Modern assessment of pulmonary function in divers cannot rely on old reference values

Wingelaar, Thijs T.; Clarijs, Paul; Ooij, Pieter-Jan A. M. van; Koch, Dave A. A.; Hulst, Rob A. van

doi:10.28920/dhm48.1.17-22

Cited by 9 publications

(6 citation statements)

References 20 publications

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“…Eligible for inclusion were healthy, non-smoking divers of the Royal Netherlands Navy. Eligible participants were fit to dive according to the European Diving Technology Committee standards, with the exception that PFT was assessed using the reference values of the Global Lung Function Initiative (Wendling and Nome, 2004; Wingelaar et al, 2018). Exclusion criteria were: recent respiratory tract infection, daily use of two or more alcoholic beverages, and/or the use of (over-the-counter) medication.…”

Section: Methodsmentioning

confidence: 99%

Pulmonary Oxygen Toxicity in Navy Divers: A Crossover Study Using Exhaled Breath Analysis After a One-Hour Air or Oxygen Dive at Nine Meters of Sea Water

Wingelaar

Ooij²,

Brinkman

et al. 2019

Front. Physiol.

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Introduction: Exposure to hyperbaric hyperoxic conditions can lead to pulmonary oxygen toxicity. Although a decrease in vital capacity has long been the gold standard, newer diagnostic modalities may be more accurate. In pulmonary medicine, much research has focussed on volatile organic compounds (VOCs) associated with inflammation in exhaled breath. In previous small studies after hyperbaric hyperoxic exposure several methyl alkanes were identified. This study aims to identify which VOCs mark the development of pulmonary oxygen toxicity.Methods: In this randomized crossover study, 12 divers of the Royal Netherlands Navy made two dives of one hour to 192.5 kPa (comparable to a depth of 9 msw) either with 100% oxygen or compressed air. At 30 min before the dive, and at 30 min and 1, 2, 3, and 4 h post-dive, exhaled breath was collected and followed by pulmonary function tests (PFT). Exhaled breath samples were analyzed using gas chromatography–mass spectrometry (GC–MS). After univariate tests and correlation of retention times, ion fragments could be identified using a standard reference database [National Institute of Standards and Technology (NIST)]. Using these fragments VOCs could be reconstructed, which were then tested longitudinally with analysis of variance.Results: After GC–MS analysis, seven relevant VOCs (generally methyl alkanes) were identified. Decane and decanal showed a significant increase after an oxygen dive (p = 0.020 and p = 0.013, respectively). The combined intensity of all VOCs showed a significant increase after oxygen diving (p = 0.040), which was at its peak (+35%) 3 h post-dive. Diffusion capacity of nitric oxide and alveolar membrane capacity showed a significant reduction after both dives, whereas no other differences in PFT were significant.Discussion: This study is the largest analysis of exhaled breath after in water oxygen dives to date and the first to longitudinally measure VOCs. The longitudinal setup showed an increase and subsequent decrease of exhaled components. The VOCs identified suggest that exposure to a one-hour dive with a partial pressure of oxygen of 192.5 kPa damages the phosphatidylcholine membrane in the alveoli, while the spirometry and diffusion capacity show little change. This suggests that exhaled breath analysis is a more accurate method to measure pulmonary oxygen toxicity.

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Section: Methodsmentioning

confidence: 99%

Pulmonary Oxygen Toxicity in Navy Divers: A Crossover Study Using Exhaled Breath Analysis After a One-Hour Air or Oxygen Dive at Nine Meters of Sea Water

Wingelaar

Ooij²,

Brinkman

et al. 2019

Front. Physiol.

