foundation. org/ 8125). South Pacific Underwater Medicine Society Journal 33 (4). . Retrieved 2009-08-07. [2] In his 1989 book, Advanced Wreck Diving, author and leading technical diver, Gary Gentile, commented that there was no accepted term for divers who dived beyond agency-specified recreational limits for non-professional purposes. Revised editions use the term technical diving, and Gary Gentile published a further book in 1999 entitled The Technical Diving Handbook. [3] Bret Gilliam (1995-01-25). Deep Diving (http:/ / books. google. com/ ?id=HVbjgdorRXAC& pg=PT1& lpg=PT1& dq=bret+ gilliam+ deep+ diving& q=). p.15. ISBN9780922769315. . Retrieved 2009-09-14.. [4] Gorman, Des F (1992). "High-tech diving". South Pacific Underwater Medicine Society Journal 22 (1). [5] Gorman, Des F (1995). "Safe Limits: A International Dive Symposium. Introduction." (http:/ / archive. rubicon-foundation. org/ 6425). South Pacific Underwater Medicine Society Journal 25 (1). . Retrieved 2009-08-07. [6] Hamilton Jr, RW (1996). "What is technical diving? (letter to editor)" (http:/ / archive. rubicon-foundation. org/ 6266). South Pacific Underwater Medicine Society Journal 26 (1). . Retrieved 2009-08-07. [7] As most technical diving training agencies point out, references to "decompression diving" is a misnomer, as all dives involve an element of decompression as the diver off-gases. However, the term decompression diving is often used to describe diving which involves one or more mandatory decompression stops prior to surfacing. [8] PADI, Enriched Air Diving, page 91. ISBN 978-1-878663-31-3 [9] "Technical Diving" (http:/ / oceanexplorer. noaa. gov/ technology/ diving/ technical/ technical. html). NOAA. February 24, 2006. . Retrieved 2008-09-25. [10] Many recreational diving agencies recommend diving no deeper than 30 metres (100ft), and suggest an absolute limit of 40 metres (130ft). (http:/ / www. padi. com/ english/ common/ courses/ rec/ continue/ deepdiver. asp) [11] There is a reasonable body of professional opinion that considers decompression diving to be the sole differentiator for "technical" diving. SSI (http:/ / www. divessi. com/ techxr) [12] Some certification agencies prefer to the term "cavern diving" to cave penetration within recreational diving limits. [13] http:/ / www. padi. com/ padi/ en/ kd/ icedivercourse. aspx [14] http:/ / www. naui. org/ technical_divers. aspx [15] http:/ / www. padi. com/ padi/ en/ kd/ semiclosedrebreather. aspx [16] Some training agencies regard solo diving within the "recreational" sphere. SDI (http:/ / www. tdisdi. com/ index. php?did=60& site=3) [17] Mitchell, SJ (2007). "Technical Diving." (http:/ / archive. rubicon-foundation. org/ 9061). In: Moon RE, Piantadosi CA, Camporesi EM (eds.). Dr. Peter Bennett Symposium Proceedings. Held May 1, 2004. Durham, N.C.: (Divers Alert Network). . Retrieved 2011-01-15. [18] "Deep Air IS Stupdity" (http:/ / www. bluebeyond. com. au/ modx/ bluebeyond-dive-deep-air-is-stupidity. html). . Retrieved 2009-09-03. [19] "TDI - Extended Range Diver" (http:/ / www. tdisdi. com/ index. php?did=80& site=2). . Retrieved 2009-09-03. [20] Hamilton, K; Lalibert, MF; Heslegrave, R (1992). "Subjective and behavioral effects associated with repeated exposure to narcosis". Aviation, space, and environmental medicine 63 (10): 8659. PMID1417647. [21] John Lippmann, DAN. "How deep is too deep?" (http:/ / www. diversalertnetwork. org/ medical/ articles/ article. asp?articleid=29). . Retrieved 2009-09-03. [22] "SSI TechXR - Technical diving program" (http:/ / www. divessi. com/ txr). Scuba Schools International. . Retrieved 2009-06-22.

Footnotes External links

http://www.TechDivingMag.com http://www.TechnicalDiving.com Select publications on technical diving and technical diving history (http://archive.rubicon-foundation.org/ dspace/simple-search?query=technical+diving&submit=Go) - Hosted by the Rubicon Foundation RebreatherPro (http://www.rebreatherpro.com) Jill Heinerth's interactive multimedia technical diving site Transitioning to technical diving (http://www.liquidtravel.org/transitioning-to-technical-diving.html)

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Trimix (breathing gas)

Trimix is a breathing gas, consisting of oxygen, helium and nitrogen, and is often used in deep commercial diving and during the deep phase of dives carried out using technical diving techniques.[1] [2] With a mixture of three gases it is possible to create mixes suitable for different depths or purposes by adjusting the proportions of each gas. The mixture of helium and oxygen with a 0% nitrogen content is generally known as Heliox. This is frequently used as a breathing gas in deep commercial diving operations, where it is often recycled to save the expensive helium component. Analysis of two-component gases is much simpler than three component gases.

Mixes
Advantages of helium in the mix
The main reason for adding helium to the breathing mix is to reduce the proportions of nitrogen and oxygen below those of air, to allow the gas mix to be breathed safely on deep dives.[1] A lower proportion of nitrogen is required to reduce nitrogen narcosis and other physiological effects of the gas at depth. Helium has very little narcotic effect.[3] A lower proportion of oxygen reduces the risk of oxygen toxicity on deep dives. The lower density of helium reduces breathing resistance at depth.[1] [3] Because of its low molecular weight, helium enters and leaves tissues more rapidly than nitrogen as the pressure is increased or reduced (this is called on-gassing and off-gassing). Because of its lower solubility, helium does not load tissues as heavily as nitrogen, but at the same time the tissues can not support as high an amount of helium when super-saturated. In effect, helium is a faster gas to saturate and desaturate, which is a distinct advantage in saturation diving, but less so in bounce diving, where the increased rate of off-gassing is largely counterbalanced by the equivalently increased rate of on-gassing.

