Chapter 29 - Barometric Hazards

Chapter 29 Outcome Competencies
After completing this chapter, the reader

should be able to:
1. Define underlined terms used in this
chapter.
2. Calculate the pressure at any habitable
depth under water or altitude above
sea level.
3. Calculate the molar fraction or partial
pressure of oxygen, nitrogen, carbon
Prerequisite Knowledge
Prior to beginning this chapter, the reader
should review the following chapters:
Chapter
Number
2
13
Chapter
Topic
Environmental and
Occupational Toxicology
Principles and
Instrumentation for
dioxide, etc., in air at any of the above Calibrating Air Sampling
pressures. Equipment
4. Anticipate the effects and estimate the
incidence of hypoxia and benign acute In addition, a college-level knowledge of
mountain sickness. physics, chemistry, and mathematics is
5. Propose some potential control helpful.
schemes for hypoxia and benign acute
mountain sickness.
6. Anticipate the effects of nitrogen nar-
cosis, oxygen and carbon dioxide toxic-
ities and the conditions at which they
might occur.
7. Explain the principles behind changing Key Topics
the composition of the air used in
NITROX and saturation diving.
I. Physical Principles
8. Calculate the change in trapped gas
A. Boyle’s Law
volume resulting from a change in
B. Dalton’s Law
depth or altitude.
C. Henry’s Law
9. Anticipate the magnitude of change
associated with barotrauma.
II. Hypobaric Hazards
10. Discuss the cause and forms of decom-
A. Recognition of Hypobaric Hazards
pression sicknesses and describe the
B. Control of Hypobaric Hazards
control approaches used to mitigate
decompression sickness.
III. Hyperbaric Hazards
A. Recognition of Hyperbaric Hazards
B. Control of Hyperbaric Hazards
Key Terms
IV. Changing Pressure Effects
A. Recognition of Changing Pressure
acclimatization • airtight caisson • barotrauma
Hazards
• benign acute mountain sickness • bottom
B. Control of Pressure Changes
time • Boyle’s law • carbon dioxide toxicity •
Dalton’s law • decompression schedule •
decompression sicknesses • dysbaric
osteonecrosis • dysbarism • hematocrit •
hemoglobin • Henry’s law • high altitude
cerebral edema • high altitude pulmonary
edema • high pressure nervous syndrome •
hyperbaric • hypobaric • hypoxia • NITROX •
oxygen toxicity • partial pressure • pressure •
saturation diving • solubility coefficient •
time of useful consciousness • Valsalva
maneuver
952 ____________________________ The Occupational Environment: Its Evaluation, Control, and Management, 3rd edition
Copyright AIHA® For personal use only. Do not distribute.

Barometric
Hazards
29
William Popendorf, PhD, CIH
Introduction benign acute mountain sickness (AMS) and

the more life-threatening high-altitude pul-
Although hygienists should be able to con- monary edema (HAPE) and high-altitude
tribute to improving the control of baromet- cerebral edema (HACE). In normal air (20.9%
ric hazards, there are currently no oxygen) these effects do not begin to be
Occupational Safety and Health detectable until at least 2000 m (6000 ft)
Administration (OSHA) regulations govern- above sea level (ASL); however, the same
ing work at altitude, and hygienists seem to range of effects can occur at or near sea
have had little direct influence on managing level if the fraction of oxygen is reduced as
diving hazards. Similarly, although several might be present in a confined space.
books and numerous book chapters are Hyperbaric conditions can produce nar-
available on health hazards associated with cotic-like effects from high inert gas pres-
abnormal atmospheric pressure, the focus sure (especially nitrogen, although high-
of most of these references is more on the pressure helium also can have neurologic
physiological and medical responses to pres- effects) and toxic effects from high oxygen
sure, rather than on the environmental ele- or carbon dioxide pressure. Nitrogen and
ments and work practices that hygienists helium are also responsible for adverse
might be trying to control. This chapter health effects following a rapid decrease in
begins with the basic science needed to total pressure during ascent after an
anticipate and recognize the physical condi- extended period of pressurization.
tions constituting a barometric hazard, and Changes in pressure can cause adverse
discusses the health effects associated with health effects via at least two mechanisms:
each type of hazard, but tries to put an (1) pain or traumatic injury from the expan-
emphasis on the management and control sion or contraction of trapped gas as the
of barometric hazards in some of industry’s pressure changes, and (2) the formation of
more novel workplaces. inert gas bubbles within supersaturated tis-
From an occupational hygiene perspec- sues that can produce a range of decom-
tive, barometric hazards can be categorized pression sicknesses (DCSs). A combination of
as (1) hypobaric (low pressure) hazards, (2) the two mechanisms can produce a poten-
hyperbaric (high pressure) hazards, and (3) tially fatal arterial gas embolism. DCS most
hazards from changes in pressure (predomi- commonly arises following a rapid decrease
nantly, but not exclusively, decreases from from a “hyperbaric” pressure to normal pres-
high to low pressure). This chapter is orga- sure (typical of diving, underwater construc-
nized to follow these three categories. tion, and work in pressurized caissons or
Hypobaric conditions produce adverse tunnels); however, DCS can also occur fol-
health effects due to a lack of oxygen, lowing a rapid decrease from near sea level
specifically the low absolute partial pres- pressure to a hypobaric pressure (typical of
sure of oxygen (PO2 in mmHg). Health effects flight crews).
include both direct symptoms of hypoxia The following sections of this chapter
and groups of indirect symptoms including first discuss the physical principles and
Section 4: Physical Agent Recognition and Evaluation _________________________________________________________953

AIHA® — American Industrial Hygiene Association
Table 29.1 — Common Units of Pressure Equivalent to One Standard Atmosphere

14.696 pounds per square inch (psi) 101325 Newtons per square meter (N/m²)
29.920 inches of mercury (in Hg) 101.325 kiloPascals (kPa)
760 millimeters of mercury (mm Hg) 1.01325 bars (B)
physiological mechanisms underlying all of historical footnote, Robert Boyle hired a

these barometric hazards, then discuss each then young Robert Hooke to make an air
of the categories of hazards individually. pump with which he not only studied the
The general sequence covers conditions physical behavior of gases but also observed
defining each hazard, the nature of its animal responses to pressure. Boyle’s law
health effects, and viable controls for these can be formulated as Equation 29-1 or as the
hazards. This chapter does not stress med- more general universal (or ideal) gas law,
ical diagnosis, treatment, or the toxicologi- Equation 29-2.
cal mechanisms underlying these hazards;
the interested reader is directed toward the P × V = constant (29-1)
extensive bibliography cited throughout.
P×V = n×R×T (29-2)
Physical Principles where:
Dysbarism is a generic term applicable to
any adverse health effect due to a differ- P = total pressure, atmospheres
ence between ambient pressure and the V = gas volume, L
total gas pressure in tissues, fluids, or cavi- n = moles of gas; its mass in g
ties of the body. To understand the physical divided by its molecular weight.
and physiological effects of pressure, an R = universal gas constant,
occupational hygienist should have a thor- 0.08205 L × atm /K/mole
ough understanding of three physical gas T = absolute temperature in degrees
laws: Boyle’s law, Dalton’s law, and Henry’s Kelvin, K = °C + 273.15
law, which are discussed in subsequent sec-
tions. These three laws underlie most of the Boyle’s law applies to the expansion and
hazards associated with dysbarisms. All contraction of gases within the body due to
three of these laws relate to ambient pres- changes in external pressure. Expanding gas
sure that changes with altitude above sea trapped within the lung, middle ear, sinuses,
level and with depth below the surface of or stomach (gastrointestinal [GI] tract) can
water. Pressure is the force per unit surface cause pain, and rapidly expanding gas can
area exerted by the molecules of a fluid in actually cause traumatic injury, called a
contact with a body. Barometric hazards to barotrauma. One use of the universal gas
humans are most easily referenced to differ- law familiar to occupational hygienists is to
ences from the normal living environment of find the molar volume of any gas at normal
one standard atmosphere, which can be temperature (T=25°C = 298.15 K) and pressure
expressed in several common units, as listed (P=1 atm):
in Table 29.1. Pressure measured relative to
the local atmosphere is sometimes called V RT 0.08205 L × atm/K/mole × 298.15 K
“gauge pressure” with units such as “psig,” — = —– = —————————————————
in which “g” is for gauge. Hypobaric and div- n P 1 atm
ing conditions are reported in the literature
as absolute pressure, but conditions in com-
pressed air construction work is usually = 24.45 L/mole (29-3)
stated in gauge pressure.
Another useful application is finding the
density (ρ) of a known gas. For instance, the
Boyle’s Law density of air can be found knowing its mol-
Boyle’s law (postulated in 1662) states that ecular weight (MW) is 28.96 g/mole (see
the volume of a gas at constant temperature Table 29.2):
is inversely proportional to its pressure. As a