View full text Add to dashboard Cite

show abstract

“…Eligible for inclusion were healthy, non-smoking personnel of the Royal Netherlands Navy, who were fit to dive according to the European Diving Technology Committee standards; with the exception that pulmonary function tests (PFT) were assessed using the reference values of the Global Lung Function Initiative (Wendling et al, 2004; Wingelaar et al, 2018). Exclusion criteria were: recent respiratory tract infection, daily use of two or more alcoholic beverages, and/or the use of (over-the-counter) medication.…”

Section: Methodsmentioning

confidence: 99%

Markers of Pulmonary Oxygen Toxicity in Hyperbaric Oxygen Therapy Using Exhaled Breath Analysis

et al. 2019

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“…In compliance with international professional standards, military divers in the Netherlands undergo yearly medical assessments, including routine CXR (AP and lateral) at initial assessment, at the Royal Netherlands Navy Diving Medical Center (Wendling and Nome, 2004). Additionally, divers were referred to a military pulmonary specialist for HRCT imaging when spirometry showed a vital capacity >120% higher than ERS/ECSC-1993 reference values, even though a diver could have been free of symptoms of pulmonary disease [The latter practice has since been abandoned, as it was found to be inaccurate when using modern GLI-2012 reference values (Wingelaar et al, 2018;Wingelaar-Jagt et al, 2020)]. The records of all divers who underwent CXR and HRCT between January 2013 and June 2018 were included in this study.…”

Section: Data Collectionmentioning

confidence: 99%

“…According to our old protocol, subjects with a vital capacity ≥120% higher than predicted by the ERS/ECSC-1993 guidelines were regarded as abnormal and referred to a pulmonary specialist. New insights gained from the GLI-2012 guidelines made these criteria obsolete (Wingelaar et al, 2018;Wingelaar-Jagt et al, 2020). Because almost all of our subjects had a PFT within 95% of normal (i.e., a Z-score of ±1.96), the subgroups would have been too small for accurate analysis.…”

Section: Strengths and Limitationsmentioning

confidence: 99%

Routine Chest X-Rays Are Inaccurate in Detecting Relevant Intrapulmonary Anomalies During Medical Assessments of Fitness to Dive

Wingelaar

Bakker²,

Nap

et al. 2021

Front. Physiol.

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Introduction: Intrapulmonary pathology, such as bullae or blebs, can cause pulmonary barotrauma when diving. Many diving courses require chest X-rays (CXR) or high-resolution computed tomography (HRCT) to exclude asymptomatic healthy individuals with these lesions. The ability of routine CXRs and HRCT to assess fitness to dive has never been evaluated.Methods: Military divers who underwent yearly medical assessments at the Royal Netherlands Navy Diving Medical Center, including CXR at initial assessment, and who received a HRCT between January and June 2018, were included. The correlations of CXR and HRCT results with fitness to dive assessments were analyzed using Fisher's exact tests.Results: This study included 101 military divers. CXR identified bullae or blebs in seven divers, but HRCT found that these anomalies were not present in three subjects and were something else in four. CXR showed no anomalies in 94 subjects, but HRCT identified coincidental findings in 23 and bullae or blebs in seven. The differences between CXR and HRCT results were statistically significant (p = 0.023). Of the 34 subjects with anomalies on HRCT, 18 (53%) were disqualified for diving.Discussion: Routine CXR in asymptomatic military divers does not contribute to the identification of relevant pathology in fitness to dive assessments and has a high false negative rate (32%). HRCT is more diagnostic than CXR but yields unclear results, leading to disqualification for diving. Fitness to dive tests should exclude routine CXR; rather, HRCT should be performed only in subjects with clinical indications.

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Modern assessment of pulmonary function in divers cannot rely on old reference values

Cited by 9 publications

References 20 publications

Pulmonary Oxygen Toxicity in Navy Divers: A Crossover Study Using Exhaled Breath Analysis After a One-Hour Air or Oxygen Dive at Nine Meters of Sea Water

Pulmonary Oxygen Toxicity in Navy Divers: A Crossover Study Using Exhaled Breath Analysis After a One-Hour Air or Oxygen Dive at Nine Meters of Sea Water

Markers of Pulmonary Oxygen Toxicity in Hyperbaric Oxygen Therapy Using Exhaled Breath Analysis

Routine Chest X-Rays Are Inaccurate in Detecting Relevant Intrapulmonary Anomalies During Medical Assessments of Fitness to Dive

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