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By Reilly Fogarty
Header image by Derk Remmers
Most divers don’t spend much time thinking about isobaric counter diffusion (ICD), and it’s not just because it has an inconveniently long name. The phenomenon is complicated to understand, depends on mechanisms that are partially or wholly theoretical, and falls squarely in the unknown gray area of decompression science. As a result, students in technical courses receive varying information about the subject, depending on their instructor’s understanding of it.
Some consider the topic irrelevant to divers while others recognize that a functional understanding is mandatory for modern mixed-gas diving. A combination of infrequent exposure, lack of research and widely spread misinformation have made ICD an unapproachable subject for many divers. Here’s what we know and what we’re still researching.
Isobaric counterdiffusion is not a concept that’s limited to diving. The phenomenon describes the diffusion of different gases into and out of tissues after a change in gas composition and the physiological effects of those gas switches. This is relevant in hyperbarics, anesthesia and diving and aerospace. As divers we’re most concerned with what happens with a gas switch during a mixed-gas dive, and research in related fields can provide useful data.
The effects of ICD as they relate to divers primarily involve the movement of two inert gases in opposite directions at equal ambient pressures, hence the term “isobaric,” in tissues and blood. The relative speeds of counterdiffusion are affected by many factors including density, surface tension and viscosity in fluids, as well as a variety of physiological factors, membrane properties and specific gas interactions (Oswaldo, 2017). Gas diffusion itself is a fascinating and broad topic but one for another day, so for the sake of understanding ICD it can be simplified somewhat. Fundamentally the issues related to ICD center around a disparity in the speed at which one inert gas diffuses into the body while another diffuses out. This can occur with a slow saturated gas exiting a tissue and a fast saturating gas entering or vice versa.
Superficial ICD occurs when the inert gas breathed by a diver diffuses more slowly into the body than the gas surrounding the body. Because this requires being surrounded by a gas with a high diffusivity it is most often seen in saturation divers breathing air or a low-helium content gas in a heliox environment. This can theoretically occur in diving and is the reason that new mixed-gas divers are told to avoid using a suit-inflation gas containing helium (besides that fact that it has low thermal conductivity i.e. its cold!).
Helium has a diffusivity that’s approximately 2.65 times that of nitrogen (Lambertson, 1989), and because of that disparity it can diffuse into the skin quickly while nitrogen diffuses more slowly. The slow diffusion of nitrogen from the fluids and tissues of the body while the helium saturates the skin can cause supersaturation in some superficial tissues that can result in gas bubble formation. These gas bubbles can cause painful, red lesions on the skin, but the phenomenon does not occur when the gases are reversed and the breathing gas has a greater diffusivity.
If ICD is a concept you’ve encountered before it’s likely deep tissue ICD that you’ve been exposed to. This second type of ICD occurs when one breathing gas is exchanged for another of different diffusivity, as in a gas switch from say a nitrox travel gas to a trimix bottom mix or from a trimix bottom mix to a nitrox decompression gas. As with superficial ICD, this occurs when a gas with high diffusivity is transported into a tissue more rapidly than a slower-diffusing gas is transported out. The result is the same: supersaturation of some tissues and bubble formation. These bubbles can cause itching followed by joint pain and have been more recently associated with inner-ear decompression sickness, although the bubble formation could contribute to other types of decompression sickness as well.
Quantifying the risk of ICD and identifying cases of decompression sickness (DCS) that resulted from ICD rather than other risk factors can be difficult, but there is significant research correlating several proposed mechanisms to increased bubble counts and DCS in human and animal models. Like DCS, ICD is fairly well accepted academically on a correlational basis, but the specific mechanisms require additional research to confirm.
Data from as early as 1977 indicates a risk of ICD in divers even within recreational depths, with increased bubble counts observed in goats saturated at 5 atmospheres and switched from a breathing gas containing 4.7 atmospheres of nitrogen to 4.7 atmospheres of helium (D’Aoust, 2017). Similarly, saturation divers on the Hydra V mission experienced DCS following a gas switch from hydreliox to a faster-diffusing heliox mixture, with the gas switch thought to have caused the DCS (Rostain, 1987).