Disadvantages of helium in the mix

Helium conducts heat six times faster than air; often helium breathing divers carry a separate supply of a different gas to inflate drysuits. This is to avoid the risk of hypothermia caused by using helium as inflator gas. Argon, carried in a small, separate tank, connected only to the inflator of the drysuit is preferred to air, since air conducts heat 50% faster than argon.[4] Dry suits (if used together with a buoyancy compensator) still require a minimum of inflation to avoid "squeezing", i.e. damage to skin caused by pressurizing dry suit folds. Some divers suffer from hyperbaric arthralgia during descent.[5] Helium dissolves into tissues more rapidly than nitrogen as the ambient pressure is increased (this is called on-gassing). A consequence of the higher loading in some tissues is that many decompression algorithms require deeper decompression stops than a similar decompression dive using air, and helium is more likely to come out of solution and cause decompression sickness following a fast ascent.

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Advantages of reducing oxygen in the mix

Lowering the oxygen content increases the maximum operating depth and duration of the dive before which oxygen toxicity becomes a limiting factor. Most trimix divers limit their working oxygen partial pressure [PO2] to 1.4 and may reduce the PO2 further to 1.3 or 1.2 depending on the depth, the duration and the kind of breathing system used [open circuit vs closed circuit rebreather][1] [2] [6] [7]

Advantages of keeping some nitrogen in the mix

Retaining nitrogen in trimix can contribute to the prevention of High Pressure Nervous Syndrome, a problem that can occur when breathing heliox at depths beyond about 130 metres (430ft).[1] [8] [9] [10] Nitrogen is also much less expensive than helium.

Naming
Conventionally, the mix is named by its oxygen percentage, helium percentage and optionally the balance percentage, nitrogen. For example, a mix named "trimix 10/70" or trimix 10/70/20, consisting of 10% oxygen, 70% helium, 20% nitrogen is suitable for a 100-metre (330ft) dive. The ratio of gases in a particular mix is chosen to give a safe maximum operating depth and comfortable equivalent narcotic depth for the planned dive. Safe limits for mix of gases in trimix are generally accepted to be a maximum partial pressure of oxygen (ppO2see Dalton's law) of 1.0 to 1.6 bar and maximum equivalent narcotic depth of 30 to 50 m (100 to 160 ft). At 100m (330ft), "12/52" has a PPO2 of 1.3 bar and an equivalent narcotic depth of 43m (141ft). In open-circuit scuba, two classes of trimix are commonly used: normoxic trimixwith a minimum PO2 at the surface of 0.18 and hypoxic trimixwith a PO2 less than 0.18 at the surface.[11] A normoxic mix such as "19/30" is used in the 30 to 60 m (100 to 200 ft) depth range; a hypoxic mix such as "10/50" is used for deeper diving, as a bottom gas only, and cannot safely be breathed at shallow depths where the ppO2 is less than 0.18 bar. In fully closed circuit rebreathers that use trimix diluents, the mix can be hyperoxic in shallow water because the rebreather automatically adds oxygen to maintain a specific ppO2.[12] Less commonly, hyperoxic trimix is sometimes used on open circuit scuba. Hyperoxic trimix is sometimes referred to as Helitrox or TriOx. See breathing gas for more information on the composition and choice of gas blends.

Blending
Gas blending of trimix involves decanting oxygen and helium into the diving cylinder and then topping up the mix with air from a diving air compressor. To ensure an accurate mix, after each helium and oxygen transfer, the mix is allowed to cool, its pressure is measured and further gas is decanted until the correct pressure is achieved. This process often takes hours and is sometimes spread over days at busy blending stations.[13] A second method called 'continuous blending' is now gaining favor.[13] Oxygen, helium and air are blended on the intake side of a compressor. The oxygen and helium are fed into the air stream using flow meters, so as to achieve the rough mix. The low pressure mixture is analyzed for oxygen content and the oxygen and helium flows adjusted accordingly. On the high pressure side of the compressor a regulator is used to reduce pressure of a sample flow and the trimix is analyzed (preferably for both helium and oxygen) so that the fine adjustment to the intake gas flows can be made. The benefit of such a system is that the helium delivery tank pressure need not be as high as that used in the partial pressure method of blending and residual gas can be 'topped up' to best mix after the dive. This is important mainly because of the high cost of helium.

Trimix (breathing gas) Drawbacks may be that the high heat of compression of helium results in the compressor over-heating (especially in tropical climates) and that the hot trimix entering the analyzer on the high pressure side can affect the reliability of the analysis. DIY versions of the continuous blend units can be made for as little as $200 (excluding analyzers).[13]
[14]

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"Standard" mixes
Although theoretically trimix can be blended with almost any combination of helium and oxygen, a number of "standard" mixes have evolved (such as 21/35, 18/45 and 15/55). Most of these mixes originated from filling the cylinders with a certain percentage of helium, and then topping the mix with 32% enriched air nitrox. The "standard" mixes evolved because of three coinciding factors - the desire to keep that equivalent narcotic depth (END) of the mix at approximately 34 metres (112ft), the requirement to keep the partial pressure of oxygen at 1.4 ATA or below at the deepest point of the dive, and the fact that many dive shops stored standard 32% enriched air nitrox in banks, which simplified mixing.[15] The use of standard mixes makes it relatively easy to top up diving cylinders after a dive using residual mix - only helium and banked nitrox needs to be used to top up the residual gas from the last fill. The method of mixing a known nitrox mix with helium allows analysis of the fractions of each gas using only an oxygen analyser, since the ratio of the oxygen fraction in the final mix to the oxygen fraction in the initial nitrox gives the fraction of nitrox in the final mix, hence the fractions of the three components are easily calculated. It is demonstrably true that the END of a nitrox-helium mixture at its maximum operating depth (MOD) is equal to the MOD of the nitrox alone.

Hyperoxic trimix
The National Association of Underwater Instructors (NAUI) uses the term "helitrox" for hyperoxic 26/17 Trimix, i.e. 26% oxygen, 17% helium, 57% nitrogen. Helitrox requires decompression stops similar to Nitrox-I (EAN28) and has a maximum operating depth of 44 metres (144ft), where it has an equivalent narcotic depth of 35 metres (115ft). This allows diving throughout the usual recreational range, while decreasing decompression obligation and narcotic effects compared to air.[16] GUE and UTD also promote hyperoxic trimix, but prefer the term "TriOx". Other divers question whether this proliferation of terminology is useful, and feel that the term Trimix is sufficient, modified as appropriate with the terms hypoxic, normoxic and hyperoxic, and the usual forms for indicating constituent gas fraction.

