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Plogmark O, Silvanius M, Olsson M, Hjelte C, Ekström M, Frånberg O. Measuring whole body inert gas wash-out. Diving Hyperb Med 2023; 53:321-326. [PMID: 38091591 PMCID: PMC10944667 DOI: 10.28920/dhm53.4.321-326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 10/16/2023] [Indexed: 12/18/2023]
Abstract
Introduction Quantifying inert gas wash-out is crucial to understanding the pathophysiology of decompression sickness. In this study, we developed a portable closed-circuit device for measuring inert gas wash-out and validated its precision and accuracy both with and without human subjects. Methods We developed an exhalate monitor with sensors for volume, temperature, water vapor and oxygen. Inert gas volume was extrapolated from these inputs using the ideal gas law. The device's ability to detect volume differences while connected to a breathing machine was analysed by injecting a given gas volume eight times. One hundred and seventy-two coupled before-and-after measurements were then compared with a paired t-test. Drift in measured inert gas volume during unlabored breathing was evaluated in three subjects at rest using multilevel linear regression. A quasi-experimental cross-over study with the same subjects was conducted to evaluate the device's ability to detect inert gas changes in relation to diving interventions and simulate power. Results The difference between the injected volume (1,996 ml) and the device's measured volume (1,986 ml) was -10 ml. The 95% confidence interval (CI) for the measured volume was 1,969 to 2,003 ml. Mean drift during a 43 min period of unlaboured breathing was -19 ml, (95% CI, -37 to -1). Our power simulation, based on a cross-over study design, determined a sample size of two subjects to detect a true mean difference of total inert gas wash-out volume of 100 ml. Conclusions We present a portable device with acceptable precision and accuracy to measure inert gas wash-out differences that may be physiologically relevant in the pathophysiology of decompression sickness.
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Affiliation(s)
- Oscar Plogmark
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Lund, Sweden
- Swedish Armed Forces Diving and Naval Medicine Center, Swedish Armed Forces, Karlskrona, Sweden
- Corresponding author: Oscar Plogmark, Sölvegatan 19, 221 85 Lund, Sweden, ORCiD: 0009-0008-3230-8807,
| | - Mårten Silvanius
- Blekinge Institute of Technology, Department of Mathematics and Natural Science, Karlskrona, Sweden
| | - Max Olsson
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Lund, Sweden
| | - Carl Hjelte
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Lund, Sweden
- Swedish Armed Forces Diving and Naval Medicine Center, Swedish Armed Forces, Karlskrona, Sweden
| | - Magnus Ekström
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Lund, Sweden
| | - Oskar Frånberg
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Lund, Sweden
- Blekinge Institute of Technology, Department of Mathematics and Natural Science, Karlskrona, Sweden
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Hjelte C, Plogmark O, Silvanius M, Ekström M, Frånberg O. Risk assessment of SWEN21 a suggested new dive table for the Swedish armed forces: bubble grades by ultrasonography. Diving Hyperb Med 2023; 53:299-305. [PMID: 38091588 PMCID: PMC10944666 DOI: 10.28920/dhm53.4.299-305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 09/30/2023] [Indexed: 12/18/2023]
Abstract
Introduction To develop the diving capacity in the Swedish armed forces the current air decompression tables are under revision. A new decompression table named SWEN21 has been created to have a projected risk level of 1% for decompression sickness (DCS) at the no stop limits. The aim of this study was to evaluate the safety of SWEN21 through the measurement of venous gas emboli (VGE) in a dive series. Methods A total 154 dives were conducted by 47 divers in a hyperbaric wet chamber. As a proxy for DCS risk serial VGE measurements by echocardiography were conducted and graded according to the Eftedal-Brubakk scale. Measurements were done every 15 minutes for approximately 2 hours after each dive. Peak VGE grades for the different dive profiles were used in a Bayesian approach correlating VGE grade and risk of DCS. Symptoms of DCS were continually monitored. Results The median (interquartile range) peak VGE grade after limb flexion for a majority of the time-depth combinations, and of SWEN21 as a whole, was 3 (3-4) with the exception of two decompression profiles which resulted in a grade of 3.5 (3-4) and 4 (4-4) respectively. The estimated risk of DCS in the Bayesian model varied between 4.7-11.1%. Three dives (2%) resulted in DCS. All symptoms resolved with hyperbaric oxygen treatment. Conclusions This evaluation of the SWEN21 decompression table, using bubble formation measured with echocardiography, suggests that the risk of DCS may be higher than the projected 1%.
