Resuscitation 93 (2015) 4045

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Resuscitation
j o u r n a l h o m e p a g e : w w w.e l s e v i e r.c o m / l o c a t e / r e s u s c i t a t i o n

Simulation and education

Mechanical ventilation and resuscitation under water: Exploring one

of the last undiscovered environments A pilot study
James DuCanto a ,dYannick Lungwitz be , Andreas Koch ec , Wataru Khler c , Laurie
Gessell d
, Jack Simanonok , Norbert Roewer , Peter Kranke , Bernd E. Winkler e,
a

Department of Anesthesiology, Medical College of Wisconsin, Aurora St. Lukes Medical Center, Milwaukee, USA
Department of Anesthesiology, University of Ulm, Germany
c
German Naval Medical Institute, Kiel-Kronshagen, Germany
d
Department of Hyperbaric Medicine, Aurora St. Lukes Medical Center, Milwaukee, USA
e
Department of Anesthesia and Critical Care, University Hospital of Wuerzburg, Germany
b

a r t i c l e

i n f o

Article history:
Received 4 December 2014
Received in revised form 5 May 2015
Accepted 26 May 2015
Keywords:
Drowning submersion
Oxylator mechanical ventilation
Cardiopulmonary resuscitation (CPR)
LUCAS chest compression
Pentax AWS S100 airway scope

a b s t r a c t
Introduction: Airway management, mechanical ventilation and resuscitation can be performed almost
everywhere even in space but not under water. The present study assessed the technical feasibility
of resuscitation under water in a manikin model.
Methods: Tracheal intubation was assessed in a hyperbaric chamber lled with water at 20 m of depth
using the Pentax AWS S100 video laryngoscope, the FastrachTM intubating laryngeal mask and the
Clarus optical stylet with guidance by a laryngeal mask airway (LMA) and without guidance. A closed
suction system was used to remove water from the airways. A test lung was ventilated to a maximum
depth of
50 m with a modied Oxylator EMX resuscitator with its expiratory port connected either to a
demand
valve or a diving regulator. Automated chest compressions were performed to a maximum depth of 50 m
using the air-driven LUCASTM 1.
Results: The mean cumulative time span for airway management until the activation of the ventilator
was 36 s for the FastrachTM , 57 s for the Pentax AWS S100, 53 s for the LMA-guided stylet and 43 s for
the stylet without LMA guidance. Complete suctioning of the water from the airways was not possible
with the suction system used. The Oxylator connected to the demand valve ventilated at 50 m depth
with a mean ventilation rate of 6.5 min1 vs. 14.7 min1 and minute volume of 4.5 l min 1 vs. 7.6 l min1
compared to the surface. The rate of chest compression at 50 m was 228 min1 vs. 106 min1
compared to surface. The depth of compressions decreased with increasing depth.
Conclusion: Airway management under water appears to be feasible in this manikin model. The suction
system requires further modication. Mechanical ventilation at depth is possible but modications of
the Oxylator are required to stabilize ventilation rate and administered minute volumes. The LUCASTM
1 cannot be recommended at major depth.
2015 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
Drowning a leading cause of death and severe injury1,2
is associated in severe cases with a poor outcome, high lethality
and high long-term morbidity,3 especially when occurring in open
water4 in areas with no lifeguards on duty. The latest guidelines of

A Spanish translated version of the abstract of this article appears as Appendix

in the nal online version at http://dx.doi.org/10.1016/j.resuscitation.2015.05.024.
Corresponding author at: Department of Anesthesia and Critical Care,
University
Hospital of Wuerzburg, Oberduerrbacher Str. 6, 97080 Wuerzburg, Germany.
E-mail address: bernd.e.winkler@gmail.com (B.E. Winkler).
http://dx.doi.org/10.1016/j.resuscitation.2015.05.024
0300-9572/ 2015 Elsevier Ireland Ltd. All rights reserved.