More recent work on decompression models of the inner ear have indicated that even a transient increase in gas tension (the relationship between breathing gas and gas saturated in the body) related to a switch from a high-helium-content gas to a nitrogen mix may increase the risk of inner-ear decompression sickness (IEDCS). This model is particularly interesting because the diffusion of gases across the round window is extremely low (bordering on negligible), which complicates the transport of inert gases in the ear. Data from Doolette and Mitchell suggests that these gas switches could result in a temporary increase in gas tension as the nitrogen input exceeds the removal of helium via perfusion in the vascular compartment and diffusion in the peri- and endolymph causing bubble formation and growth (Doolette, 2003).
There are several variables to consider with this model, but the data appears sound and the mechanism provides a likely explanation for the well-documented cases of IEDCS related to gas switching in technical diving. Other models have been proposed to explain these incidents, and these vary by physiological models and diffusion constants used, but most focus on tissue supersaturation as a result of varying gas tension following a gas switch (Burton, 2004).
Academic Versus Application
The challenge with the varied research into the mechanisms of ICD is that it can be difficult to determine what’s prudent to include in your dive planning and what data might not reflect reality. The good news is that the general aspects of ICD are fairly well understood, even if the specific mechanisms are theoretical. Reducing variances in gas diffusivity and transient tissue tension via conservative dive planning is relatively easy to do and poses no significant additional risk. Decompression obligations may be increased in some instances, but some mixed-gas courses are already including some ICD considerations, primarily related to IEDCS.
Extending this to minimize the risks associated with ICD is not complicated, but specific recommendations are unfortunately not readily apparent. Lambertson proposed that switching from a helium mixture to a nitrogen mixture would be acceptable but the reverse should include recompression — something unlikely to be an option during a dive charter. Doolette and Mitchell propose a more practical approach: minimizing the switch from trimix to nitrox on ascent or planning to perform these switches at depth or in shallow water to minimize supersaturation.
Doolette and Mitchell propose a more practical approach: minimizing the switch from trimix to nitrox on ascent or planning to perform these switches at depth or in shallow water to minimize supersaturation.
There are some specific recommendations for preventing ICD (using the rule of fifths, calculating theoretical helium and nitrogen compartments, etc.), but these lack evidence and may or may not prevent incidents. What we can say is that planning your gas switching to minimize supersaturation due to transient tissue tensions, minimizing your switches from high-helium-content gases to low (as appropriate for your acceptable risk levels), and increasing conservatism as depth and dive time increase (due to increased tissue saturation levels) are good ways to keep yourself safe.
The mechanisms may not yet be definite, but the data can back up these recommendations. And when there is no increase in risk with the conservative approach, it makes sense to go that route. Keep an eye on upcoming research in this area; while ICD can cause problems, some researchers are proposing that isobaric underdiffusion could decrease risk on technical dives, so it’s possible that your gas planning might be in for a shakeup in the near future.
- Oswaldo, C. Gas diffusion among bubbles and the DCS risk. (November 24, 2017)
- Lambertson, Christian J (1989). Relations of isobaric gas counterdiffusion and decompression gas lesion diseases. In Vann, RD. “The Physiological Basis of Decompression”. 38th Undersea and Hyperbaric Medical Society Workshop UHMS Publication Number 75(Phys)6-1-89. http://archive.rubicon-foundation.org/6853.
- D’Aoust, B. G., Smith, K. H., Swanson, H. T., White, R., Harvey, C. A., Hunter, W. L., … Goad, R. F. (1977, August 26). Venous gas bubbles: production by transient, deep isobaric counterdiffusion of helium against nitrogen.
- Rostain, JC; Lemaire, C; Gardette-Chauffour, MC; Naquet, R (1987). Bove; Bachrach; Greenbaum (eds.). “Effect of the shift from hydrogen-helium-oxygen mixture to helium oxygen mixture during a 450 msw dive”. Underwater and Hyperbaric Physiology IX. Bethesda, MD, USA: Undersea and Hyperbaric Medical Society.
