Cardiovascular changes induced by cold water immersion during hyperbaric hyperoxic exposure.

The present study was designed to assess the cardiac changes induced by cold water immersion compared with dry conditions during a prolonged hyperbaric and hyperoxic exposure (ambient pressure between 1.6 and 3 ATA and PiO(2) between 1.2 and 2.8 ATA). Ten healthy volunteers were studied during a 6 h compression in a hyperbaric chamber with immersion up to the neck in cold water while wearing wet suits. Results were compared with measurements obtained in dry conditions. Echocardiography and Doppler examinations were performed after 15 min and 5 h. Stroke volume, left atrial and left ventricular (LV) diameters remained unchanged during immersion, whereas they significantly fell during the dry session. As an index of LV contractility, percentage fractional shortening remained unchanged, in contrast to a decrease during dry experiment. Heart rate (HR) significantly decreased after 5 h, although it had not changed during the dry session. The changes in the total arterial compliance were similar during the immersed and dry sessions, with a significant decrease after 5 h. In immersed and dry conditions, cardiac output was unchanged after 15 min but decreased by almost 20% after 5 h. This decrease was related to a decrease in HR during immersion and to a decrease in stroke volume in dry conditions. The hydrostatic pressure exerted by water immersion on the systemic vessels could explain these differences. Indeed, the redistribution of blood volume towards the compliant thoracic bed may conceal a part of hypovolaemia that developed in the course of the session.

Haemodynamic changes induced by submaximal exercise before a dive and its consequences on bubble formation.

OBJECTIVES: To evaluate the effects of a submaximal exercise performed 2 h before a simulated dive on bubble formation and to observe the haemodynamic changes and their influence on bubble formation. PARTICIPANTS AND METHODS: 16 trained divers were compressed in a hyperbaric chamber to 400 kPa for 30 min and decompressed at a rate of 100 kPa/min with a 9 min stop at 130 kPa (French Navy MN90 procedure). Each diver performed two dives 3 days apart, one without exercise and one with exercise before the dive. All participants performed a 40 min constant-load submaximal and calibrated exercise, which consisted of outdoor running 2 h before the dive. Circulating bubbles were detected with a precordial Doppler at 30, 60 and 90 min after surfacing. Haemodynamic changes were evaluated with Doppler echocardiography. RESULTS: A single bout of strenuous exercise 2 h before a simulated dive significantly reduced circulating bubbles. Post-exercise hypotension (PEH) was observed after exercise with reductions in diastolic and mean blood pressure (DBP and MBP), but total peripheral resistance was unchanged. Stroke volume was reduced, whereas cardiac output was unchanged. Simulated diving caused a similar reduction in cardiac output independent of pre-dive exercise, suggesting that pre-dive exercise only changed DBP and MBP caused by reduced stroke volume. CONCLUSION: A single bout of strenuous exercise 2 h before a dive significantly reduced the number of bubbles in the right heart of divers and protected them from decompression sickness. Declining stroke volume and moderate dehydration induced by a pre-dive exercise might influence inert gas load and bubble formation.

Echocardiography in military oxygen divers.

BACKGROUND: Oxygen divers undergo environmental stressors such as immersion, ventilation with scuba, cold exposure, and increased ambient pressure. All of these stressors may be responsible for acute hemodynamic modifications. We hypothesized that repeated hyperbaric hyperoxia exposure induces long-term cardiovascular modifications. METHODS: A Doppler echocardiography was conducted on 20 military oxygen divers (average 12 yr diving experience) and compared with 22 controls. Parameters known to be modified by acute hyperoxic exposure, such as left ventricular (LV) function (systolic and diastolic) and arterial compliance, were analyzed. RESULTS: Controls and divers were matched appropriately for age and height, although the divers had a higher body mass index and aerobic capacity. Left atrial and left ventricular diameters did not differ between the two groups. On the other hand, left ventricular mass was significantly higher in the elite military divers (209 +/- 43 g) in comparison with the control group (172 +/- 48 g), even when LV mass was indexed to body surface area. Left ventricular systolic and diastolic function indices, stroke volume, cardiac index, peripheral vascular resistance, and systemic compliance were comparable between the two groups. CONCLUSION: A greater LV mass was observed in oxygen military divers. The echocardiographic differences between divers and controls could be attributed to the high level physical training undertaken by the military divers. Some stressors, such as cold water immersion, repeated hyperoxic exposures, scuba breathing, and long distance swimming, could have participated to the echocardiographic findings in oxygen divers.

N-terminal pro brain natriuretic peptide increases after 1-h scuba dives at 10 m depth.