the European Resuscitation Council (ERC) contain the recommendation to initiate rescue ventilation while the victim is still in the
water5 because in-water resuscitation has been demonstrated to
enhance the survival rate and neurological outcome.6
Whenever possible, drowning victims should be rescued to the
surface to perform CPR. Nevertheless, there are cases in which an
ascent to the surface is impossible within an acceptable time
range, e.g. if patients are trapped underwater, in cave and mining
rescues, in the case of injured combat divers in hostile areas or
after long and deep dives when direct ascent to the surface
would result in fatal decompression sickness.
In cases in which people could be resuscitated or at least ventilated in air-lled cavities under water, like in maritime accidents

J. DuCanto et al. / Resuscitation 93 (2015) 4045

similar to those of the Korean ferry Sewol or the Costa Concordia, an ascent to the surface with ongoing ventilation and chest
compressions would be desirable.
Airway management, mechanical ventilation and resuscitation
are performed every day in the operating room, emergency room,
intensive care unit and pre-hospital emergency service. Airway
management during microgravity simulation for space simulation has been evaluated in studies7,8 as well as techniques for
resuscitation in hypogravity have been developed and
scientically investigated. 9,10 However, there is one untouched
eld until now: the underwater environment.
We therefore modied devices for airway management, endotracheal suctioning, mechanical ventilation and chest compression
underwater. The present pilot study assessed the technical feasibility of underwater tracheal intubation, suctioning, mechanical
ventilation and automated underwater chest compressions in a
manikin model.
2. Materials and methods
Airway management, suctioning, mechanical ventilation and
chest compressions were assessed in four separate trials. The
exper- iments were performed in a Haux Hydra hyperbaric
chamber of the German Naval Medical Institute in Kronshagen,
Germany (Haux Lifesupport, Karlsbad-Ittersbach, Germany). The
chamber
was completely lled up with 28 C warm fresh water. Previous
testing of the underwater ventilation device was performed
sepa- rately in a water lled container in the hyperbaric chamber
(Fink Engineering, Warana, Australia) of the Aurora St. Lukes
Medical Center and conrmed reliable function of the device
with inspira- tory times at depth comparable to the surface
throughout a range of depths prior to the experiment at the
German Naval Medi- cal Institute. All parts of the experiment
were recorded with the security cameras of the chamber as
well as
several underwater video cameras for subsequent
analysis. Videos of the airway man- agement procedures,
mechanical ventilation and automated chest compressions are
presented as online supplements. Furthermore, an online
supplement presents further details on the workow and the
devices used in the present study.
2.1. Manikin model and measurements
A Laerdal Resusci Anne manikin was used for the
experiments, specically modied by removing all electronic
components. The manikin had slightly negative buoyancy and
was lying on the bot- tom of the chamber and not mounted to
the chamber. The test lung of the manikin was replaced by an
IMT ventilator test lung (IMT Medical, Buchs, Switzerland) to
equal the compliance char- acteristics of a real human lung. The
test lung was installed in the mannequin for the airway
management experiments. For ventila- tion assessment, the test
lung was connected to the ventilator with a spirometer placed in
between.
2.2. Actors in play
The airway procedures were performed by an anesthetist
SCUBA diver who was equipped with full SCUBA breathing gear.
He per- formed intubation on the knees in semi-prone position at
the head side of the manikin and was constantly attended by a
safety diver of the German Navy.
2.3. Airway management and endotracheal suction
The feasibility of tracheal intubation was assessed completely
submerged at a single depth of 20 m
(200 kPa
above
atmospheric pressure). Preceding tests performed in shallow