Chapter 29 — Barometric Hazards
mass n MW (28.96 g/mole) Table 29.2 — Chemical Composition of Standard Dry Air
ρ = –—— = ——— = –———–––– = 1.184 g/L (29-4) Molecular
V V 24.45 L/mole Chemical Component Weight MWi × Yi Yi (%)
Nitrogen (N2) 28.0134 78.084 21.8740
The pressure created by a fluid depends
Oxygen (O2) 31.9988 20.948 6.7031
on the height and density of the fluid above Argon (A) 39.948 0.934 0.3731
it. Thus, pressure decreases with altitude Carbon dioxide (CO2) 44.0099 0.0314 0.0138
above sea level and increases with depth Neon (Ne) 20.183 0.00182 0.0004
below the surface of water. Changes in Helium (He) 4.0026 0.00052 0.00000
absolute pressure with depth are easy to Sum of molar fractions = 99.9997
anticipate because water is practically
Molecular weight via Equation 29-9 = 28.96440
incompressible. Thus, pressure increases
linearly with depth. However, water density Source: Reference 1
does differ between fresh water at 1 kg/L
(62.4 lb/ft;) and sea water 1.026 kg/L (64.0
Table 29.3 — Values of κ for Use in Equation 29.5 with
lb/ft;). And it is important to remember that
Depth Below the Surface of Water
the pressure at the water’s surface is always
1 local atmosphere (and at sea level the Depth in Feet Depth in Meters
local atmosphere is approximately 1 stan- Fresh Water 33.8 10.3
dard atmosphere). Thus, the pressure in Sea Water 33.1 10.1
absolute total atmospheres (ATA) at any
depth in terms of either feet or meters may
be found using Equation 29-5: Table 29.4 — Values of κ for Use in Equation 29-6 (or Power
of 2) to Anticipate the Normal Pressure at Altitudes Above
Punderwater = Sea Level (ASL)
≤ 20,000 ft ≤ 6100 m
Plocal + (depth/κ) ≈ 1 atm. + (depth/κ) (29-5) For Equation 29-6 25,970 7915
For Power of 2 18,000 5500
where Plocal = either 1 atm or a lower air pres-
sure if above sea level (see Equation 29-6)
and κ= chosen from Table 29.3 based on the PASL = Pat sea level × e(-altitude/κ) (29-6)
density of the water and units of depth.
where κ is chosen from Table 29.4 based on
Example 1. Find the total pressure while
the units of altitude ASL.
repairing an oil rig at a depth of 185 feet
under the Gulf of Mexico. Use κ = 33 in Although air temperature does change
Equation 29-5 to find the total pressure at a with altitude,1 it turns out that this change
depth in sea water given in feet (denoted as is sufficiently uniform that atmospheric
fsw for feet of sea water). Because the sur- pressure can still be approximated by an
face is at sea level, Punderwater = 1 atm + exponential formula.(1) The coefficients in
185/33.1 = 1 atm + 5.6 = 6.6 ATA. Table 29.4 were optimized to predict P to
Changes in pressure with altitude are within ±1% for most terrestrially accessible
slightly more complex because air is com- altitudes (up to 20,000 ft or 6100 m), but they
pressible. Its density varies according to will overestimate P by >10% above 35,000 ft.
Boyle’s law inversely with pressure, which Table 29.4 also includes coefficients for pow-
itself varies with the height of the atmos- ers of two, which some readers may find
phere above it. If the air temperature were more intuitive (similar to a half-life). Thus,
constant, this change in pressure with alti- the atmospheric pressure at an altitude of
tude would be an exact exponential rela- 18,000 ft or 5500 m is approximately one-half
tionship of the form in Equation 29-6. that at sea level.
1Under normal conditions, temperature drops about 2°C per 1000 ft in altitude. This is called an
“adiabatic lapse rate,” which in the NOAA standard atmosphere is 1.9803EC = 3.5645EF) up to 36,000
feet (~11,000 m) where the constant temperature stratosphere begins.

Example 2. Find the local barometric Table 29.5 — Solubility Parameters (Henry's
pressure at Logan, Utah (altitude 4455 ft or Constants) of Some Gases of Physiologic
1358 m ASL), on a normal day. Interest
Gas S in Water S in Lipid S Lipid
Pat sea level = normal pressure = 1 atm = 760 mm Hg (cc/mL/atm) (cc/mL/atm) S Water
Cyclopropane .204 11.2 55.0
Pat Logan = 760 × e(-1358 / 7915) = 760 × 0.842 = 640 mm Hg Argon .0262 .1395 5.3
Nitrogen .01206 .0609 5.0
Pat Logan = 760 × 2(-4455 / 18,000) = 760 × 0.842 = 640 mm Hg Oxygen .0238 .112 4.7
Nitrous oxide .435 1.4 3.2
Helium .0087 .0148 1.7
This example predicts that normal
Carbon dioxide .5797 .88 1.5
atmospheric pressure at that location mea- Ethyl ether 15.6 15.2 1.0
sured by a barometer will be 640 mm Hg.
Note, however, that weather bureaus and
airports always adjust their readings for
their local altitude and would still “report” a The partial pressure exerted by each
pressure of 760 mm Hg or 29.92 inches Hg on component is proportional to its molecular
a normal day. Changes in the equivalent sea concentration in the mixture. Thus, partial
level pressure caused by weather fronts are pressure (Pi) is but one measure of airborne
normally within ±25 mm Hg (or ±1 inch Hg). concentration. Equation 29-8 relates Pi to
Thus, a hygienist could specify a nonstan- the more familiar occupational hygiene con-
dard local pressure either by inserting the centration term of parts per million (ppm), or
pressure reported by a local weather bureau molecules of a contaminant per million mol-
or airport into Equation 29-6 with errors ecules of air.
within ±1%, by assuming the day is standard
and insert 760 or 29.92 into Equation 29-6 Pi × 106
with errors of ±3% (25/760 or 1/29.92), or by ppmi = ————— = Yi × 106 (29-8)
finding a working barometer (although the PATA
pressure may still easily change ±1% during
a day). Dalton’s law can be used to determine
how much oxygen is available in the ambi-
Dalton’s Law ent air, in the lung, or in the alveoli either at
Dalton’s law involves a term called “partial altitude when the total P is low or when
pressure.” The partial pressure of substance i high concentrations of other gases displace
(abbreviated Pi) is simply the force per unit oxygen even at sea level. The molecular com-
position of air is quite constant with alti-
surface area exerted by molecules of one spe-
tude. Table 29.2 lists the U.S. and interna-
cific chemical in contact with a body. John
tionally agreed standard composition
Dalton conducted extensive research in phys-
applicable to all humanly habitable alti-
ical chemistry and formulated the modern
tudes.2 This table also calculates the molec-
atomic theory (for which the unit of atomic
ular weight (MW) of standard dry air using
mass was given his name). Dalton’s law
Equation 29-9(1); humidity can reduce the
(1801), sometimes called the law of partial
molecular weight of air by 0.1 to 0.2 g.
pressures, states that the total pressure (P) of
a mixture of gases is equal to the sum of its
Σ(Yi × MWi)
independent partial pressures, Equation 29-7.
MWmixture = —————— (29-9)
PATA = ΣPi = Σ[Yi × PATA] = Σ(Yi)
(Y1 + Y2 + … + Yn) × PATA (29-7) Henry’s Law

Henry’s law (proposed by William Henry in
where Yi = the molar fraction of gas i in the 1803) states that the equilibrium concentra-
total mixture = Pi/PATA. tion of a gas dissolved into a liquid will
2The U.S. standard atmosphere is identical to those adopted by the ISO and ICAO (International Civil
Aviation Organization) through 11 km.

equal the product of the partial pressure of Example 3. Assuming that a carbonated
the gas times its solubility in the liquid. The beverage is initially bottled in equilibrium
gas solubility in a given liquid (shown in with carbon dioxide at 1 atm (i.e., 100% CO2),
Equation 29-10 as Si) is usually called Henry’s how much CO2 gas is dissolved in a 12 oz
constant. (0.355 L) bottle? Use Equation 29-10 to find the
concentration of gas in the bottled liquid,
Ci in solution = Si × Pi (29-10a) then the volume of gas trapped in the bottle.
Vi in solution = Vliquid × Ci (29-10b) CCO2 = 1 atm × .5797 cc/mL/atm = 580 cc/L

(analogous to 58% CO2)
where
VCO2 = Vliquid × CCO2 = 355 mL × .580 cc/mL
Ci = concentration of gas i dissolved = 206 cc.
in solution, cm³/mL = cc/mL
Pi = partial pressure of gas i, atm The same method can be used to find
Si = solubility coefficient of gas i in a that only about 0.06 cc of CO2 will be in the
given solute, cc/mL/atm bottle if it is left open until it comes into
Vi = volume in either cc of dissolved equilibrium with normal air that contains
gas i or mL of liquid only about 314 ppm according to Table 29.2.
Thus, one can see that when that bottle is
Henry’s law has been successfully used first opened, there is 3185 times more CO2 in
outside the body to relate a contaminant’s the beverage than there will be when it
concentration in water (or other solvent) comes back into equilibrium with ambient
to its vapor pressure and, therefore, to its air.
rate of evaporation from or absorption
into that media.(2–5) Physiologically, CO2 in a fresh beverage 1,000,000 ppm
Henry’s law can predict the body’s absorp- ——————————— = ——————— = 3185
tion of most gases from the alveoli of the CO2 in an old beverage 314 ppm
lung, its rate of transport via the blood,
and the amount of gas that can be stored This “supersaturated” ratio is sufficient
in tissue where it can eventually have an to cause bubbles to form rapidly within the
adverse effect. It is important to realize beverage when it is opened, bubbles that
that because blood is mostly water, the can comprise as much as 58% of its liquid
rates of gas absorption, transportation to volume. Only if the pressure is released slow-
tissues, and eventual desorption from tis- ly and the evolved gas can dissipate, is it
sues are all primarily dependent on the possible for such a beverage to lose its fizz
gas’s water solubility (with the exception without forming bubbles.
of oxygen because of hemoglobin).
However, the mass of gases stored in lipid
tissues, such as myelinated neurons and
Hypobaric Hazards
collagen at joints, is determined by the Occupational examples of hypobaric condi-
gas’s lipid solubility. Henry’s law predicts tions include high-altitude construction or
that the greater the ratio of a gas’s lipid to mining, and aviation (especially aircrews or
water solubility, the more slowly these passengers under rapid loss of pressurization
gases can be carried back out of lipid tis- conditions). The number of hygienists actively
sues after leaving high pressure, which is involved in these settings is probably less
especially a problem for poorly perfused than warranted by the range of hazards and
tissues like collagen within joints. It also number of people exposed. Effects of hypo-
turns out that the anesthetic quality of a baric health hazards include the following.
gas is highly correlated to its lipid or oil
solubility (related to the lipid nature of (1) Hypoxia due to insufficient oxygen pro-
myeline). Values of Henry’s constants for duces symptoms that range from barely
some physiologically important gases are detectable to completely disabling
listed in Table 29.5, rank ordered by their depending on the severity of the cellu-
lipid/water solubility ratios. lar oxygen depletion. Normal increases