- Doolette, David J; Mitchell, Simon J (June 2003). “Biophysical basis for inner ear decompression sickness”. Journal of Applied Physiology. 94 (6): 2145–50. doi:10.1152/japplphysiol.01090.2002. PMID 12562679.
- Burton, Steve (December 2004). “Isobaric Counter Diffusion”. ScubaEngineer.
Note: The British Sub Aqua Club (BSAC) recommends that divers allow for a maximum of 0.5 bar difference in PN2 at the point of the gas switch. According to former BSAC Tech lead Mike Rowley, “The recommendation isn’t an absolute but a flexible advisory value so a 0.7 bar differential isn’t going to bring the Sword of Damocles down on you.”
When he’s not working with DAN on safety programs, Reilly Fogarty can be found running technical charters and teaching rebreather diving in Gloucester, Mass. Reilly is a USCG licensed captain whose professional background includes surgical and wilderness emergency medicine as well as dive shop management.
Why Do Divers Run Out Of Gas?
Not surprising, the answer is more complicated than simply, they neglected to look at their gauges. Here Aussie diving medical researcher and former editor of DAN’s Annual Diving Report, Peter Buzzacott dives into several deep datasets including DAN’s Incident Reporting System (DIRS) and nearly four decades of cave diving incident data, to tease out some insights on gas emergencies and get a handle on the risks. Don’t stop those S-drills!
by Peter Buzzacott
See companion story for a guestimate of the risk: What is the Risk of Running Out of Gas?
Next year it will be 30 years since I first learned to dive. At the time, I had no idea that diving would occupy such a large part of my life. I distinctly remember kneeling on the sandy bottom end of the Great Barrier Reef, sharing a regulator with my buddy, and seeing sunlight rippling down through crystal clear water. On one of these “confined water” dives we had to swim horizontally for 10 m/30 ft holding our regulators out of our mouths and blowing a steady stream of bubbles. This wasn’t as easy as it sounds and we had to ration our bubbles to make it the whole way. Then, on an open water dive, the instructor took turns holding us with one hand and gripping a rope with the other while we took a breath, took the second stage out of our mouths, and then went for the surface, breathing out all the way. Up, down, up, down, the instructor went, with each student—one at a time.
Most of today’s recreational dive courses do not include buddy breathing, they teach gas sharing with an alternate air source (AAS). Even before COVID-19, the buddy breathing skill had disappeared from most recreational training programs. The controlled emergency swimming ascent (CESA) has also disappeared from some programs.
When I became an instructor, I made many hundreds of these but, now that I think about it, I don’t recall ever seeing anyone actually make one for real after running out of gas. These days everyone dives with two second stage regulators. In technical diving, we even dive with at least two cylinders; so, I wonder, do technical divers run out of gas and, if they do, then why?
What Do The Experts Say?
Some years ago, I asked a panel of 27 diving experts a similar question regarding recreational divers in general.1 The panel consisted of nine diving/hyperbaric doctors who had treated hundreds of injured divers; nine expert dive guides, most of whom were instructors; and nine expert recreational divers who had dived all over the world and written hundreds of feature articles for dive magazines.
At the time, I suspected divers mostly ran out of gas because they didn’t pay attention to their gauge. But, to my surprise, the experts suggested about 20 reasons, such as diving deeper than usual, diving in a current, not wanting to end the dive for their buddy, using a smaller tank than their buddy, being underweighted, and many others, all of which sounded plausible.
I sent the whole list of potential causes back to the group and asked them to rank, in their opinion, the five most likely causes. Then I gave five points to everyone’s most likely potential cause, four points to the second most likely, and so on. I added up all of the points and then ranked all the causes according to the total score. Then I sent this ranked list back to the group for one last review and asked them to consider the “weight of opinion” from the group as a whole, and to reconsider their top five reasons.
