Buddy Breathing: Is it Time for Change?

Scuba Diving | Dive Training Magazine

It is interesting to remember back on decisions to run some of these articles. This one was especially hard. We were advised by many to leave it alone. It didn’t help that we were still new in the industry and trying to be profitable — not a good time for risk.

When this article was published, PADI and some of the other agencies required their instructors to teach the skill of buddy breathing – air sharing using the primary regulator. Because buddy breathing very often didn’t allow for peoples’ real reactions in an out-of-air emergency, it could be dangerous. So for the magazine to recommend that the skill should be removed as a requirement in the training standards (which Alex did in his editorial opinion at the end of the story), would go against the certifying agencies and their instructors.

The problem for Dive Training was that our magazine is shipped to all of the nation’s dive stores (who were required by their agencies to train the skill) to give to their students (to whom they were teaching the skill). So we knew that if their customers would read the article and object to learning the skill, (especially because everyone was terrified about the transmission of AIDS at the time), there was nothing that the stores and instructors could do. We imagined that stores all over would send their shipment of magazines to the dumpster, or abandon the publication altogether.

The article would also put the agencies in a bad place, not just because it put their stores between a rock and a hard place, but because, as an industry lawyer strongly reminded us, with the next buddy breathing accident the article will be in the courtroom as ‘Exhibit 1’ on the easel of the deceased’s lawyer, and we will have been responsible for costing the industry millions.

I remember the fun. Alex did an excellent job of discussing the issue in the proper context, and largely as a result of the article the agencies either banned teaching the skill or made it optional.

— Mark Young, Publisher


Content below originally published in Dive Training, November 1993.


An Editorial Opinion

By Alex Brylske

In my role as the technical editor of Dive Training, I strive to maintain the utmost balance and objectivity in my work. At times, however, the issues seem too important not to express an opinion. In my 22 years as a diving educator, I have witnessed enormous changes in the way divers are trained. Changes to skill training are most often a result of improved technology, and usually result in little controversy.

Buddy breathing, however, is somewhat different than other skills divers learn. It’s one of the few techniques in which the incompetence of one diver can actually threaten the life of another. More than once, poor buddy breathing performance has resulted in two victims.

In formulating my opinion on the matter, I have been influenced most by what I believe is simple common sense and experience. In the absence of true objective, scientific inquiry into out-of-air emergency responses, there really are no other guidelines to aid us in making a decision. Based on my assessment of the issue, I have concluded that buddy breathing – the practice of sharing a single regulator among two divers – should be abandoned as an emergency procedure for recreational scuba divers. Alternate air source use should be adopted as the only method of sharing air in an emergency. I base this conclusion on the following considerations.

In a real out-of-air emergency, a diver has to make decisions quickly. Of course, the stress induced by such an emergency makes this decision-making process more complicated than normal – particularly for the diver who is out of air. The last thing in the world someone in this state of mind should be asked to do is search through an array of options and select which one he thinks is best. Just as in a fire drill, there should be one and only one choice of action. Training a diver in both alternate air source use and buddy breathing, I believe, clouds the diver’s thought process, and in a real emergency situation can cause confusion

This is not merely a theoretical argument. I have seen the negative consequences of providing divers with options to deal with out-of-air emergencies. On a number of occasions, I have witnessed students confuse the techniques of buddy breathing with alternate air source use (particularly those aspects relating to buddy contact). This has occurred in both entry-level and instructor-level classes. My conclusion is that if such confusion occurs in the controlled setting of a swimming pool, how can we expect better performance in a real emergency?

I agree with Dr. Egstrom’s assessment that divers can indeed learn buddy breathing to a point where they are competent even under stress, if they practice it often enough. But, I simply do not see it as feasible in the structure of a typical entry-level scuba course to devote the extraordinary amount of time required (17 to 21 trials) to master the technique – particularly considering that it is not even the best method of dealing with the situation. The better option is to take the time now spent on the antiquated skill of buddy breathing and devote it to mastering skills that might prevent out-of-air emergencies, such as improving awareness of air monitoring and buoyancy control.

The other unique aspect of the buddy breathing argument is that we cannot base our decision solely on issues related to learning and retention. Unlike any other skill a diver learns, buddy breathing requires consideration of something which no one living in the 1990’s can ignore – disease transmission.

Certainly there are circumstances where the value of an action outweighs the potential risk of contracting a communicable disease. But the benchmark in drawing such a conclusion must be that taking that risk is the best possible option. For example, no one would deny that mouth-to-mouth resuscitation is a better option than the old chest-pressure/arm-lift method. Hence, in this case, the effectiveness of the technique far outweighs the risk of disease transmission.

