What is the treatment for barotrauma?

Treatment of Barotrauma

The treatment of barotrauma depends critically on the type and severity: pulmonary barotrauma requires immediate oxygen supplementation, lung-protective ventilation strategies if mechanically ventilated, and chest tube placement for pneumothorax, while ear barotrauma is managed with decongestants, analgesics, and pressure equalization techniques. 1, 2

Initial Assessment and Stabilization

Immediate Oxygen Therapy

• Provide supplemental oxygen to maintain SpO₂ >92% in all patients with barotrauma 1
• Use caution with high-flow oxygen therapy as it may worsen barotrauma by increasing pressure gradients 1, 2
• Standard nasal cannula or face mask oxygen is preferred over high-flow systems initially 1

Identify the Type of Barotrauma

The clinical presentation determines management:

Pulmonary barotrauma manifests as:

• Pneumothorax, pneumomediastinum, or subcutaneous emphysema 3, 1
• Central chest discomfort, hoarseness, and dyspnea (pneumomediastinum) 3
• Arterial gas embolism with neurological symptoms, impaired consciousness, or sudden cardiovascular collapse 3

Ear barotrauma presents with:

• Ear pain, hearing loss, or tympanic membrane rupture 2, 4
• Difficulty equalizing pressure during descent/ascent 3

Management of Pulmonary Barotrauma

Tension Pneumothorax

• Immediate chest tube insertion is required for tension pneumothorax 1
• This is a life-threatening emergency that cannot wait for imaging confirmation 3

Pneumomediastinum

• Most cases resolve with conservative management including rest, oxygen, and observation 3
• Monitor for progression to pneumothorax or subcutaneous emphysema 3

Arterial Gas Embolism

• Rapid recompression with hyperbaric oxygen therapy is the definitive treatment and may improve prognosis 1, 4
• This represents the most severe form of barotrauma and requires immediate transfer to a hyperbaric facility 3
• Supportive care includes 100% oxygen, IV fluids, and positioning (though optimal positioning remains debated) 4

Mechanical Ventilation Considerations

If the patient requires intubation and mechanical ventilation:

• Limit tidal volumes to 6-8 mL/kg of ideal body weight 3, 1
• Keep peak airway pressures <30 cm H₂O 1
• Use longer expiratory times (inspiratory to expiratory ratio 1:4 or 1:5) 3
• Employ permissive hypercapnia (maintaining pH >7.2) to avoid excessive airway pressures 3, 1
• These lung-protective strategies prevent further barotrauma from positive pressure ventilation 3, 1

Management of Ear Barotrauma

Mild to Moderate Cases

• Decongestants to improve eustachian tube function 2, 4
• Analgesics for pain control 2
• The Toynbee maneuver (swallowing with pinched nostrils) helps equalize pressure 2

Severe Cases with Tympanic Membrane Rupture

• Consider short-term corticosteroid therapy if laryngeal edema is present 1, 2
• Myringotomy or surgical repair may be required for persistent cases 2
• Vasoconstrictor drugs can help reduce mucosal edema 4

Special Considerations and Prevention

Documentation and Follow-up

• Patients with barotrauma history should have this documented prominently in their medical records 1
• Recurrent barotrauma tends to be more severe than the original incident, emphasizing prevention importance 1

Imaging and Risk Assessment

• Obtain chest X-ray to confirm tube placement and identify complications after intubation 3
• Consider CT scanning to identify subpleural blebs or cysts not evident on plain radiographs 1
• Pulmonary function testing focusing on flow rates at low lung volumes may assess recurrence risk 1

Addressing Underlying Causes

• Address underlying causes of excessive coughing or airway narrowing to prevent recurrence 1
• Patients with asthma or airway disease have increased barotrauma risk and require careful management 3
• Reinstructing patients on proper pressure equalization techniques before returning to diving or pressure exposure is essential 2, 5

Common Pitfalls to Avoid

• Do not administer oxygen via airway exchange catheters during tracheal tube exchange, as even low-flow oxygen risks barotrauma if the catheter tip migrates beyond the carina 3
• Avoid aggressive ventilation with high tidal volumes or pressures in at-risk patients 3
• Even shallow dives or small pressure changes can cause significant barotrauma 2
• Close monitoring is essential as residual airway edema may persist after initial treatment 1