in respiratory ventilation cannot pre- Recognition of Hypobaric Hazards

vent some decrease in a person’s ability
As previously discussed, the ambient total
to perform extended strenuous work. In
pressure at any practical altitude can be pre-
cases of rapid decompression or
dicted using Equation 29-6. If total pressure
removal of supplemental oxygen, one’s
decreases but the mixture of gases stays the
ability to perform lifesaving responses
same, the partial pressures of oxygen and
can be limited to a potentially very
nitrogen decrease in parallel with the total
short time of useful consciousness.
pressure. Thus, a quantitative prediction of
(2) Benign AMS (also referred to as simple
these ambient partial pressures at any alti-
AMS or mild/moderate AMS) is a con-
tude can be made by applying the molar com-
stellation of symptoms highlighted by
position YN2 and YO2 from Table 29.2 and the
frontal headaches that can range from
discomforting to incapacitating. change in total pressure from Equation 29-6:
Benign AMS is precipitated by a rapid
ascent, has no objective diagnostic cri- Pambient N2 = 0.78084 × 760 × 2(feet/18,000) (29-11a)
teria, but will generally resolve sponta-
neously within 3 to 5 days.
(3) High altitude cerebral edema (HACE, Pambient O2 = 0.20948 × 760 × 2(feet/18,000) (29-11b)
also termed cerebral AMS) is believed
to be the endpoint of progressive As long as there are no local sources of
benign AMS. High altitude pulmonary emission, absorption, or consumption of
edema (HAPE, also termed pulmonary either gas, the molar ratio of 78.084% nitro-
AMS), may or may not be preceded by gen to 20.948% oxygen in ambient air will
benign AMS. HACE and HAPE both always be about 3.73 to 1. Now, using
reveal definitive objective findings, and Dalton’s law (Equation 29-7) and adjusting
their symptoms can progress rapidly to for the presence of other natural inert gases:
become life threatening if not treated
by a prompt descent to a lower alti- 0.99032 PATA = PN2 + PO2 = 3.73 PO2 + PO2
tude. For this reason HACE and HAPE
are categorized by some to be malig- = 4.73 PO2 (29-11c)
nant AMS in contrast to less serious
benign AMS.(6) Therefore, in ambient air, PO2 ≈
(4) Chronic mountain sickness (CMS or
PATA/4.78. Physiologically, the situation
Monge’s disease) can affect long-term
becomes a little more complicated. The
mountain residents. CMS is a loss in
composition of gases changes as air enters
pulmonary acclimatization that results
the respiratory tract, as summarized in
in alveolar hypoventilation and ensu-
Table 29.6.(8,9) One of the first changes to
ing cyanosis, low arterial saturation,
occur is the complete humidification of the
increased erythrocytosis with
air before reaching the alveoli. The lung’s
increased hematocrit, pulmonary
concentration of water vapor is nominally
hypertension, and right heart enlarge-
always 47 mm Hg, equal to the vapor pres-
ment. Affected individuals have varied
sure of water at the body’s core tempera-
neuropsychological symptoms.
ture of 37.2°C (or 99°F). This constant PH2O
Because the time of response of CMS is
so delayed relative to industrial per- of 47 mm Hg is a small molar fraction when
sonnel transfers, it is considered herein the total P is 760 mm Hg at sea level, but it
to be outside the occupational hygien- becomes an increasing fraction as the total
ist’s realm (if that is possible). The pressure drops with altitude. The body can
interested reader is referred to Heath easily exhale 1 to 2 L of water per day, con-
and Williams(6) or Ward et al.(7) tinually humidifying typically dry mountain
(5) DCS can occur at high altitude with air and contributing an additional risk of
symptoms identical to but usually less dehydration at altitude.(7)
severe than those following underwa- The next change is the simultaneous
ter diving. A full discussion of DCS is absorption of oxygen and release of carbon
deferred to the Changing Pressure dioxide within the alveoli. Alveolar PO2 is
Effects section. less than lung PO2 because some oxygen is

Table 29.6—Physiological Partial Pressures (mmHg) when Breathing Normal Air

Altitude Ambient Air Physiological PressuresA,B AlveolarB
(ft ASL) total P PO2 PH2O PCO2 ΔPO2 PO2
0 760 159 47 40 (40) –38 (–38) 104 (104)
10,000 523 110 47 36 (23) –26 (–19) 67 (77)
20,000 349 73 47 24 (10) –19 (–9) 40 (53)
30,000 226 47 47 24 (7) –15 (–6) 18 (30)
40,000 141 29 47 not humanly tolerable
50,000 87 18 47 not humanly tolerable
62,800 47 10 47 water at body temperature boils
AThe partial pressures (mmHg) of alveolar CO2 exhaled and O2 absorbed decreases at higher
altitudes due to increasing respiratory minute volume.
BThe first set of PO are unacclimatized values; the second are for acclimatized persons.(8,9)
2
absorbed into the blood for distribution to Pambient total – Pinert gas
the body. This absorbed oxygen (listed in PO2 = —————————— (29-12c)
Table 29.6 as ΔPO2) is ~38 mm Hg at sea level 4.78
and decreases with altitude in a nonlinear
fashion in response to both the decreasing Accounting for the presence of water
oxygen initially within the alveoli and the vapor in the lung and for the liberation of
increasing respiratory minute volume (the physiologic PCO2 yields a new distribution of
latter varies with the degree of acclimatiza- gases, and in particular a reduced concen-
tion). Increased respiration decreases the tration of oxygen reaching the lung:
amount of oxygen absorbed per breath
(ΔPO2), thereby increasing the average alveo- Plung total = 4.78PO2 in lung + PH2O +
lar oxygen and helping to maintain the oxy-
gen saturation within the blood. Meanwhile, PCO2 + (Pinert gas) (13a)
the PCO2 released from blood into the alve-
oli is about 40 mm Hg at sea level and
decreases at higher altitudes to a plateau of PO2 in lung = [Plung total – PH2O –
about 24 mm Hg at 24,000 feet (7300 m). The
normal ambient PCO2 is so much smaller
PCO2 – (Pinert gas)] / 4.78 (29-13b)
than physiologic levels at any altitude in
Table 29.6 that it may be disregarded.3
From this oxygen initially reaching the
Dalton’s law can be used again to
approximate the physiological dynamics of lungs, an experimentally predictable
respiration at increased altitudes shown in amount of oxygen will be absorbed into the
Table 29.6. The effect of a potential inert gas alveoli (ΔPO2) to yield Equation 29-14:
is inserted here for completeness because
the same hypoxic effects caused by a low PO2 in alveoli = [Pambient total – PH2O – PCO2 –
total pressure of air at altitude can also
occur at sea level if an inert gas displaces (Pinert gas)] / 4.78 – PO2 (29-14)
air. Inert gas concentrations are normally
negligible except in confined spaces (dis- Example 4. Find the alveolar oxygen par-
cussed in Chapter 46). Applying Equation 29-7 tial pressure in an unacclimatized person at
similar to its use in Equation 29-11c: 30,000 feet, the approximate height of
Mount Everest. Equations 29-6 and
Pambient total = SPi = PN2 + PO2 + (Pinert gas) (29-12a) 29-12–29-14 can be used in sequence:
Pambient total = 760 e(30,000/24,540) = 224 mm Hg

Pambient total = 4.78PO2 + (Pinert gas) (29-12b) (versus 226 from NOAA(1))
3Because ambient YCO2 is only about 315 ppm (Table 29.2), ambient PCO2 found using Equation 7 is only
0.2 mm Hg at sea level and decreases with altitude (similar to Equation 11).

can calculate using Dalton’s law, Henry’s law,

and sea level data from Tables 29.5 and 29.6,
that only about 0.2 cc O2 can be dissolved into
100 mL of blood plasma acting as water ver-
sus about 20 cc O2 /100 mL (often called “20
volume percent”) contained in normally oxy-
genated blood with hemoglobin. Moreover,
rather than a linear relationship with the par-
tial pressure of oxygen predicted by Henry’s
law, hemoglobin binds with oxygen in a bene-
ficially nonlinear way. As shown by the center
line in Figure 29.1, which depicts hemoglobin
at a normal blood pH of 7.4 (corresponding to
an alveolar PCO2 of 40 mm Hg), blood is at
least 95% oxygen saturated at an alveolar
oxygen partial pressure as low as 85 mm Hg.
The body’s response to less oxygen in the
Figure 29.1—The oxyhemoglobin dissociation curves for human
blood is to increase its respiration rate, dri-
blood at 37°C and pH of 7.6, 7.4 (normal), and 7.2.(10)
ving off CO2, increasing the blood’s pH, and
further increasing the carrying capacity of
hemoglobin.(9) Thus, hemoglobin gives the
alveolar PH2O = 47 mm Hg (at body core temperature) body a very robust tolerance to modest alti-
tudes, as summarized in Table 29.7.
alveolar PCO2 = 24 mm Hg (known by experiment) One of the first physiological symptoms
of hypoxia is shortness of breath on exer-
ΔPO2 = 15 mm Hg (also known by experiment) tion. The unacclimatized person’s initial
physiologic response of increasing respira-
alveolar PO2 = (224 – 47 – 24) / 4.78 – 15 = tion will be somewhat thwarted by the sec-
17 mm Hg (versus 18 mm Hg from Table 25.6). ondary effect of hyperventilation to
decrease the blood’s carbon dioxide concen-
Hemoglobin’s affinity for oxygen is a tration (see PCO2 in Table 29.7), which
major contributor of physiological tolerance increases its pH and tends to lower respira-
to hypobaric conditions. Hemoglobin in red tion. The body will partially acclimatize to
blood cells carries about 50 times more oxy- altitude in 2–5 days, facilitating hyperventi-
gen than is dissolved in blood plasma. One lation (see further discussion in Control of
Table 29.7 — Summary of Direct Physiological Responses to Hypobaric Pressures(11–14)

Ambient Alveoli Blood Eqv. Sea
Altitude P O2 P O2 O2 Level
(ft) mmHg mmHg % sat. Health Effects Y O2 Yinert
< 6000 >127 >82 >95 none except on maximum exertion 17% 21%
12,000 101 65 90-95 decreased night vision and AMS symptoms 13% 37%
18,000 79 44 75-85 euphoria, loss of coordination 10% 51%
>18,000 limited by the time of useful consciousness (TUC)
20,000 73 40 74-82 TUC = 10-20 minutes 9.6% 55%

25,000 59 25 45-55 TUC = 3-5 minutes 8% 63%
30,000 47 21 30-40 TUC = 1-2 minutesA 6% 71%
35,000 37 12 15-20 TUC = 30-60 secondsA 5% 77%
40,000 29 12 10-15 TUC = 15-20 secondsA 4% 82%
Note: The concentrations of inert gas sufficient to create the equivalent levels of hypoxia at sea level
were calculated from ambient PO2 using Equation 29-12.
AComplete loss of consciousness will result above 30,000 feet.