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Affiliation(s)
- Carl Hjelte
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Lund, Sweden
- Swedish Armed Forces Diving and Naval Medicine Center, Swedish Armed Forces, Karlskrona, Sweden
- Sahlgrenska University Hospital, Anesthesia and Intensive Care, Gothenburg, Sweden
- Corresponding author: Dr Carl Hjelte, Kungsladugårdsgatan 113B. 414 76, Gothenburg, Sweden, ORCiD: 0009-0009-5522-8735,
| | - Oscar Plogmark
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Lund, Sweden
- Swedish Armed Forces Diving and Naval Medicine Center, Swedish Armed Forces, Karlskrona, Sweden
| | - Mårten Silvanius
- Swedish Armed Forces Diving and Naval Medicine Center, Swedish Armed Forces, Karlskrona, Sweden
- Blekinge Institute of Technology, Department of Mathematics and Natural Science, Karlskrona, Sweden
| | - Magnus Ekström
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Lund, Sweden
| | - Oskar Frånberg
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Lund, Sweden
- Blekinge Institute of Technology, Department of Mathematics and Natural Science, Karlskrona, Sweden
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Silvanius M, Rullgård H, Eckström M, Frånberg O. Proposed Thalmann algorithm air diving decompression table for the Swedish Armed Forces. Undersea Hyperb Med 2023; 50:67-83. [PMID: 37302072 DOI: 10.22462/01.01.2023.37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The Swedish Armed Forces (SwAF) air dive tables are under revision. Currently, the air dive table from the U.S. Navy (USN) Diving Manual (DM) Rev. 6 is used with an msw-to-fsw conversion. Since 2017, the USN has been diving according to USN DM rev. 7, which incorporates updated air dive tables derived from the Thalmann Exponential Linear Decompression Algorithm (EL-DCM) with VVAL79 parameters. The SwAF decided to replicate and analyze the USN table development methodology before revising their current tables. The ambition was to potentially find a table that correlates with the desired risk of decompression sickness. New compartmental parameters for the EL-DCM algorithm, called SWEN21B, were developed by applying maximum likelihood methods on 2,953 scientifically controlled direct ascent air dives with known outcomes of decompression sickness (DCS). The targeted probability of DCS for direct ascent air dives was ≤1% overall and ≤1‰ for neurological DCS (CNS-DCS). One hundred fifty-four wet validation dives were performed with air between 18 to 57 msw. Both direct ascent and decompression stop dives were conducted, resulting in incidences of two joint pain DCS (18 msw/59 minutes), one leg numbness CNS-DCS (51 msw/10 minutes with deco-stop), and nine marginal DCS cases, such as rashes and itching. A total of three DCS incidences, including one CNS-DCS, yield a predicted risk level (95% confidence interval) of 0.4-5.6% for DCS and 0.0-3.6% for CNS-DCS. Two out of three divers with DCS had patent foramen ovale. The SWEN21 table is recommended for the SwAF for air diving as it, after results from validation dives, suggests being within the desired risk levels for DCS and CNS-DCS.