Unfortunately, with buddy breathing this just isn’t the case. Using an alternate air source is, by far, superior to sharing a single regulator. So, in essence, what we are asking divers to do is accept some risk of disease transmission – however slight – in exchange for what isn’t even the best alternative in solving a problem. So what’s the solution? In my opinion, the solution to the problem of handling out-of-air emergencies is in the hands of every diver. It involves taking a stance both personally and as a community. First, divers should refuse to dive with anyone who is so irresponsible as to not use an alternate air source. This decision should require little deliberation. After all, a diver who doesn’t have an alternate air source is saying, “My buddy’s safety isn’t worth the both and expense of dealing with an out-of-air emergency using the safest possible means.” I, for one, don’t care to dive with such a person.

Furthermore, dive operators and industry leaders should encourage the mandatory use of alternate air sources through whatever resources they have at their disposal. Some specific recommendations include:

  • Dive operators should have alternate air sources on all rental equipment and require that divers have them for all supervised activities.
  • Equipment manufacturers should agree on standardized design parameters for all types of alternate air source devices.
  • Training organizations, working with manufacturers, should come to an industry-wide agreement on how to teach and use alternate air sources.

Feature: Buddy Breathing – Is it Time for Change?

By Alex Brylske

Compared to other recreational activities, scuba diving is very unique. Unlike any other sport, factors such as cold, decompression status and a finite air supply dictate the extent of our underwater journeys. Learning how to deal with these limitations is also the focus of our training.

Divers have no control over the temperature of the water, nor how they are affected by decompression. But we can have a great deal of control over managing our air supplies. Through good physical conditioning, avoiding conditions that cause excessive breathing, and using tanks of appropriate capacity, divers can easily maximize the limited air supply they carry underwater. Unfortunately, even with the best of preparation and training, circumstances can arise in which divers unintentionally run out of air.

While much of the classroom diving instruction we receive deals with how to adapt to the environment and keep track of our decompression status, it’s in the skill training where we learn how to handle out-of-air emergencies. Generally, out-of-air emergencies are categorized into either independent actions (controlled swimming and buoyant emergency ascents) or dependent actions (alternate air source use and buddy breathing). One of the most controversial out-of-air skills is also one of the oldest – buddy breathing. The purpose of this article is to take an in-depth look at just why this time-honored technique has been called into question and offer a new perspective for divers of the 1990s.

What Is It and Where Did It Come From?

As not all divers learn buddy breathing during their entry-level training, lets first review the procedure. (The sidebar “Training Organizations Speak Out on Buddy Breathing” will explain the positions of the various diver training programs on buddy breathing.)

Unlike using an alternate air source – where the out-of-air diver breathes from a spare regulator or redundant air source – buddy breathing involves sharing a single regulator.

The technique begins with the out-of-air diver signaling his status to his buddy (using the “cut-throat” sign) and indicating that he needs air by pointing to his mouth. The buddy with air – called the “donor” – quickly approaches the out-of-air diver, or “receiver.” The donor’s regulator is then shared back and forth in two-breath cycles while the buddy team ascends to the surface.

This technique has been used since the earliest days of recreational diving, and along with the emergency ascent (originally termed the “blow and go”), it became one of the two ways a diver could respond to running out of air at depth.

Back when recreational diving began, all regulators were of a double hose configuration (like the ones you may have seen on reruns of the 1950s adventure series Sea Hunt). One advantage of this design was that it made it easy for two divers in a face-to-face position to share the regulator mouthpiece. A simple and straightforward technique, buddy breathing soon became a hallmark of diver safety.

Buddy breathing was a particularly important skill in the early days of diving because running out of air was a common occurrence (so common it wasn’t even considered an “emergency”). Lacking reserve valves or submersible pressure gauges, divers had little idea how much air was actually in their tanks while they were underwater. But by the mid-1960s, with the introduction of submersible pressure gauges, continual and accurate sir supply monitoring was possible. And running out of air became much less common.

The Controversy

By the late 1960s, the double-hose regulator was being replaced by the single-hose design, and buddy breathing continued to be taught as a vital out-of-air emergency response. What many instructors failed to recognize, however, was that while they had numerous, advantages over the double-hose design, single-hose regulators made buddy breathing a more complicated technique.

One complicating factor was that the single-hose configuration made sharing the regulator more difficult. In the standard face-to-face position, the donor had to bend the hose in an awkward position to give the receiver access to the second-stage. Instructors soon found that it was easier for the receiver to approach the donor’s left side and make the exchange side by side. This added an important new consideration: The receiver now had to know from which side to approach the donor – an irrelevant consideration when using a double-hose regulator.