water conditions

41

42

J. DuCanto et al. / Resuscitation 93 (2015) 4045

demonstrated that direct laryngoscopy was almost impossible due

to the light refraction when performed under water: the intubating physician had to position his head close to the oor and
even in this position it was hard to get a sufcient view to the
vocal cords. Therefore, the feasibility of intubation with the
Pentax AWS S100 video laryngoscope (Pentax, Tokyo, Japan), the
Clarus optical stylet (Clarus Medical, Minneapolis, USA) and
the LMA FastrachTM intubating laryngeal mask (Teleex Medical,
Athlone, Ireland) was evaluated and each maneuver was
performed three times. The Pentax AWS S100 scope was enclosed
in a special water- tight enclosure. The Clarus optical stylet was
utilized without any modication in two ways: (1) through an AirQ (Mercury Medical, Inc., Clearwater, USA) intubating laryngeal
mask to guide the scope to the glottis and (2) directly without
LMA guidance. Each tracheal intubation attempt was considered
successful if an airway was established within 2 min and if
lling of the test lung with air was observed.
The endotracheal suction system used was based on the LSP
aspirator (Allied Healthcare Products, St. Louis, USA), a gas driven
system capable of generating 400 mm Hg of suction at the surface with a constant ow of compressed gas at 30 l per min. The
purge valve of a snorkel was placed at the bottom of the
collecting container to empty the container of water while
immersed with- out disassembling the device. A KimVent
(Kimberly-Clark, Roswell, USA) closed tracheal suction system
was inserted underwater between the tracheal tube and the
ventilator. During pre-tests in
1 m depth, the device completely removed water from the airways, i.e. emptying of the test lung airways, tube and hoses did
not collect water into a measuring cap. The suctioning procedure
was considered successful if at 20 m depth water was completely
removed from the trachea of the manikin followed by effective
ventilation.

2.4. Mechanical ventilation

Mechanical ventilation was performed with the Oxylator
EMX (CPR Medical Devices, Toronto, Canada), an open circuit resuscitator. The ventilation is pressure controlled with
inspirationexpiration switches determined by a ceramic permanent magnet. The unmodied version of the Oxylator EMX
failed during previous underwater ventilation experiments in the
hyperbaric chamber.11 A recent modication of the Oxylator
(FR-300B) is available for the rescue of mining accident victims.
The FR-300B combines an Oxylator and a demand valve to prevent the inhalation of toxic gases from the environment if the
patient starts to breathe spontaneously. In the present study, the
expiration port of the Oxylator EMX was connected to a LSP
demand valve (Allied Healthcare Products, St. Louis, USA) and to a
Aqua Lung US-Divers (Aqua Lung America, Cousteau, USA) SCUBA
(self-contained underwater breathing apparatus) diving regulator.
Congured in this manner, spontaneous breathing was enabled
under water and the valve system and the expiration port of the
Oxylator were protected from water. For the assessment of efcacy of mechanical ventilation, a Jaeger Master Screen spirometer
(Jaeger, Hoechberg, Germany) was placed above the water surface while both, the Oxylator EMX and the test lung were
placed at the same depth under water. The system was
calibrated at depth according to
the manufacturers
instructions. The subse- quent parameters were derived from the
spirometry: tidal volume, minute volume, breathing rate,
breathing cycle
length, inspiration time, expiration time,
inspiration:expiration ratio. All parameters were assessed every 5
m from surface pressure up to a maximum depth of 50 m and for
both combinations, the Oxylator connected to a LSP demand
valve and the Oxylator connected to a SCUBA regulator.

Table 1
Time requirement for orotracheal intubation procedures at 20 m depth.
Device

Time to insertion of
supraglottic airway (s)

Time to tracheal insertion

of endotracheal tube (s)

Fastrach intubating laryngeal mask

(video 1)
Pentax AWS video laryngoscope
(video 2)
Clarus optical Stylet with Air-Q
laryngeal mask
Clarus optical Stylet with retromolar
technique (video 3)

10 3 s

52s

Time to cuff ination (s)

Time to ventilation (s)

19 3 s

30 5 s

36 5 s

38 6 s

51 6 s

57 3 s

38 4 s

48 4 s

53 3 s

25 7 s

38 9 s

43 8 s

One anesthetist performed each technique three times. Cumulative time (total time for each phase until time to ventilation) requirement in seconds for airway
management
(including all procedures to orotracheal intubation) at 20 m depth. Time to ventilation represents time from initiation of airway procedures to completion of procedure
when tracheal tube is connected to activated Oxylator. Supraglottic airways were only used for guidance of endotracheal intubation. Data are presented in seconds as
mean standard deviation. Videos of the airway procedures are presented in the online supplement.

