Hyperbaric trials of oxygen decompression in tunnelling.

D. R. Lamont Health and Safety Executive. V. Flook Unimed Scientific Ltd. C.E. Grainger Health and Safety Executive ABSTRACT: The paper describes hyperbaric trials which were carried out to compare an existing air decompression table used in UK compressed air tunnelling (the Blackpool Tables), with the equivalent decompression table to which oxygen breathing procedures had been added. The problems encountered in organising and conducting the trials along with the results of the trials are reported. 1. INTRODUCTION On 17 September 2001, a decompression regime which included routine oxygen breathing from the 0.6 bar stage downwards, became the only decompression regime approved under the Work in Compressed Air Regulations (1996) which apply to compressed air tunnelling in the UK. This was the most recent and certainly the most controversial change in UK decompression procedures over the past 60 years. A summary of the other changes, which have taken place, can be found in Lamont (1997). The change to routine oxygen decompression came only after an extensive assessment of the medical benefits and increased safety risks arising from the use of oxygen. Some of these studies have already been published (Lamont, Buckland, Bettis and Humbleton, 1998, Lamont, Walsh and Plant, 1999, Thyer, Wilday and Andrews 2001),and others will be published in the future. 2. BACKGROUND 2.1. History representing approximately 500,000 man decompressions over a period of over 30 years, were deposited in the Decompression Sickness Registry. This was set up under the auspices of the Medical Research Council at the University of Newcastle in 1964 and operated until 1984. Since the mid 1990s the Health and Safety Executive (HSE) has been collecting decompression data from contractors on completion of work in compressed air at any pressure and with help of the industry, has also obtained copies of the records from most UK contracts operating at one bar and over since 1984. The Newcastle Registry data was analysed by Evans under a research grant from HSE. Data collected by HSE has only been subject to preliminary analysis, which was reported by Lamont (2000). In that paper, Lamont compared the incidence of decompression illness (DCI) from contracts after 1984 with that from the study by Evans. He concluded that on the basis of the standardised bends ratio, the incidence of DCI since 1984 was approximately twice that in the period studied by Evans. Lamont calculated that for a range of pressure/time exposures, relatively frequently undertaken in the UK, the single exposure ris k factor could be over 2%. It should be noted that in the UK diving industry where routine oxygen decompression has been standard practice for many years, the

The UK has probably the most extensive collection of tunnelling decompression dat a, in the world. Records from a number of major compressed air tunnelling projects,

incidence of DCI is one to two orders of magnitude lower than in tunnelling. The use of oxygen for decompression purposes in tunnelling was not completely new, as the Guidance to the Work in Compressed Air Regulations (1996) recommended that oxygen be available for the therapeutic treatment of DCI where a medical lock was required on site.

Regulations 1996, although there was a growing awareness of the high incidence of DCI resulting from their use. Because of the anticipated resistance to an oxygen decompression regime, it was decided not to consider its introduction until after the 1996 Regulations had come into force, however the regulations were drafted in such a way that any future change in the decompression regime could be accommodated without the need to change the Regulations. 3. TRIALS PLANNING AND LOGISTICS 3.1. Timescale

2.2.

Related studies

In the mid 1990s there was concern in HSE at the apparently high incidence of DCI on a number of contracts where miners were working at pressures around 0.9 bar. As a consequence Flook undertook field studies at the request HSE which confirmed th at the levels of inert gas bubbles in the miners bloodstream was sufficiently high for them to be at significant risk of DCI. This was followed by a theoretical study, in which Flook was asked to identify means by which the incidence of DCI could be reduc e d . F l o o k a d v i s e d t h a t s i g n i f i c a n t reductions in inert gas burden could be achieved by the use of oxygen breathing during decompression. Both studies were published as an HSE Contract Research Report (1998). Although oxygen decompression had been routinely used in France and Germany for a number of years, there was little published evidence of its benefits. HSE therefore decided to undertake trials to quantify the health benefits to be gained from oxygen breathing. 2.3. Blackpool Tables Since the mid 1960s the decompression tables which have been approved for use in the UK have been those known within the compressed air tunnelling industry as the "Blackpool" tables (Construction Industry Research and Information Association, 1973) after the location of the tunnel on which they were first used. These tables were first approved for use under the Work in Compressed Air Special Regulations 1958 and this approval was continued in the Work in Compressed Air