History as a diving gas

1919 Professor Elihu Thompson speculates that helium could be used instead of nitrogen to reduce the breathing resistance at great depth.[17] The effects from narcosis was not proven until the salvage of the USS Squalus in 1939.[17] Heliox was used with air tables resulting in a high incidence of decompression sickness so the use of helium was discontinued.[18] 1925 The US Navy begins examining helium's potential usage and by the mid 1920's lab animals were exposed to experimental chamber dives using heliox. Soon, human subjects breathing heliox 20/80 (20% oxygen, 80% helium) had been successfully decompressed from deep dives. 1937 Several test dives are conducted with helium mixtures, including salvage diver Max "Gene" Nohl's dive to 127 meters.[19] [20]

Trimix (breathing gas) 1939 US Navy used heliox in USS Squalus salvage operation.[17] 1965 First saturation dives using heliox. 1970 Hal Watts performs dual body recovery at Mystery Sink (126 m). Cave divers Sheck Exley and Jochen Hasenmayer use heliox to a depth of 212 meters. 1979 A research team headed by Peter B. Bennett at the Duke University Medical Center Hyperbaric Laboratory began the "Atlantis Dive Series" which proved the mechanisms behind the use of trimix to prevent High Pressure Nervous Syndrome symptoms.[20] 1987 First mass use of trimix and heliox: Wakulla Springs Project. Exley teaches non-commercial divers in relation to trimix usage in cave diving. 1991 Billy Deans commences teaching of trimix diving for recreational diving. Tom Mount develops first trimix training standards (IANTD). Use of trimix spreads rapidly to North East American wreck diving community. 1994 Combined UK/USA team, including leading wreck divers John Chatterton and Gary Gentile, successfully complete a series of wreck dives on the RMS Lusitania expedition to a depth of 100 meters using trimix. 1995 The National Oceanographic and Atmospheric Administration (NOAA) and Key West Divers team up to conduct the first NOAA-sponsored trimix dives on the wreck of USS Monitor off Cape Hatteras, NC. NOAA's mix, initially called "Monitor Mix" became NOAA Trimix I, with decompression tables published in the NOAA Diving Manual. 2001 The Guinness Book of records recognises John Bennett as the first scuba diver to dive to 1000ft, using Trimix. 2005 David Shaw sets depth record for using a trimix rebreather, dying while repeating the dive.[21] [22] Source: "Trimix and heliox diving" [23]. February 14, 2002. Retrieved 2008-10-07.

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References
[1] Brubakk, A. O.; T. S. Neuman (2003). Bennett and Elliott's physiology and medicine of diving, 5th Rev ed.. United States: Saunders Ltd.. pp.800. ISBN0702025712. [2] Gernhardt, ML (2006). "Biomedical and Operational Considerations for Surface-Supplied Mixed-Gas Diving to 300 FSW." (http:/ / archive. rubicon-foundation. org/ 4655). In: Lang, MA and Smith, NE (eds). Proceedings of Advanced Scientific Diving Workshop (Washington, DC). . Retrieved 2008-08-28. [3] "Diving Physics and "Fizzyology"" (http:/ / www. bishopmuseum. org/ research/ treks/ palautz97/ phys. html). Bishop Museum. 1997. . Retrieved 2008-08-28. [4] "Thermal conductivity of some common materials" (http:/ / www. engineeringtoolbox. com/ thermal-conductivity-d_429. html). The Engineering ToolBox. 2005. . Retrieved March 9, 2010. "Argon:0.016; Air:0.024; Helium:0.142 W/mK" [5] Vann RD and Vorosmarti J (2002). "Military Diving Operations and Support" (http:/ / www. bordeninstitute. army. mil/ published_volumes/ harshEnv2/ HE2ch31. pdf). Medical Aspects of Harsh Environments, Volume 2 (Borden Institute): p980. . Retrieved 2008-08-28.

Trimix (breathing gas)