2.5. Chest compressions

The LUCASTM 1 (Jolife AB, Lund, Sweden) was used for mechanical chest compressions. The LUCASTM 1 is a gas driven automatic
chest compression device. Since the measurement of compression
depth proved to be extremely difcult and error-prone at depth,
assessment of the LUCASTM was limited to compression rate.
Chest compression rate was assessed every 5 m from surface
pressure up to a depth of 50 m.

cleaning from lubricant to obtain optimal results. Intubation

with the FastrachTM did not present any technical difculties.
The LSP suction unit suctioned water very slowly at 20 m
depth and failed to
remove water
from the
airways
completely. The collecting container was easily emptied
without any problems through the purge valve at the bottom of
the container. When the FastrachTM was used, the protrusion of the
suction catheter over the special tip of the FastrachTM endotracheal
tube was not possible.

3. Results

3.2. Mechanical ventilation

3.1. Airway management and endotracheal suction

Mechanical ventilation was performed in 5 m steps to the maximum depth of 50 m without a technical failure of the device. The
ventilation characteristics of both trials, the Oxylator attached to a
LSP demand valve and the Oxylator attached to a SCUBA regulator
are presented in Table 2. With increasing depth, tidal volume and
inspiration time increased while ventilation rate, minute volume
and inspiration:expiration ratio decreased in both systems tested
(video 4 and video 5). An intrusion of water into the airways or
ventilator was not observed in any of the systems.

Four tracheal intubation procedures were successfully performed at 20 m with the three devices tested. Videos of the
procedures are available online (FastrachTM : video 1, Pentax
AWS: video 2, Clarus stylet without LMA guidance: video 3). The
elapsed time required for
the individual steps of airway
management is presented in Table 1. Two technical difculties
were observed dur- ing the airway management procedures. The
Pentax AWS S100 laryngoscope almost slipped out of the
hands and toward the surface on two occasions due to the
buoyancy of the air-lled cover of the modied AWS video
laryngoscope. During intubations with the Clarus stylet, the lens
tip of the stylet required periodic

3.3. Chest compressions

The LUCASTM 1 device withstood the excursion to depth without
any damages and performed the chest compressions up to a depth

Table 2
Ventilation characteristics of the modied Oxylator EMX, 2 congurations.
a: LSP demand valve
Depth LSP

10

15

20

25

Ambient pressure
Inspiratory tidal volume
Breathing cycle duration
Inspiration time
Inspiration:expiration ratio
Ventilation rate
Minute volume

kPa
ml
s
s
1:x
min1
l min1

100
517 8
4.1 0.1
1.6 0.1
1:1.5
14.7
7.6

150
578 16
4.7 0.2
2.0 0.1
1:1.4
12.8
7.4

200
617 8
5.4 0.1
2.4 0.1
1:1.3
11.1
6.9

250
637 7
6.0 0.1
2.7 0.1
1:1.3
10.0
6.4

300
653 12
6.4 0.1
2.9 0.1
1:1.2
9.4
6.1

350
672 8
7.0 0.1
3.1 0.1
1:1.3
8.5
5.7

30
400
701 12
7.6 0.2
3.5 0.1
1:1.2
7.8
5.5

35

40

45

50

450
500
550
600
730 4
769 18
728 12
695 35
8.1 0.1
9.0 0.1
9.1 0.1
9.2 0.1
3.7 0.1
4.4 0.2
4.3 0.1
4.5 0.1
1:1.2
1:1.1
1:1.1
1:1.1
7.4
6.6
6.6
6.5
5.4
5.1
4.8
4.5