In the early summer of 2000 there had been some discussion between the authors and colleagues in HSE about the possibility of undertaking hyperbaric trials. It was only in early August 2000 that the decision was made to go ahead with them and to have the results available by the end of December that year The logistics inv olved in meeting this timescale were considerable. Once the protocol for the trials was agreed, the resources to conduct them had to be put in place. To ensure their completion within the agreed timescale: two teams of miners, fit to work in compressed air, a hyperbaric chamber of sufficient size to allow realistic manual work to be undertaken in it, and the scientific and physiological monitoring facilities to support the trials

All had to be sourced and brought together at short notice. 3.2. Protocol for Trials

As a first step a pressure/time profile had to be selected for the trials and the number of exposures to be undertaken decided. In choosing the pressure/time profile, the authors referred to the analysis by Lamont 7 and initially selected a pressure/time exposure of 1.85 bar for 6 hours as this had been shown to give a

single exposure risk factor of approximately 2%. In selecting this profile, the authors were deliberately seeking to use one that was known to cause a high incidence of DCI so that there was the greatest potential for the benefits of oxygen decompression to be demonstrated. Subsequently following consultation with the contract medical adviser, the exposure period was reduced to 4 hours. It was decided that 72 exposures would be required to give sufficient data to make the results just statistically valid whilst at the same time minimising the costs. These exposures were to be achieved by using two teams, each of six miners, with individual miners undergoing 6 exposures decompressing on air or oxygen. T o c o m p l y w i t h H S E g u i d a n c e 8, t w o acclimatisation shifts, of 2 and 3 hours respectively, were required for each miner. This potentially gave a total of 96 exposures for the trials. An alternative would have been to use a large number of miners each for one shift however this was ruled out on the grounds of cost and the non -availability of sufficient miners. The decompression profile used for both air and oxygen is shown in Figure 1. It corresponds to table 5, line 8 of the Blackpool tables.

between. This gave an oxygen dose of 112 Oxygen Tolerance Units (OTUs) per exposure. 3.3. National Hyperbaric Centre

The National Hyperbaric Centre (NHC) was chosen for the trials because of the unique facilities it could offer. The centre which is located in Aberdeen, the centre of the N Sea oil exploration industry in the UK, had till then been used only for hyperbaric trials for the diving industry. NHC houses a sophisticated saturation diving complex and 3m diameter x 8 m long working chamber. The saturation system has the capability of supporting a 16 man team to pressures of 65 bar - a depth of 650 metres of water and hyperbaric engineering techniques can be trialed at depths equivalent to 1000 metres of seawater in the working chamber. A feature of this chamber is that one end can be removed so that relatively large and heavy pieces of equipment can be loaded into it. NHC is located adjacent to Aberdeen Royal Infirmary, where the medical facilities include a hyperbaric operating theatre and other medical support for therapeutic treatments. The exposure pressure of 1.8 bar, selected for the trials, was obviously well within the capability of the complex. 3.4. Availability of critical resources