[6] Acott, C. (1999). "Oxygen toxicity: A brief history of oxygen in diving" (http:/ / archive. rubicon-foundation. org/ 6014). South Pacific Underwater Medicine Society Journal 29 (3). ISSN0813-1988. OCLC16986801. . Retrieved 2008-08-28. [7] Gerth, WA (2006). "Decompression Sickness and Oxygen Toxicity in US Navy Surface-Supplied He-O2 Diving." (http:/ / archive. rubicon-foundation. org/ 4654). In: Lang, MA and Smith, NE (eds). Proceedings of Advanced Scientific Diving Workshop (Washington, DC). . Retrieved 2008-08-28. [8] Hunger Jr, W. L.; P. B. Bennett. (1974). "The causes, mechanisms and prevention of the high pressure nervous syndrome" (http:/ / archive. rubicon-foundation. org/ 2661). Undersea Biomed. Res. 1 (1): 128. ISSN0093-5387. OCLC2068005. PMID4619860. . Retrieved 2008-08-28. [9] Bennett, P. B.; R. Coggin; M. McLeod. (1982). "Effect of compression rate on use of trimix to ameliorate HPNS in man to 686 m (2250 ft)" (http:/ / archive. rubicon-foundation. org/ 2920). Undersea Biomed. Res. 9 (4): 33551. ISSN0093-5387. OCLC2068005. PMID7168098. . Retrieved 2008-04-07. [10] Campbell, E. "High Pressure Nervous Syndrome" (http:/ / www. scuba-doc. com/ HPNS. html). Diving Medicine Online. . Retrieved 2008-08-28. [11] Tech Diver. "Exotic Gases" (http:/ / www. techdiver. ws/ exotic_gases. shtml). . Retrieved 2008-08-28. [12] Richardson, D; Menduno, M; Shreeves, K. (eds). (1996). "Proceedings of Rebreather Forum 2.0." (http:/ / archive. rubicon-foundation. org/ 7555). Diving Science and Technology Workshop.: 286. . Retrieved 2008-08-28. [13] Harlow, V (2002). Oxygen Hacker's Companion. Airspeed Press. ISBN0967887321. [14] "Continuous trimix blending with 2 nitrox sticks (English)" (http:/ / shadowdweller. skynetblogs. be/ post/ 3924720/ continuous-trimix-blending-with-2-nitrox-stic). The shadowdweller. 2006. . Retrieved 2008-08-28. [15] TDI Advanced Gas Blender manual [16] "NAUI Technical Courses: Helitrox Diver" (http:/ / www. naui. org/ technical_divers. aspx#070). NAUI Worldwide. . Retrieved 2009-06-11. [17] Acott, Chistopher (1999). "A brief history of diving and decompression illness." (http:/ / archive. rubicon-foundation. org/ 6004). South Pacific Underwater Medicine Society Journal 29 (2). ISSN0813-1988. OCLC16986801. . Retrieved 2009-03-17. [18] Behnke, Albert R. (1969). "Some early studies of decompression.". In: the Physiology and Medicine of Diving and Compressed air work. Bennett PB and Elliott DH. Eds. (Balliere Tindall Cassell): 226251. [19] staff (1937-12-13). "Science: Deepest Dive" (http:/ / www. time. com/ time/ magazine/ article/ 0,9171,758630-1,00. html). Time Magazine. . Retrieved 2011-03-16. [20] Camporesi, Enrico M (2007). "The Atlantis Series and Other Deep Dives." (http:/ / archive. rubicon-foundation. org/ 9057). In: Moon RE, Piantadosi CA, Camporesi EM (eds.). Dr. Peter Bennett Symposium Proceedings. Held May 1, 2004. Durham, N.C.: (Divers Alert Network). . Retrieved 2011-03-16. [21] Mitchell SJ, Cronj FJ, Meintjes WA, Britz HC (February 2007). "Fatal respiratory failure during a "technical" rebreather dive at extreme pressure" (http:/ / www. ingentaconnect. com/ content/ asma/ asem/ 2007/ 00000078/ 00000002/ art00001). Aviat Space Environ Med 78 (2): 816. PMID17310877. . Retrieved 2009-07-29. [22] David Shaw. "The Last Dive of David Shaw" (http:/ / www. youtube. com/ watch?v=mF4iFJ-G74o). . Retrieved 2009-11-29. [23] http:/ / www. techdiver. ws/ trimix_eng. shtml

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Article Sources and Contributors

