UC San Diego Guidelines for Evaluation of Divers during
COVID-19 pandemic

Charlotte Sadler, MD, Miguel Alvarez Villela, MD, Karen Van Hoesen, MD,
Ian Grover, MD , Tom Neuman, MD, and Peter Lindholm, MD, PhD,Background:
Coronavirus Disease 2019 (COVID-19) has become a global pandemic with SARS-CoV2
infecting millions of people and resulting in thousands of hospitalizations and deaths worldwide.
Research examining the origins and structure of the virus, its pathogenesis, and the clinicalfeatures of its acute presentation is growing at a fast pace. However, as a nascent pandemic, thelong-term sequelae to be expected in those who have survived the acute disease are largely
unknown. SARS-CoV2 infection manifests primarily as atypical pneumonia, but in severe
disease other complications are common, including cardiac and thromboembolic disease.
Scuba diving is a passion for many recreational divers, but, more importantly, it also represents a
critical component of the commercial diving industry and scientific research. UCSD runs a
diving medicine clinic that sees approximately 250 divers per year, most of whom are employed
as commercial and scientific divers. As society begins to re-open after quarantines, many ofthese divers are presenting to our (and others’) clinic requesting guidance and clearance on
returning to dive after the pandemic.
COVID-19 and Diving:
We are presented with the challenge of performing fitness to dive evaluations in the context of adisease in which the natural history is currently unknown. In what we know of thepathophysiology of the disease, the pulmonary, cardiac, and thromboembolic/hypercoagulable
disease seems to be relevant to divers. Potential long-term sequelae include decreased exercise
tolerance, increased susceptibility to cardiac events such as heart failure, pulmonary edema, andarrhythmia, structural changes of the lung leading to increased risk for barotrauma, and increased
risk of decompression sickness from underlying hypercoagulability.
Unfortunately, we do not have the luxury of waiting 6-12 months to evaluate our divers when
there will likely be much better information to provide evidence-based guidelines. Thus, we havedeveloped working guidelines based on the limited evidence of sequelae of COVID-19 availableand our experiences with other diseases that share similar features, such as pneumonia andcardiomyopathy. We fully anticipate we will be able to revise these guidelines as more evidence
becomes available. They are not meant to be prescriptive, but to share our experience with otherinstitutions and organizations who are faced with similar challenges.
Our goal has been to categorize divers based on the history and severity of their illness and basetheir return to dive evaluation accordingly. As with any illness, ultimately the work up is left tothe discretion of the evaluating physician. Our plan is to update them frequently as we gain moreexperience and more evidence becomes available. The following guidelines are referring todivers who are completely asymptomatic after their illness, including exercise tolerance (seebelow). Before using the guidelines below, a few terms warrant definition:May 8, 2020

UC San Diego Guidelines for Evaluation of Divers during COVID-19 pandemic

Charlotte Sadler, MD, Miguel Alvarez Villela, MD, Karen Van Hoesen, MD, Ian Grover, MD, Tom Neuman, MD, and Peter Lindholm, MD, PhDDefinitions of terms used in guidelines:
COVID-19-suspected Illness
We define a COVID-19-suspected illness as a diver who had symptoms consistent with COVID19 with or without a positive PCR or antibody test, given that testing is currently unreliable andmany were not tested. As more accurate antibody testing is developed and becomes widely
available it will likely be useful in guiding these evaluations. We are currently using the CDC
case definition (updated April 5, 2020) of COVID-19 for those patients who did not have PCR orantibody confirmed illness:
At least two of the following symptoms: fever (measured or subjective), chills,rigors, myalgia, headache, sore throat, new olfactory and taste disorder(s)OR
at least one of the following symptoms: cough, shortness of breath, or difficulty
breathingOR
Severe respiratory illness with at least one of the following: Clinical orradiographic evidence of pneumonia, or Acute respiratory distress syndrome(ARDS)AND
No alternative more likely diagnosis
Exercise ToleranceThis is likely the most important definition used in our guidelines and it is vital that physiciansevaluate it carefully. It is our belief that a diver with significant cardiac or pulmonary
pathophysiology would not have a normal exercise tolerance. However, the definition of theword normal is critical. First, the diver must have returned to his or her baseline level of exercise
and tolerance. Even minor deviations from their baseline (“getting more winded,” longer
recovery times, etc) warrants further testing and investigation. Second, the physician must be
satisfied that the diver’s exercise regimen warrants an appropriate exertional test for diving.
There are no universally agreed upon recommendations on an exercise tolerance level needed forall divers, but the ADCI guidelines for commercial divers require a minimum level of 10 METS.
If the physician is not convinced that the diver’s self-reported exercise level meets appropriate
criteria or concerned that it would not reveal underlying cardiac or pulmonary disease, further
testing is warranted.