Hypobaric Hazards section). The combined % increase in

benefits of hemoglobin’s natural affinity for –—————— =
oxygen, an initial increase in cardiac output, light intensity
and even modest increases in respiration
are so effective that very little physiologic 80 × ln(1 – altitude in feet/19,400) (29-15)
effects of altitude can be detected below
6000 feet (1800 m) except that an oxygen This effect suggests that special precau-
debt can develop more rapidly if near maxi- tions should be taken to avoid working in
mum exertion. This was perhaps most vividly poor lighting conditions at high altitude
demonstrated in the 1968 Summer Olympics work sites. A discussion of the cluster of the
in Mexico City (2300 m; 7546 ft) in which no less direct and slightly delayed symptoms
world records were established in events collectively called AMS that can occur about
lasting longer than 2.5 minutes.(14) Mental 12,000 feet will be postponed briefly.
performance is also not affected below a Except for the aviation industry and
PO2 equivalent to 6000 ft.(11) recreation, work above 18,000 is quite rare.
Regarding inert gases in confined spaces, High altitude hazard recognition training for
it can be noted in Table 29.7 that 6000 feet is pilots and flight crews includes their expo-
equivalent to 17% oxygen at sea level. Figure sure to the early symptoms of hypoxia (light-
29.1 shows that the oxyhemoglobin will still headedness and peripheral tingling) that usu-
be >95% saturated under this condition. This ally precedes euphoria, incoordination, and
observation implies that the OSHA require- the loss of the ability to take corrective steps
ment to ventilate any time the oxygen con- to ensure ones own survival. The special case
tent is less than 19.5% [29 CFR 1910.94(d)(9)(vi)] of responding to rapid decompression at alti-
has no real basis in health. The American tudes above 20,000 ft emphasizes the limited
Conference of Governmental Industrial time of useful consciousness(8) sometimes
Hygienists’ threshold limit value recommen- also called the effective performance time.(10)
dation of a YO2 the molar fraction of oxygen, It is incumbent on the flight crew (and benefi-
cial to passengers) to don masks providing
of 18% or an equivalent PO2 of 135 mm Hg is a
100% oxygen within the sometimes very short
similarly conservative health hazard at sea times listed in Table 29.7.
level that if applied literally (using Equation In contrast to the direct effects of hypox-
29-11) would ban all work over 3750 feet ia described previously, two clinically impor-
above sea level. Such guidance might best be tant, related, yet distinct groups of indirect
described as a good practice standard. Given and slightly delayed responses to altitude
that providing fresh air to a workplace is gen- have been identified. What was initially
erally cheap (although perhaps time-consum- called AMS has now been subdivided into
ing), abundant oxygen should be available benign AMS and what at least some call
unless it is consumed, an unreasonable malignant AMS.(15)
amount of some other gas or vapor is allowed Benign AMS constitutes an array of
in the workplace air (that is likely to be toxic symptoms that may begin to develop in trav-
or explosive well before it creates an oxygen elers from near sea level within 6–12 hours
deficient health hazard), or ventilation is after arriving at altitudes above 8000 ft (2500
marginal. However, more severe displace- m), especially when travel is rapid as by air
ments of oxygen at sea level (shown on the or car. Symptoms include headache (very
right side of Table 29.7) are capable of caus- common and nearly always in the frontal
ing the full range of hypoxic symptoms. region), difficulty sleeping (the next most
The decrease in night vision acuity common symptom), lightheadedness or
among the next group of symptoms in Table dizziness, nausea or vomiting, and fatigue or
29.7 manifests itself in lower sensitivity to weakness. Symptom severity ranges from
stimuli and decreased peripheral vision and mild (discomforting) to severe (incapacitat-
contrast discrimination.(10,12) The percentage ing). Physical examination of those with
increase in the light intensity necessary to symptoms has revealed that about 25%
maintain an equivalent retinal response exhibited chest crackles or peripheral pul-
may be estimated using Equation 29-15, monary edema.(16) Symptoms beyond a
determined by regressing the data summa- headache normally increase gradually, peak
rized by Gagge and Shaw.(8) on the second or third day, and resolve

Table 29.8 — Reported Incidence of Benign AMS Symptoms of patients with HAPE rapidly
Altitude progress to a dry cough, production of a
(ft) (meters) Incidence Data Source foamy pink sputum, audible bubbling and
gurgling sounds during breathing, and
6200-9600 1900-2940 25% 17
cyanosis of the lips and extremities. Early
9350 2850 9% 18
10,000 3050 13% 18 recognition of these acute symptoms, con-
11,975 3650 34% 18 servative field diagnosis, and prompt action
14,250 4343 43%A 16 is essential to prevent further progression
13,910 4240 53% 19 into a coma followed by death within 12
AIf the person is flown to 9186 ft, 60% incidence; 31% if hiking hours. The patient should be given oxygen,
from 3940 ft. restricted in activity, and taken immediately
to a lower altitude. If oxygen or descent is
not possible, oral nifedipine should be
administered.(20) Recovery without complica-
tions is normally quite rapid. Although the
themselves by the fourth or fifth day. Thus, recovered patient should be cautious, he or
the term “benign” was adopted to differenti- she may later return to high altitude with-
ate this pattern from the more life-threaten- out further trouble.(6,7)
ing manifestations of AMS.(6,7) The incidence The incidence of HAPE is uncertain. One
of benign AMS can be anticipated from prior study reported rates of 0.9% in residents
studies as summarized in Table 29.8, returning to 10,000 feet ASL after short visits
although the subjective nature of benign to a lower altitude.(21) Heath and Williams
AMS makes its diagnosis a variable.(6,7) summarized the incidence among studies of
Symptoms of benign AMS subside spon- mixed populations at altitudes between
taneously (without treatment) and will not 10,000 and 20,000 ft (2800–6195 m) as 0.5 to
necessarily affect the same traveler repeat- 1.5%.(6) They also cited studies reporting
edly or with the same severity. Treatment of rates of subclinical pulmonary edema diag-
symptoms with ibuprofen may be better at nosed radiologically ranging from 12 to 66%.
relieving symptoms of headache than HAPE is slightly more prevalent among the
aspirin, but Ward et al.(7) advocates volun- young, apparently healthy, and therefore
tary hyperventilation, which also promotes probably more active segments of a popula-
acclimatization. Acetazolamide (Diamox®, tion. The mechanism(s) of HAPE is unclear. It
250 mg twice daily) may be used either as a may or may not be related to the mecha-
prophylaxis beginning 24 to 48 hours before nisms causing benign AMS, but the most
ascending or to relieve symptoms.(7) prevalent theory imputes pulmonary vaso-
Dexamethasone has been found to be equal- constriction due to the accumulation of
ly effective for treatment.(20) Prevention by water in extravascular spaces. Preventive
avoiding rapid ascents is widely touted,(6,7) guidelines are broadly similar to those for
but the recommended schedule of 1 to 2 benign AMS with the added caution against
days per 1000 feet above 9000 feet is not overexertion the first few days after rapidly
compatible with the fast pace of most non- traveling or returning to altitudes above
recreational temporary assignments. 9000 ft (2700 m). Nifedipine can be taken as
It is important to be able to differentiate prophylaxis in people with a history of
benign AMS symptoms from the less com- HAPE.(20) Acetazolamide (Diamox) is not pro-
mon but more severe and life-threatening tective against HAPE.(7)
forms of AMS that may develop. Dickinson(15) HACE is even less understood than HAPE.
proposed the term “malignant AMS” to Ward et al.(7) and Hackett et al.(20) believe
encompass HAPE and HACE, although this that HACE is a direct progression of benign
categorization is not as widely accepted as AMS to include cerebral edema, whereas
benign AMS.(6) The edema in HAPE is charac- Heath and Williams(6) believe that thrombo-
terized by the release of large quantities of sis also plays a part. The symptoms of HACE
a high protein fluid into the lung. include many benign AMS symptoms but are
Differential symptoms (often denied by the differentiated by disturbed consciousness
patient) include severe breathlessness (in (irrationality, disorientation, and even hallu-
84% of cases) and chest pain (in 66%), with or cinations), abnormal reflex and muscle con-
without the above symptoms of benign AMS. trol (ataxia, bladder dysfunction, and even

convulsions), and/or papilloedema (swelling Acclimatization is a remarkably effec-

of the optic disc). HACE is rarer than HAPE, tive long-term control for habitable high alti-
although symptoms of mixed HACE and tudes. Acclimatization changes the balance
HAPE frequently occur. As with HAPE, early between two respiratory control mecha-
recognition and action are essential to pre- nisms. After initial exposure to low oxygen,
vent a fatal HACE outcome. Fortunately, both the reaction of peripheral chemoreceptors
conditions require the same treatment with (PO2 sensors in the carotid and aortic bodies)
oxygen and evacuation to a lower altitude. If is to increase the respiratory minute volume;
medication is feasible, dexamethasone however, increased respiration decreases
should be administered immediately, and the blood PCO2 and increases its pH, which
acetazolimide should be given if descent is decreases the stimulation of the respiratory
delayed.(20) Knowledge of HAPE and HACE is a center within the brain. This natural balance
vital component of a hazard communication initially limits the body’s ability to increase
program for supervisors and workers at high respiration in response to a feeling of
altitude. breathlessness. For example, the work
capacity of a new arrival at 17,000 feet
Control of Hypobaric Hazards would be expected to be reduced by 50%.(9)
This would be aggravated if the work
The full paradigm of occupational hygiene
required a respirator.
controls is applicable to the hypobaric work-
The first adaptation to altitude is a
place. The classically preferred option of
reduction over 2 to 5 days in the blood’s bicar-
source control is only practical in aircraft
bonate ion concentration (HCO3), decreasing
where the total pressure inside a pressur-
the negative sensitivity of the respiratory
ized cockpit or cabin can be increased.
center to increased ventilation. Thereafter,
Modern commercial, turbine powered air-
the peripheral chemoreceptors can more eas-
craft maintain a maximum interior-to-exteri-
ily increase respiratory minute volumes four-
or pressure differential of about 8.6 psi,
to fivefold, increasing one’s work capacity
which will maintain a cabin altitude of no
back toward normal. This is also the time
more than 8000 feet. General aviation opera-
period over which symptoms of benign AMS
tions are restricted to cabin altitudes of
(should they occur) generally subside. The
12,500 ASL without personal protection.
length of a corresponding administrative
Various forms of personal protective
restriction to the intensity of a new arrival’s
equipment similar to supplied-air respira-
work schedule is shorter than but roughly
tors are available to increase the YO2 in the
analogous to the 1 week often recommended
breathing air. The maximum option of pro- for heat stress acclimatization.
viding 100% oxygen extends the no-effect For more extended stays at altitude,
zone to about 35,000 feet.(9,11) An annoying, longer term physiologic changes further ben-
sometimes painful, but usually resolvable efit one’s working capacity. After a period of
result of breathing 100% oxygen is the ten- 2–3 weeks, the body’s hematocrit4 and blood
dency for the body to absorb the high con- volume begin to increase up to 50 to 90%
centrations of oxygen from the middle ear above normal, and the initial increase in car-
overnight.(22) If the Eustachian tube does not diac output begins to return toward normal.
open spontaneously to relieve the resulting Following the initial drop to 50% of one’s sea
pressure difference, the Valsalva maneuver level capacity at 17,000 feet, these changes
described in the Changing Pressure Effects can be expected to raise one’s work capacity
section should be performed. Supplemental to about 70% within 2 to 3 months.(9) Other
oxygen is generally limited to short-term use changes in cardiovascular circulation occur
in aircraft systems or Himalayan expedi- even more slowly but are most pronounced
tions. However, Ward et al.(7) suggests in persons born and raised at high altitude.
adding 5% oxygen indoors via the use of Selection criteria for temporary work at
electrically powered oxygen concentrators high altitude are not particularly restrictive.
to relieve symptoms of hypoxia. Among the factors not considered detrimental
4Hematocrit is the percentage of cellular matter in a volume of whole blood, normally 42% (15 g Hb/
100 mL) for men and 38% (13.5 g Hb/100 mL) for women.(9)

