First Real-Life Data on the Diving Response in Healthy Children.

Swimming and diving are popular recreational activities, representing an effective option in maintaining and improving cardiovascular fitness in healthy people. To date, only little is known about the cardiovascular adaption to submersion in children. This study was conducted to improve an understanding thereof. We used a stepwise apnea protocol with apnea at rest, apnea with facial immersion, and at last apnea during whole body submersion. Continuous measurement of heart rate, oxygen saturation, and peripheral resistance index was done. Physiologic data and analysis of influencing factors on heart rate, oxygen saturation, and peripheral vascular tone response are reported. The current study presents the first data of physiologic diving response in children. Data showed that facial or whole body submersion leads to a major drop in heart rate, and increase of peripheral resistance, while the oxygen saturation seems to be unaffected by static apnea in most children, with apnea times of up to 75 s without change in oxygen saturation.

Unlocking the depths: multiple factors contribute to risk for hypoxic blackout during deep freediving.

PURPOSE: To examine the effect of freediving depth on risk for hypoxic blackout by recording arterial oxygen saturation (SpO2) and heart rate (HR) during deep and shallow dives in the sea. METHODS: Fourteen competitive freedivers conducted open-water training dives wearing a water-/pressure proof pulse oximeter continuously recording HR and SpO2. Dives were divided into deep (> 35 m) and shallow (10-25 m) post-hoc and data from one deep and one shallow dive from 10 divers were compared. RESULTS: Mean ± SD depth was 53 ± 14 m for deep and 17 ± 4 m for shallow dives. Respective dive durations (120 ± 18 s and 116 ± 43 s) did not differ. Deep dives resulted in lower minimum SpO2 (58 ± 17%) compared with shallow dives (74 ± 17%; P = 0.029). Overall diving HR was 7 bpm higher in deep dives (P = 0.002) although minimum HR was similar in both types of dives (39 bpm). Three divers desaturated early at depth, of which two exhibited severe hypoxia (SpO2 ≤ 65%) upon resurfacing. Additionally, four divers developed severe hypoxia after dives. CONCLUSIONS: Despite similar dive durations, oxygen desaturation was greater during deep dives, confirming increased risk of hypoxic blackout with increased depth. In addition to the rapid drop in alveolar pressure and oxygen uptake during ascent, several other risk factors associated with deep freediving were identified, including higher swimming effort and oxygen consumption, a compromised diving response, an autonomic conflict possibly causing arrhythmias, and compromised oxygen uptake at depth by lung compression possibly leading to atelectasis or pulmonary edema in some individuals. Individuals with elevated risk could likely be identified using wearable technology.

Underwater pulse oximetry reveals increased rate of arterial oxygen desaturation across repeated freedives to 11 metres of freshwater.

INTRODUCTION: Recreational freedivers typically perform repeated dives to moderate depths with short recovery intervals. According to freediving standards, these recovery intervals should be twice the dive duration; however, this has yet to be supported by scientific evidence. METHODS: Six recreational freedivers performed three freedives to 11 metres of freshwater (mfw), separated by 2 min 30 s recovery intervals, while an underwater pulse oximeter measured peripheral oxygen saturation (SpO2) and heart rate (HR). RESULTS: Median dive durations were 54.0 s, 103.0 s and 75.5 s (all dives median 81.5 s). Median baseline HR was 76.0 beats per minute (bpm), which decreased during dives to 48.0 bpm in dive one, 40.5 bpm in dive two and 48.5 bpm in dive three (all P < 0.05 from baseline). Median pre-dive baseline SpO2 was 99.5%. SpO2 remained similar to baseline for the first half of the dives, after which the rate of desaturation increased during the second half of the dives with each subsequent dive. Lowest median SpO2 after dive one was 97.0%, after dive two 83.5% (P < 0.05 from baseline) and after dive three 82.5% (P < 0.01 from baseline). SpO2 had returned to baseline within 20 s after all dives. CONCLUSIONS: We speculate that the enhanced rate of arterial oxygen desaturation across the serial dives may be attributed to a remaining 'oxygen debt', leading to progressively increased oxygen extraction by desaturated muscles. Despite being twice the dive duration, the recovery period may be too short to allow full recovery and to sustain prolonged serial diving, thus does not guarantee safe diving.