OBJECTIVES: The N-terminal pro brain natriuretic peptide (N-BNP) is a promising cardiac natriuretic peptide used as a clinical hormonal marker in cardiac dysfunction. The main stimulus for N-BNP synthesis and secretion is cardiac wall stress, which is recognized as a common denominator of many cardiac diseases. Diving is associated with environmental factors leading to variations in thoracic blood volume and hemodynamic changes. The purpose of the present study was to examine the changes in the concentration of N-BNP in healthy men during and after scuba diving. METHOD: There were 10 healthy military divers (mean age 33 yr) who performed a dive in the sea for 1 h at 10 m depth. Venous blood samples were taken at timed intervals to allow evaluation of plasma levels of N-BNP at different steps, namely at To (before immersion), at T30 min (during the dive, after a short surfacing), at T60 min (right after surfacing), at T300 min (post-dive), and finally at T24 h. Peptide blood concentrations were determined by electrochemoluminiscence immunoassay. Data were analyzed using parametric statistics. RESULTS: When compared with To, the results show a significant increase of N-BNP levels (in % of baseline levels) at T60(128 +/- 5%, p < 0.043) and at T300 (149 +/- 8%, p < 0.001). CONCLUSION: This preliminary study reveals that N-BNP rises with scuba diving. Our findings suggest that diving involves a mechanical strain on the heart with a persistent endocrine myocardial activity post-dive.

Bubble incidence after staged decompression from 50 or 60 msw: effect of adding deep stops.

OBJECTIVES: The French Navy uses the Marine Nationale 90 (MN90) decompression tables for air dives as deep as 60 msw. The resulting incidence of decompression sickness (DCS) for deep dives (45-60 msw) is one case per 3000 dives. METHODS: Three protocols with experimental ascent profiles (EAPs) were tested in the wet compartment of a hyperbaric chamber. For each protocol, eight subjects dove to 50 or 60 msw and ascended according to the standard MN90 table or an EAP. Precordial bubbles were monitored with Doppler sensors at 30-min intervals after surfacing. Protocol I went to 60 msw and used deep stops beginning at 27 msw. Protocol II was a repetitive dive to 50 msw with a 3-h surface interval; the EAP made the first deep stop at 18 msw. Protocol III again went to 60 msw, but the EAP used a single, shorter deep stop at 25 msw. RESULTS: For Protocol I, all divers developed bubbles at Spencer grade 2-3 and still had bubbles 120 min after surfacing; there was no statistical difference between bubbling for the MN90 and EAP, but one diver presented a case of DCS after the EAP. For Protocol II, the EAP produced severe bubbling for the eight divers. Those findings led to stopping the EAPs with the longer deep stops used in Protocols I and II. Protocol III again showed no difference between the standard and modified profiles. DISCUSSION: The addition of deep stops requires careful consideration. Two of our EAPs made no difference and one produced increased bubbling.

Aerobic exercise 2 hours before a dive to 30 msw decreases bubble formation after decompression.

BACKGROUND: A single bout of aerobic exercise 24 h before a dive significantly reduces the formation of circulating venous gas emboli (VGE) on decompression. The purpose of this investigation was to determine the effect of aerobic exercise 2 h before a dive. METHODS: There were 16 trained military divers who were compressed to 30 msw (400 kPa) for 30 min breathing air in a dry hyperbaric chamber at rest, then decompressed at a rate of 10 m x min(-1) with a 9-min stop at 3 msw. Each diver performed two dives 3 d apart, one with and one without exercise that consisted of running for 45 min at 60-80% of maximum heart rate (estimated as 220 - age). VGE were graded according to the Spencer scale using a pulsed Doppler detector on the precordium at 30 min (T30) and 60 min (T60) after surfacing. RESULTS: Mean bubble grades at T60 were 1.25 for control dives and 0.44 for dives preceded by exercise, the difference being highly significant. None of the divers showed an increase in venous bubble grade after exercise. CONCLUSION: Like exercise 24 h ahead, 45 min of running 2 h before a dive decreases bubble formation after diving, suggesting a protective effect of aerobic exercise against DCS. The threshold of exercise intensity and duration necessary to change venous circulating bubbles is unknown. Mechanisms underlying the protective effect of exercise remain unclear. Rather than altering the nitrogen elimination rate, exercise may affect the population of gaseous nuclei from which bubbles form.

A European code of good practice for hyperbaric oxygen therapy.

