American Journal of Emergency Medicine 33 (2015) 363–366

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American Journal of Emergency Medicine

journal homepage: www.elsevier.com/locate/ajem

Original Contribution

Factors associated with residual symptoms after recompression in type I

decompression sickness☆,☆☆
Jungyoup Lee, M.D. a, Kyuseok Kim, M.D., Ph.D b,⁎, Sunkyun Park, M.D., Ph.D. c
a
Department of Emergency Medicine, Maritime Medical Center, the Republic of Korea Navy, Changwon, Korea
b
Department of Emergency Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Korea
c
Underwater Medical Institute, Maritime Medical Center, the Republic of Korea Navy, Changwon, Korea

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: The aim of this study is to investigate factors associated with residual symptoms after hyperbaric oxygen
Received 16 October 2014 therapy (HBOT) in type I decompression sickness (DCS).
Received in revised form 3 December 2014 Basic procedures: An HBOT registry, which includes patients with type I DCS, was analyzed retrospectively. We
Accepted 6 December 2014 divided enrolled patients into two groups; complete resolution group and residual symptom (RS) group after a
single HBOT session. We investigated factors associated with residual symptoms at discharge with univariable
and multivariable analyses. Restrictive cubic spline curve and a test for trend analysis were used to show the
trend of therapeutic response after HBOT based on time from symptom onset to HBOT.
Main findings: In a total of 195 patients, 131 (67.2%) patients were included in the RS group after single HBOT.
Prolonged time from symptom onset to recompression was independently associated with residual symptoms
(P = .004). When patients who underwent recompression within 24 hours from symptom were included in
the reference group, the adjusted odds ratios (AOR) (95% confidence interval) of residual symptoms after
HBOT were the following: 24 to 96 hours, 2.24 (0.75-6.65); 96 to 240 hours, 3.31 (1.08-10.13); more than 240
hours, 22.83 (2.45-231.43). In terms of sort of diving, commercial and recreational divers had higher probability
of residual symptoms than military divers (AOR, 4.78 and 33.36, respectively).
Principal conclusions: Early HBOT is associated with rapid symptom elimination after treatment in type I DCS.
Military divers showed a more immediate response after recompression in comparison with commercial and
recreational divers.
© 2014 Elsevier Inc. All rights reserved.

1. Introduction investigate therapeutic response to HBOT in patients with type I DCS

Decompression sickness (DCS) is caused by inert gas bubbles in tis-
sue and blood previously dissolved within tissues during or after inade-
quate decompression from hyperbaric exposure. Standard treatment for
DCS in divers is hyperbaric oxygen therapy (HBOT), which reduces bub-
ble volume and eliminates inert gas [1]. There are two types of DCS I and
II. Type I is the milder type of DCS and manifests as musculoskeletal
pain, cutaneous symptoms, and lymphatic obstruction [2]. With the de-
velopment of HBOT, the reported therapeutic success rate for type I DCS
is high [3–5]. Although many patients with type I DCS recover complete-
ly after a single HBOT session, some patients experience residual pain at
discharge that reduces over several days, and some need to undergo
surgery because of dysbaric osteonecrosis [6–9]. This study aimed to
☆ Funding: No.
☆☆ Prior Presentations: no.
⁎ Corresponding author. Department of Emergency Medicine, Seoul National
University, Bundang Hospital, 300 Gumi-dong, Bundang-gu, Sungnam-si, Gyeonggi-do,
463–707, Republic of Korea. Tel.: +82 31 787 7572; fax: +82 31 787 4055.
E-mail address: dremkks@snubh.org (K. Kim).
and to identify the clinical factors associated with residual symptoms
after a single HBOT session.
2. Materials and methods
2.1. Study hospital and setting
The study hospital is a 200-bed naval hospital with a multiplace hy-
perbaric oxygen chamber located in an urban setting. Both military di-
vers and civilian divers with DCS are admitted to the emergency
department (ED), and only patients who need HBOT are referred to
the underwater medical institute of our hospital for HBOT. In the ED,
we check the chest radiography and perform a full neurologic examina-
tion to identify pneumothorax, type II DCS, and arterial gas embolism
(AGE). We permit patients with type I DCS to sip a small amount
water, but not use any analgesics and intravenous fluids. We apply the
US Navy treatment Table 5 or 6 to enroll patients according to the US
Navy Diving Manual. When patients arrive at 60 f. and symptoms are
eliminated within 10 minutes, we progress to Table 5. If patients have
residual symptoms at 60 f. after 10 minutes, Table 6 is used [1].