Case Studies in Physiology: Is blackout in breath-hold diving related to cardiac arrhythmias?

Syncope or "blackout" (BO) in breath-hold diving (freediving) is generally considered to be caused by hypoxia. However, it has been suggested that cardiac arrhythmias affecting the pumping effectivity could contribute to BO. BO is fairly common in competitive freediving, where athletes aim for maximal performance. We recorded heart rate (HR) during a static apnea (STA) competition, to reveal if arrhythmias occur. Four male freedivers with STA personal best (PB) of 349 ± 43 s, volunteered during national championships, where they performed STA floating face down in a shallow indoor pool. A non-coded Polar T31 chest strap recorded R-R intervals and a water- and pressure-proof pulse oximeter arterial oxygen saturation. Three divers produced STA near their PB without problems, whereas one diver ended with BO at 5 min 17s, which was 12 s beyond his PB. He was immediately brought up by safety divers and resumed breathing within 10 s. All divers attained similar lowest diving HR (47 ± 4 beats/min), but HR recordings displayed a different pattern for the diver ending with BO. After a short tachycardia, the three successful divers developed bradycardia, which became more pronounced during the second half of the apnea. The fourth diver developed pronounced bradycardia earlier, and at 2.5 min into the apnea, HR started alternating between approximately 50 and 140 beats/min, until the diver lost consciousness. At resumed breathing, HR returned to baseline. Nadir oxygen saturation was similar for all divers. We speculate that arrhythmia could have contributed to BO, by lowering stroke volume leading to a systolic blood pressure drop, affecting brain perfusion.NEW & NOTEWORTHY Heart rate during prolonged breath-holding until the point of loss of consciousness has not previously been published. The recordings show that blackout was preceded by a period of persistent alterations in R-R intervals, whereby an ectopic beat followed every normal heartbeat. Explanations for this deviating heart rate pattern could be either premature atrial contractions or premature ventricular contractions following every atrial beat, i.e., bigeminy, which could have compromised cardiac pumping function and caused/contributed to blackout.

Corrigendum: Using Underwater Pulse Oximetry in Freediving to Extreme Depths to Study Risk of Hypoxic Blackout and Diving Response Phases.

[This corrects the article DOI: 10.3389/fphys.2021.651128.].

First Evaluation of a Newly Constructed Underwater Pulse Oximeter for Use in Breath-Holding Activities.

Studying risk factors in freediving, such as hypoxic blackout, requires development of new methods to enable remote underwater monitoring of physiological variables. We aimed to construct and evaluate a new water- and pressure proof pulse oximeter for use in freediving research. The study consisted of three parts: (I) A submersible pulse oximeter (SUB) was developed on a ruggedized platform for recording of physiological parameters in challenging environments. Two MAX30102 sensors were used to record plethysmograms, and included red and infra-red emitters, diode drivers, photodiode, photodiode amplifier, analog to digital converter, and controller. (II) We equipped 20 volunteers with two transmission pulse oximeters (TPULS) and SUB to the fingers. Arterial oxygen saturation (SpO2) and heart rate (HR) were recorded, while breathing room air (21% O2) and subsequently a hypoxic gas (10.7% O2) at rest in dry conditions. Bland-Altman analysis was used to evaluate bias and precision of SUB relative to SpO2 values from TPULS. (III) Six freedivers were monitored with one TPULS and SUB placed at the forehead, during a maximal effort immersed static apnea. For dry baseline measurements (n = 20), SpO2 bias ranged between -0.8 and -0.6%, precision between 1.0 and 1.5%; HR bias ranged between 1.1 and 1.0 bpm, precision between 1.4 and 1.9 bpm. For the hypoxic episode, SpO2 bias ranged between -2.5 and -3.6%, precision between 3.6 and 3.7%; HR bias ranged between 1.4 and 1.9 bpm, precision between 2.0 and 2.1 bpm. Freedivers (n = 6) performed an apnea of 184 ± 53 s. Desaturation- and resaturation response time of SpO2 was approximately 15 and 12 s shorter in SUB compared to TPULS, respectively. Lowest SpO2 values were 76 ± 10% for TPULS and 74 ± 13% for SUB. HR traces for both pulse oximeters showed similar patterns. For static apneas, dropout rate was larger for SUB (18%) than for TPULS (<1%). SUB produced similar SpO2 and HR values as TPULS, both during normoxic and hypoxic breathing (n = 20), and submersed static apneas (n = 6). SUB responds more quickly to changes in oxygen saturation when sensors were placed at the forehead. Further development of SUB is needed to limit signal loss, and its function should be tested at greater depth and lower saturation.