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Breathing gas Source: http://en.wikipedia.org/w/index.php?oldid=446017928 Contributors: Adrian.benko, Ajchapman, Antarctic-adventurer, Anthony Appleyard, BAICAN XXX, Balthazarduju, Basilicofresco, Benemin, Bogdangiusca, BrendanRyan, Canis Lupus, Captain-n00dle, Casrenooij, CommonsDelinker, Correctaboot, Cybercobra, DaGizza, DabMachine, Dave3141592, Downward machine, Empyema, EncMstr, FJPB, Fibrosis, Foobar, GProcter, Gene Hobbs, Gene Nygaard, Gobonobo, Headbomb, Jaganath, Jaredroberts, Jpxt2000, Jumbo Snails, Jumping cheese, Jwinius, Keenan Pepper, Leptictidium, Leuko, Mark.murphy, Michael Hardy, Mild Bill Hiccup, Mion, NickelShoe, Nickthechemist, Nono64, Phrasecloud, RexxS, Rjwilmsi, SamH, Sbharris, Sceptre, Scubafish, Sir Vicious, Snowolf, Soap, Stewartadcock, TBloemink, TenOfAllTrades, Thumperward, 96 anonymous edits Decompression sickness Source: http://en.wikipedia.org/w/index.php?oldid=446085554 Contributors: 06jh2157, 2D, Abtract, Abyssadventurer, AdamantBMage, Aetkin, Agateller, Airwolfe04, Aitias, Alansohn, Albrozdude, Alex.tan, Altenmann, Andonic, Anthony Appleyard, Arcadian, Autarch, AzaToth, Badger Drink, Balexander667, Bbatsell, Bbtommy, Bcorr, Bento00, Betacommand, Blackhawk charlie2003, Bletch, Bluelion, Bnet504, Bobo192, Bryan Derksen, Bsadowski1, Btyner, Bushytails, Cab88, Can't sleep, clown will eat me, Capricorn42, Chinasaur, Chris the speller, ChrisCork, Chrislk02, Christian75, Clotho, Cobaltcigs, CommonsDelinker, Crum375, Cyclonenim, Darth Maddolis, Darthgriz98, Dassaultdriver, Dave3141592, David Eppstein, DavidCary, Dazzamcnazzar, Decodiver, Deglr6328, Dekisugi, Denislarsen, Dfrg.msc, Dougofborg, Dr. Blofeld, Dr. Doof, Draeco, Drgarden, Drilnoth, Drphilharmonic, Dulciana, Dycedarg, EdDavies, Egmontaz, El C, Eleassar777, EncMstr, Epbr123, Eraserhead1, Erich gasboy, Ex nihil, Excirial, Expyram, Extraordinary, Famously Sharp, Faradayplank, Fbv65edel, Felsenst, Finavon, Fudoreaper, Fuzheado, GProcter, GTBacchus, GaryW, Gene Hobbs, Gene Nygaard, Geoventurer, Gr0ff, Graham87, Greg L, Grfnkmp, Gkhan, HappierPanda, Hawkeye1444, Headbomb, Hello32020, Herd of Swine, Heron, Hicville50, Hike395, Horsten, Hu12, Hut 8.5, Ijustam, J.delanoy, Jack Merridew, Jammelsauce, Jmh649, John of Reading, Johnred32, JoshG, Jrdioko, KNewman, Karenjc, Kbh3rd, Keith Edkins, Kevin Saff, Kingpin13, Kingturtle, Kitsunedai, Kosebamse, Kubigula, LOL, Legis, Leuko, Lightmouse, Longhair, Lowellian, MKoltnow, Malcolm Farmer, ManHomewood, Mark Richards, Mark.murphy, Markjoseph125, Marsian, Max Schwarz, Mbeatty, Mceder, MeltBanana, Mentifisto, Mh26, Michael Hardy, Michaelsbll, Michagal, Mike1024, Minesweeper, Moondyne, Mottmon, Mushroom, Nehrams2020, Nicholasjarvie, NikoSilver, Nitroshockwave, Nono64, Norman Yarvin, Nuggetboy, Nuttycoconut, OAC, Oblivious, Otsykes, Owain.davies, PacificBoy, Pardon me stellar, Patrick, Patstuart, Pazzah, Pbsouthwood, PhilipMW, PierreAbbat, Piledhigheranddeeper, Pinikas, Pjf, Porqin, PowerCS, Procpuarie, Rdsmith4, Rep07, RexxS, Richard W.M. Jones, Rjwilmsi, Rogerd, Ron S, Rosarinagazo, Roseanne74, RupertMillard, Sanguinity, Sbharris, ScottJ, Scubadoc, Seejyb, Sfmammamia, SilentGuy, SiobhanHansa, Sirius683, Snigbrook, SomeStranger, Spellmaster, Stefan, Supaluminal, Swpb, Taoster, Tarquin, Tempodivalse, The Anome, The Thing That Should Not Be, Thiseye, Tide rolls, Tnxman307, Tom Yates, Trevor MacInnis, Trumpet marietta 45750, Trelio, Vargob, Vasi, Voyaging, W guice, Walton One, Wellspring, WesleyDodds, WikiLaurent, WillyJS, Wizardman, Wokwiki424, Woohookitty, X!, Xzqx, Zachlipton, 381 ,55 anonymous edits Deep diving Source: http://en.wikipedia.org/w/index.php?oldid=438713788 Contributors: 2, 84user, Alfie66, Animesouth, Anthony Appleyard, Aqualungs, Auraavail, Bryan Derksen, D0762, Davewild, David Newton, Dekisugi, DelanaSmall, Derek.cashman, DiverDave, Docu, Ebayburt, Ellipsis, Gene Hobbs, Hamiltondaniel, Huw Powell, Ianjm, JohnI, Kanazawakid, Legis, Lightmouse, Mark.murphy, Monk3ysonfire, MrWhipple, Nonoisense, OceanVortex, Oleg Eterevsky, Onco p53, Owain.davies, Pjf, Plutonium27, Poppy, ReelExterminator, RexxS, Rholton, RichSed, Selachi, Sirscuba, SpiderJon, Thomei08, Toon05, Vasi, Watch Rider, Wavelength, Xosema, Zaratus, 64 anonymous edits Equivalent air depth Source: http://en.wikipedia.org/w/index.php?oldid=374000974 Contributors: Anthony Appleyard, Chessphoon, Gene Hobbs, GregorB, KRBROWN92, Kaal, Mark.murphy, Michael Hardy, Paul A, RexxS, Steinsky, YK Times, 4 anonymous edits Equivalent narcotic depth Source: http://en.wikipedia.org/w/index.php?oldid=375646843 Contributors: CBM, Paul A, RexxS, 6 anonymous edits High-pressure nervous syndrome Source: http://en.wikipedia.org/w/index.php?oldid=444229703 Contributors: Aarchiba, Angry bee, Anthony Appleyard, Cvf-ps, Dbutler1986, Dhartung, Elendil's Heir, Fang Aili, Feezo, Gene Hobbs, Gene Nygaard, Hamiltondaniel, Mark.murphy, RexxS, Rob.bastholm, Scubasixstring, Strait, Swpb, Tony1, Trovatore, Verne Equinox, Wavelength, Zantolak, 26 anonymous edits List of diving hazards and precautions Source: http://en.wikipedia.org/w/index.php?oldid=446018402 Contributors: Aarchiba, Alai, Andreas Ravn, Anthony Appleyard, BD2412, Beach drifter, Benea, Benjicharlton, Clovis Sangrail, DiverDave, Elkman, ErelOnline, Erich gasboy, Ewlyahoocom, Ex nihil, Fiftytwo thirty, GULLIVER ARM, Gene Hobbs, GoatOverlord, Haruth, Hmoul, JHunterJ, Jaganath, Joyous!, Kbdank71, Kosebamse, Legis, Leuko, Longhair, MacGyverMagic, Mark.murphy, Marshman, Mbell, Mingfx, Mion, Neckro, Nehrams2020, Neutrality, Nono64, Otsykes, Owain.davies, Pazzah, Pbsouthwood, Randroide, RexxS, RoyBoy, SCEhardt, Smile a While, Swpb, Vary, Youremyjuliet, 48 anonymous edits Maximum operating depth Source: http://en.wikipedia.org/w/index.php?oldid=445676160 Contributors: A930913, Anthony Appleyard, Diza, Euchiasmus, Gambitq72, Gene Hobbs, Hibsch, Huw Powell, Lightdarkness, Lumpy Dog, Mark.murphy, Pearle, RexxS, Sbharris, Sn0wflake, Unixsage, WikiWayne, Xanzzibar, 5 anonymous edits Nitrogen narcosis Source: http://en.wikipedia.org/w/index.php?oldid=446002188 Contributors: (, 151.24.146.xxx, 