the joys of hbo

Comprehensive Healthcare Solutions

How I learned to love “PRESSURE”

The Joys of HBO


“HAPPY” Patients


Unhappy Patients

Barotrauma (squeeze)Otic (ear)Pulmonary (lung)GI (colon)Dental (tooth)Sinus


Sighing is a marker for stress


Boyle’s Law


Pressure-Volume Relationship


Is Boyle’s Law an issue for every pressure vessel?


Delta Sub


Unhappy Patients

Barotrauma (squeeze)Ear (most common)Pulmonary (most serious)GI (colon)Dental (tooth)Sinus


Pulmonary Barotrauma

Tissue damage

Emphysema

Pneumothorax

Air embolism


Lung Anatomy


Mediastinal Shift


Tension Pneumothorax


DiagnosisChest pain ↑Blood Pressure ↓Respiratory Rate ↑Breath sounds ↓Bell Tympany ←Hyper-resonance ←Tracheal shift →


Chest Tube


Questions?


The Ear

Under Pressure


Why Talk About Ears Most frequent pressurerelated injuryPoor understanding ofequalization techniquesEar damage (Barotrauma) is…

*PREVENTABLE*


Pressure-Volume Relationship


Ear at Sea Level


Ear at 2.6 FSW


Locked Ear at 3.9 FSW


Forceful Valsalva


The Present Strategy

How do we most often judge middle ear equalization ability?

Test of pressure???

Patient query???

“Reactive” instead of “Proactive”

I HOPENOT!

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Objectives

Recognize “Ear Fear”

Assess pressurization effortwith “Doc’s Technique”

Become proficient in 3 methodsof Middle Ear pressurization

Learn PROACTIVE intervention


What is “Ear Fear”?

Pressure is uncomfortable

Childhood pain -> adult fear

Retrograde tear duct inflation

Confusion over instructions


Assessing Equalization Effort

The Doc’s Technique: Watch The Nose Inflate!

Palpate firmness of inflationand compare it to your own equalization effort

Watch for “Excessive Effort”


Otoscopy

Identify landmarks

Check mobility of the TM

Verify TM bulge withpresssurization of the middle ear


Normal Ear


Pneumatic Otoscopy


Bony Exostosis


Hemotympamum


Video Otoscopy


Pressurization Techniques

Valsalva Maneuver (1704)

Frenzel Maneuver (1932)

Lowry Technique (1950s)Combination maneuverPressurize and swallow


Antonio Valsalva Pinch nostrils closed

Increase pressure in chest

Cheeks tight, not puffed out

Should not be a prolonged effortengorgement – venous returnnever on ascent!


Herman Frenzel “Luftwaffe”

“The Throat Piston”

Close vocal cords

Pinch nostrils closed

Raise the back third of tongue

Feel “Adams Apple” elevate


Advantages

Does not adversely effect blood flow

Independent of respirations

Can be performed with mouth open

Easy to teach and practice

“Bobbing Adams Apple”


Teaching TechniquesBazooka vs Otovent


So Many MethodsSo Little Time

Pressurization methods work best“Eustachian Tube Awareness”Combination methods work wellbut are harder to learnPerform effective technique“Early and Often”


How Hard to BlowNever “forceful” - just “ADEQUIT”

Never blow hard to relieve ear squeeze. Pressurization is a preventive maneuver

Never perform a Valsalva on ascent. Use swallow, yawn or jaw thrust


Doc’s Motto:

Never give up…there is always a way

In extreme cases consider PE tubes


Summary

Watch out for “Ear Fear” and the “Excessive Effort” signWatch the nose for proper inflationBob your Adams AppleVerify ME pressurization prior to treatment by watching the TM bulge


Where to get more information

Doc’s Diving Medicine Homepage

“divingdoc.com”

the joys of hbo

Documents

pressure vessel

test of pressure

equalization effortwatch

frenzel maneuver

lowry technique

tmverify tm bulge

chestcheeks tight

patient query