Using Underwater Pulse Oximetry in Freediving to Extreme Depths to Study Risk of Hypoxic Blackout and Diving Response Phases.

Deep freediving exposes humans to hypoxia and dramatic changes in pressure. The effect of depth on gas exchange may enhance risk of hypoxic blackout (BO) during the last part of the ascent. Our aim was to investigate arterial oxygen saturation (SpO2) and heart rate (HR) in shallow and deep freedives, central variables, which have rarely been studied underwater in deep freediving. Four male elite competitive freedivers volunteered to wear a newly developed underwater pulse oximeter for continuous monitoring of SpO2 and HR during self-initiated training in the sea. Two probes were placed on the temples, connected to a recording unit on the back of the freediver. Divers performed one "shallow" and one "deep" constant weight dive with fins. Plethysmograms were recorded at 30 Hz, and SpO2 and HR were extracted. Mean ± SD depth of shallow dives was 19 ± 3 m, and 73 ± 12 m for deep dives. Duration was 82 ± 36 s in shallow and 150 ± 27 s in deep dives. All divers desaturated more during deeper dives (nadir 55 ± 10%) compared to shallow dives (nadir 80 ± 22%) with a lowest SpO2 of 44% in one deep dive. HR showed a "diving response," with similar lowest HR of 42 bpm in shallow and deep dives; the lowest value (28 bpm) was observed in one shallow dive. HR increased before dives, followed by a decline, and upon resurfacing a peak after which HR normalized. During deep dives, HR was influenced by the level of exertion across different diving phases; after an initial drop, a second HR decline occurred during the passive "free fall" phase. The underwater pulse oximeter allowed successful SpO2 and HR monitoring in freedives to 82 m depth - deeper than ever recorded before. Divers' enhanced desaturation during deep dives was likely related to increased exertion and extended duration, but the rapid extreme desaturation to below 50% near surfacing could result from the diminishing pressure, in line with the hypothesis that risk of hypoxic BO may increase during ascent. Recordings also indicated that the diving response is not powerful enough to fully override the exercise-induced tachycardia during active swimming. Pulse oximetry monitoring of essential variables underwater may be an important step to increase freediving safety.

Thermal balance of spinal cord injured divers during cold water diving: A case control study.

INTRODUCTION: This study compared the thermal balance of spinal cord injured (SCI) divers and able-bodied (AB) divers during recreational cold-water dives. METHODS: Ten divers (5 AB, 5 SCI) in matched pairs dived in a shallow lake (temperature 6°C) for 30 to 36 min wearing 5 mm 'Long John' neoprene wetsuits. A gastrointestinal temperature radio pill recorded gastro-intestinal temperature (Tgi) prior to, immediately after and at 5, 10, 15, 30, 60, 120 min post-dive. Subjective ratings of temperature perception were recorded concomitantly using a visual analogue scale (VAS). RESULTS: No difference between SCI and AB divers in Tgi before the dive was observed (P = 0.85). After the dive, SCI divers cooled significantly more than AB at all measured time intervals (P < 0.001). Post dive, the mean maximum fall in Tgi during the recovery phase in SCI divers was 0.85°C (SD 0.20) and in the AB group was 0.48°C (0.48). In addition, there was greater individual variation in SCI divers compared to AB divers. There were no statistically significant differences in temperature perception between the groups either before or at any time after the dives. CONCLUSIONS: In contrast to AB divers, divers with SCI were unable to maintain Tgi during short shallow dives in 6°C water and their temperatures fell further post-dive. The reduction in Tgi was not reflected in the subjective ratings of temperature perception by the SCI divers. The study was too small to assess how the level of spinal injury influenced thermal balance.

Diving Into Research of Biomedical Engineering in Scuba Diving.