Next was the problem of clearing the regulator. The ease with which double-hose regulators free-flowed aided in clearing them. But most single-hose regulators do not have this tendency to easily free-flow. As we all know, to clear the second-stage, you must either exhale into the mouthpiece or push the purse button. When buddy breathing, divers must continually exhale between exchanges of the regulator to avoid a lung expansion injury while ascending. Unfortunately, this need to continually exhale sometimes leaves the diver without enough air to clear the regulator by exhalation, making the purge the only option. This makes it absolutely essential that the buddy breathing team have access to the purge button at all times.

Unfortunately, the most comfortable way for the donor to hold a second-stage is by covering the purge button (particularly on models with front-mounted purges). But holding the second-stage this way doesn’t allow access to the purge button by the receiver, making it difficult or impossible for him to get any air from the device if he cannot exhale into it. This consideration further complicates buddy breathing with a single-hose regulator. Yet, as double-hose regulators did not have – or need – purge buttons, this was not even an issue when buddy breathing began.

A third factor in buddy breathing which has been complicated by modern technology is buoyancy control. The introduction of the buoyancy compensator (BC) enabled divers to continually alter their water displacement and maintain neutral buoyancy. While this has important benefits in most circumstances, it makes buddy breathing more difficult and complex.

Buddy breathing requires the use of both hands – one to maintain continual contact with the other diver and the other to manipulate the regulator. Before the advent of the BC, there was little change in a diver’s buoyancy during an ascent. (The only effect on buoyancy resulted from the change in water displacement caused by an expanding exposure suit.) Thus, controlling buoyancy was a minor consideration during buddy breathing. The modern BC, however, changed all that. A BC has some air in it at virtually all times. So, during an ascent a diver must contend with what could be a significant increase in buoyancy caused by the expansion of this air. This is usual a simple matter to deal with – unless you’re buddy breathing.

Most in the instructional community argue that dealing with buoyancy control while buddy breathing is too much to handle, and it should therefore be a secondary priority. They contend that letting go of the buddy or the regulator to adjust buoyancy could cause more problems than the adjustment would solve. In the even of excessive positive buoyancy, their advice is to “flare out” – a technique in which the divers bend their knees to present more surface area of their fins in the water column. The increased resistance tends to slow the ascent without having to delete air from the BC.

Others suggest altering the buddy contact position to allow manipulation of the BC while continuing to buddy breathe. This requires a great deal of coordination, however, and without extensive practice the technique can easily result in compromising the success of a buddy breathing attempt. The point is, regardless of where one stands on the issue of buoyancy control, it can greatly complicate the procedure of sharing a single regulator.

Some instructors point to these complicating factors and conclude that buddy breathing should be abandoned as an out-of-air emergency option. Furthermore, they say that, as submersible pressure gauges make air management so simple, out-of-air emergencies have become far less common today than in the past. This lack of need has resulted in a lack of practice, causing skill competence in buddy breathing to decay soon after a diver’s entry-level training.

Adding credence to this argument is how the standard scuba configuration has changed over the years. When buddy breathing was adopted, it was the only method a diver had to reach the surface with the assistance of his buddy. This changed with the introduction of alternate air source devices (spare second-stages, alternate inflation regulators, and redundant air supplies). Today, alternate air sources have become an essential part of the diver’s equipment ensemble. They are required for all diver training activities, as well as by an increasing number of dive operators and charter boats. Their acceptance has become so universal that it’s now considered irresponsible to dive without one.

Advocates of abandoning buddy breathing further maintain that the technique is a holdover from the past. They argue that to a modern-day diver, learning to buddy breather is like learning hand signals in a diver’s education class. While the technique might work, it has been obviated by modern technology and merely wastes valuable time in the training process that could be put to better use.

Finally, it’s argued that buddy breathing is a particularly complex skill. And although students can master it in the controlled environment of a training session, the stress induced by a real, unexpected out-of-air emergency is quite a different matter. As evident of the likely results of buddy breathing in a real emergency, buddy breathing foes point to documented cases where buddy breathing attempts have failed, causing double fatalities.

On the other side of the issue, advocates of retaining buddy breathing point out two compelling arguments. First, while alternate air sources have become commonplace, not every diver uses one. This is particularly tru of divers trained outside of North America. And if a diver doesn’t have an alternate air source, buddy breathing is the only option for a shared air ascent. Secondly, they contend that if divers practice the technique often enough, buddy breathing works.