b: AquaLung US-Divers SCUBA regulator

Depth SCUBA

10

15

20

25

30

35

40

45

50

Ambient pressure
Inspiratory tidal volume
Breathing cycle duration
Inspiration time
Inspiration:expiration ratio
Ventilation rate
Minute volume

kPa
ml
s
s
1:x
min1
l min1

100
546 9
4.6 0.1
1.4 0.1
1:2.4
12.9
7.1

150
541 17
5.4 0.1
1.7 0.1
1:2.3
11.2
6.1

200
585 7
6.3 0.1
2.0 0.1
1:2.2
9.5
5.6

250
614 4
7.1 0.1
2.3 0.1
1:2.1
8.4
5.2

300
641 16
7.8 0.1
2.5 0.1
1:2.2
7.7
5.0

350
654 16
8.3 0.2
2.7 0.1
1:2.1
7.2
4.7

400
628 9
8.8 0.1
2.8 0.1
1:2.2
6.8
4.3

450
648 20
9.5 0.1
3.1 0.1
1:2.0
6.3
4.1

500
647 21
9.9 0.1
3.3 0.1
1:2.0
6.1
3.9

550
650 22
10.2 0.2
3.4 0.1
1:2.0
5.9
3.8

600
650 14
10.5 0.1
3.5 0.1
1:2.0
5.7
3.7

Table presents the ventilation characteristics of the modied Oxylator EMX assembled in 2 congurations with the LSP demand valve and the AquaLung US-Divers
SCUBA (Self Contained Underwater Breathing Apparatus) regulator in 5 m steps from the surface to 50 m. Units are given in the second column. Data are presented as mean
standard deviation. Standard deviations are presented as far as available from the spirometry software. Video samples of the device at 0 m and 50 m are presented in
video 4 (LSP
demand valve) and video 5 (SCUBA regulator). The ventilator was attached to the test lung with a spirometer placed in between. Tidal volumes increased at depth as well
as inspiration and expiration times with more pronounced increases of the inspiration. Ventilation rate and minute volumes decreased subsequently.

Table 3
Compression
depth.

rate

of

the

LUCAS

at

Depth (m)

Compression rate (min 1 )

0
5
10
15
20
25
30
35
40
45
50

106
117
132
146
160
175
182
193
206
215
228

Table presents the compression rate achieved with the LUCAS at the individual
depths.

of 50 m. The device withstood the descent to depth and the

ascent without any damages. Chest compression rate increased
with depth (Table 3), and compression depth visually decreased
with depth (video 6). The compression depth was not recorded
for technical reasons.
4. Discussion
4.1. Airway management and endotracheal suction
Based on the results of these simulations, all methods of
airway management used in the present study can be considered
feasible in the underwater environment. Success rates and times to
perform intubations were similar to
studies of airway
management under adverse conditions such as the requirements
of wearing protective equipment,12 intubating in a face-to-face
position13 or intubat- ing morbidly obese patients.14 However,
each airway management procedure requires a certain devicedependent training. The air- way management was performed by
an anesthetist diver in the present study and extensive training
might be required to achieve similar results in the hands of a
non-anesthetist
rescue diver. The Pentax AWS video
laryngoscope and the Clarus stylet have been evaluated in
several studies and each device has certain advan- tages and
disadvantages. The discussion of all specic advantages and
disadvantages does not appear to be target-aimed in the context of underwater intubation. The time requirement for all
airway procedures was similar for the Pentax AWS S100 and the
optical stylet without LMA guidance but about 10 s longer when
guiding the stylet via an LMA. LMA guidance can be helpful in
difcult air- ways in real-life scenarios. One problem in the
present study was the buoyancy of the air lled cover of the
modied AWS S100 video laryngoscope. The laryngoscope almost
slipped out of the hands of the endoscopist and toward the
surface on two occasions but a lanyard or an alternative case
with reduced buoyancy might solve this problem caused by
buoyancy. The mechanically robust design of the optical stylet
tolerated immersion to depth without any modication of the
device. Blind intubation with the FastrachTM intubating laryngeal
is a mechanically robust solution for under- water purposes
since it does not contain any electronic parts, but lacks the ability
to visually conrm placement of the tracheal tube. Manikin
training studies have demonstrated high success rates in persons
unexperienced with the FastrachTM device15,16 and the use
appears to be intuitive.17 Furthermore, it can potentially be performed in scenarios in which the patient and the video monitor
cannot be seen due to murky water.
Supraglottic airway devices are easier to insert than a tracheal
tube but the maximum peak pressures are limited due to the
sealing of these devices in the pharynx. High airway pressures
have been reported to be required to ensure a sufcient
ventilation in severely hypoxemic drowning
victims.5
The