The physiologic response of the human body to different environments is a complex phenomenon to ensure survival. Immersion and compressed gas diving, together, trigger a set of responses. Monitoring those responses in real time may increase our understanding of them and help us to develop safety procedures and equipment. This review outlines diving physiology and diseases and identifies physiological parameters worthy of monitoring. Subsequently, we have investigated technological approaches matched to those in order to evaluated their capability for underwater application. We focused on wearable biomedical monitoring technologies, or those which could be transformed to wearables. We have also reviewed current safety devices, including dive computers and their underlying decompression models and algorithms. The review outlines the necessity for biomedical monitoring in scuba diving and should encourage research and development of new methods to increase diving safety.

User settings on dive computers: reliability in aiding conservative diving.

INTRODUCTION: Divers can make adjustments to diving computers when they may need or want to dive more conservatively (e.g., diving with a persistent (patent) foramen ovale). Information describing the effects of these alterations or how they compare to other methods, such as using enriched air nitrox (EANx) with air dive planning tools, is lacking. METHODS: Seven models of dive computer from four manufacturers (Mares, Suunto, Oceanic and UWATEC) were subjected to single square-wave compression profiles (maximum depth: 20 or 40 metres' sea water, msw), single multi-level profiles (maximum depth: 30 msw; stops at 15 and 6 msw), and multi-dive series (two dives to 30 msw followed by one to 20 msw). Adjustable settings were employed for each dive profile; some modified profiles were compared against stand-alone use of EANx. RESULTS: Dives were shorter or indicated longer decompression obligations when conservative settings were applied. However, some computers in default settings produced more conservative dives than others that had been modified. Some computer-generated penalties were greater than when using EANx alone, particularly at partial pressures of oxygen (PO2) below 1.40 bar. Some computers 'locked out' during the multi-dive series; others would continue to support decompression with, in some cases, automatically-reduced levels of conservatism. Changing reduced gradient bubble model values on Suunto computers produced few differences. DISCUSSION: The range of possible adjustments and the non-standard computer response to them complicates the ability to provide accurate guidance to divers wanting to dive more conservatively. The use of EANx alone may not always generate satisfactory levels of conservatism.

Decompression management by 43 models of dive computer: single square-wave exposures to between 15 and 50 metres' depth.

INTRODUCTION: Dive computers are used in some occupational diving sectors to manage decompression but there is little independent assessment of their performance. A significant proportion of occupational diving operations employ single square-wave pressure exposures in support of their work. METHODS: Single examples of 43 models of dive computer were compressed to five simulated depths between 15 and 50 metres' sea water (msw) and maintained at those depths until they had registered over 30 minutes of decompression. At each depth, and for each model, downloaded data were used to collate the times at which the unit was still registering "no decompression" and the times at which various levels of decompression were indicated or exceeded. Each depth profile was replicated three times for most models. RESULTS: Decompression isopleths for no-stop dives indicated that computers tended to be more conservative than standard decompression tables at depths shallower than 30 msw but less conservative between 30-50 msw. For dives requiring decompression, computers were predominantly more conservative than tables across the whole depth range tested. There was considerable variation between models in the times permitted at all of the depth/decompression combinations. CONCLUSIONS: The present study would support the use of some dive computers for controlling single, square-wave diving by some occupational sectors. The choice of which makes and models to use would have to consider their specific dive management characteristics which may additionally be affected by the intended operational depth and whether staged decompression was permitted.

Heart rate variability during static and dynamic breath-hold dives in elite divers.

