Diving Doctor: Chest Pain After Scuba Diving May Not Be An Emergency

Q: After diving, I ­experienced chest pain, shortness of breath and hoarseness. is something ­seriously wrong?

A: What you experienced is fortunately a relatively minor medical problem, but it could have been life threatening. Pulmonary barotrauma is a category of injury that includes air embolism, pneumothorax, mediastinal emphysema and subcutaneous emphysema. (I have covered air embolism and pneumothorax in previous columns.)

All of these problems are a direct result of over-expansion of the air sacs within the lungs (called alveoli) due to a rapid ascent without appropriate exhaling or because of blockages in the airways. The latter can occur with medical problems like asthma or emphysema. When these air sacs over-expand and rupture, the air has to go somewhere. If it escapes into the pleural cavities (where the lungs are located) then pneumothorax occurs and medical intervention may be necessary. If the air finds its way into the blood vessels (also damaged in pulmonary over-expansion), then air embolism occurs, a true medical emergency that may be rapidly fatal.

In your case it appears that the air found another route. Air can go into the middle of the chest where the heart is located, called the mediastinum. The resulting problem is known as mediastinal emphysema. Air in this location can press on branches of the vagus nerve, causing hoarseness and coughing. It can also result in chest pain and even shortness of breath. Occasionally air tracks beneath the skin (subcutaneous emphysema) of the upper chest and neck. You can actually press on the skin and feel the air underneath when this occurs.

Both mediastinal emphysema and subcutaneous emphysema are relatively minor medical problems and will go away with time. Treatment in the Emergency Department may include breathing oxygen to make the problem resolve more quickly. However, more than one type of pulmonary barotrauma can be present and the diver should be evaluated and observed for symptoms of pneumothorax or air embolism.

James L. Caruso is a 30-year veteran of the U.S. Navy, serving as ship’s doctor, undersea medical officer and flight surgeon. His experience includes a fellowship in Diving and Hyperbaric Medicine at Duke University Medical Center; today he is Denver’s chief medical examiner.