As an expert panel, the group moved toward consensus. Just as I’d suspected, failing to monitor the gauge was the number one proposed potential cause of running out of gas, followed by inexperience, overexertion, inadequate training, and poor dive planning. Other than perhaps an unexpected current or underweighting leading to overexertion, the proposed reasons leaned toward human factors rather than the other two types of factors in the classic diving injury causal triad—those being environmental factors and equipment factors (Figure 1).2,3,4
The process I’d followed to gather expert consensus of opinion is called a “Delphi” process, which was originally developed by International Business Machines Corporation (IBM) to make forecasts on matters about which there was considerable uncertainty i.e. where there is little data. Opinions aren’t solid evidence; however, they can point towards a direction worth investigating.
Next, I visited Divers Alert Network(DAN) as an intern and worked on an analysis of diving fatalities within a subset of technical divers—cave divers. More on that later, but while there, I had the opportunity to examine a large dataset of recorded dives from Project Dive Exploration, headed by Drs. Richard Vann and Petar Denoble.
The dataset we had at that time revealed over 50,000 dives recorded by more than 5,000 recreational divers, (including an unknown number of technical divers). We examined these data in two ways. First, to control for environmental and equipment factors, and to focus on demographic (or human) factors, we counted each diver just once and compared those divers who had reported running out of gas, (during any recorded dive in that dataset), with divers who had not run out of gas. Surprisingly (to me), having run out of gas was more common than expected among older females (males were more likely to report other problems, like rapid ascent).
Next, to control for the human factors, we looked at just the dives made by divers who had made both at least one dive where they ran out of gas, and at least one dive where they did not run out of gas. I wanted to know what it was about those dives that might have caused the divers to run out of gas. Well, it turned out the out-of-gas dives were deeper, shorter (probably because they were deeper), often made from a live-aboard or charter boat, and involved a higher perceived workload.5 Hmmm… Perhaps overexertion was a factor after all.
After returning to Western Australia to undertake a PhD researching this, I spent the next few years recording 1,000 recreational dive profiles made by 500 divers. I recorded their start and end pressures, tank size, and noted factors such as current, how they felt their workload was (resting/light, moderate, or severe/exhausting), how many dive experiences they had, and what previous dive training they had completed. For the analysis, dives made by divers who exited with <50 bar/725 psi of pressure (needle in the red zone, n=183) were compared with other dives recorded at the same time at the same dive site (n=510) by divers who exited with >50 bar/725 psi pressure remaining (needle not in the red zone).
Ending a dive low on gas was correlated with younger males with a longer break since their last dive, fewer lifetime dives, at deeper depth, and a higher rate of gas consumption (adjusted to an equivalent surface air consumption (SAC) rate, for comparison between dives made at different depths). Perhaps more tellingly, compared with 1% of the dives with >50 bar/725 psi at the exit, 11% of the low-on-gas divers reported being surprised at the end of the dive by how low their remaining gas pressure was.6 A more detailed analysis of the average workload associated with recreational diving, using this same dataset, identified that higher perceived SAC rate was not associated with sex but was associated with older age, lower dive certification, fewer years of diving, higher perceived workload, and other factors.7
Technically Out of Gas
Returning to the topic of technical diving, a colleague and I re-examined the DAN cave diving fatality reports collection that I had worked with as an intern, and this time we concentrated on the previous 30 years of data: 1985-2015. Dividing it into two equal halves which we referred to as the “early” and “late” groups, reading each report carefully, and using a reliable cave diving fatality factors flow-chart previously developed,5 we classified factors associated with each cave diving fatality and then compared the two groups.