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Affiliation(s)
- Mårten Silvanius
- Department of Mathematics and Natural Sciences, Blekinge Institute of Technology, Karlskrona Sweden
- Swedish Armed Forces Diving and Naval Medicine Centre, Karlskrona Sweden
| | - Hans Rullgård
- Department of Mathematics and Natural Sciences, Blekinge Institute of Technology, Karlskrona Sweden
| | - Magnus Eckström
- Department of Respiratory Medicine and Allergology, Institution for Clinical Sciences, Lund University, Lund, Sweden
| | - Oskar Frånberg
- Department of Mathematics and Natural Sciences, Blekinge Institute of Technology, Karlskrona Sweden
- Department of Respiratory Medicine and Allergology, Institution for Clinical Sciences, Lund University, Lund, Sweden
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Kjellberg A, Douglas J, Pawlik MT, Kraus M, Oscarsson N, Zheng X, Bergman P, Frånberg O, Kowalski JH, Nyren SP, Silvanius M, Skold M, Catrina SB, Rodriguez-Wallberg KA, Lindholm P. Randomised, controlled, open label, multicentre clinical trial to explore safety and efficacy of hyperbaric oxygen for preventing ICU admission, morbidity and mortality in adult patients with COVID-19. BMJ Open 2021; 11:e046738. [PMID: 34226219 PMCID: PMC8260306 DOI: 10.1136/bmjopen-2020-046738] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION COVID-19 may cause severe pneumonitis and trigger a massive inflammatory response that requires ventilatory support. The intensive care unit (ICU)-mortality has been reported to be as high as 62%. Dexamethasone is the only of all anti-inflammatory drugs that have been tested to date that has shown a positive effect on mortality. We aim to explore if treatment with hyperbaric oxygen (HBO) is safe and effective for patients with severe COVID-19. Our hypothesis is that HBO can prevent ICU admission, morbidity and mortality by attenuating the inflammatory response. The primary objective is to evaluate if HBO reduces the number of ICU admissions compared with best practice treatment for COVID-19, main secondary objectives are to evaluate if HBO reduces the load on ICU resources, morbidity and mortality and to evaluate if HBO mitigates the inflammatory reaction in COVID-19. METHODS AND ANALYSIS A randomised, controlled, phase II, open label, multicentre trial. 200 subjects with severe COVID-19 and at least two risk factors for mortality will be included. Baseline clinical data and blood samples will be collected before randomisation and repeated daily for 7 days, at days 14 and 30. Subjects will be randomised with a computer-based system to HBO, maximum five times during the first 7 days plus best practice treatment or only best practice treatment. The primary endpoint, ICU admission, is defined by criteria for selection for ICU. We will evaluate if HBO mitigates the inflammatory reaction in COVID-19 using molecular analyses. All parameters are recorded in an electronic case report form. An independent Data Safety Monitoring Board will review the safety parameters. ETHICS AND DISSEMINATION The trial is approved by The National Institutional Review Board in Sweden (2020-01705) and the Swedish Medical Product Agency (5.1-2020-36673). Positive, negative and any inconclusive results will be published in peer-reviewed scientific journals with open access. TRIAL REGISTRATION NCT04327505. EudraCT number: 2020-001349-37.