151.24.190.xxx, 62.253.64.xxx, 62.92.51.xxx, 63.61.173.xxx, Aarchiba, Acdx, Adashiel, Alansohn, Amore proprio, Aquaregia27, Arrenlex, Arsenikk, BaileyZRose, Barticus88, Chzz, Cmdrjameson, Colonies Chris, Conversion script, Crum375, DMG413, Darthgriz98, Dave3141592, David Fuchs, Derek.cashman, Dinomite, Dogosaurus, Dougluce, DragonflySixtyseven, Erich gasboy, Eubulides, Extraordinary, Feezo, Finavon, FirstPrinciples, Floaterfluss, Foobar, Franamax, Gaius Cornelius, Garion96, Gene Hobbs, Gogo Dodo, Gr0ff, Graham87, Hqb, Huw Powell, Ixfd64, J.delanoy, Jamesdterry, Jmh649, JonathanDP81, Keenan Pepper, Killiondude, Koavf, Korath, Kosebamse, Kouhoutek, Laban712, Laurascudder, Legis, Mark Zinthefer, Mark.murphy, Mceder, Michael Hardy, MichaelVernonDavis, Milen, Milo99, Moshe Constantine Hassan Al-Silverburg, Muad, Mygerardromance, Nakon, Nono64, Notheruser, Onco p53, Otsykes, Owain.davies, Pakaran, PierreAbbat, Pjf, RexxS, Rhombus, Rich Farmbrough, Rjstott, Rjwilmsi, Roadrunner, Sbharris, Scubadoc, Serpent's Choice, Signalhead, Splamo, Splibubay, Stefan, TachyonJack, Tempshill, Vasiliy Faronov, VernoWhitney, WhatamIdoing, Ynhockey, , 120 anonymous edits Nitrox Source: http://en.wikipedia.org/w/index.php?oldid=441166257 Contributors: 62.92.51.xxx, A More Perfect Onion, Abiermans, Amatulic, Anthony Appleyard, AtonX, Bathat, BenFrantzDale, Biorem, Cades of the Cove, Carey Evans, Clotho, Conversion script, Dave3141592, DiverDave, Elkman, Eternal-sun, Farzanegan, Fuhghettaboutit, Gambitq72, Gene Hobbs, Goldom, Gorm, Headbomb, Hibsch, Hklygre, Hugo-cs, Karn, Killian441, KingTT, Klparrot, Kpjas, Kurykh, Legis, Leuko, Lexicon, Lovibond, Mark.murphy, Mbeatty, Mboverload, MeltBanana, MichaelBillington, MichaelHaeckel, Mion, Mtiller, Nonnormalizable, Nono64, Patrick, PaulHanson, Petterfs, Ploum's, Quadell, RexxS, Rgoodermote, Rich Farmbrough, RichiH, Sbharris, Scubadiver-dad, Spitfire26, Stefan, Stubblyhead, SunDragon34, Swpb, The ClayJar, The Random Editor, Tlunsford, Vk steve, Wperdue, , 76 anonymous edits Oxygen toxicity Source: http://en.wikipedia.org/w/index.php?oldid=442424026 Contributors: A More Perfect Onion, Aaron Kauppi, Ahpook, Amore proprio, Anandology, Angela, Anthony Appleyard, Arcadian, Art LaPella, AtonX, Axl, Basilicofresco, Bigbuck, BitterMan, Bodybagger, Brandingularity, Brianski, Bryan Derksen, BryanG, Campdavid, Canglesea, Casliber, Cdshioshei, ChildofMidnight, Chzz, Circeus, Countincr, Crfoster, DJ Clayworth, Dabomb87, Dancter, Danski14, Dave3141592, Davemarshall04, Delldot, Derek.cashman, Diberri, Dkazdan, DroEsperanto, Drpepper469, Ebr32y8432321121212, Egghead06, Epbr123, Erich gasboy, Eubulides, FKmailliW, FNG0027, Farras Octara, Farzanegan, Finavon, Foobar, Gene Hobbs, H Padleckas, Harland1, Hatcat, Headbomb, Hede2000, Hmoul, Idran, Intermedichbo, Jenda, Jfdwolff, Jmh649, Jordekurt, Jrockley, Julesd, Kaszeta, Keenan Pepper, KnowledgeOfSelf, Kosebamse, Krj373, LWF, LilHelpa, Lotje, Lucius1976, Mark.murphy, Materialscientist, Mmoneypenny, Mnation2, N5iln, Nakon, Nergaal, Nono64, Otsykes, Owain.davies, Pablo X, Piledhigheranddeeper, Prodego, RexxS, Rich Farmbrough, Rifleman 82, Rjwilmsi, S0ckpupet, Sbharris, Scott Roy Atwood, Scubadoc, Sirius683, Sirmylesnagopaleentheda, Snowmanradio, Sunapi386, Swatrecon, TAMilo, Thue, TimVickers, WATransplant, Wavelength, WolfmanSF, Wouterstomp, WriterHound, Xanzzibar, Yamakiri, Yobol, Zigger, 83 ,55 anonymous edits Partial pressure Source: http://en.wikipedia.org/w/index.php?oldid=445830116 Contributors: Alexknight12, Andre Engels, Antandrus, Anthony Appleyard, ArcticWind88, Auntof6, Bdesham, Bensaccount, Bitjungle, Bryan Derksen, Calvin 1998, Cesiumfrog, Christian75, CiaPan, Cristianrodenas, Crowsnest, DabMachine, Dhollm, Dictabeard, Dj Capricorn, Djd sd, Duk, ESkog, El C, Fabiform, Fgb, Fyyer, Gaterion, Gene Nygaard, Gentgeen, Gits (Neo), Grenavitar, Gunnar Larsson, Headbomb, Herbee, Hooperbloob, Itub, Izehar, JabberWok, Joelholdsworth, Johnuniq, Jonathan654321, Kjhskj75, Mark.murphy, Mausy5043, Mbeychok, Mentisock, Michael Hardy, Momet, Mpeisenbr, Nneonneo, Patrick, Peachypoh, Petergans, Peterlin, Pflatau, Physchim62, Postrach, Pt, Quarl, Qxz, RexxS, Sbharris, Shoefly, Sodium, Steamroller Assault, Straker, V8rik, Vsmith, WRK, Webdinger, Zvn, 91 anonymous edits Rebreather Source: http://en.wikipedia.org/w/index.php?oldid=446788456 Contributors: .:Ajvol:., ARHAPSTF, Alan Au, Alansohn, Alex.tan, Alexander UA, Altes2009, AndyCarroll, Animum, Anshuk, Anthony Appleyard, Arawak3, Ashley Pomeroy, Atlant, Attilios, Banaticus, BecauseWhy?, Bgpartri, BillC, Billlion, Bluekieran, Bluez57, Bobblewik, Brainsik, Branciforte3241, Brianski, Carlroller, Ccrvic, Cedricverdier, Chasnor15, Chem-awb, Chrislk02, Cjpuffin, Clayhalliwell, Cloudo, Cremepuff222, Crum375, Cyrius, DabMachine, Dave3141592, Deli nk, Diverite, Dolphin51, Dycedarg, EddEdmondson, Elonka, Elysdir, Emdx, Epbr123, Ex nihil, Famously Sharp, Firien, Frencheigh, Gamkiller, Gene Hobbs, Gobonobo, Gr0ff, GraemeLeggett, Hadal, Headbomb, Heyydude12, Hydraton31, Ian Dunster, Idiosyncrat, Ironholds, Ixfd64, J Swarbrick, JTN, JamesMLane, Jasonvds, Javabrett, Jeus, Jolenine, Jooler, Julesd, KVDP, Karn, Kbdank71, Keller.baum, Kintaro, Knobunc, Koavf, Lmaltier, Lx, MadRat Jack, Maeglin Lmion, Mark.murphy, Marokwitz, Mattmexico63, McHildinger, Moppet65535, Mottmon, Nakon, Naruto Tron, Nasnema, Nedrutland, Nick Number, Nimur, Niteowlneils, No bubbles, Obli, Omegatron, OnePt618, Owain.davies, PBarak, Pankkake, PaulGGraham, Phinneus, Pushnell, Quartertone, RexNL, RexxS, Rich Farmbrough, Rich257, Rmfitzgerald50, Rmhermen, RobertAlanHarris, RobertGougaloff, Rps, SDC, SEWilco, Saimhe, ScubaMagazinedotnet, Sea diver, Seashorewiki, Simon.goodchild, Sirscuba, Sitethief, Skepticus, Spokane wheels, Srice13, Stephen j koch, Steven J. Anderson, Subversive.sound, Superm401, Swerdnaneb, Swpb, Technopat, Th1rt3en, The Man in Question, The Obfuscator, Themfromspace, Tholzel, Thumperward, Todd Vierling, Travelbird, Trovatore, UnbiasedHistory, Vicarious, Viking6, Wabernat, WhiteDragon, Woodshed, Woohookitty, XHT5, Xianggang, Xobnkaj, Ynhockey, ZayZayEM, Zoicon5, Zwiadowca21, , 248 anonymous edits