to high altitude are increased age, postmy- Compressed air work in construction is a
ocardial infarction if symptom-free for several less common occupation. Pressure supplied
months, controlled hypertension, asthma, to an airtight caisson used to be a common
and well-controlled diabetes.(6) Travel to high technique to reduce the infusion of water or
altitudes is not recommended for those with mud while digging bridge pilings (see Figure
effort angina, a recent myocardial infarction, 29.2). As workers removed the undersurface
chronic bronchitis, emphysema, and intersti- mud and sand, the caisson would settle
tial lung disease.(6) Hard data on reproductive until reaching a stratum where a stable
hazards to pregnant women have not been structural foundation could be formed. Air
developed, but high altitude travel while preg- pressure has also been applied in tunnels
nant is generally not advised due to fetal and mines to control water intrusion during
oxygen requirements.(6,7) construction. A 1975 National Institute for
Occupational Safety and Health document
Hyperbaric Hazards estimated there were about 5000 profession-
al divers and caisson workers in the United
The most common occupation associated States exposed to hyperbaric hazards.(26)
with hyperbaric conditions is underwater OSHA limits compressed air workers’ maxi-
diving.(23) Occupational diving is expanding mum pressures to the equivalent of 112 fsw
into new frontiers like fish farming.(24)
to protect them not only from the direct haz-
ards of hyperbaric conditions described in
this section, but also from the indirect haz-
ards resulting after return to normal pres-
sures (described in the Changing Pressure
Effects section). Hygienists are often
involved in construction projects but rarely
have direct responsibilities for diving opera-
tions. The material covered in this section
and the Changing Pressure Effects section
should provide the technical bases to
enhance hygienists’ support functions to
specialized and highly trained supervisory
staff.
Three major health hazards (among a
wide array of all hazards) associated with
hyperbaric conditions are discussed here.
(1) Gas narcosis caused by nitrogen in nor-
mal air during dives of more than 120
feet (35 m); helium, substituted for nitro-
gen in “mixed gas diving,” can cause a
contrasting effect called high pressure
nervous syndrome beyond 500 fsw.
(2) Gas toxicity caused by oxygen and car-
bon dioxide; the damage of oxygen to
the lung and brain (central nervous sys-
tem [CNS]) varies with the time of expo-
sure and depth. Although a carbon
dioxide partial pressure of 15–40 mmHg
will stimulate the central respiratory
sensor, concentrations >80 mmHg sup-
press respiration.
(3) Another group of effects can occur
after leaving hyperbaric conditions too
rapidly. Because they do not occur dur-
Figure 29.2—A compressed air caisson with separate air locks for ing residence in one barometric condi-
personnel and bottom muck.(25) tion, DCS and dysbaric osteonecrosis

are discussed in the Changing Pressure Table 29.9 — Severity of Nitrogen Narcosis Symptoms
Effects section. with Depth in Feet and Pressure in ATA
Divers and (more commonly) com- Depth PATA PN2
pressed air workers can face other nonbaro- (ft) (atm) (atm) Symptoms
metric risks including microbes and para- 100 4.0 3.1 reasoning measurably slowed.
sites,(27–31) noise,(27,28,32–34) silica,(35) radon,(36) 150 5.5 4.3 joviality; reflexes slowed; idea
fire,(23,28,37) and toxic chemicals during under- fixation.
water cleanup operations.(28) Thus, the recog- 200 7.0 5.5 euphoria; impaired concentration;
nized acute and chronic barometric effects drowsiness.
covered herein are only a portion of the 250 8.6 6.7 mental confusion; inaccurate
total health risks faced by these workers. observations.
300 10.1 7.9 stupefaction; loss of perceptual
Some novel effects from high pressure have
faculties.
also be reported on typical occupational
hygiene evaluation equipment, such as a Sources: References 9, 22, 28
negative indication of oxygen sensors in
response to sudden changes in pressure.(38)
Other long-term hyperbaric effects, such as PN2 = YN2 × PATA = 0.7808 × 6.6 = 5.2 atm.
those summarized by Farmer and Moon(39)
are neither well established nor otherwise The concentration of nitrogen in solu-
discussed herein. tion can then be determined from Henry’s
law as expressed in Equation 29-10 and data
Recognition of Hyperbaric Hazards from Table 29.5:
The first of these hazards is the result of the
narcotic effect of any gas absorbed into CN2 in water = SN2 in water × PN2 =
neural tissues. The potential of a gas to pro- 0.01206 cc/mL/atm × 5.2 atm = 0.062 cc/mL
duce a narcotic effect is proportional to its
solubility in the lipid layers surrounding CN2 in lipid = SN2 in lipid × PN2 =
neural tissue (the Meyer Overton rule for 0.0609 cc/mL/atm × 5.2 atm = 0.314 cc/mL
anesthetic gases). Thus, the narcotic effect
of a gas increases with its oil solubility and One can see that the concentration of N2
with its partial pressure in accordance with in lipid tissues at saturation is much more
Henry’s law (Equation 29-10). Henry’s con- than in the blood. Although it takes time for
stants for selected anesthetic gases (cyclo- sufficient nitrogen to be transported by the
propane, nitrous oxide, and ethyl ether) are blood to saturate the whole body, neurolog-
provided in Table 29.5 as useful points of ref- ic tissue is so perfused by blood that symp-
erence. Pressure increases with depth under- toms of nitrogen narcosis can be quite rapid.
water, as described by Equation 29-5. Each Because the severity of symptoms listed in
component of the breathing air maintains Table 29.9 depends on the gas concentration
its own constant molar fraction of the in neural lipids, severity depends primarily
increasing total pressure in accordance with on depth and not on time at depth; however,
Dalton’s law (Equation 29-7). Thus, the par- severity also depends strongly on personal
tial pressure and potential lipid concentra- susceptibility, experience, training, rate of
tion of each gas can be predicted at any descent, and level of exertion.(22,27,28,40)
depth (or pressure created by other means). The second group of hyperbaric haz-
ards is due to the toxicity of common air
Example 5. Find the N2 partial pressure constituents such as oxygen and carbon
in air and the potential concentration of dioxide at high pressures. The hazards of
nitrogen in saturated tissues for a worker oxygen were first explored as a result of
repairing an oil rig 185 feet under the Gulf of World War II attempts to dive with pure
Mexico. oxygen to avoid nitrogen hazards and cre-
Starting with a total pressure of 6.6 ATA ating bubbles of exhaled air by using a
from Example 1, Dalton’s law as expressed closed circuit self-contained breathing
in Equation 29-7 can be used to find the frac- apparatus (called a rebreather).(22,28,41,42)
tion of the total pressure contributed by Most symptoms of oxygen toxicity can be
nitrogen: categorized as either pulmonary (coughing,

3000 fsw, yielding PCO2 = 24 mmHg. However,

the combination of the accumulation of
exhaled carbon dioxide at increased pres-
sure (either in the breathing system’s dead
space or due to a malfunction) can rapidly
cause toxic effects.(48) Using Henry’s law and
Table 29.5, the concentration of carbon diox-
ide in lipids at 80 mmHg is less than half
that of nitrogen at 3.6 ATA, supporting the
suggestion that the toxic effect of carbon
dioxide may be due to a different mecha-
nism than that of oxygen and nitrogen.(49) On
the other hand, there is likely to be an inter-
action between the early response to carbon
dioxide causing an increase in respiration
Figure 29.3—Recommended limits of exposure to inspired and an episode of CNS oxygen toxicity.(22,28)
oxygen.(28)
Control of Hyperbaric Hazards
The options available to control hyperbaric
substernal soreness, and pulmonary hazards get progressively more complex.
edema) or CNS (including body soreness, Prevention of carbon dioxide toxicity is sim-
nausea, muscular twitching, and convul- ply a matter of good system design and
sions).(27,40,45) The toxic mechanism is maintenance. OSHA regulations for commer-
believed to be related to the increase in cial diving operations (29 CFR 1910.430 and
oxygen free radicals.(9,43,44) Both symptoms 1926.1090) limit CO2 to 1000 ppm in supply air
and severity vary inversely with pressure and to 0.02 ATA within the mask, usually by
and time of exposure, as shown in Figure assuring that the flow of surface supplied air
29.3.(27,40,42,45,46) CNS hazards predominate for to masks and helmets is at least 4.5 actual
exposures in the time frame of a working cubic feet per minute at any depth at which
day, whereas pulmonary effects are more they are operated. The 0.02 ATA is equivalent
of a concern after longer times, such as dur- to 1000 ppm at 20 atm (or 627 fsw).
ing saturation diving or recompression Most oxygen toxicity can be prevented
therapy for DCS. The pulmonary curve in by keeping oxygen’s partial pressure below 1
Figure 29.3 corresponds to about a 12% atm, and when that is not possible, by limit-
change in vital capacity.(46) The CNS curve is ing the diver’s time of exposure above 1 atm.
more judgmental. Although the CNS curve Dalton’s law indicates how the partial pres-
implies an asymptote near 1.5 ATA,(22,45) a sure of oxygen can be controlled by reducing
plan should be in place to deal with convul- its molar fraction (YO2) in the breathing
sions any time the oxygen partial pressure air.(22,28) In fact, dives to depths of over 1000
exceeds 1.0 atm.(27) It is notable that the ft (300 m) use only around 1% oxygen to keep
onset of life-threatening convulsions is not PO2 to less than 0.5 ATA.(39) The U.S. Navy
necessarily preceded by the less severe
Diving Manual recommends keeping the
symptoms.(22,41)
oxygen partial pressure during routine satu-
Carbon dioxide becomes toxic when it
ration diving at 0.21 ATA (equivalent to nor-
suppresses respiration. Normally an
mal air at sea level), to between 0.44 and
increase in PCO2 decreases blood pH, which
0.48 ATA during depth changes, and to a
acts to increase the respiratory minute vol- maximum of 1.25 ATA for short intervals.(22)
ume. However, at PCO2 >80 mmHg (about The NOAA Diving Manual time limits when
twice the IDLH value), the respiratory con- diving with pure oxygen (which NOAA
trol center becomes depressed and soon admits are conservative) are superimposed
ceases to function.(47) Thus, carbon dioxide is on Figure 29.3.(28)
not toxic at exhaled air concentrations at Administratively limiting depth is a sim-
sea level (40 mmHg in Table 29.6). Nor is it ple but only marginally effective control for
toxic if normal ambient air (314 ppm CO2 in nitrogen narcosis. For instance, the deepest
Table 29.2) is compressed over 90 times to routine air supplied dive recommended in