Some even take exception with the idea that buddy breathing is an overly complex skill. Dr. Glen Egstrom, Professor Emeritus of Kinesiology and former diving office at the University of California at Los Angeles (UCLA), sees the issue as one of practice rather than complexity. Egstrom notes, “I am of the opinion that the skills which must be mastered (in buddy breathing) do not vary significantly in complexity with the rest of the (out-of-air) techniques…I tend to regard buddy breathing as a skill which is presented early in the course and rehearsed during each training session. We have found that 17-21 trials will develop the ability swim and share air at the same time.”

A New Concern

Most of the issues we’ve discussed have been debated for many years. More recently, a concern has arisen over what implications buddy breathing might hold for disease transmission. As the technique requires that the same regulator be placed in one diver’s mouth, then in the mouth of his buddy, it’s easy to understand why this would be of particular concern.

Some contend that the risk of infection is virtually nonexistent. One reason is that the regulator mouthpiece is briefly “washed” by the water between exchanges. Furthermore, advocates of buddy breathing add that, in pool environments, disease organisms are also unlikely to survive in chlorinated water. While this might sound like a plausible theory, experience shows otherwise.

In preparing this article, Dive Training consulted a number of experts in the health care field, and the consensus of opinion was that the risk of transmission is, indeed, low. However, there are some issues that warrant consideration, if not concern.

The disease transmission issue was summed by Gloria Bartholomew, a licensed nurse and certified American Red Cross HIV/AIDS Educator in an interview with Dive Training. A recreational diver for over 20 years whose full-time job is educating health care professionals about HIV and how to manage the risk of transmission, Bartholomew provided a unique perspective.

On the subject of HIV, Bartholomew was – like most of her colleagues – of the opinion that the risk of transmission during buddy breathing was very low. “As far as HIV is concerned,” she said, “it’s a very fragile virus and simply doesn’t live long outside the body. Its only known method of transmission is via blood and by seminal or vaginal fluids – not saliva.”

Bartholomew’s option was confirmed in a communication with an information specialist at the National HIV/AIDS Hotline, a program of the Center for Disease Control in Atlanta. The spokesman agreed that while HIV can be found in saliva and urine, it’s not at a sufficient level of concentration to transmit the disease.

Still, some instructors suggest that, while it might be extremely unlikely, there are circumstances whereby transmission is at least possible. They point to instances where blood, not saliva, could be transferred. For example, might it not be possible to transfer the virus via blood if students have bleeding sores in their mouths or have their gums abraded by an overzealous buddy during a regulator exchange? On this point, Bartholomew explained, “The mechanism of transmission is blood to blood. So, while transmission might be a remote possibility, it would require that both the donor and receiver have some kind of open wound or sore in their mouths.”

Yet, while the risk of HIV infection is probably not a concern, that doesn’t mean that divers are off the hook entirely. What worries Bartholomew about buddy breathing is the risk of other, far more common and communicable diseases. She cautions, “The biggest problem in buddy breathing that I see if the potential transmission of hepatitis B, which is a more likely problem than HIV in diving or any other area.” Bartholomew added that, although it’s a relatively minor concern in the context of HIV and hepatitis B, risk of transmitting the herpes virus is also present. This fear has indeed been born out by experience. At least one case of herpes and two cases of hepatitis have been reported as a result of buddy breathing.

Conclusion

In the final analysis, whether someone chooses to include buddy breathing in their repertoire of out-of-air emergency responses is a personal matter. Evidence seems to support the contention that it’s a viable option if it’s practiced enough. But it’s certainly foolhardy to assume buddy breathing is of any value if you never practice it.

Regardless of where you come down on the issue of buddy breathing, it should never be considered a substitute for using an alternate air source. Even if you are completely comfortable buddy breathing under any circumstance, it’s unlikely your buddy will have this same level of competence. It’s common sense: Having a spare regulator to use in an emergency is better than sharing one.

Perhaps the best summation of this long-standing controversy is provided by Dr. Egstrom. In a letter to Dive Training, he writes, “The issue of sharing air has become so complex due to equipment innovations. It is my belief that we have now developed multiple solutions for a rare and usually avoidable problem. This is unfortunate since each of the solutions requires that the buddy team, or unplanned donor or recipient, be specifically prepared to execute the same technique. An analysis of each of the devices will reveal a series of steps that must be learned to a high degree of comfort or the stresses induced in an emergency may result in confusion and failure.