http://dx.doi.org/10.1016/j.ajem.2014.12.011
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2.2. Data collection 2.4. Statistics

An HBOT registry, which includes patients who undergo HBOT in our
hospital, was analyzed retrospectively. The following data were record-
ed in the database: age, sex, symptoms, maximal depth of diving, type of
diving, repetitive diving, rapid ascent, hard underwater work, time from
surfacing to symptoms, time from symptoms onset to HBOT, and resid-
ual symptoms after HBOT. Clinical data were obtained from the patient's
statement and recorded by the attending physician. Hard underwater
work was recorded according to the patient's subjective expression. Re-
petitive diving was defined as any dive performed while the diver had
residual nitrogen gas in his body from a previous dive. We considered
patients who did not follow the decompression table as having residual
nitrogen gas [1]. Rapid ascent was defined as any dive that violated the
diving decompression schedule according to the US Navy Diving Manu-
al [1]. Residual symptoms (%) after HBOT were described as a percent-
age in comparison with the initial symptoms according to the
patient's statement. We contacted enrolled patients to obtain missed
values in the database and investigate the therapeutic results after dis-
charge. This study was approved by the institutional review board of
the Korean Military Medical Association.
2.3. Inclusion and exclusion criteria
Eligible patients were more than 15 years old, diagnosed with type I
DCS, and underwent HBOT between August 2004 and December 2013.
Patients who were diagnosed with type II DCS or AGE were excluded.
Patients whose symptoms were limited to muscles, joints, skin, and
lymphatic system were classified as type I DCS. If there were any one
of neurologic, respiratory, or circulatory symptoms, the patients were
classified as type II DCS. Arterial gas embolism was defined when pa-
tients had neurologic symptoms and a history of rapid ascent, breath
holding, or the presence of lung injury such as pneumothorax [1].
We described the baseline demographic data, information on diving,
and the overall treatment result of enrolled patients. Continuous vari-
ables were presented as the mean with standard deviation and were
compared with Student t test. Binominal variables were presented as
the frequency of occurrence and were compared with the χ 2 test. We
divided enrolled patients into two groups: complete resolution (CR)
group and residual symptom (RS) group after a single HBOT session,
and investigated the different variables in both groups with univariable
analysis. Subsequently, a multivariable analysis was performed to find
independent factors using significant variables (P b .05) identified
through the univariable analysis. Before performing multivariable anal-
ysis, we divided the time from symptom onset to recompression using
the interquartile range (median, 96 hours; interquartile range, 24-240
hours). We assumed that significant variables in the multivariable anal-
ysis could be factors that influence immediate symptom elimination
after HBOT in type I DCS. Restricted cubic spline curve and a test for
trend analysis were used to show the trend of early therapeutic re-
sponse based on time from symptom onset to recompression [10]. C-
statistics was used to evaluate the predictive function of our model
and area under the receiving operating curve (AUC), and 95% confi-
dence intervals (CIs) were calculated. In addition to multivariable logis-
tic regression, we performed a modified Poisson regression to estimate
the risk ratio of the risk factors [11]. A two-sided test was used with a 5%
level of significance. All calculations were performed using STATA ver-
sion 13.0 (StataCorp, College Station, Texas, USA).
3. Results
A total of 271 patients were admitted to our hospital for HBOT dur-
ing the study period. Of these patients, 67 were diagnosed with type II
DCS and 2 were diagnosed with AGE. Two hundred two patients were
diagnosed with type I DCS, and 195 patients were analyzed in our

Fig. 1. Study population.