ventilation of drowning

victims with certain supraglottic airways has been demonstrated

to fail if high ventilation pressures are required.18 Furthermore,
our previous underwater experiments demonstrated that the
ongoing intrusion of minor amounts of water results in a failure
of venti- lation if a laryngeal tube is used.11 Thus, ventilation
effectiveness might be limited when using supraglottic airway
devices in drown- ing victims5 and especially under water when
a proper sealing and high tolerable ventilation pressures are
essential. Therefore, tracheal intubation is essential. Based on our
results, tracheal intu- bation can be achieved in a manikin with all
approaches evaluated. Time to ination of tracheal tube cuffs was
relatively long due to the deliberate use of water to inate the
tracheal tube cuffs in order to avoid changes of the cuff volume
associated with changes in ambient depth, i.e. ambient pressure.
The LSP aspirator aspirated water to a depth of 20 m. However,
its effectiveness with respect to removing of water from the tracheal tube and ventilation tubing was insufcient at depth in
contrast to the 1 m pre tests. The ow rate of gas through the
ven- turi outlet port of the LSP aspirator was not adequate to
generate clinically signicant suction at 20 m depth. The
compressed gas consumption of the LSP aspirator would limit
the gas supply to
both the Oxylator and the suction unit. It was observed that
water
could not be completely removed from the airways and the test
lung following each tracheal intubation maneuver.
One general limitation is that ventilator test lungs do not
repre- sent the physiology of lungs in a drowning victim.
Modications of the aspirator which enable higher gas ow
can enhance suction but also result in an even higher gas
consumption.
4.2. Mechanical ventilation
Ventilation of the ventilator test lung was observed to be
reliable from the surface to 50 m depth with the modied
Oxylator - demand valve apparatus. The ventilation did not fail
at any depth and intrusion of water was not observed. This
demonstrates for the rst time that mechanical ventilation under
water is generally possible. However, keeping the ventilator
settings identical at every depth, the inspiration time of each
ventilatory cycle increased with increasing depths, and the
ventilation rate and minute volumes decreased consecutively at
depth. This observation is explained by the fact that the Oxylator
delivers constant inspiratory ow rates that are determined by
predened outlet openings which are cali- brated to ventilate
human lungs at sea level pressure. Previous wet hyperbaric
testing of the Oxylator EMX in the Aurora St. Lukes Medical
Center Hyperbaric chamber revealed that the modied
Oxylator demonstrated inspiratory times at 50 m nearly identical
to the inspiratory time at the surface when the unit was powered
by a heliumoxygen mixture with 20% of oxygen (HeliOx 80/20).
The use of HeliOx in underwater rescue ventilation would mean a
sud- den switch from nitrogen to helium, as the patient was
breathing air prior to rescue. Sudden gas changes have been
discussed to result in so-called isobaric counterdiffusion19 and an
increased risk of decompression sickness. However, the general
risk of decompres- sion sickness due to isobaric counterdiffusion
appears to be low.20
Nevertheless, HeliOx gas mixtures are expensive, and less costly
approaches like a further modication of the Oxylator to permit
higher gas ows during the inspiratory cycle are more promising.
A depth-dependent increase in the ow rates inside the
Oxylator would probably be
the best solution. Further
modications are therefore required.
4.3. Chest compressions
Continuous chest compressions were performed at various
depths, but the compression rate exceeded an acceptable rate for

