Fatal respiratory failure during a "technical" rebreather dive at extreme pressure

A diving fatality at the extreme depth of 264 m fresh water is described. The diver was equipped with an underwater video camera which recorded events leading to his death. These events corroborated predictions about respiratory complications at extreme pressure made by early researchers. Review of the video and relevant literature resulted in the following physiological interpretation: an increase in respired gas density during descent caused a progressive increase in resistance to flow in both the airways and the breathing circuit. Initially, this was associated with a shift to ventilation at higher lung volumes, a relative degree of hypoventilation, and mild permissive hypercapnia. The promotion of turbulent airway flow by increasing gas density resulted in effort-independent expiratory flow at lower flow rates than usual. The consequent inability to match ventilation to the demands of physical work at the bottom precipitated a spiraling crisis of dyspnea, increasing PaCO2, and wasted respiratory effort, thus producing more CO2. Extreme hypercapnia eventually led to unconsciousness. This tragic case provides a timely and salient lesson to a growing population of deep "technical" divers that there are physiological limitations that must be understood and considered when planning extreme dives.