3.4.1. The Chamber The availability of the NHC complex was central to the success of the project. Fortunately, there were three periods, September and November 2000 and January 2001 when the complex would be available for sufficient time to undertake the trials. To meet HSE's December 2000 deadline obviously ruled out the January 2001 slot. Figure1 - The decompression profile used in the trials In accordance with the earlier recommendations by Flook 9, oxygen was administered in 20 minute periods with a 5 minute air break 3.4.2. Monitoring It was decided that ultrasonic and Doppler monitoring would be required and experts from the Defence and Civil Institute of Environmental Medicine (DCIEM) in Canada

were approached to do the monitoring. Unfortunately prior commitments precluded their participation at the time the NHC chamber was available in November. It was therefore obvious that the trails had to take place in September 2000 - within 4 to 6 weeks of the decision being made to hold them. 3.5. Miners

contract medical adviser and a nation al trades union official was briefed on the trials. Although the NHC maintained a list of divers familiar with the requirements of hyperbaric trials, there was no such pool of experienced miners. There was no way of knowing how the miners would react to the trials so there was some concern in case the miners decided to leave after one exposure. Fortunately they did not and after initial familiarisation brought their own brand of humour to the trials. 3.7. Appointed Doctor

The final problem to be addressed was to get sufficient miners to undertake the work in the chamber. In mid -2000 there were relatively few tunnelling contracts under way in the UK. This meant that many of the major tunnelling contractors had no miners in their employment. Those that had work were employing only the minimum number of miners required. Some miners had found alternative employment in the construction industry and were understandably not prepared to give that up for the prospect of only 8 days work in Aberdeen. Fortunately however, one of the tunnelling contractors approached, agreed to help in sourcing miners through their contacts in the industry. This involved contacting men in both the UK and Ireland. Everyone who works in compressed air has to be medically fit. Experience had shown that only just over half of those examined were likely to be declared medically fit. It was therefore necessary to have a pool of around 18 miners available for medical examination in order to get the 12 needed for the trials. In fact 20 miners had to be examined on this occasion. In order to minimise travel costs, the first six miners including all those coming from Ireland who were declared fit, were used in the first trial. Thereafter a team of miners from Central Scotland and Northern England was used, supplemented by a couple of men from two tunnelling contracts under way at that time in England. 3.6. Briefing

Only a doctor who has been appointed by HSE under the 1996 Regulations, can carry out medical examinations of fitness to work in compressed air. Because so few contracts in compressed air are undertaken, there were only a couple of doctors in the UK who were appointed at that time. It transpired that neither doctor was appointed to carry out compressed air medicals in Scotland so a rather rapid appointment had to be arranged. In accordance with HSE guidance, the appointed doctor was also the contract medical adviser. 3.8. Decompression Illness From the data available, it was thought likely that one case of decompression illness could occur during the trials. Because of the need for acclimatisation, two cases were even considered possible. 3.9. Ethical Approval Ethical approval for the trials was so ught from the Aberdeen University ethics committee. Despite the risk of DCI, the committee chairman considered the work not to be within their remit because the trials were being conducted in accordance with existing Regulations and no invasive techniques were planned. 3.10. Work It was considered important that whilst in the working chamber the miners should undergo

All miners were fully briefed on the purpose of the trials and how the trials were to be carried out. They had confidential access to the

physical exercise similar to that which they would experience in normal manual tunnelling operations. Three tonnes of gravel was therefore placed in the working chamber, which the miners shovelled from one to another in a manner similar to mucking out a tunnel face. 3.11. Contractual issues To overcome some contractual problems, it was decided that the work should be carried out fewer than 2 separate c ontracts. One contract was placed with the NHC for the provision of the hyperbaric complex and associated control and life support systems. The second contract was placed with Unimed Scientific Limited for the provision of professional services, the monitoring team and the miners to take part in the trial. 3.12. Cost The cost of the trials was approximately 190k of which the NHC facilities accounted for approximately 100k and the miners 50. 4. TRIALS CONDUCT 4.1. Model Study