In 2001 the Working Group (WG) "Safety" was created within the European COST Action B14 "Hyperbaric Oxygen Therapy" with the main objectives to elaborate recommendations of good practice for hyperbaric medicine and to follow the European normalisation process of hyperbaric chambers. During three years of preparation of the European Code of Good Practice (ECGP) for HBO, the relevant documents concerning safety in hyperbaric chambers from each European country have been revised. The initial document drew on the BHA "Health and Safety for Therapeutic Hyperbaric Facilities: A Code-of Practice" (2000), and later on it was modified using national regulations and standards (from Belgium, Finland, France, Germany, Greece, Italy, Portugal, and Spain), as well as European Norms and existing experience from experts of hyperbaric centres, committees, professional and scientific associations. The ECGP for HBO consists of chapters dedicated to staffing (including responsibilities, competencies and education, minimum team during hyperbaric sessions, fitness and health surveillance), equipment, gas supply, risk management and procedures (including standard and emergency operating procedures, maintenance, record keeping, and patient safety). It also includes ECHM Educational and Training Standards for the Staff of Hyperbaric Centres (1997), ECHM Recommendation for Safety in Multiplace Medical Hyperbaric Chambers (1998), as well as COST B14 Working Group "Technical Aspects" Final Report (2001) including a risk analysis conducted specifically for therapeutic hyperbaric facilities. Many efforts have been spent to make the ECGP for HBO compatible with the new project of the European Norm prEN 14931 "Pressure vessels for human occupancy (PVHO)--Multiplace pressure chamber system for hyperbaric therapy--Performance, safety requirements and testing", which has been prepared at the same time by the CEN/BT/TF 127. Both groups (CEN/BT/TF 127 and COST B14 WG "Safety") cooperated extensively in the field of safety aspects of using hyperbaric chambers as medical devices, and both final versions of documents include many cross references. Being prepared by international Working Group "Safety" and after acceptation by all members of the COST B14 action, the ECGP for HBO represents a harmonised European view on safety in therapeutic hyperbaric facilities and can be used as a reference document for European countries for Guidelines, Regulations, and Standards in hyperbaric medicine.

Consequences of prolonged total body immersion in cold water on muscle performance and EMG activity.

The consequences of a prolonged total body immersion in cold water on the muscle function have not been documented yet, and they are the object of this French Navy research program. Ten elite divers were totally immerged and stayed immobile during 6 h in cold (18 and 10 degrees C) water. We measured the maximal voluntary leg extension (maximal voluntary contraction, MVC) and evoked compound muscle potential (M wave) in vastus lateralis and soleus muscles at rest, after a submaximal (60% MVC) isometric extension allowing the measurement of the endurance time (Tlim). The power spectrum of surface electromyograms (EMG) was computed during 60% MVCs. MVCs and 60% MVC maneuvers were repeated four times during the immersion. Data were compared with those obtained in a control group studied in dry air condition during a 6-h session. Total body cooling did not affect MVC nor Tlim. The M wave duration increased in the coolest muscle (soleus), but only at 10 degrees C at rest. There were no further fatigue-induced M wave alterations in both muscles. During 60% the MVCs, a time-dependant increase in the leftward shift of the EMG spectrum occurred at the two temperatures. These EMG changes were absent in the control group of subjects studied in dry air. The plasma lactate concentration was elevated throughout the 18 and mostly the 10 degrees C immersion conditions. Throughout the 18 degrees C immersion study, the resting potassium level did not significantly vary, whereas at 10 degrees C, a significant potassium increase occurred soon and persisted throughout the study. Thus, total body immersion in cold water did not affect the global contractile properties of leg muscles during static efforts but elicited significant alterations in electromyographic events which may be related to the variations of interstitial fluid composition.

Haemodynamic effects of hyperbaric hyperoxia in healthy volunteers: an echocardiographic and Doppler study.

In the present study, we observed the haemodynamic changes, using echocardiography and Doppler, in ten healthy volunteers during 6 h of compression in a hyperbaric chamber with a protocol designed to reproduce the conditions as near as possible to a real dive. Ambient pressure varied from 1.6 to 3 atm (1 atm=101.325 kPa) and partial pressure of inspired O2 from 1.2 to 2.8 atm. Subjects performed periods of exercise with breathing through a closed-circuit self-contained underwater breathing apparatus (SCUBA). Subjects did not eat or drink during the study. Examinations were performed after 15 min and 5 h. After 15 min, stroke volume (SV), left atrial (LA) diameter and left ventricular (LV) end-diastolic diameter (LVEDD) decreased. Heart rate (HR) and cardiac output (CO) did not vary, but indices of the LV systolic performance decreased by 10% and the LV meridional wall stress increased by 17%. After 5 h, although weight decreased, the serum protein concentration increased. Compared with values obtained after 15 min, SV and CO decreased, but LV systolic performance, LA diameter, LVEDD and LV meridional wall stress remained unchanged. Compared with the reference values obtained at sea level, total arterial compliance decreased, HR remained unchanged and CO decreased. In conclusion, hyperbaric hyperoxia results in significant haemodynamic changes. Initially, hyperoxia and the SCUBA system are responsible for reducing LV preload, increasing LV afterload and decreasing LV systolic performance, although CO did not change. Prolonged exposure resulted in a further decrease in LV preload, because of dehydration, and in a further increase in LV afterload, due to systemic vasoconstriction, with the consequence of decreasing CO.