What is the treatment for barotrauma?

Treatment of Barotrauma

The treatment of barotrauma depends critically on the type and severity: pulmonary barotrauma requires immediate supplemental oxygen, consideration of recompression therapy for arterial gas embolism, and management of pneumothorax if present, while ear and sinus barotrauma typically respond to decongestants, analgesics, and pressure equalization techniques. 1, 2

Initial Assessment and Stabilization

Immediate Oxygen Therapy

• Provide supplemental oxygen to maintain SpO₂ >92% in all cases of barotrauma 1
• Use caution with high-flow oxygen therapy as it may paradoxically worsen barotrauma 1, 2
• Ensure reliable measurement of arterial oxygen saturation to avoid both hypoxemia and hyperoxia 3

Identify the Type of Barotrauma

The clinical presentation determines treatment approach:

Pulmonary barotrauma presents with:

• Pneumomediastinum: central chest discomfort, hoarseness, dyspnoea 3
• Arterial gas embolism: neurological symptoms, impaired consciousness, convulsions, or sudden death from coronary embolism 3
• Pneumothorax: respiratory distress and decreased breath sounds 3

Ear/sinus barotrauma presents with:

• Facial pain, pressure sensation, dental pain 4
• Hearing loss, tinnitus, or vertigo 5
• Infraorbital nerve paresthesia in severe maxillary sinus cases 4

Management of Pulmonary Barotrauma

Severe Cases with Arterial Gas Embolism

• Rapid recompression therapy is the definitive treatment and may improve prognosis 1
• This requires immediate transfer to a hyperbaric oxygen facility 6
• Do not delay recompression for diagnostic imaging if clinical suspicion is high 3

Pneumothorax Management

• Chest tube insertion is required for tension pneumothorax 1
• Obtain chest radiograph to detect pneumothorax and assess for rib fractures 3
• Monitor for development of tension physiology, especially in mechanically ventilated patients 3

If Mechanical Ventilation is Required

Apply lung-protective strategies to prevent further barotrauma 1:

• Limit tidal volumes to 6-8 mL/kg ideal body weight 3, 1
• Keep peak airway pressures <30 cm H₂O 1
• Use positive end-expiratory pressure of 4-8 cm H₂O 3
• Employ slower respiratory rates with longer expiratory times (inspiratory:expiratory ratio 1:4 or 1:5) 3
• Permit mild hypercapnia (pH >7.2) to avoid excessive airway pressures 3, 1

Sedation and Neuromuscular Blockade

• Adequate sedation reduces oxygen consumption and patient-ventilator dyssynchrony 3
• Short-term neuromuscular blockade (<48 hours) may reduce barotrauma risk without increasing ICU-acquired weakness 3
• If using neuromuscular blockade, continuous EEG monitoring is recommended to detect seizures 3

Management of Ear and Sinus Barotrauma

Conservative Treatment (First-Line)

• Decongestants to improve Eustachian tube and sinus ostia patency 2, 4
• Analgesics for pain control 2
• B vitamins for nerve-related symptoms 4
• Short-term corticosteroids if laryngeal edema or significant inflammation is present 1, 2

Pressure Equalization Techniques

• Toynbee maneuver (swallowing with pinched nostrils) helps prevent recurrence 2
• Reinstructing patients on proper equalization methods is essential before any return to diving 7

Surgical Intervention

• Endoscopic sinus drainage for persistent sinus barotrauma 4
• Myringotomy for severe middle ear barotrauma 2
• Tympanoscopy if round window membrane rupture is suspected 5

Monitoring and Follow-Up

Imaging Studies

• Chest radiograph for pulmonary barotrauma to assess tube placement and detect complications 3
• CT scanning to identify subpleural blebs or cysts not evident on plain radiographs 1
• These findings may indicate increased risk of recurrence 1

Functional Assessment

• Pulmonary function testing, particularly flow rates at low lung volumes, helps assess recurrence risk 1
• Audiometry and vestibular testing for ear barotrauma cases 5
• Transcranial or carotid Doppler ultrasonography to detect right-to-left shunts in inner ear decompression illness 5

Long-Term Considerations

• Document barotrauma history prominently in medical records 1
• Recurrent barotrauma tends to be more severe than the initial incident 1
• Address underlying causes of increased barotrauma risk (asthma, airway narrowing, lung cysts) 3, 2
• Close monitoring is essential as residual airway edema may persist 1

Critical Pitfalls to Avoid

• Even shallow pressure changes can cause significant barotrauma—do not dismiss symptoms based on depth of exposure 2
• Patients with asthma or airway narrowing have markedly increased risk and require heightened vigilance 3, 2
• Delayed treatment of nerve compression from sinus barotrauma may result in permanent changes 4
• Inner ear barotrauma and decompression illness result in residual cochleovestibular damage in more than 75% of patients, emphasizing the importance of early aggressive treatment 5
• Hypercapnia induced by hyperventilation causes cerebral ischemia in post-cardiac arrest patients, but permissive hypercapnia is well-tolerated when avoiding barotrauma 3