Figure 2 - Theoretical predictions of the amount of gas in bubbles for air breathing and for oxygen breathing decompressions 4.3. Bubble monitoring Following decompression, the miners were monitored for decompression bubbles by both Doppler and ultrasonic scanning. Each miner was monitored by both techniques at 20 minute intervals for the first 3 hours following the end of decompression. Miners with high bubble counts were monitored at 30 minute intervals for a further 2 hours. Monitoring was carried out with the miners at rest and immediately following slight mus cular activity. The grading system used for the ultrasonic scanner was non-linear and identified 6 levels of bubbling from no bubbles to total whiteout. 4.4. Oxygen Breathing Throughout the trials when oxygen breathing was required it was done through the use of full-face masks. These have the advantage of ensuring no inward leakage of nitrogen and also of reducing the outward leakage of oxygen to the chamber atmosphere. The selection of oxygen breathing was randomised so that t h o s e c a r r y i n g o u t t h e m o n i t o r ing were unaware of the decompression procedure used. 4.5. Decompression Illness One miner suffered a pain only DCI event on his first full exposure following acclimatisation. He was recompressed and recovered fully but

The trials were informed by the earlier work of Flook9 In this, a mathematical model had been used to compare the volume of gas as bubbles in the central venous blood following a standard Blackpool table decompression with air throughout, with the same profile but which partly used oxygen as the breathing gas. This showed that the gas volume and hence the risk of DCI could be significantly reduced by using oxygen during decompression in this case from the 0.6 bar stop downwards. 4.2. Theoretical predictions Figure 2 shows the predictions for bot h the decompression carried out using air and the decompression with oxygen from the 0.6 bar stop. Along the right hand side of the figure are tentative predictions of the Doppler bubble scores.

on medical advice was excluded from the remainder of the trial. 5. RESULTS 5.1. Maximum Bubble Scores Table 1 shows the median values for maximum bubble scores for Doppler and ultrasonic scanning using air and oxygen both at rest and after movement. Since the numbers were non linear, median rather than average values are quoted. The significant reduction in bubble counts resulting from use of oxygen can be seen.

Table 2 Time to maximum bubbling From this tab l e i t c a n b e s e e n t h a t p e a k bubbling typically was occurring 1 to 2 hours following the end of decompression. All miners were monitored for a minimum of 3 hours after decompression with a significant number being monitored for a further 2 hours. As a further check, a small number of miners were monitored for an additional 3 hours after which there was still significant bubbling on movement (8 hours after decompression was completed). 5.3. Acclimatisation

Doppler At rest Air Oxygen After movement Air Oxygen 4 1 3 0

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In the past, proper acclimatisation has been thought to be important in reducing DCI. Although only a few results were available, no evidence of an acclimatisation response was detected from the monitoring results. 5.4. Relationship between Bubble Scores and Body Fat Excessive body fat may be a factor predisposing someone to DCI. As part of the medical examination, each miner was given an anthropological assessment. This covered height, weight and skin fold thickness. From these measurements a number of standard indices including Ponderal Index and Body Mass Index were calculated but there was no obvious relationship between any of the indices and bubble score. 5.5. Fluid Balance Some attempt was made to check body fluid balance during the trials and to check the specific gravity of the miners urine as indicator of p o s s i b l e d e h y d r a t i o n . N o o b v i o u s relationship was found between urine specific gravity before and after exposure. 6. CONCLUSIONS The maximum bubble scores following air decompression in the trials were well within the range expected to give rise to decompression illness.

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Table 1 Median values of maximum bubble scores 5.2. Time Profile of Bubbling

Despite the wide scatter in the results, it became apparent from the tests just how long it took following decompression for the bubble scores to peak. Table 2 shows the time to maximum bubble score based on the results available from monitoring at approximately 20 minute intervals.

Doppler At rest Air Oxygen After movement Air Oxygen 89 +/- 63 98 +/- 52 91 +/- 53 114 +/- 55

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115 +/- 53 123 +/- 73

119 +/- 53 108 +/- 72

There was a significant reduction in bubble scores following the use of oxygen decompression and the reduction was to levels at which decompression illness would be unlikely to occur. There was some individual variation in the extent o f the benefit produced by oxygen. The pain only decompression illness event, which occurred, was in accordance with expectations given the pressure/time, exposure and number of exposures involved in the trials. The time to peak bubble flow was significantly greater than that allowed for in conventional decompression practice. In this miners are required to remain on site for one to two hours following decompression as a precaution against DCI. The results allowed a first step to be derived for an empirical relationship between theoretical prediction and human trials for Doppler results and this is shown in Figure 3.