the U.S. Navy Diving Manual is 190 fsw.(22) The distortion of human speech (a “Donald
5.3 atm of N2 is well into the range of nitro- Duck” effect) that eventually requires elec-
gen narcosis symptoms described in Table tronic processing to become intelligible.(22,52)
29.9, and the 1.4 atm of O2 is approaching the
time limited range of oxygen toxicity in Changing Pressure Effects
Figure 29.3. Reducing or removing nitrogen
The recognized adverse health effects of
within the source of breathing air can be a
changing pressure include two acute symp-
cost-effective control in certain conditions.
toms and one chronic symptom. The following
Reducing the nitrogen/oxygen ratio by using
effects can occur in changing either from nor-
enriched oxygen mixtures (called NITROX)
mal to hypobaric conditions or from hyperbar-
can speed the ascent rate, thus decreasing
ic to normal or hypobaric conditions.
the total diving time, but NITROX is limited
to a shallower depth than air diving because (1) Expanding or contracting trapped
of oxygen’s own toxicity at pressures of more gases can cause pain, potentially lead-
than 1 atm. A separate published decompres- ing to barotrauma. This acute symptom
sion schedule limits diving with 68% N2 32% and potential damage can occur during
O2 NITROX to a depth of 130 fsw.(22,28) either ascent or descent but are poten-
tially most severe when gases are
Substituting helium for all or most of the
expanding. Barotrauma to the lungs
nitrogen (called “mixed gas diving”) is a cost-
(pulmonary barotrauma) can result in a
effective control for deeper dives. Helium’s
fatal arterial gas embolism.
major advantage is its lower lipid solubility,
(2) DCS due to the evolution of inert gas
allowing deeper dives than with normal air.
bubbles inside the body. Acute symp-
Its higher molecular diffusivity and lower
toms of DCS can occur during a
lipid/water solubility ratio than nitrogen
decrease in pressure, but most com-
also allow it to reach and depart from equi-
monly occur soon after an ascent has
librium with the body’s tissues more quickly
been completed.
during a dive. Unfortunately, helium is less
(3) Dysbaric osteonecrosis causes
stable in solution, requiring its decompres-
detectable bone lesions most common-
sion schedule to have more stops and take
ly on the body’s long bones. Although
longer than nitrogen to prevent bubbles
its etiology is unknown, this chronic
from forming in tissues, that is, supersatura-
disease is likely to be related to the
tion is limited to 1.7× ambient, compared
evolution of gas bubbles that may be
with 2 to 3× for nitrogen. Schedules for sur-
too small to cause symptoms diag-
face supplied He/O2 dives to 380 fsw are
nosed as DCS.
available.(22,28) Deeper dives are only practi-
cal by keeping the diver under pressure for
Recognition of Changing Pressure
several days (called “saturation diving”). A
slow rate of compression is necessary to Hazards
avoid symptoms of high pressure nervous Pain and barotrauma from expanding or
syndrome such as nausea, fine tremors, and contracting gases while transiting between
incoordination that can begin to appear at pressure zones are direct effects predictable
about 500 fsw.(22,28) Dives deeper than 1000 from Boyle’s law. The most common sites of
fsw have been made using a trimix of nitro- pain from trapped gases are teeth, the GI
gen, helium, and oxygen; physiological tract, sinuses, middle ear, and lungs (the lat-
research has found that the narcotic poten- ter particularly during ascent).(53–55) In addi-
tial of a small amount of nitrogen can be tion, compression of trapped gases between
used to balance the stimulatory effect of the individual and his or her equipment can
helium at high pressure. Helium presents also cause trauma. For example, if the air-
other problems. Its high thermal diffusivity space between diver and mask is not regu-
combined with the high gas density and spe- larly equalized, a diver could end up with
cific heat at depth cause more rapid heat small blood vessel hemorrhage of the eyes.
exchange rates requiring careful protection A tight fitting wet-suit hood against the ear
from hypothermia in the typically cold could cause an external ear barotrauma.
underwater temperatures.(22,27,50,51) Helium’s The expansion of trapped gas caused by
low molecular weight causes a high-pitched dental decay can actually cause a tooth to

crack or a dental filling to become dislodged where κ = the altitude coefficient for
during ascent; good dental care will prevent Equation 29-6 taken from Table 25.4; ΔP = the
this problem. Divers and flyers should antici- change in pressure in the same units as P,
pate and not attempt to suppress the following; P = the initial pressure found
release of natural gases of digestion that using Equation 29-6.
expand during ascent. For most people, opening the
The sinuses are hollow, membrane-lined Eustachian tubes during descent requires
spaces within the skull bones connected to some conscious action like yawning or
the nasal cavity by narrow passages. swallowing. The Valsalva maneuver is a
Blockage of these passages due to nasal more active technique used by flyers and
congestion or a head cold can cause pain some divers to force air up their Eustachian
during either ascent or descent. Sinus pain tubes by closing their mouth, holding their
during descent is called “sinus squeeze.” nose, and trying to exhale. This technique
Divers should be trained to detect blocked may also clear slightly blocked sinuses.
sinuses and not dive with a cold or an aller- However, external forces on the Eustachian
gic inflammation. tube at a ΔP of 90 mmHg usually prevent it
The most common source of pain on from opening, even with the help of the
descent is from the contraction of air in the Valsalva maneuver.(54) Thus, Farmer and
middle ear if the Eustachian tubes are Moon(39) recommend that divers clear their
inflamed or blocked. The Eustachian tubes ears every 2 ft (corresponding to 50 mmHg
normally relieve outwardly (during ascent) in Table 25.10). Should a blockage occur,
at a small pressure difference (ΔP) of only a divers should be trained to stop and rise
couple of mmHg. However, it usually requires back up a few feet before attempting to
at least 15 mmHg to relieve inwardly (during clear and proceed.(22)
descent). If not relieved, pain can begin to The most severe outcome of expanding
occur at 50–100 mmHg, and the eardrum will gases is pulmonary barotrauma. An increase
rupture at 100–500 mmHg. Equation 29-5 can
in gas volume of 20 to 30% can cause an ini-
be used to find the change in depth for any
tially full lung to rupture. A trapped gas vol-
pressure. Some examples are given in Table
ume expands in proportion to the change in
29.10. However, because pressure is not lin-
relative pressure, as predicted by Boyle’s
ear with altitude above sea level, the change
law. In contrast with changes in absolute
in altitude to achieve a similar fixed ΔP
pressure as described previously, changes in
varies with the starting altitude above sea
relative pressure are not constant with
level and the direction (ascending or
depth. Equation 29-17 (derived from
descending), as given by Equation 29-6. To
Equation 29-5) can be used to find the
achieve an air pressure difference of 500
change in depth necessary to create a given
mmHg is rare, because it requires, for
instance, a descent to sea level starting relative change in pressure.
at a pressure altitude of at least 27,000 feet
ASL (8200 m). ⎡ Vinitial ⎤
Δdepth = – ([initial depth] + κ) × ⎢1 – ——– ⎥ (29-17)
⎢ ⎥
Δaltitude descending = κ × ln [1 – (ΔP/P)] (29-16a) ⎣ Vfinal ⎦
Δaltitude ascending = κ × ln [(ΔP/P) + 1] (29-16b) where κ = coefficient from Table 29.3

depending on the water density and units of
depth; V = the gas volumes before and after
the change in depth.
Table 29.10 — Change in Seawater Depth
Corresponding to a Selected Change in During ascent, Δdepth is negative, gases
Absolute Pressure (ΔP) expand, and the initial volume is smaller than
ΔP Δdepth the final (larger) volume. This ratio is also the
mm Hg atm fsw m final (lower) pressure to the initial (higher)
15 0.020 0.662 0.202 pressure. Example 6 uses Equation 17 to show
50 0.066 2.18 0.667 that equal relative changes in pressure and
100 0.132 4.37 1.33 volume occur over smaller distances at shal-
500 0.658 21.78 6.65 low depths than when starting from deeper

depths. This implies an important lesson to be sickness,” “caisson worker’s syndrome,” or