Article Sources and Contributors

Technical diving Source: http://en.wikipedia.org/w/index.php?oldid=437697999 Contributors: Ali@gwc.org.uk, Anthony Appleyard, AtonX, Auntof6, Bento00, BillGarrett, Bluez57, Breals, Crum375, Dave3141592, Destynova, DiverDave, Editus Reloaded, Elf, Evercat, Extraordinary, Finavon, Finell, Gene Hobbs, Georgekwatson, Gerard.Newman, Gorm, Gr0ff, Gxdoyle, Hike395, Hu12, Jhog1978, KingScuba, Kintaro, Krich, Lari-fari, Laubzega, Legis, Leigh, Lightmouse, LoverOfArt, Maldivian, Mark.murphy, Michael Hardy, Michagal, O'Dea, Owain.davies, Pcpcpc, Pengo, Phirst, PontBrownJm, RexxS, Rjwilmsi, RupertMillard, SCEhardt, Sanspeur, SenorBeef, Sirscuba, SlipperyHippo, SteOsu, SummerPhD, Superm401, Tabletop, TheJoby, Tossmysalad, Triddle, Watch Rider, Woohookitty, 105 anonymous edits Trimix (breathing gas) Source: http://en.wikipedia.org/w/index.php?oldid=441541942 Contributors: 62.253.64.xxx, 62.92.51.xxx, 84user, A2Kafir, Alfie66, Algorithm, Anthony Appleyard, Aquanaut, Bryan Derksen, Bubbleboys, Collabi, Conversion script, Cryptic C62, Cybercobra, Cyrius, Dolphin51, Download, Dsyzdek, EddEdmondson, Ehagerty, Gene Hobbs, Gorm, HaeB, Hamiltondaniel, Headbomb, Hede2000, Hephaestos, Johan Lont, KingTT, Kpjas, Legis, Lotje, Lubos, Mark.murphy, Matt Gies, Mav, Mc2246, Mfischman, Michael Hardy, Mion, Nathan, Nihiltres, Pbsouthwood, PierreAbbat, RexxS, Rich Farmbrough, Rongen, Spetzna-, SpiderJon, Spiritia, Unixsage, Vuonghn, Wasell, 49 anonymous edits

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Image Sources, Licenses and Contributors