realistic CPR, exceeding 132 compressions per minute beyond 10

m

depth (Table 3). Recent data indicate that the likelihood of ROSC
is the highest at 125 min1 and that higher rates are associated
with decreased ROSC rates but similar hospital discharge rates.21
However, the manufacturer species the compression depth with
45 cm at the surface. Because of the decreasing compression
depth with increasing water depth, the range of 40.355.3 mm
com- pression depth associated with the best survival rates in a
recent multicenter trial22 will quickly be undercut at depth.
Hence, the use of an unmodied LUCASTM 1 device cannot be
recommended for sufcient chest compressions at depths below
10 m. Nevertheless, the LUCASTM 1 device was not damaged during the study and might therefore be a useful tool for water
rescue forces above and slightly below the water surface. A
substantial concern regarding the use of the LUCASTM 1 device
underwater is the rate of compressed gas consumption, which
would likely draw from the same compressed gas source that
powers the ventilation and suction apparatus. An air supply from
the surface is one poten- tial solution to this problem. However,
the gas driven LUCASTM 1 is no longer manufactured at the
moment and it remains unclear whether the manufacturer would
produce a new LUCASTM capable of underwater compression with
constant compression depth and constant compression rate.

Institute (HHMI). The devices tested in this study were provided

by the manufacturers without charge.

5. Limitations

References

The experiments were conducted in well lit, clear fresh water

in a hyperbaric chamber and open water conditions can differ
con- siderably. Buoyancy is more pronounced in salt water and
might therefore complicate the procedures. The airway
procedures were performed by an anesthetist SCUBA diver
familiar with the devices used. In some countries, these
procedures will
not be
permitted to non-physicians.
Furthermore, data from manikin studies cannot be transferred to
human use without limitations, especially with regard to the
airway management and the ventilation characteris- tics of an
injured lung after drowning. Fresh animal or human lungs rejected
for transplantation would better reect the characteristics of a
real drowning victim but the authorities did not agree to use
animal or human lungs inside the wet hyperbaric chamber.
In scenarios with a high risk for accidents, the complete
rescue equipment and well trained staff must be located directly
at the diving site to minimize delay.
6. Conclusions
In the present manikin model, tracheal intubation was possible with all devices evaluated within less than 1 min. Mechanical
ventilation was successful with the modied Oxylator EMX but
further modications are required to ensure more constant tidal
and minute volumes at various depths. Profound modications to
the suction system are required to achieve sufcient endotracheal
suction at depth. Modications to the LUCASTM are essential to
ensure efcient compressions rates and compressions depths in
line with the present guidelines.
The mechanical ventilation with the modied Oxylator is not
optimal yet. But even today, the device would likely permit the
res- cue of a patient with traumatic brain injury during a cave or
mining accident who can be intubated above the water surface
and trans- ported over a short distance underwater while being
mechanically ventilated.

Conict of interest statement

All authors do not have a conict of interest.
Acknowledgements
We thank the authorities of the German Navy for the opportunity to use their hyperbaric chamber for our experiments as well
as the staff of the Hydra chamber for their help in conducting
to study. Furthermore, we thank the manufacturers CPR Medical
Devices (Oxylator ) and Physio Control (LUCASTM ) for providing
their devices without charge.
Appendix A. Supplementary data
Supplementary data associated with this article can be found,
in the online version, at http://dx.doi.org/10.1016/j.resuscitation.
2015.05.024

1.
2.
3.
4.

5.

6.
7.

8.
9.

10.

11.

12.

13.

14.

15.

16.

17.

Funding
18.

No funding was received from the National Institutes of

Health (NIH), Wellcome Trust or Howard Hughes Medical

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