In the late (more recent) group, the proportion of cave divers who were trained in cave diving had significantly improved, perhaps due to increased awareness of the need for proper cave diver training before entering a flooded cave. The majority of the 67 trained cave divers in our dataset were diving with two cylinders on their back (doubles), and the late group was diving further into the cave than the early group. Of the 67 trained cave divers, 41 (62%) had run out of gas. Looking at the five “golden rules” of cave diving, the “rule of thirds” was the most common (n=20) rule that was suspected to have been broken by the trained cave divers: the most lethal.9
So, it would seem that some technical divers do run out of gas, though thankfully that appears rare. We should bear in mind that cave divers may differ from other types of technical divers in their procedures, demography, and equipment; their environment (by definition) certainly differs from that of wreck divers.
Currently, I know of no ongoing research into out-of-gas incidents among technical divers, other than the current Diving Incident Reporting System, hosted by DAN. An analysis of the first 500 reported incidents recently examined every incident—recreational and/or technical—during which the diver ran out of gas.10 The sample (n=38) was divided into two groups: those who made a controlled ascent (e.g. on a buddy’s donated regulator) and those who made rapid ascent (e.g. a bolt to the surface).
Among divers who reported having run out of gas, but survived to report the incident, 57% of the rapid ascents resulted in a reported injury. Among the 24 controlled ascents, just 29% reported an injury.10
Among divers who reported having run out of gas, but survived to report the incident, 57% of the rapid ascents resulted in a reported injury. Among the 24 controlled ascents, just 29% reported an injury.10 This modern finding is in line with the statistics reported 27 years ago by Dr. Chris Acott when he analyzed more than 1,000 diving incident reports. Examining 189 out-of-gas incident reports, Dr. Acott found 89 made a rapid ascent, and 58% of those reported an injury. Among the 79 controlled ascents, only 6% reported an injury.11
Table 1 shows the total number of dive incidents in each category, after adding both studies together. It seems to me that, while we have moved on from buddy-breathing and the controlled emergency swimming ascent, in the last 30 years the problem of running out of gas has not gone away.
|No Injury |
|Non-rapid ascent||91 (88)||12 (12)||103 (50)|
|Rapid ascent||43 (42)||60 (58)||103 (50)|
|Total||134 (65)||72 (35)||206 (100)|
In conclusion, the evidence confirms what we all know: running out of gas is associated with diving injuries and fatalities. It appears that the level of correlation of demography information (like age and sex) with out-of-gas incidents may depend upon the study design, the pool of divers studied, and/or the specific potential causes of running out of gas being investigated. For example, in one study, older females were more likely to self-report out of gas problems; in another study, young males’ remaining gas was measured and observed to be low. In yet another study, SAC rate increased when perceived workload increased, regardless of sex.
Therefore, I’d suggest it is prudent to consider everyone potentially at risk of running out of gas and, in order to mitigate this risk, both recreational and technical divers should be proficient in gas planning and monitoring their remaining gas, regardless of age and/or sex.
[Ed.note—Most agencies today require some level of proficiency in managing emergency out of gas scenarios. For example, GUE requires divers at all levels to train regularly for this eventuality. This training also emphasizes gas management strategies like “minimum gas reserves” and the related “one third” rule to ensure divers always have enough supply to share gas aka buddy breathe from any point in the dive, and all the way to the surface. Violation of these strategies risks insufficient gas in all environments.]
The influence of workload is interesting, and technical divers who perceive an elevated workload may well remember that this has been associated with both higher rates of gas consumption and unexpectedly running low on gas. So, when detecting a current or perceiving an elevated workload, I recommend keeping a closer-than-usual eye on the remaining gas and, if a current is suspected before the dive, then plan for an elevated SAC rate.
The influence of training/certification consistently appears to be associated with the risk of running out of gas, as does having made fewer lifetime dives. Highly trained and experienced divers might bear this in mind when diving with buddies who are newer to our sport. Offer them opportunities to gain experience and recommend additional training when they are ready. We were all inexperienced once.
Technology has improved in recent years; for example, tank pressure transponders are more reliable today than ever before. It is possible that in the future these resources, coupled with audible alarms, may prove to be highly effective at preventing technical divers from running out of gas. Until we know how effective such alarms are at preventing out-of-gas dives, our best course of action is to dive within the limits of our training and experience, and to keep an eye on our remaining gas.
