Influence of scuba diving on asymptomatic isolated pulmonary bullae

Pulmonary blebs and bullae are generally considered an absolute contra-indication for scuba diving, because of a high estimated risk of pulmonary overpressure syndrome due to air-trapping inside the bulla. This is primarily based on a number of retrospective studies and case reports; formal prospective evidence of a higher risk is lacking. We present three cases where a pulmonary bulla was radiographically shown to increase in diameter, seemingly related to scuba diving activity, and causing ultimately a barotraumatic diving accident. These cases provide pathophysiological clues as to how even an isolated, non-ventilated bulla can be the cause of pulmonary barotrauma. The most likely mechanism for this phenomenon is a 'stretching' of the bulla upon ascent from the dive: after a period of compression (Boyle's Law), there is a gradual diffusion of air through the bulla wall, with restoration to its initial size by the end of the dive. Upon ascent, the air diffuses only slowly out of the bulla, causing a temporary increase in diameter and stretching of the bulla wall. This repeated stretching causes the bulla to grow gradually. At one point, the cyst wall may become critically thin and rupture during the ascent.