Image:NEDU gaslab.jpg Source: http://en.wikipedia.org/w/index.php?title=File:NEDU_gaslab.jpg License: Public Domain Contributors: US Navy File:Decompression chamber.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Decompression_chamber.jpg License: Public Domain Contributors: Jayme Pastoric File:Caisson Schematic.svg Source: http://en.wikipedia.org/w/index.php?title=File:Caisson_Schematic.svg License: Creative Commons Attribution-ShareAlike 3.0 Unported Contributors: me (Yk Times) File:Atrial septal defect-en.png Source: http://en.wikipedia.org/w/index.php?title=File:Atrial_septal_defect-en.png License: Creative Commons Attribution-Sharealike 3.0 Contributors: Manco Capac File:Preparing for recompression.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Preparing_for_recompression.jpg License: Public Domain Contributors: Avron, Diwas, Kauczuk, Rocket000, Tangopaso File:Aladin-pdc.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Aladin-pdc.jpg License: Creative Commons Attribution-Sharealike 3.0 Contributors: Aladin-pdc.png: RexxS derivative work: RexxS (talk) File:Nasa decompression chamber.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Nasa_decompression_chamber.jpg License: Creative Commons Attribution 2.0 Contributors: Mike File:Eads Bridge panorama 20090119.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Eads_Bridge_panorama_20090119.jpg License: Creative Commons Attribution-Sharealike 3.0 Contributors: Kbh3rd File:Early diving recompression chamber at Broome, Western Australia.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Early_diving_recompression_chamber_at_Broome,_Western_Australia.jpg License: Public Domain Contributors: Haymanj File:Trevor Jackson returns from SS Kyogle.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Trevor_Jackson_returns_from_SS_Kyogle.jpg License: Creative Commons Attribution-Sharealike 3.0 Contributors: Avraham, J Milburn, Qldtech, 3 anonymous edits File:Decompression Dive-Preparation.JPG Source: http://en.wikipedia.org/w/index.php?title=File:Decompression_Dive-Preparation.JPG License: Creative Commons Attribution 3.0 Contributors: DiverDave (talk). Original uploader was DiverDave at en.wikipedia File:Trimix label.png Source: http://en.wikipedia.org/w/index.php?title=File:Trimix_label.png License: Public Domain Contributors: RexxS Image:Console-narc.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Console-narc.jpg License: Public Domain Contributors: RexxS File:Lipid bilayer section.gif Source: http://en.wikipedia.org/w/index.php?title=File:Lipid_bilayer_section.gif License: Public domain Contributors: Bensaccount File:Gas blending equipment cropped.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Gas_blending_equipment_cropped.jpg License: Public Domain Contributors: User:Mark.murphy File:The Meyer-Overton correlation.png Source: http://en.wikipedia.org/w/index.php?title=File:The_Meyer-Overton_correlation.png License: Public Domain Contributors: Akuznetsova Image:EANxDecal.png Source: http://en.wikipedia.org/w/index.php?title=File:EANxDecal.png License: GNU Free Documentation License Contributors: AtonX, Man vyi, Serguei S. Dukachev, 1 anonymous edits Image:Nitrox tables.JPG Source: http://en.wikipedia.org/w/index.php?title=File:Nitrox_tables.JPG License: Public Domain Contributors: --Legis (talk - contribs). Original uploader was Legis at en.wikipedia Image:Cylinder mod.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Cylinder_mod.jpg License: Public Domain Contributors: RexxS File:File-Oxygen toxicity testing.jpeg Source: http://en.wikipedia.org/w/index.php?title=File:File-Oxygen_toxicity_testing.jpeg License: Public Domain Contributors: UK Admiralty Image:Clark1974.svg Source: http://en.wikipedia.org/w/index.php?title=File:Clark1974.svg License: Public Domain Contributors: Prepared by User:Gene Hobbs from diagram in journal article (see source). Author of article: Clark, John M. (SVG version by User:RexxS) Image:Lipid peroxidation.svg Source: http://en.wikipedia.org/w/index.php?title=File:Lipid_peroxidation.svg License: Public Domain Contributors: Tim Vickers, after Young IS, McEneny J (2001). "Lipoprotein oxidation and atherosclerosis". UNIQ-nowiki-2-6637f6b6bf0d647c-QINU Biochem Soc Trans UNIQ-nowiki-3-6637f6b6bf0d647c-QINU UNIQ-nowiki-5-6637f6b6bf0d647c-QINU 29 UNIQ-nowiki-6-6637f6b6bf0d647c-QINU (Pt 2) UNIQ-nowiki-7-6637f6b6bf0d647c-QINU 35862. PMID 11356183. http://www.biochemsoctrans.org/bst/029/0358/bst0290358.htm.Vectorized by . File:Human eye cross section detached retina.svg Source: http://en.wikipedia.org/w/index.php?title=File:Human_eye_cross_section_detached_retina.svg License: GNU Free Documentation License Contributors: Erin Silversmith from an original by en:User:Delta G derivative work: RexxS File:Human eye cross section scleral buckle.svg Source: http://en.wikipedia.org/w/index.php?title=File:Human_eye_cross_section_scleral_buckle.svg License: GNU Free Documentation License Contributors: Erin Silversmith from an original by en:User:Delta G derivative work: RexxS (talk) Image:Incidence of ROP.svg Source: http://en.wikipedia.org/w/index.php?title=File:Incidence_of_ROP.svg License: Public Domain Contributors: RexxS Image:Paul Bert.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Paul_Bert.jpg License: Public Domain Contributors: Destrguil Image:Vapor Pressure Chart.png Source: http://en.wikipedia.org/w/index.php?title=File:Vapor_Pressure_Chart.png License: Public Domain Contributors: Mbeychok File:Plongee-RecycleurInspiration 20040221-153656.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Plongee-RecycleurInspiration_20040221-153656.jpg License: Creative Commons Attribution-Share Alike Contributors: EMDX Image:British navy frogman.jpg Source: http://en.wikipedia.org/w/index.php?title=File:British_navy_frogman.jpg License: Public Domain Contributors: Post-Work: User:W.wolny Image:oxygen rebreather.PNG Source: http://en.wikipedia.org/w/index.php?title=File:Oxygen_rebreather.PNG License: Creative Commons Attribution-Sharealike 3.0 Contributors: Mark.murphy Image:semi-closed circuit rebreather.PNG Source: http://en.wikipedia.org/w/index.php?title=File:Semi-closed_circuit_rebreather.PNG License: Creative Commons Attribution-Sharealike 3.0 Contributors: Mark.murphy File:Semi-closed circuit rebreather.JPG Source: http://en.wikipedia.org/w/index.php?title=File:Semi-closed_circuit_rebreather.JPG License: Public Domain Contributors: KVDP Image:fully-closed circuit rebreather.PNG Source: http://en.wikipedia.org/w/index.php?title=File:Fully-closed_circuit_rebreather.PNG License: Creative Commons Attribution-Sharealike 3.0 Contributors: Mark.murphy File:Closed circuit rebreather.JPG Source: http://en.wikipedia.org/w/index.php?title=File:Closed_circuit_rebreather.JPG License: Public Domain Contributors: KVDP Image:Aa aerorlox1.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Aa_aerorlox1.jpg License: GNU Free Documentation License Contributors: Anthony Appleyard, Kelly Image:Rebr rn parts labelled.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Rebr_rn_parts_labelled.jpg License: GNU Free Documentation License Contributors: Alkivar, Anthony Appleyard Image:Inspiration back with arrows.JPG Source: http://en.wikipedia.org/w/index.php?title=File:Inspiration_back_with_arrows.JPG License: Public Domain Contributors: KVDP Image:Deepursuit.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Deepursuit.jpg License: Public Domain Contributors: Xobnkaj File:TechDiving NOAA.jpg Source: http://en.wikipedia.org/w/index.php?title=File:TechDiving_NOAA.jpg License: unknown Contributors: D. Kesling File:Tech diving decompression stop.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Tech_diving_decompression_stop.jpg License: Creative Commons Attribution-Sharealike 2.0 Contributors: http://flickr.com/photos/pratts/ File:Tec diver with sidemount tanks.JPG Source: http://en.wikipedia.org/w/index.php?title=File:Tec_diver_with_sidemount_tanks.JPG License: Public Domain Contributors: --Legis (talk contribs)

License

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License
Creative Commons Attribution-Share Alike 3.0 Unported http:/ / creativecommons. org/ licenses/ by-sa/ 3. 0/