Lung Squeeze: Coughing Your Lungs Out

Dr Schneider dives into the particulars of lung squeeze – a largely misunderstood and unknown diving condition affecting breath-hold divers.

“Lung squeeze” is a condition that is practically unique to breath-hold diving. Scuba divers are not really aware of it and, sadly, most doctors have never heard of it, let alone learnt to treat it. There are many urban legends about this rather poorly defined and largely misunderstood phenomenon. So, let us dive into the topic and hopefully avoid getting a brain squeeze in the process! 

“Lung squeeze” is also known as chest squeeze or more formally as pulmonary barotrauma (PBT) of descent. PBT is thus damage or injury to the lungs as a result of the effects of increased environmental pressure on the closed gas spaces of the lungs during breath-hold diving.

The description and definition refers to what happens to the lungs because of increased pressure during descent. Some authorities include tracheal squeeze as part of the broader concept of PBT.

So, using this imperfect definition, let us consider what these effects actually are. How does increased environmental pressure affect the closed gas spaces of the lungs?


In order to better understand PBT, it is necessary to revisit some basic physics and physiology.

First, Boyle’s law: “The volume of a given mass of gas is inversely proportional to its pressure if the temperature remains constant.” By this gas law, it is understood that the volume of gas in a closed system or space will decrease as the ambient pressure increases and vice versa. In breath-hold diving, our lungs represent the closed gas containing space with the increased ambient pressure provided by the water’s hydrostatic pressure during descent. For every 10 metres of seawater (msw), an additional 1 atmosphere (ATA) of pressure is incurred. Take note that this inverse volume decrease as pressure increases follows an exponential curve, as shown in the table below.
Secondly, some basic understanding of lung volume is required. The total lung capacity (TLC) of a 1.7 m, 70 kg male is roughly 7 ℓ. As the lung volume is emptied down to the absolute minimum, the lowest volume is called the residual volume (RV). The other volumes are not of major significance to the topic and are added for reference purposes.
The figure below shows the lung volume and constituents of a breath-hold diver.
Originally, the assumption was that RV represented the minimum volume that the lungs could achieve before mechanical damage would start to ensue. In other words, it should be safe to dive on breath-hold to a depth where the compression effect on the lungs does not exceed a volume reduction to less than RV. RV is usually 20-25% of the total lung volume after full inhalation. Thus, according to Boyle’s law, RV would be reached at about 35-45 msw (i.e. 4.5-5.5 ATA) making this the breath-hold depth limit. Clearly, this is not the case, however, as freediving depth records now exceed 200 msw. This prompted the discovery of other physiological mechanisms that play a role. Besides actual partial collapse of the chest cavity itself, the most important additional compensatory mechanism is the central pooling of blood in the chest from the surrounding tissues. This allows for the accumulation of up to 1.5 ℓ of blood in the blood vessels of the chest.

Essentially, the central pooling of blood in the chest equalises the pressure gradient when the RV is reached and thereby decreases the effective RV and allows for deeper depths to be attained safely. This mechanism increases the pressure in the pulmonary vascular bed and subsequently in the pulmonary capillaries with rupture and haemorrhage both being a possible consequence of the pressure.

In practice, these mechanisms allow the lungs to be compressed down to about 5% of the TLC in highly-trained breath-hold champions. This begs the question of whether this would set the absolute limits for breath-hold diving? Even so, it is not uncommon for these athletes to cough up blood and the feats they achieve do not translate to everyone. 

Although it may seem that PBT is limited to very deep dives, there are several reports of PBT occurring with shallow diving – typically repetitive dives with short surface intervals, even as shallow as 4 msw. It may be that more is going on than compression. It is well known that fluid can accumulate in the lungs simply as a function of being in water (as in so-called head-out immersion) or with surface swimming. Individual anatomical, physiological, pathological and day-to-day variations all play a role in the development of PBT.