See companion story for an estimate of the risk: What is the Risk of Running Out of Gas?
Do you think that it could it happen to you?
1. Buzzacott P, Rosenberg M, Pikora T. Using a Delphi technique to rank potential causes of scuba diving incidents. Diving and Hyperbaric Medicine. 2009;39(1):29-32.
2. Edmonds, C. and Walker, D. Scuba diving fatalities in Australia and New Zealand: The human factor. SPUMS J. 1989;19(3): 94-104.
3. Edmonds, C. and Walker, D. Scuba diving fatalities in Australia and New Zealand: The environmental factor. SPUMS J. 1990;20(1): 2-4.
4. Edmonds, C. and Walker, D. Scuba diving fatalities in Australia and New Zealand: The equipment factor. SPUMS J. 1991;21(1): 2-5.
5. Buzzacott P, Denoble P, Dunford R, Vann R. Dive problems and risk factors for diving morbidity. Diving and Hyperbaric Medicine. 2009;39(4):205-9.
6. Buzzacott P, Rosenberg M, Heyworth J, Pikora T. Risk factors for running low on gas in recreational divers in Western Australia. Diving and Hyperbaric Medicine. 2011;41(2):85-9.
7. Buzzacott P, Pollock NW, Rosenberg M. Exercise intensity inferred from air consumption during recreational scuba diving. Diving and Hyperbaric Medicine. 2014;44(2):74-8.
8. Buzzacott P, Zeigler E, Denoble P, Vann R. American cave diving fatalities 1969-2007. International Journal of Aquatic Research and Education. 2009;3:162-77.
9. Potts L, Buzzacott P, Denoble P. Thirty years of American cave diving fatalities. Diving and Hyperbaric Medicine. 2016;46(3):150-4.
10. Buzzacott P, Bennett C, Denoble P, Gunderson J. The Diving Incident Reporting System. In: Denoble P, editor. DAN Annual Diving Report 2019 Edition: A Report on 2017 Diving Fatalities, Injuries, and Incidents. Durham (NC): Divers Alert Network; 2020. p. 49-67.
11. Acott C. Diving incidents – Errors divers make. Safe Limits: An international dive symposium; 1994; Cairns: Division of Workplace Health and Safety.
12. Buzzacott P, Schiller D, Crain J, Denoble PJ. (2018). Epidemiology of morbidity and mortality in US and Canadian recreational scuba diving. Public Health 155: 62-68.
13. Buzzacott P. (editor) (2016). DAN Annual Diving Report 2016 Edition: A report on 2014 data on diving fatalities, injuries, and incidents. Durham, NC, Divers Alert Network
14. Buzzacott P (editor) (2017). DAN Annual Diving Report 2017 Edition: A Report on 2015 Diving Fatalities, Injuries, and Incidents. Durham (NC), Divers Alert Network.
15. Buzzacott P and Denoble PJ. (editors) (2018). DAN Annual Diving Report 2018 Edition: A report on 2016 data on diving fatalities, injuries, and incidents. Durham, NC, Divers Alert Network
16. Denoble PJ. (editor) (2019). DAN Annual Diving Report 2019 Edition: A Report on 2017 Diving Fatalities, Injuries, and Incidents. Durham (NC), Divers Alert Network.
You can add a diving incident to the DAN database by name or anonymously here: Diving Incident Reporting System (DIRS).
Dr. Peter Buzzacott MPH, PhD, FUHM, is a former PADI Master Instructor and TDI Advanced Nitrox/Decompression Procedures instructor, having issued >500 diver certifications. Today he is an active cave diver, holding various advanced cave diver certifications including advanced (hypoxic) trimix diver, and he is gradually gaining experience with CCR diving. To finance this, he conducts research into diving injuries and decompression/bubble modeling at Curtin University in Perth, Western Australia.
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Why Do Divers Run Out Of Gas?
Not surprising, the answer is more complicated than simply, they neglected to look at their gauges. Here Aussie diving medical...