conveyed in training: the risk of pulmonary various common names listed in Table 29.11.
barotrauma is actually greater for a given DCS is completely different from the preced-
ascent starting from a shallow depth than ing direct effects of expanding gases. DCS is
ascending the same distance starting a caused indirectly by the formation of inert
greater depth. In fact, pulmonary barotrauma gas bubbles at one or more locations within
has actually been documented in a breath- the body.
hold ascent to the surface from a depth of 1 m Example 5 can be extended to a human
(3 ft).(56) Pulmonary barotrauma can lead to a analogy of the “pop bottle” in Example 3.
pneumothorax (air escaping into the pleural The nominal distribution of a 70 kg human
space), interstitial emphysema (air escaping body is 58% water (or 40.6 L), 20% fats, lipids,
into the surrounding pulmonary tissue), and oils (or ~14 L), and 22% solids (mainly
and/or an arterial gas embolism of the heart bone). Thus, the volumes of gas (V) in each
or brain (air escaping into the arterial circula- compartment at 185 fsw can be determined
tion). Arterial gas embolism is second to using Equation 29-10:
drowning as a cause of death in sport
divers.(57) Divers and compressed air workers VN2 in body water =
must be trained not to hold their breath dur- 0.062 cc/mL × 40.6 L = 2.5 L N2 in water
ing normal ascent and to consciously exhale
during a rapid or emergency ascent. VN2 in body lipid =
0.314 cc/mL × 14 L = 4.4 L N2 in lipids
Example 6. Find the change in depth
necessary for a gas volume to expand by
25% starting at initial depths of 10, 100, A total volume of 7 L nitrogen is about
and 500 feet of sea water. the size of a basketball.
From Table 29.3 for feet of sea water, κ = As pointed out in the Physical Principles
33.1, and for this problem, Vinitial/Vfinal = section, when discussing high lipid-to-water
1/1.25 = 0.80. Using Equation 29-17 for the solubility ratios, the rate at which inert
three initial depths given: gases such as N2 are transported by blood is
slow compared to the capacity of lipid tissue
Initially at 10 feet: to absorb them. This difference creates a
depth = ( 10 + 33.1) × (0.80 – 1) = -8.6 feet. beneficial time lag for gas absorption that
allows ascents from short dives to be made
Initially at 100 feet: without any constraints on decompression.
depth = (100 + 33.1) × (0.80 – 1) = -27 feet. But the slow gas desorption rate creates a
hazard during ascent from longer dives. Due
Initially at 500 feet: to either desire or necessity, divers can easily
depth = (500 + 33.1) × (0.80 – 1) = -107 feet. decompress to lower pressures at rates much
faster than the stored gases can be resorbed
DCS is the most commonly known of the back into the blood and exhaled out of the
many dysbarisms. It is sometimes referred to body. The desorption rate from any location
as “evolved gas dysbarism,” “compressed air in the body is determined by
Table 29.11 — Distribution of Initial DCS Symptoms Reported Among Divers and Tunnel
Workers
Relative Incidence (%)
Location of DCS Common Professional Tunnel Recreational

Bubbles Symptom(s) Type Term Divers(58) Workers(58) Divers(39,59)
Joints pain on flexure I bends 70–90% 55–90% 41%
Skin altered skin sensation, I 1–15% 0–10% 20%
itching, or rash
Brain-spine dizziness, headache, loss of II staggers 10–35% 8–25% 35%
coordination, weakness
Chest cough, dyspnea, pain on II chokes 2–8% 1–7% 3%
breathing

(1) the difference between tissue and even the number of divers from which rates
blood gas concentrations, which could be assessed is unknown. The distribu-
depends on the dive’s depth and tion of symptoms in Table 29.11 is only
“bottom time,” and among those cases reported to the respec-
(2) the perfusion of tissue(s) by blood into tive databases. The incidences following
which the inert gas must dissolve (in three sets of hyperbaric chamber dives are
general, skeletal lipid tissues are per- summarized in Table 29.12. Farmer and
fused less thoroughly than are muscle, Moon(39) cited reports of DCS risk of 0.1 to
CNS, or other organs). 0.2% in commercial diving operations,
Note that the tissue has to have a high- whereas another report claims 31% of divers
er partial pressure compared with the blood have experienced DCS at least once.(61) These
for gas to be removed from the tissue (a two rates would be statistically compatible
ratio of the gas concentration within tissue after 370 to 185 dives, respectively, if the
or a liquid to its equilibrium concentration probability of an incident were distributed
in its surrounding fluid that is greater than randomly. The incidence of DCS among com-
unity is called “supersaturation”). However, pressed air workers has been reported to be
if the pressure ratio is too large, bubble for- about 0.5% in two large groups(62,63) and
mation and DCS occur. 0.07% in another.(64) Differences in rates may
Symptoms of DCS can range from irritat- be due to differences in the decompression
ing to severe. The common names given to schedules used (both between and within
DCS depend on its symptoms, and its symp- divers and compressed air workers), in the
toms in turn depend on the location of the lack of adherence to those schedules (a func-
gas bubbles (Table 29.11). The location of the tion of training and supervision), or in the
bubbles largely determines the seriousness detection and reporting protocols (such as
of the sickness. Beyond the descriptors in day-to-day versus periodic medical supervi-
Table 29.11, a simple medical classification sion and working almost individually versus
of DCS has evolved. Type I DCS symptoms in large groups).
involve only skin, lymphatic, or joint pain. The same DCS phenomenon can occur in
Type II DCS involves respiratory symptoms, hypobaric chamber trainers, in flight crews
neurologic or auditory-vestibular symptoms, in unpressurized aircraft, in someone flown
and symptoms of shock or barotrauma. Type from near sea level to a high mountain facili-
II DCS is potentially life threatening. Of ty, and in someone who flies soon after div-
course, nothing is completely simple. For ing. Incidence rates among hypobaric cham-
instance, Arthur and Margulies(60) pointed ber technicians have been reported to be as
out that skin marbling (from intradermal low as 0.25%(66) to about 0.35%(67,68) and as
bubbles) is indicative of impending systemic high as 0.62%(69) while hypoxia orientation
involvement and should be treated as Type training was conducted at pressure alti-
II DCS. Elliott and Moon(59) reported that tudes ranging from 25,000 to 30,000 ft
recreational divers suffering DCS are initial- (7500–9,000 m); however, incident rates can
ly more likely to have Type I symptoms, but exceed 10% at simulated altitudes above
most eventually progress to Type II. 30,000.(70,71) Both physiological and epidemio-
The incidence of DCS is largely unknown logical studies show that DCS is likely to
for various reasons. Literally thousands of occur at about a 15% incidence rate when
cases of DCS have been reported among underwater diving is followed by flying, that
divers,(39,58,61) but the frequency of diving or is, going from hyperbaric to hypobaric condi-
tions.(72) The U.S. Navy Diving Manual Table
Table 29.12 — Incidence of DCS Among Chamber Dive 9–5 specifies wait times of up to 24 hours
Trials in the United States and Canada prior to flying following air dives to various
depths and times (commercial airline cabin
Number Depth Bottom Time
of Mean (range) Mean (range) Breathing DCS pressure is maintained at an altitude equiv-
Dives Meters Minutes Gas Incidence alent to 8000 ft ASL).
Dysbaric osteonecrosis is perhaps the
1041 45 (15–88) 22 (5–120) air 3.0%
647 66 (36–100) 32 (10–100) He-O2 4.2%
least known barometric pressure hazard,
both technically and publicly. Although it
261 92 (43–123) 33 (15–90) He-O2 12.%
was first recognized among caisson workers
Source: Reference 65 early in the 20th century by Bornstein and

Plate(73) and is now known to also affect the “Haldane rule.”(81) However, the majority
divers,(26,39,59,74) many believe that it is still of the recommended initial standard air
not widely recognized, adequately decompression ratios are close to but
researched, or effectively controlled by cur- exceed this ratio, as denoted by the gray
rent practices.(26,75,76) Dysbaric osteonecrosis area of Figure 29.4. Only a small portion of
(also called aseptic bone necrosis) manifests the long dives to depths between 35 and 60
itself as regions of bone and marrow necro- ft complies with this 2:1 guidance.(22) It is
sis, especially of the humerus, femur, or tibia important to understand that existing
(the “long bones”). The lesions are indistin- decompression schedules have been defined
guishable histologically from necrosis from and refined based on symptoms rather than
other causes. The condition is generally on preventing bubbles per se or by using
asymptomatic, with detection relying on dif- good epidemiologic health surveillance.(27)
ferential diagnosis of high quality radi- The background level of DCS even when
ographs and by excluding other causes.(75–77) decompression guidelines are followed, the
In two British studies the prevalence of ragged pattern of the exceedance zone, and
detectable bone lesions was reported as the detection of bubbles in blood by
24% among compressed air workers(77) and Eckenhoff et al.(79) and Ikeda et al.(80) after
6.2% among divers.(61) Most of these lesions saturation dives to depths of only 25 ft sug-
were in the head, neck, or shaft of the long gest the limited degree of control afforded
bones, where they are generally benign. by these guidelines.
However, 3.7% of compressed air workers The substitution of helium for nitrogen
had lesions adjacent to articulating sur- (discussed in the Hyperbaric Hazards sec-
faces, where they can cause degenerative tion) changes the dynamics of gas absorp-
changes.(77) “Juxtaarticular” lesions were tion and desorption but does not remove the
found in 1.2% of divers, with at least 15% of bubble hazard. The use of one-atmosphere
these divers (0.2% overall) actually experi- suits is a recent development that has some
encing joint damage (in shoulders of divers promise if issues of functional flexibility can
and in shoulders and hips of compressed air be overcome.(39) However, the high costs and
workers).(61) There are strong positive associ- low availability of new technologies cause
ations between lesions and length of diving the vast majority of divers to continue to
experience (but not age), the maximum use conventional administrative controls
that rely on decompression schedules.
depth dived (none were found in those who
Along with guidance for dives that do
had never dived below 30 m [100 ft]), and a
not require decompression, the U.S. Navy
history of at least one prior DCS (although
Diving Manual has four basic decompression
lesions can also occur without any known
prior acute DCS symptoms).(61)
There is no direct evidence for any clear
etiology to osteonecrosis. Microbubbles can
be detected electronically before symptoms
are detected.(78–80) In the absence of other
pathological etiologies, it is plausible that
these asymptomatic bubbles could account
for the prevalence of osteonecrosis in divers
without a history of DCS.(61) The prevalence
of dysbaric osteonecrosis is significant and
perhaps still being underestimated by the
occupational health establishment.
Control of Pressure Changes