Not all cases of PBT are recognised as they occur. Some features are transient. Others may be confused with common chest ailments like flu or pneumonia. When both manifest and are recognised, the following symptoms (i.e. complaints) and signs (i.e. actual demonstrable abnormalities) are associated with PBT.
  • Chest pain
  • Shortness of breath
  • Sensation of fluid in lungs
  • Coughing
  • Fatigue
  • Sensation of squeezing or constriction of chest during descent
  • Dizziness
  • Nausea
  • Weakness
  • Paraesthesia
  • Faintness
  • Hyperventilation
  • Coughing up bright red blood or foamy blood
  • Vomiting
  • Respiratory distress
  • Disorientation
  • Loss of consciousness
  • Neurological fallout
  • Cardio-respiratory arrest
  • Death
From the long list of manifestations it can be seen that PBT may range from mildly irritating to fatal. In terms of duration, it can be very short or last up to a few months. Re-occurrences are common and the question of permanent damage arises.

Whether you are a competitive breath-hold diver or simply spend a lot of time in water, it is worth considering some of the following tips to try to minimise or avoid PBT:
  • Maintain your fitness, especially respiratory fitness.
  • Build up your carbon dioxide (CO₂) tolerance to reduce lung contractions. These contractions are involuntary gasps against a closed glottis or mouth in breath-hold divers as the physiological breakpoint is reached due to CO₂ levels stimulating breathing efforts.
  • Warm up to reduce contractions at depth.
  • Avoid stretching out at depth with arms or neck. No excessive or violent movements are required or desired.
  • Improve and train your ribcage flexibility.
  • Dive to depths you are comfortable with and avoid panicking.
  • Turn before you experience contractions at depth.
  • Build up slowly when starting to dive to depth.
  • Avoid deep dives immediately after prolonged travel, especially if you have changed time zones or experienced jet lag. Recover completely first.
  • Learn techniques to relax while diving, especially at depth, and concentrate on releasing tension from around the chest area specifically.
  • Learn the Frenzel or mouth-fill technique for equalisation as it is gentler and uses less air.
  • If you have a history of PBT, rest the day after a deep dive as there appears to be an increased risk of a PBT on the second day, even at shallower depths.
  • If you start to experience symptoms similar to a previous PBT while diving, terminate the dive.
  • Maintain regular depth training sessions during your off-season as well.
  • Start exhaling just before the surface. Prior training in this regard is recommended.

Management of PBT follows basic emergency medical management principles, with the level of care being escalated or maintained depending on the initial clinical presentation and progression of the problem.

A sensible protocol includes the following:
  • Stop diving and ensure the safety of the injured diver.
  • Stop any physical activity. Let the dive buddy assist in buoyancy and towing of the injured diver to a location where exiting the water can be accomplished.
  • Allow the injured diver to rest and ensure comfort.
  • If available and possible, let the injured diver breathe 100% medical oxygen.
  • Encourage oral fluid intake if the injured diver’s airway is secure and the diver is fully conscious, but avoid alcohol.
  • Access emergency medical services as quickly as possible depending on available facilities and expertise. The DAN hotline is a good choice for first contact as they can be of great assistance in accessing medical services and they “speak the language of divers”.
  • Seek medical consultation, preferably with a diving physician as soon as possible.
  • Rest for at least two weeks before resuming diving and preferably after being cleared fit to dive by a diving physician.
  • Precautionary planning is better than playing catch up.

PBT is a curious and much debated problem amongst breath-hold divers. There is still much to learn about this condition and there are various ways in which it can be avoided or mitigated. Perhaps it is indeed the absolute depth barrier to deep breath-hold diving. Who knows? Today’s barriers are tomorrow’s trophies. In the meantime, dive safely and do not forget to enjoy it. 
  • Brubakk, A.O. & Neumann, T.S. Bennett and Elliot’s Physiology and Medicine of Diving. 5th edition.
  • Edmonds, C., Lowry, C., Pennefather, J. & Walker, R. Diving and Subaquatic Medicine. 4th edition.