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 J. Lee et al. / American Journal of Emergency Medicine 33 (2015) 363–366 365

Table 1 Table 3
Clinical presentation of enrolled patients Multivariable logistic regression of predictive factors for residual symptoms after a single
HBOT session
Total N = 195 (%)
OR 95% CI
Musculoskelectal pain 186 (95.4)
Shoulder 119 (61.0) Time from symptom to recompression, h
Knee 35 (17.9) ≤24 Reference
Elbow 25 (12.8) 24-96 2.24 0.75-6.65
Neck 19 (9.7) 96-240 3.31 1.08-10.13
Lower back 9 (4.6) ≥240 23.84 2.45-231.43
Ankle 7 (3.6) Type of diving
Pelvis 7 (3.6) Military divers Reference
Hand 7 (3.6) Commercial divers 4.78 1.43-15.92
Foot 4 (2.1) Recreational divers 33.36 3.43-323.71
Thigh 3 (1.5) Repetitive diving 1.04 0.39-2.77
Cutis marmorata 2 (1.0)
Abbreviation: OR, odds ratio.
Data are presented as number (percentage) of patients.

Using univariable analysis, the time delay from symptom onset to

study after excluding 7 patients with missing values. After the first
HBOT session, symptoms were relieved in all enrolled patients. Sixty-
four patients (32.8%) recovered completely after a single HBOT session
and classified into the CR group. Patients who discharged with residual
pain (131. 67.2%) were classified into the RS group. Average residual
pain (%) of the RS group at discharge was 35.5 % in comparison with ini-
tial symptoms. When we followed up enrolled patients through phone
counseling, 121 (92.3%) of 131 patients had recovered from symptoms
within 1 month. Eight patients had residual pain over 1 month after
recompression, and 2 patients underwent surgery for shoulder
osteonecrosis (Fig. 1). When patients who had residual pain over 1
month or needed surgery were classified as therapeutic failure, the
treatment success rate was 94.9%. Among enrolled patients, 186
(95.4%) patients accompanied at least one of muscle or joint pain.
Shoulder pain was the most common symptom followed by knee,
elbow, and neck pain. None of the enrolled patients had lymphatic
obstruction (Table 1).
Table 2
Univariable analysis of baseline characteristics, clinical presentation and time factors
Complete Residual
recovery symptom
n = 64 n = 131
recompression was significantly longer in the RS group than in the CR
group (P = .045). The military diving group had more patients with
early symptom relief than other groups (P = .006) (Table 2). Because
recompression time is delayed, more patients would have residual
symptoms at discharge in multivariable analysis. However, there was
no significant difference in residual symptoms between within the
24-hour group and the 24- to 96-hour group (Table 3). In the restrictive
cubic spline curve, the probability of residual symptoms at discharge
after recompression was increased with delayed time to recompression
(Fig. 2). Patients who underwent delayed treatment tended to have re-
sidual symptoms after a single HBOT session in a test for trend analysis
(P = .004). With regard to diving type, the military diving group had
higher immediate symptom elimination than the commercial diving
group, followed by the recreational diving group (Table 3). Although pa-
tients without repetitive diving showed a more immediate response
after HBOT than patients with repetitive diving in the univariable anal-
ysis, this result did not retain significance in the multivariable analysis
(Table 3). Predictability of the multivariable logistic regression model
was 0.77 (95% CI, 0.68-0.86) as measured by AUC. Estimate risk ratio
was calculated with a modified Poisson regression. Significant variables
were the same as the multivariable logistic regression, and incidence
P
rate ratio was regarded as the risk ratio. The AUC of the modified
Poisson regression model was 0.76 (95% CI, 0.67-0.85) (Table 4).

