Hypercapnia in diving: a review of CO2 retention in submersed exercise at depth
Authors:   Department of Anesthesiology, Duke University Medical Center, Durham, N.C, Dunworth Sophia A. ,   Center for Hyperbaric Medicine & Environmental Physiology, Duke University Medical Center, Durham, N.C., Natoli Michael J. ,   Department of Anesthesiology, Duke University Medical Center, Durham, N.C,   Center for Hyperbaric Medicine & Environmental Physiology, Duke University Medical Center, Durham, N.C., Cooter Mary ,   Department of Anesthesiology, Duke University Medical Center, Durham, N.C., Cherry Anne D. ,   Department of Anesthesiology, Duke University Medical Center, Durham, N.C,   Center for Hyperbaric Medicine & Environmental Physiology, Duke University Medical Center, Durham, N.C., Peacher Dionne F. ,   Department of Anesthesiology, Duke University Medical Center, Durham, N.C,   Center for Hyperbaric Medicine & Environmental Physiology, Duke University Medical Center, Durham, N.C.,   Department of Anesthesia, University of Iowa, Iowa City, Iowa, Potter Jennifer F. ,   Department of Anesthesiology, Duke University Medical Center, Durham, N.C,   Center for Hyperbaric Medicine & Environmental Physiology, Duke University Medical Center, Durham, N.C.,   Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, Wester Tracy E. ,   Department of Anesthesiology, Duke University Medical Center, Durham, N.C,   Center for Hyperbaric Medicine & Environmental Physiology, Duke University Medical Center, Durham, N.C.,   Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, S.C., Freiberger John J. ,   Department of Anesthesiology, Duke University Medical Center, Durham, N.C,   Center for Hyperbaric Medicine & Environmental Physiology, Duke University Medical Center, Durham, N.C., Moon Richard E. ,   Department of Anesthesiology, Duke University Medical Center, Durham, N.C,   Center for Hyperbaric Medicine & Environmental Physiology, Duke University Medical Center, Durham, N.C.,   Department of Medicine, Duke University Medical Center, Durham, N.C.
Published: January 2018

Carbon dioxide (CO2) retention, or hypercapnia, is a known risk of diving that can cause mental and physical impairments leading to life-threatening accidents. Often, such accidents occur due to elevated inspired carbon dioxide. For instance, in cases of CO2 elimination system failures during rebreather dives, elevated inspired partial pressure of carbon dioxide (PCO2) can rapidly lead to dangerous levels of hypercapnia. Elevations in PaCO2 (arterial pressure of CO2) can also occur in divers without a change in inspired PCO2. In such cases, hypercapnia occurs due to alveolar hypoventilation. Several factors of the dive environment contribute to this effect through changes in minute ventilation and dead space. Predominantly, minute ventilation is reduced in diving due to changes in respiratory load and associated changes in respiratory control. Minute ventilation is further reduced by hyperoxic attenuation of chemosensitivity. Physiologic dead space is also increased due to elevated breathing gas density and to hyperoxia. The Haldane effect, a reduction in CO2 solubility in blood due to hyperoxia, may contribute indirectly to hypercapnia through an increase in mixed venous PCO2. In some individuals, low ventilatory response to hypercapnia may also contribute to carbon dioxide retention. This review outlines what is currently known about hypercapnia in diving, including its measurement, cause, mental and physical effects, and areas for future study.