INSIGHT | H&S - COMPRESSED AIR WORK
and under-reporting of the condition, especially if cases are relatively infrequent. Current UK guidance for doctors appointed by the HSE
to undertake compressed air medical work recommends long-bone X-rays or MRI ‘only in suspected cases’26
.
However, potentially prolonged delays between incident exposures and the development of symptoms mean that cases of DON in compressed air workers will rarely be detectable through clinical assessment at final project health checks, unless long bone screening is carried out as part of the health surveillance programme. Practice in the post-exposure screening of
asymptomatic compressed air workers is currently varied in the UK. The incurred cost of any long bone MRI screening programme means that this inconsistency has commercial implications. Revision of guidance is now underway at the BTS CAWG to promote consistency in practice. It is suggested that the current ‘absence of evidence’
of recently diagnosed cases of DON in the modern compressed air workforce cannot be accepted as ‘evidence of absence’ of risk of DON in modern compressed air work. There is a clear need to confirm the true incidence of DON in the modern compressed air workforce. Using long bone MRI screening as part of a properly supervised post-exposure health surveillance programme provides a means to achieve this.
CONCLUSION AND RECOMMENDATIONS While DON prevalence in modern UK CAW remains uncertain, historical experience and contemporaneous cases worldwide suggest an ongoing potential risk. The persisting risk of decompression sickness, despite modern UK decompression techniques, and strong association between these two conditions, further supports this. There is, therefore, a need for continued health surveillance for DON. Findings from the MSc study indicates that MRI
Above: A compressed air worker using the lock communication system during a hyperbaric intervention PHOTO CREDIT: TRHA
DON therefore meets at least two of the three
regulatory criteria to mandate health surveillance. It is a known work-related disease and there is a valid, low- risk screening technique. The only uncertainty arises over the current likelihood of the condition developing with UK compressed air techniques and working practices. It is clear that compressed air work – especially using
air decompression techniques – is associated with an increased risk of DON, and the associated health burden for the workforce, when compared to diving. The late and non-specific presentation of joint DON, similar to many other occupational diseases (such as silicosis or asbestos-related disease, for example) means that unless an appropriate health surveillance programme is carried out then a majority of cases are likely to be missed. This risks under-recognition, under-diagnosis
34 | July 2025
presents a reliable, low-risk screening technique which is likely to be accessible and acceptable to the UK workforce. The evidence base suggests that long bone MRI as part of post-exposure health surveillance will facilitate the early detection of DON in compressed air workers. Implementation of routine post-exposure MRI long
bone surveillance in compressed air workers would provide critical data on the condition’s current incidence and inform decompression safety protocols. Given the historical burden of DON in the UK
compressed air workforce, the potential severity of the disease, and the availability of an effective screening method, there is a compelling case for adopting long bone MRI for routine post-exposure health surveillance in asymptomatic compressed air workers. Until comprehensive data confirm otherwise, the risk of DON should not be overlooked in modern, and future, CAW practice. Guidance on the practical implementation of MRI as
a screening tool for DON is now being developed by the BTS CAWG.
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