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Affiliation(s)
- Anders Kjellberg
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Johan Douglas
- Department of Anaesthesia and Intensive Care, Blekinge Hospital Karlskrona, Karlskrona, Sweden
| | - Michael T Pawlik
- Department of Anaesthesiology and Intensive Care Medicine, Catholic Charities Hospital, St. Josef, Regensburg, Germany
| | - Michael Kraus
- Department of Anaesthesiology and Intensive Care Medicine, Bergmannsheil und Kinderklinik Buer GmbH, Gelsenkirchen, Germany
| | - Nicklas Oscarsson
- Department of Anesthesiology and Intensive Care, University of Gothenburg Sahlgrenska Academy, Goteborg, Sweden
| | - Xiaowei Zheng
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Peter Bergman
- Department of Laboratory Medicine, Division of Clinical Microbiology, Karolinska Institute, Stockholm, Sweden
| | - Oskar Frånberg
- Department of Mathematics and Natural Science, Blekinge Institute of Technology, Karlskrona, Sweden
| | | | - Sven Paul Nyren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Radiology Solna, Karolinska University Hospital, Stockholm, Sweden
| | - Mårten Silvanius
- Department of Mathematics and Natural Sciences, TIMN, Blekinge Institute of Technology, Karlskrona, Sweden
- SwAF Diving and Naval Medicine Centre, Swedish Armed Forces, Karlskrona, Sweden
| | - Magnus Skold
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Respiratory Medicine and Allergy, Karolinska University Hospital, Stockholm, Sweden
| | - Sergiu-Bogdan Catrina
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Center for Diabetes, Academic Specialist Center, Stockholm, Sweden
| | - Kenny A Rodriguez-Wallberg
- Department of Reproductive Medicine, Division of Gynecology and Reproduction, Karolinska Universitetssjukhuset, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Peter Lindholm
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Department of Emergency Medicine, UCSD, La Jolla, California, USA
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Affiliation(s)
- Mårten Silvanius
- Department of Mathematics and Natural Sciences Blekinge Institute of Technology Karlskrona Sweden
| | - Oskar Frånberg
- Department of Mathematics and Natural Sciences Blekinge Institute of Technology Karlskrona Sweden
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Silvanius M, Mitchell SJ, Pollock NW, Frånberg O, Gennser M, Lindén J, Mesley P, Gant N. The performance of 'temperature stick' carbon dioxide absorbent monitors in diving rebreathers. Diving Hyperb Med 2019; 49:48-56. [PMID: 30856667 DOI: 10.28920/dhm49.1.48-56] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Accepted: 12/09/2018] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Diving rebreathers use canisters containing soda lime to remove carbon dioxide (CO2) from expired gas. Soda lime has a finite ability to absorb CO₂. Temperature sticks monitor the exothermic reaction between CO₂ and soda lime to predict remaining absorptive capacity. The accuracy of these predictions was investigated in two rebreathers that utilise temperature sticks. METHODS Inspiration and rEvo rebreathers filled with new soda lime were immersed in water at 19°C and operated on mechanical circuits whose ventilation and CO₂-addition parameters simulated dives involving either moderate exercise (6 MET) throughout (mod-ex), or 90 minutes of 6 MET exercise followed by 2 MET exercise (low-ex) until breakthrough (inspired PCO₂ [PiCO₂] = 1 kPa). Simulated dives were conducted at surface pressure (sea-level) (low-ex: Inspiration, n = 5; rEvo, n = 5; mod-ex: Inspiration, n = 7, rEvo, n = 5) and at 3-6 metres' sea water (msw) depth (mod-ex protocol only: Inspiration, n = 8; rEvo, n = 5). RESULTS Operated at surface pressure, both rebreathers warned appropriately in four of five low-ex tests but failed to do so in the 12 mod-ex tests. At 3-6 msw depth, warnings preceded breakthrough in 11 of 13 mod-ex tests. The rEvo warned conservatively in all five tests (approximately 60 minutes prior). Inspiration warnings immediately preceded breakthrough in six of eight tests, but were marginally late in one test and 13 minutes late in another. CONCLUSION When operated at even shallow depth, temperature sticks provided timely warning of significant CO₂ breakthrough in the scenarios examined. They are much less accurate during simulated exercise at surface pressure.
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Affiliation(s)
- Mårten Silvanius
- Swedish Armed Forces Diving and Naval Medicine Centre, Karlskrona, Sweden.,Blekinge Institute of Technology, Karlskrona, Sweden
| | - Simon J Mitchell
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Neal W Pollock
- Department of Kinesiology, Université Laval Québec, QC, Canada
| | | | - Mikael Gennser
- School of Technology and Health, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Jerry Lindén
- Swedish Armed Forces Diving and Naval Medicine Centre, Karlskrona, Sweden
| | | | - Nicholas Gant
- Department of Exercise Sciences, University of Auckland.,Corresponding author: Nicholas Gant, Department of Exercise Sciences, Centre for Brain Research, University of Auckland, Auckland 1142, New Zealand,
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