The purpose of this study was to assess the differences in cardiac autonomic modulation during maximal static (SA) and dynamic (DA) underwater apneas. Arterial oxygen saturation (SpO(2)), heart rate (HR) and HR variability (SD1 from Poincaré plot and short-term fractal-like scaling exponent, α(1)) were analyzed at the immersed baseline (3 min) and initial, mid- and end-phases (each 30s) of SA and DA in nine elite breath-hold divers. DA and SA lasted 78 ± 8 and 225 ± 20s (mean ± SEM), respectively, and resulted in similar decrements in end-stage SpO(2) (78 ± 3 and 75 ± 3%, p=0.352). During DA, initial increase in HR (from 80 ± 5 to 122 ± 5 bpm, p<0.001) was followed by gradual decrease towards the baseline at mid-apnea and end-apnea phase (101 ± 6 and 80 ± 8 bpm, respectively). During SA, HR decreased at mid-apnea (from 78 ± 4 to 66 ± 3 bpm, p=0.004) but did not decrease further at end-apnea phase (66 ± 4b pm). Decreased SD1 was observed at the initial phase of DA (from 28 ± 5 to 10 ± 4 ms, p=0.005) being lower compared with SA (24 ± 4 ms, p=0.005). At the end of DA and SA, SD1 tended to increase above the baseline (62 ± 16 and 66 ± 10 ms, p=0.128 and p=0.093, respectively, p=0.602 DA vs. SA). α(1) tended to be higher at the end of DA compared with SA (1.17 ± 0.10 vs. 0.79 ± 0.10, p=0.059). We concluded that apnea blunts the effects of exercise on cardiac vagal activity at the end of DA. However, higher HR during DA compared with SA indicates larger cardiac sympathetic activity during DA, as suggested also by slightly higher α(1).

Solid-state electrolyte sensors for rebreather applications: a preliminary investigation.

INTRODUCTION: Recently developed prototypes of zirconium dioxide and NASICON-based micro solid-state electrolyte oxygen (O2) and carbon dioxide (CO2) sensors were tested for their potential suitability in rebreathers. The O2 sensor has a quasi-indefinite lifetime, whilst that of the CO2 sensor is approximately 700 h. This is a preliminary report of a new technological application. METHODS: The O2 sensor was tested in a small pressure chamber to a partial pressure of oxygen (PO2) of 405 kPa (4 bar). The CO2 sensor was tested up to 10 kPa CO2. The response times to a step change of pressure were measured, and cross-sensitivity for helium tested using trimix. A rebreather mouthpiece was modified so that breath-by-breath gas recordings could be observed. Power consumption to heat the sensors was measured. RESULTS: The O2 sensor demonstrated non-linearity, particularly above 101.3 kPa (1 bar) PO2, whereas the output of the CO2 sensor showed an inverse logarithmic relationship. Cross-sensitivity to helium was observed. The mean t90 response times were 90 (SD 10) ms for the O2 sensor, and 100 (SD 10) ms for the CO2 sensor. Breath-by-breath recordings showed slight damping of the CO2 trace due to electronic filtering. Power consumption was 1.5-2 W per sensor. CONCLUSIONS: The fast response times would allow accurate breath-by-breath measurement. Even though the O2 sensor has a non-linear response, measurement is possible using multi-point calibration. Further design is necessary to allow trimix to be used as the diluent. A major disadvantage is the high power consumption needed to heat the sensors to high temperatures.

Cardiovascular changes during underwater static and dynamic breath-hold dives in trained divers.

Limited information exists concerning arterial blood pressure (BP) changes in underwater breath-hold diving. Simulated chamber dives to 50 m of freshwater (mfw) reported very high levels of invasive BP in two divers during static apnea (SA), whereas a recent study using a noninvasive subaquatic sphygmomanometer reported unchanged or mildly increased values at 10 m SA dive. In this study we investigated underwater BP changes during not only SA but, for the first time, dynamic apnea (DA) and shortened (SHT) DA in 16 trained breath-hold divers. Measurements included BP (subaquatic sphygmomanometer), ECG, and pulse oxymetry (arterial oxygen saturation, SpO2, and heart rate). BP was measured during dry conditions, at surface fully immersed (SA), and at 2 mfw (DA and SHT DA), whereas ECG and pulse oxymetry were measured continuously. We have found significantly higher mean arterial pressure (MAP) values in SA (∼40%) vs. SHT DA (∼30%). Postapneic recovery of BP was slightly slower after SHT DA. Significantly higher BP gain (mmHg/duration of apnea in s) was found in SHT DA vs. SA. Furthermore, DA attempts resulted in faster desaturation vs. SA. In conclusion, we have found moderate increases in BP during SA, DA, and SHT DA. These cardiovascular changes during immersed SA and DA are in agreement with those reported for dry SA and DA.

Advanced instrumentation for research in diving and hyperbaric medicine.