The risk of DCS is controlled by administra-
tively limiting the pressure ratio during
ascent (the inverse of the volume ratio used Figure 29.4—Diving conditions above the top solid line require
in Equation 29-17). Early experimental no decompression. Conditions below the bottom solid line
research by J.S. Haldane recommended a require exceptional approval. The first decompression stop for
maximum ratio of 2:1 for saturated tissues, conditions in gray is at a pressure ratio greater than 2.(22)

schedules, each with various options, exemp-

tions, and response contingencies.(22) These Stop, feet (m) Stop Chamber Total
schedules are constructed to limit depth on Time Time Hold Time
the basis of narcosis, to limit bottom time on 30 (9.1) 12 12
the basis of oxygen toxicity, and to limit 20 (6) 41 53
ascent time on the basis of DCS and include 20 foot equiv. 41 94
“a practical consideration of working time 10 foot equiv. 78 172 = 2:52 hours
versus decompression time.”(22)
Example 9. The U.S. Navy schedule for
(1) The Standard Air Decompression
surface decompression using oxygen for the
schedule (see Example 7) is applicable
same dive to 100 ft for 120 minutes as in
to either scuba or surface-supplied
Example 7 allows both a shorter ascent time
divers breathing air, who completely
of 6 minutes and a reduced surface decom-
decompress either in the water or in a pression time breathing oxygen of only 53
diving bell or chamber before reaching minutes.
surface pressures. The maximum rec-
ommended air dive is 190 ft for 40 min-
utes with emergency dives allowed to Stop, feet (m) Stop Chamber Total
300 ft for 180 minutes. Time Time Hold Time
30 (9.1) 3 3
Example 7. The U.S. Navy schedule for in- 40 foot equiv. 53 56 = 0:56 hours
water (“standard”) decompression from a
depth of 100 fsw (30.4 m; 4 ATA) and a bottom
(3) Surface Supplied Helium-Oxygen
time of 120 minutes requires a total decom-
Decompression procedures have under-
pression time (with time for ascent at about
gone significant revisions since 1991.
30 ft/min) of 134 minutes. The new decompression schedule (see
Example 10) can involve stops breath-
Stop, ft (m) Stop Time Total Stop Time ing the bottom-supplied mixture below
90 fsw, a 50% oxygen mixture between
30 (9.1) 12 12
90 and 40 fsw, and pure oxygen at stops
20 (6) 41 53
of 30 and 20 fsw. The normal operating
10 (3) 78 131 = 2:11 hours
limit on this schedule is 300 feet for 30
minutes.
(2) Surface Decompression allows ascents
with minimal or no stops but requires Example 10. U.S. Navy surface-supplied
the diver to transfer to a recompres- helium oxygen decompression schedule for
sion chamber within 5 minutes of the same dive to 100 ft for 120 minutes as in
reaching the surface. Surface decom- Example 7 would require a total of three
pression provides more convenient and stops.
often safer conditions than in the
water. Recompression with air extends Stop, feet (m) Stop Time Stop Time Total
the entire decompression time (see on 50% O2 on 100% O2 Hold Time
Example 8), but the faster nitrogen
wash-out rate from breathing oxygen 40 (12.2) 10 10
in the chamber allows a shorter decom- 30 (9.1) 32 42
pression schedule (see Example 9). The 20 (6) 58 100 = 1:40 hours
maximum recommended dive is still
190 feet. (4) To prevent decompression from
Helium-Oxygen Saturation Diving the
Example 8. The U.S. Navy schedule for U.S. Navy Diving Manual specifies a
surface decompression using air from the series of ascent rates of feet per hour.
same dive as in Example 7 allows an ascent For example, an ascent from saturation
time of just over 56 minutes but requires an diving at 340 ft would require 72 hours
additional surface decompression time of (or 3 days). However, saturation diving
119 minutes. allows more working time per day

(greatly reducing the total time for long qualify as “scientific diving,”(28) and diving
jobs) and avoids the hazards of multi- from vessels not subject to Coast Guard
ple compressions and decompressions. inspection (46 CFR 197.200-488). OSHA regula-
One important exception is short dives tions may be found in either General
that may be made with no decompression Industry Standards Subpart T (29 CFR
time. These limits for air dives are depicted 1910.401-441) or Construction Standards
as the times above the top heavy line in Subpart Y. Construction Standards also
Figure 25.4. For deeper and/or longer dives, include 29 CFR 1926.801 governing caissons,
decompression time requirements are a cost 29 CFR 1926.803 governing compressed air
burden on employers and a potentially bor- work, and 29 CFR 1926.804 that contains defi-
ing time for employees, an inviting incentive nitions applicable to all of Subpart S. Tables
for both parties to cut corners, resulting in a 29.13 and 29.14 provide a quick overview of
higher incidence of DCS and potentially of these OSHA work practice standards that
osteonecrosis.(58) Motivational training and frequently refer to a diving manual and to
close supervision are essential components other requirements that parallel the princi-
of a successful diving management program. ples and mechanisms outlined here and the
In the United States, OSHA regulates schedules and guidelines contained within
compressed air work, diving that does not the Navy diving manual.(22)
Table 29.13 — An Overview of OSHA 29 CFR 1910.401-441, Subpart T: Commercial Diving Operations
1910.401 - Scope and application
1910.402 - Definitions (a glossary of terms)
1910.410 - Qualifications of dive team (covers training requirements)
1910.420 - Safe practices manual (a written procedures manual shall be developed and maintained)
1910.421 - Predive procedures (covers emergency planning)
1910.422 - Procedures during dive (covers communication, decompression tables, and the dive depth-time record to be
maintained)
1910.423 - Postdive procedures (covers instructions to diver, provision of recompression chamber (required to be on-site
if the dive is outside the "no-decompression limits" and deeper than 100 fsw), and recompression
requirements if needed)
1910.424 - Scuba diving (limited to ≤ 130 fsw and specifies certain procedures)
1910.425 - Surface-supplied air diving (limited to 190 fsw (with 30 min to 220 fsw excepted) and specifies certain
procedures)
1910.426 - Mixed gas diving (specifies certain constraints and procedures)
1910.427 - Lifeboating (puts certain constraints on air supplied or mixed gas diving while the support vessel is underway)
1910.430 - Equipment (various specifications including supplied-air quality limits of 20 ppm CO and 1000 ppm CO2, hoses,
lines, masks, helmets, decompression chamber, etc)
1910.440 - Record-keeping requirements (retention of most records by employer for 5 years except records of nonincident
dives for only 1 year, and all 5-year records to be forwarded to NIOSH)
Note: Parallels 29 CFR 1926.1071-1092, Subpart Y: Construction Diving
Table 29.14 — Overview of OSHA 29 CFR 1926.800-804, Subpart S: Underground Construction, Caissons,
Cofferdams, and Compressed Air
1926.800 - Underground construction (defines general program requirements such as air quality monitoring by a
"competent person")
1926.801 - Caissons (specifies certain fall safety and pressure testing requirements)
1926.802 - Cofferdams (e.g., specifies escape provisions in case of flooding)
1926.803 - Compressed air (describes on-site supervision; annual medical certification of each employee; provision of a
"medical lock" [decompression chamber]; medical emergency identification badges such as bracelets for all
compressed air workers; posting of decompression schedules; a maximum working pressure of 50 psig; air
supply ventilation; sanitation; and fire prevention requirements)
1926.804 - Definitions (e.g., "decanting" when a person is rapidly brought to atmospheric pressure then recompressed
immediately [to be undertaken only under medical direction])
Appendix A to Subpart S - Decompression tables that differ from diving table schedules. These decompression schedules
cover much longer working times (more than 8 hours at ≤ 46 psig, equivalent to ~100 fsw), continuous slow
decompression (versus stops at multiple stages), and somewhat longer times than the Navy Diving Manual.(22)

A variety of sources of further emer- Hyperbaric hazards include barotrauma

gency and routine information are available from contracting or expanding gas, toxic
electronically. The Divers Alert Network effects from oxygen above 1 atm or carbon
(DAN) is the largest nonprofit medical and dioxide above 80 mmHg, narcosis from a PN2
research organization dedicated to the safe- above 3 to 4 atm, and high pressure nervous
ty and health of recreational scuba divers syndrome from PHe above about 15 atm.
(www.diversalertnetwork.org/). An array of Administrative control of depth to not more
international organizations [IDAN] has been than 190 fsw is recommended for air diving;
organized to provide expert emergency med- decreasing the nitrogen content of air (such
ical and referral services “24/7” to regional as in NITROX) can shorten the decompres-
diving communities including central and sion time for shallow dives, and replacing
south America, Europe, Japan, South East nitrogen with helium allows dives in excess
Asia Pacific, and Southern Africa. of 1000 fsw.
Information on diving and hyperbaric Leaving a hyperbaric condition so rapid-
medicine and physiology may also be ly that inert gas bubbles are generated with-
obtained from the Undersea and Hyperbaric in the body can cause DCS and probably
Medical Society, an international nonprofit leads to osteonecrosis. DCS and especially
organization comprised of diving or hyper- osteonecrosis remain a lingering problem
baric scientists, physicians, and technical with all decompression schedules.
specialists. This information should allow hygienists
The National Board of Diving and to be better prepared to contribute to
Hyperbaric Medical Technology is a source improving the health of workers facing baro-
of information on approved courses for metric hazards.
becoming certified in hyperbaric technology,
exams and testing schedules, training facili-
ties, and other helpful information.
Additional Sources
The NOAA Diving Program maintains a W.N. Rom: High altitude environments. In
strong training program in support of their Environmental and Occupational Medicine,
own and other governmental research and 3rd ed., pp. 1359–1387. Philadelphia:
service missions. Lippencott-Raven, 1998.
E.P. Kindwall: Medical aspects of commercial div-
ing and compressed-air work. In C. Zenz, et
Conclusion al., editors, Occupational Medicine, 2nd ed.,
pp. 343–383. St. Louis: Mosby-Year Book,
Despite hygienists’ notable absence from 1994.
the extensive barometric hazard literature,
hygienists have much to contribute to
improving the control of hazards in each of
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Chapter 29 - Barometric Hazards

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Chapter 29 - Barometric Hazards

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Chapter 29 Outcome Competencies

After completing this chapter, the reader

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Introduction benign acute mountain sickness (AMS) and

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Table 29.1 — Common Units of Pressure Equivalent to One Standard Atmosphere

physiological mechanisms underlying all of historical footnote, Robert Boyle hired a

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(Y1 + Y2 + … + Yn) × PATA (29-7) Henry’s Law

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Vi in solution = Vliquid × Ci (29-10b) CCO2 = 1 atm × .5797 cc/mL/atm = 580 cc/L

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in respiratory ventilation cannot pre- Recognition of Hypobaric Hazards

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Table 29.6—Physiological Partial Pressures (mmHg) when Breathing Normal Air

Pambient total = 760 e(30,000/24,540) = 224 mm Hg

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can calculate using Dalton’s law, Henry’s law,

Table 29.7 — Summary of Direct Physiological Responses to Hypobaric Pressures(11–14)

>18,000 limited by the time of useful consciousness (TUC)

20,000 73 40 74-82 TUC = 10-20 minutes 9.6% 55%

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Hypobaric Hazards section). The combined % increase in

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convulsions), and/or papilloedema (swelling Acclimatization is a remarkably effec-

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3000 fsw, yielding PCO2 = 24 mmHg. However,

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Δaltitude ascending = κ × ln [(ΔP/P) + 1] (29-16b) where κ = coefficient from Table 29.3

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depths. This implies an important lesson to be sickness,” “caisson worker’s syndrome,” or

Location of DCS Common Professional Tunnel Recreational

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Control of Pressure Changes

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schedules, each with various options, exemp-

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A variety of sources of further emer- Hyperbaric hazards include barotrauma

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