POSITION PAPER

Asthma and Sport SCUBA Diving

Asthma is a common medical condition affecting approximately 5 to 10% of the population. Asthmatics are encouraged by their physicians to live a normal existence utilizing bronchodilator medication as needed to do so. It is common for asthmatics to use inhalers and other medications prior to exercise to prevent or ameliorate symptoms. In fact asthma medications are one of only a few allowed participants in competitive events. SCUBA (Self Contained Underwater Breathing Apparatus) diving is a very popular sport in the United States with over five million active certified divers and hundreds of thousands newly trained each year. Although asthma, past or present, has been considered a contraindication to SCUBA diving among diving and hyperbaric physicians, this position has been questioned recently. Controversy exists regarding whether or not the SCUBA diver with asthma is at increased risk for sustaining a diving related injury. The possibilities include impaired exercise capacity with drowning, decompression sickness or air embolism due to increased susceptibility to pulmonary barotrauma. SCUBA divers may at times breathe cold, dry air at increased density while at depth. These factors, coupled with emotional stress and strenuous exercise may potentially precipitate an attack of asthma. Despite these theoretical considerations, there are few objective data to support these concerns other than anecdotal case reports. The Dive Alert Network (DAN) at www.diversalertnetwork.org collects records of dive accident data submitted from the United States, Canada and the Caribbean. In 3359 cases of decompression sickness collected over seven years there was no statistically significant difference in asthmatics versus non-asthmatics in sustaining air embolism. In over 700 fatalities reported over nine years, only three had some mention of the presence of asthma. In Britain, the British SubAqua Club (BSAC) has allowed asthmatics to dive for years. In a survey conducted by Farrell and Glanvill, 12,864 dives were logged by 104 asthmatic divers without any instance of pulmonary barotrauma. Some of the divers used inhalers regularly including on the day of diving and some divers were on steroids. Unfortunately, surveys and retrospective reviews have well-recognized limitations and prospective data controlling for severity of asthma, pulmonary function tests, and pre-dive medication are not available. International recommendations for diving and asthma vary widely. The UK Sports Diving Medical Committee Asthma Standard states that there is little evidence that moderate, controlled asthmatics are at increased risk compared to the normal population. On the other hand they state that cold-induced asthmatics should be excluded from diving as well as asthmatics who have used a bronchodilator in the preceding 48 hours. Recommendations from South Pacific Underwater Medicine Society (SPUMS) state that the relative risk for a decompression sickness is about two in asthmatics compared to the normal population and recommends provocative testing with exercise and/or hypertonic saline to exclude the presence of asthma defined by abnormal responses on these tests.
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The Undersea and Hyperbaric Medical Society (UHMS) held a symposium on asthma and diving in 1995. They concluded that although the physiology suggests that asthmatics might be at increased risk for decompression sickness and limited exercise capacity, this risk is likely to be low. Current policies may seem to be effective at reducing apparent asthma related incidents, but may unnecessarily exclude many potentially safe divers and may increase the hazard for asthmatics who dive by discouraging appropriate assessment and treatment. Data are insufficient to implicate asthma as a significant risk factor for drowning, decompression sickness or air gas embolism. Until better data are available, the following guidelines should be considered: Prospective dive applicants should be screened for the presence of asthma by history and physical examination. 1. A remote past history of asthma alone should not preclude an individual from diving. 2. Candidates with a more recent history of asthma or those with intermittent asthma should be required to have normal spirometry at rest and in response to exercise before being certified to dive. 3. Candidates with mild persistent asthma on medications should be required to have normal spirometry at rest and in response to exercise. 4. The patient has to assume responsibility to refrain from diving when asthma symptoms and/or signs are present. DAN and other organizations should be supported in their efforts to continue to collect data on asthma and divers so that recommendations can be appropriately modified in accordance with the current scientific evidence.
REFERENCES

1. Davis JC, Bove AA (eds.): Medical examination of sport SCUBA divers. Medical Seminars, 1986, p34. 2. Elliott D: Are asthmatics fit to dive? Symposium, Undersea and Hyperbaric Medical Society, April 1996. 3. British Thoracic Society guidelines on respiratory aspects of fitness for diving. Thorax Jan 2003; 58(1):3-13. 4. Francis TJR: Pulmonary. In Elliott D. (ed.): Medical assessment of fitness to dive, Proceedings of an International Conference at the Edinburgh Conference Centre, Biomedical Seminars, March 1994, pp109-111. 5. Jenkins C, Anderson SD, Wong R, Veale A: Compressed air diving and respiratory disease. Medical Journal of Australia 1993; 158:275-279. 6. Neuman TS, Bove AA, O'Connor RD, Kelsen SG: Asthma and diving. Annals of Allergy 1994; 73:344-350. 7. Van Hoesen K, Neuman TS: Asthma and SCUBA diving. Immunology and Allergy Clinics of North America 1996; 15:917-928.

DEVELOPED BY THE CTS CLINICAL PRACTICE ASSEMBLY (CPA) STEERING COMMITTEE Prepared by Ralph T. Potkin, MD, John M. Alexander, MD, and Tom S. Neuman, MD

Approved by CTS Executive Committee and CTS 1997, reviewed 2006

CTS guidelines are developed to enhance a physicians ability to practice evidence-based medicine, but these should not be considered a substitute for the experience and judgment of a health care provider.

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