No Comments


 2018 (60)
 2016 (119)
After anaesthesia Air Quality Altitude sickness Annual renewal Apnea Arthroscopic surgery BCD Badages Bag valve mask Bandaids Barbell back squat Bench press Bouyancy compensators Boyle's Law Boyle\'s Law Boyle\\\'s Law Boyle\\\\\\\'s Law Boyle\\\\\\\\\\\\\\\'s Law Brain Breast Cancer Breath hold Breath-hold Bruising Buoyancy Burnshield CGASA CO2 Camera settings Cancer Remission Cancer treatments Cancer Cape Town Dive Festival Carbon dioxide Charles' Law Charles\' Law Charles\\\' Law Charles\\\\\\\' Law Charles\\\\\\\\\\\\\\\' Law Chemotherapy Coastalexcursion Cold Water Cold care Cold Conservation Contaminants Corals Cutaneous decompression DAN Profile DAN Researchers DAN medics DAN report DCI DCS Decompressions sickness DCS DReams Dalton's Law Dalton\'s Law Dalton\\\'s Law Dalton\\\\\\\'s Law Dalton\\\\\\\\\\\\\\\'s Law Decompression Illness Decompression Sickness Decompression illsnes Diseases Dive Instruction Dive Instructor Dive accidents Dive computers Dive health Dive medicines Dive medicine Dive safety Dive staff Diveleaders Divers Alert Diving Kids Diving career Diving emergencies Diving injuries Diving suspended Diving Domestic Dr Rob Schneider EAP Ear pressure Ears injuries Emergency plans Environmental impact Equipment care Exercise Eye injuries FAQ Fatigue First Aid Equipment First Aid kits Fish Fitness Francois Burman Free diving Freediver Gas laws Gastric bypass Gordon Hiles HELP Haemorhoid treatment Health practitioner Heart High temperatures Hot Hydrostatic pressure Hypothermia Indian Ocean Inert gas Infections Instinct Instructors International travel International Irritation Kids scubadiver Labour laws Legislation Leukemis Liability Risks Life expectancy Lifestyle Low blood pressure Lung injuries MOD Maintenance Mammalian effect Maximum operating depth Medical Q Medical questionaire Medical statement Middle ear pressure Military front press More pressure Mycobacterium marinum Nitrox Non-rebreather Mask Nosebleeds O2 providers O2 servicing OOxygen maintenance Ocean pollution Orbital implants Oronasal mask Oxygen Cylinder Oxygen Units Oxygen deicit Oxygen ears Oxygen equipment Oxygen masks Oxygen supply Oxygen therapy Part 3 Plastic Pneumothorax Pool Diving Pulmanologist Pulmonary Bleb Radio communications Rashes Report incidents Rescue training Resume diving SABS 019 Safety Save our seas Science Scuba Injury Scuba children Scuba dive Scuba health Scubalearners Skin Bends Skin outbreak Skin rash Snorkeling Sodwana Bay Splits Squeezes Supplemental oxygen Surgeries Surgery The Bends The truth Thermal Notions Tides Travel tips Travel Tweezers Unconsciousness Underwater photographer Underwater pho Vaccines Vagus nerve Valsalva manoeuvers Vasvagal Syncope White balance Winter Wound dressings Wreck dive Youth diver abrasion air-cushioned alert diver altitude antibiotics antiseptics bandages bent-over barbell rows breathing air calories burn cardiovascular checklist chemo port child clearances closed circuit scuba currents cuts dead lift decompression algorithms decongestants dehydration dive injuries dive medicing dive ready child dive reflex dive tribe diver rescue dive diving attraction doctors domestic travel dri-suits dry mucous membranes dry suits dry ear spaces electroytes emergency action plans emergency assessment equalizing exposure injuries flexible tubing health hospital humidity immersion pulmonary edema (IPE join DAN longevity lower stress marine pathogens medical procedures medical risk assesment minor illness mucous membranes nasal steroids nasal newdivers nitrogen bubbles off-gassed operating theatre outgas pain plasters post dive preserve rebreather mask rebreathers risk areas saturation scissors scuba equipment scuba single use sinus infections stings strength tecnical diver thermal protection training trimix unified standards warmers water quality