The main recommendations to HSE from the trials were that: oxygen breathing on a standard Blackpool table decompression profile from 0.6 bar downwards significantly reduced the formation of inert gas bubbles As a consequence, adopting this procedure would significantly reduce the incidence of decompression illness. That reduction could be as much as 90%. Oxygen breathing should be on a 20/5 minute cycle from 0.6 bar downwards. Oxygen breathing should be carried out using full-face masks to eliminate the inward leakage of nitrogen.

Oxygen decompression in accordance with these recommendations was introduced in the UK in September 2001. At the time of drafting this paper there were no compressed air tunnels underway and therefore no site data can be reported at present. 8. CURRENT RESEARCH Research is now underway to study a range of oxygen decompression tables to determine which is theoretically the most effective. 9. ACKNOWLEDGEMENTS The short timescale with in which these trials wer e p l a n n e d a n d u n d e r t a k e n w a s o n l y possible because of co -operation and help of many individuals. These included the miners who took part in the trials, colleagues in HSE and at NHC, the UK hyperbaric medical community and the tunnelling industry in the UK particularly Byzak Construction Ltd. 10. REFERENCES Work in Compressed Air Regulations 1996, SI 1996/1656, HMSO, London. Lamont, D.R., Changes to United Kingdom Health and Safety Legislation affecting the Tunnelling Industry, Tunnelling 97, Institute of Mining and Metallurgy, London, 1997.

Figure 3 Theoretical predictions compared to Doppler results The results obtained did not now show a correlation between bubble score and normal indices of body fat content or body fluid balance. From the data available there was no obvious acclimatisation phenomenon in terms of bubble score production. The formal report on the trials was published as an HSE Contract Research Report (2001). 7. RECOMMENDATIONS

Lamont, D.R., Buckland, I., Bettis, R.J., Jagger, S.F. and Hambleton, R.T., Fire tests in a compressed air tunnel at up to 3 bar pressure, Tunnels and Metropolises, Negro and Ferreira ed., Vol 1, Balkema, Rotterdam, 1998. Lamont, D.R., Walsh, P. and Plant, I.J., A study of the behaviour of atmospheric monitoring equipment in a tunnel at atmospheric and at up to 3 bar (g), Tunnel Construction and Piling 99, Institute of Mining and Metallurgy, London, 1999. Thyer, A.M., Wilday A.J., and Andrews, S.P., An assessment of the risks associated with the use of oxygen decomprssion in compressed air workings, Proceedings of Interflam 2001, 9th International Fire Science and Engineering Conference, Edinburgh, 17th -19th S ep t . 2 0 0 1 , E d i n b u r g h , Interscience Communications. Construction Industry Research and Information Association, Results of the analysis of compressed air records in the Decompression Sickness Central Registry Funders Report/CP/6, London.

Lamont, D.R., Tunnels under pressure mitigating the human response, AITESITA 2000 World Tunnel Congress, Durban, South African Institute of Mining and Metallurgy, 2000. A guide to the Work in Compressed Air Regulations 1996 Guidance on Regulations L96; HSE Books, Sudbury, 1996. Decompression risk factors in compressed air tunnelling: options for health risk reduction Unimed Scientific Ltd, Contract Research Report 201/1998, HSE Books, Sudbury. Construction Industry Research and Information Association, A Medical Code of Practice for Work in Compressed Air Report 44; 1st Ed; London 1973. Work in Compressed Air Special Regulations 1958 SI 1958/61 HMSO, London Work in Compressed Air Special Regulations 1958 SI 1958/61 HMSO London Trials of a Blackpool table deco mpression with oxygen as the breathing gas, Unimed Scientific Ltd, Contract Research Report 369/2001, HSE Books, Sudbury.