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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
954 ____________________________ The Occupational Environment: Its Evaluation, Control, and Management, 3rd edition
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)
956 ____________________________ The Occupational Environment: Its Evaluation, Control, and Management, 3rd edition
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.
958 ____________________________ The Occupational Environment: Its Evaluation, Control, and Management, 3rd edition
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:
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).
960 ____________________________ The Occupational Environment: Its Evaluation, Control, and Management, 3rd edition
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
962 ____________________________ The Occupational Environment: Its Evaluation, Control, and Management, 3rd edition
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
964 ____________________________ The Occupational Environment: Its Evaluation, Control, and Management, 3rd edition
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,
966 ____________________________ The Occupational Environment: Its Evaluation, Control, and Management, 3rd edition
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 ⎦
968 ____________________________ The Occupational Environment: Its Evaluation, Control, and Management, 3rd edition
Table 29.11 — Distribution of Initial DCS Symptoms Reported Among Divers and Tunnel
Workers
Relative Incidence (%)
(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
970 ____________________________ The Occupational Environment: Its Evaluation, Control, and Management, 3rd edition
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.
972 ____________________________ The Occupational Environment: Its Evaluation, Control, and Management, 3rd edition
(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)
974 ____________________________ The Occupational Environment: Its Evaluation, Control, and Management, 3rd edition
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