Demographic findings 4. Discussion

Age, y 39.5 ± 1.3 40.5 ± 0.76 .498
Male sex, no. (%) 64 (100) 125 (97.4) .112
The purpose of treatment for type I DCS is to eliminate symptoms
BMI, kg/m2 23.9 ± 0.3 24.7 ± 0.3 .087
Type of diving, no. (%) such as muscle or joint pain and prevent serious complications such as
Military divers 14 (21.8) 12 (9.2) .006 osteonecrosis. We could not find any clinical factors that influenced
Commercial divers 42 (65.6) 80 (61.5) the final treatment outcome because only 5.1% of enrolled patients ex-
Recreational divers 8 (12.5) 38 (29.2)
Information on diving
Diving depth, m 31.2 ± 2.6 28 ± 0.8 .138
Repetitive diving, no. (%) 32 (50) 87 (66.7) .023
Rapid ascent, no. (%) 25 (39) 37 (28.4) .137
Hard exercising, no. (%) 12 (18.7) 27 (20.7) .741
Alcohol before diving, no. (%) 5 (13.8) 4 (17.3) .715
Symptom, no. (%)
Shoulder pain 37 (57.8) 69 (53.8) .533
Knee pain 11 (17.1) 21 (16.1) .855
Elbow pain 8 (12.5) 16 (12.3) .969
Time
Surfacing to symptom, h 7.3 ± 3.9 6.2 ± 1.7 .766
Symptom to recompression, h 66.4 ± 14.8 342.3 ± 84.2 .045
Patients with delayed treatment 17 (47.2) 73 (77.6) .001
more than 24 h, no. (%)
Treatment table 5/6 59/5 98/33 .004
Residual symptom/initial symptom, % 0 35.5 ± 1.8 b.001
Patient with residual symptom 0 (0) 10 (7.6) .032
at 1 mo, no. (%)

Continuous data are presented as mean ± SD and compared with Student t test.
Categorical data are presented as number (percentage) of patients and compared with
χ2 test.
Abbreviations: BMI, body mass index; SD, standard deviation. Fig. 2. Restrictive cubic spline curve.

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366 J. Lee et al. / American Journal of Emergency Medicine 33 (2015) 363–366

Table 4
Modified Poisson regression of predictive factors for residual symptom after a single
HBOT session
IRR
Time from symptom to recompression, h
≤24 Reference
24-96 1.35
96-240 1.48
≥240 1.85
Type of diving
Military divers Reference
Commercial divers 1.35
Recreational divers 1.58
Repetitive diving 1.03
Abbreviation: IRR, incidence rate ratio.
perienced therapeutic failure. Instead of the final treatment outcome,
we focused on rapid therapeutic response after recompression because
fast symptom relief could increase patient satisfaction and reduce med-
ical cost. In our study, fast recompression was the only correctable factor
for immediate symptom elimination after HBOT in type I DCS. With re-
gard to diving type, military divers had good immediate response after
recompression, followed by commercial divers and recreational divers.
In case of military diving, diving regulations are strict, and almost all
diving is done according to the US diving manual [1]. However, recrea-
tional divers may dive without regulation or limitation. A previous
study described that civilian divers adhere less to US Navy diving tables
than military divers [12]. Patients with type I DCS are likely to ignore
their own symptoms and delay treatment because they could have
only minor pain or skin lesions. Although type I DCS had minor symp-
toms, it can lead to serious complications such as osteonecrosis and
progress to type II DCS [13,14]. There is controversy whether early
recompression influences cause better outcome in DCS. Previous studies
have investigated the delayed time effect in DCS and showed both a
negative effect and no-effect on outcome [15–17]. Previous studies
mainly focused on type II DCS and described delayed time and final
therapeutic outcome. No previous study demonstrated the effect of de-
layed recompression on type I DCS in detail. Although delayed
recompression did not influence the final therapeutic outcome in type
I DCS in our study, more patients with early treatment had symptomatic
relief immediately after a single HBOT session. We recommended that
patients with type I DCS visit a hospital where HBOT is available as
quickly as possible for early symptom relief.
This study has several limitations. First, the percentage of men was
high in the enrolled patients. Therefore, we could not prove whether
sex influenced the therapeutic results or not. Second, we did not find
any significant factor that could influence the final therapeutic result be-
cause the number of patients with treatment failure was small. Third,
the clinical information in the database was obtained through patient
95% CI statement, and we could not verify the accuracy. Fourth, potential biases
might remain because of the retrospective nature of the study.
In conclusion, early HBOT is associated with rapid symptom elimina-
0.94-1.91 tion after treatment in type I DCS. Military divers showed a more imme-
1.07-2.05
diate response after recompression in comparison with commercial and
1.37-2.51
recreational divers.
1.23-1.85 Acknowledgments
1.16-2.15
0.83-1.28
No authors declare a conflict of interest.
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