Improving the safety of diving and increasing knowledge about the adaptation of the human body to underwater and hyperbaric environment require specifically developed underwater instrumentation for physiological measurements. In fact, none of the routine clinical devices for health control is suitable for in-water and/or under-pressure operation. The present paper addresses novel technological acquisitions and the development of three dedicated devices: * an underwater data logger for recording O2 saturation (reflective pulsoxymetry), two-channel ECG, depth and temperature; * an underwater blood pressure meter based on the oscillometric method; and * an underwater echography system. Moreover, examples of recordings are presented and discussed.

A novel wearable apnea dive computer for continuous plethysmographic monitoring of oxygen saturation and heart rate.

We describe the development of a novel wrist-mounted apnea dive computer. The device is able to measure and display transcutaneous oxygen saturation, heart rate, plethysmographic pulse waveform, depth, time and temperature during breath-hold dives. All measurements are stored in an external memory chip. The data-processing software reads from the chip and writes the processed data into a comma-separated values file which can be analysed by applications such as Microsoft Excel™ or Open Office™. The housing is waterproof and pressure-resistant to more than 20 bar (2.026 MPa) (breath-hold divers have already exceeded 200 metres' sea water depth). It is compact, lightweight, has low power requirements and is easy to use.

Underwater study of arterial blood pressure in breath-hold divers.

Knowledge regarding arterial blood pressure (ABP) values during breath-hold diving is scanty. It derives from a few reports of measurements performed at the water's surface, showing slight or no increase in ABP, and from a single study of two simulated deep breath-hold dives in a hyperbaric chamber. Simulated dives showed an increase in ABP to values considered life threatening by standard clinical criteria. For the first time, using a novel noninvasive subaquatic sphygmomanometer, we successfully measured ABP in 10 healthy elite breath-hold divers at a depth of 10 m of freshwater (mfw). ABP was measured in dry conditions, at the surface (head-out immersion), and twice at a depth of 10 mfw. Underwater measurements of ABP were obtained in all subjects. Each measurement lasted 50-60 s and was accomplished without any complications or diver discomfort. In the 10 subjects as a whole, mean ABP values were 124/93 mmHg at the surface and 123/94 mmHg at a depth of 10 mfw. No significant statistical differences were found when blood pressure measurements at the water surface were compared with breath-hold diving conditions at a depth of 10 mfw. No systolic blood pressure values >140 mmHg or diastolic blood pressure values >115 mmHg were recorded. In conclusion, direct measurements of ABP during apnea diving showed no or only mild increases in ABP. However, our results cannot be extended over environmental conditions different from those of the present study.

Oxygen sensor signal validation for the safety of the rebreather diver.

In electronically controlled, closed-circuit rebreather diving systems, the partial pressure of oxygen inside the breathing loop is controlled with three oxygen sensors, a microcontroller and a solenoid valve - critical components that may fail. State-of-the-art detection of sensor failure, based on a voting algorithm, may fail under circumstances where two or more sensors show the same but incorrect values. The present paper details a novel rebreather controller that offers true sensor-signal validation, thus allowing efficient and reliable detection of sensor failure. The core components of this validation system are two additional solenoids, which allow an injection of oxygen or diluent gas directly across the sensor membrane.

An underwater blood pressure measuring device.

Measurement of arterial blood pressure is an important vital sign for monitoring the circulation. However, up to now no instrument has been available that enables the measurement of blood pressure underwater. The present paper details a novel, oscillometric, automatic digital blood pressure (BP) measurement device especially designed for this purpose. It consists mainly of analogue and digital electronics in a lexan housing that is rated to a depth of up to 200 metres' sea water, a cuff and a solenoid for inflation of the cuff with air supplied from a scuba tank. An integrated differential pressure sensor, exposed to the same ambient pressure as the cuff, allows accurate BP measurement. Calculation of systolic and diastolic pressures is based on the analysis of pressure oscillations recorded during the deflation. In hyperbaric chamber tests to pressures up to 405 kPa, BP measurements taken with the prototype were comparable to those obtained with established manual and automated methods. Swimming pool tests confirmed the correct functioning of the system underwater. The quality of the recorded pressure oscillations was very good even at 10 metres' fresh water, and allowed determination of diastolic and systolic pressure values. Based on these results we envisage that this device will lead to a better understanding of human cardiovascular physiology in underwater and hyperbaric environments.