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UC San Diego Guidelines for Evaluation of Divers during COVID-19 pandemic

Charlotte Sadler, MD, Miguel Alvarez Villela, MD, Karen Van Hoesen, MD, Ian Grover, MD, Tom Neuman, MD, and Peter Lindholm, MD, PhD

GUIDELINES FOR DIVER EVALUATION
Category 0 Asymptomatic Diver without history of COVID-19 suspected illness

We recommend divers who have no history of COVID-19 suspected illness proceed withnormal evaluations. Additionally, we would use these criteria in those who may have had
a positive screening PCR or antibody test, but without any history of illness or symptoms
consistent with COVID-19.
a. Commercial Divers● Initial/annual exam per ADCI guidelines● Chest radiograph only if required per Q 3-year cycle● No additional testing requiredb. Scientific Divers AAUS/NOAA● Initial/recurrent exam per AAUS or NOAA guidelines● No additional testing requiredc. Recreational● Follow RSTC guidelines● No additional testing required

Category 1 Asymptomatic Diver who had a mild COVID-19-suspected illness

We define a mild illness as any patient who:
● Did not seek health care or received outpatient treatment only without evidenceof hypoxemia.
● Did not require supplemental oxygen● Imaging was normal or not required● They have returned to their baseline exercise tolerance.
Commercial Divers/Scientific Divers/Recreational● Initial/annual exam per ADCI/AAUS/NOAA/RSTC guidelines● Spirometry● Chest radiograph (PA & Lateral)● If chest radiograph is abnormal, obtain Chest CT scan
● If unknown (or unsatisfactory) exercise tolerance, perform exercise tolerance
test with oxygen saturation

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UC San Diego Guidelines for Evaluation of Divers during COVID-19 pandemic

Charlotte Sadler, MD, Miguel Alvarez Villela, MD, Karen Van Hoesen, MD, Ian Grover, MD, Tom Neuman, MD, and Peter Lindholm, MD, PhDCategory 2 Asymptomatic Diver who had a moderate COVID-19-suspected illness

We define a moderate illness as any patient who:
● required supplemental oxygen or was hypoxic● had abnormal chest imaging (chest radiograph or CT scan)● admitted to the hospital but did NOT require assisted ventilation (BIPAP, CPAP,or ventilator) or ICU level of care.
● If admitted, had documentation of a normal cardiac work up including normal
ECG and cardiac biomarkers e.g. troponin or CK-MB and BNP● They have returned to their baseline exercise tolerance.
Commercial Divers/Scientific Divers/Recreational● Initial/annual exam per ADCI/AAUS/NOAA/RSTC guidelines● Spirometry● Chest radiograph (PA & Lateral) (if abnormal, obtain Chest CT)● ECG● Echocardiogram (if no work up was done inpatient. Can forgo if had negativework up)● If unknown (or unsatisfactory) exercise tolerance, perform exercise tolerance
test with oxygen saturation● Investigation and management of any other complications or symptoms perprovider and ADCI/AAUS/NOAA/RSTC guidelines

Category 3 Asymptomatic Diver who had a severe COVID-19-suspected illness

We define a severe illness as any patient who:
● Required mechanical or assisted (CPAP, BIPAP) ventilation, or ICU admission● Cardiac involvement defined as abnormal ECG, abnormal echocardiogram, orelevated cardiac biomarkers; e.g. troponin or CK-MB and BNP (or absence ofdocumented work up)● Thromboembolic complications (such as PE, DVT, or other coagulopathy)● They have returned to their baseline exercise tolerance.
Commercial Divers/Scientific Divers/Recreational● Initial/annual exam per ADCI/AAUS/NOAA/RSTC guidelines● Spirometry● Chest radiograph (PA & Lateral) (if abnormal, obtain Chest CT)● ECG● Repeat Cardiac troponin or CK-MB and BNP to ensure normalization● Echocardiogram● Exercise Echocardiogram with oxygen saturation● Investigation and management of any other complications or symptoms perprovider and ADCI/AAUS/NOAA/RSTC guidelines

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UC San Diego Guidelines for Evaluation of Divers during COVID-19 pandemic

Charlotte Sadler, MD, Miguel Alvarez Villela, MD, Karen Van Hoesen, MD, Ian Grover, MD, Tom Neuman, MD, and Peter Lindholm, MD, PhD

Symptomatic divers or those with abnormal test results

It is not currently our plan to allow divers who are symptomatic or have abnormal testing per theguidelines above to dive (though each will need to be evaluated on a case by case basis andexceptions are to be expected). However, we do not feel this necessarily represents a lifetimeban on diving as many of the sequelae which are currently disqualifying (such as abnormal CTscans) may resolve over the next 3-6 months and re-testing may be indicated. It is currentlyunknown whether or not potential sequelae of COVID-19 will become chronic and therefore reevaluation will likely be indicated until more evidence becomes available.

Screening of diving employees prior to diving

We currently recommend following CDC guidelines for screening of an employee prior to diving
and do not feel that measuring vital signs or oxygen saturation routinely before diving arewarranted. Any diver should not dive if they currently have a fever, or have had any of thefollowing symptoms in the last 14 days (cough, shortness of breath or difficulty breathing, fever,chills, muscle pain, or new loss of smell or taste).

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