“If we could return to a single standardized solution for an out-of-air emergency, I would be pleased. Since that will not happen in my life time, I keep hoping that the use of a standardized procedure that will encompass all of the devices that can be accepted. Whatever happens, you can bet that the solution will require a reasonable amount of understanding, rehearsal, and reinforcement.”


Training Organizations Speak Out on Buddy Breathing

There is no better example of the controversial nature of buddy breathing than the divergent opinions on the skill by the various diver training organizations. As you will see, some have eliminated it from their training programs. Others require it to be taught. Some take the middle road and make training in buddy breathing an option at the discretion of the instructor. Following are position statements provided to Dive Training from several organizations.

IDEA

According to a member of IDEA’s (International Diving Educators Association) National Headquarters, “Buddy breathing is too complex a skill to master in the limited time frame of a typical entry-level class. It is also a potentially dangerous skill in that it might give divers a false sense of security that they can handle an out-of-air emergency without an alternate air source. Further, while under normal conditions, the risk of disease transmission by buddy breathing is minimal; the risk increases substantially if a student has an open sore in the mouth.

With the introduction of IDEA’s own Openwater Scuba textbook this fall, IDEA will no longer teach buddy breathing. Use of an alternate air source, either an octopus or redundant air source, will replace the buddy breathing system in entry-level classes.

We have found that, because of the difficulty of mastering the skill of buddy breathing, most students have lost proficiency in this skill within the first 90 days after finishing their class. It is a skill that must be practiced regularly in order to maintain any degree of proficiency.”

NASDS

Michael McCrory, Education Director with NASDS (National Association of Scuba Diving Schools), stressed that their organization abolished teaching air sharing via buddy breathing back in 1977. The only shared-air emergency ascent technique NASDS teaches is the use of a safe second (alternate air source). McCrory summed up the rationale for this position by quoting from the NASDS entry-level text, Safe Scuba, as follows:

“Sharing air by passing the assisting buddy’s primary second-stage back and forth (traditional method) requires considerable skill, practice, and discipline. Most basic diving courses provide training in sharing air in the traditional method under highly controlled situations. This training can lead to a false sense of confidence regarding one’s skill to deal with a difficult sharing air situation. Very few basic diving courses provide training in sharing air under stressful conditions. The students, therefore, obtain no understanding of their response in an emergency. Some attempts at sharing air in the traditional method have led to tragedy in the form of double drowning in which both members of the buddy team were lost… Share air only if you have a safe second-stage.” If the diver has no spare second-stage, NASDS advises that the diver execute an emergency swimming ascent.

NAUI

Jim Brown, writing on behalf of the National Association of Underwater Instructors (NAUI), offered the following comments:

“According to NAUI Diving Course Standards, NAUI instructors are required to teach the skill of buddy breathing in the Openwater I Scuba Diver course (NAUI’s entry-level scuba certification program). It is one of four emergency ascent options taught. The other options (provided a normal ascent is not possible) are an emergency swimming ascent, sharing air by means of an extra second-stage, e.g., octopus, and a buoyant ascent. NAUI recommends that out-of-air divers attempt to make an emergency swimming ascent, or, if possible, breathe from a donor’s alternate air source while ascending at a near-as-normal rate of ascent as possible. Buddy breathing and buoyant ascents are the least desirable of the options available.

The standard and validity of the skill have, from time to time, been questioned by NAUI instructors. A recent issue of Sources (NAUI’s instructor periodical) featured member’s opinions regarding teaching buddy breathing. Late last year, a survey was also mailed to NAUI members regarding the skill. Members were asked if the skill should be maintained, taught as an option or eliminated. Twenty four percent were in favor of eliminating the skill; 24 percent thought it should be an optional skill taught at the discretion of the instructor; 52 percent favored keeping the standard as is.”

PADI

According to Drew Richardson, PADI’s (Professional Association of Diving Instructors) Vice President of Training, Education, and Memberships, “It is my observation that there seems to be no middle ground on this issue. Instructors are either strongly for or strongly against teaching the skill. PADI’s position has been that buddy breathing continues to be an option (although not the first method of choice) for out-of-air emergencies and remains a requirement of the PADI Open Water Diver Course. This is largely to address an international community. In many areas of the world, divers still do not utilize alternate air sources…However, we are looking for members’ views of the continued viability of buddy breathing… (A recently mailed survey) will be the largest, most comprehensive, and most international survey of its kind ever to explore this issue. (It will to go 55,000 professional PADI educators in 100 countries.)

There are a growing number of educated and enthusiastic divers who are uncomfortable in performing the skills because of health concerns…However, since buddy breathing skills are required for Open Water certification, individuals who choose not to perform this skill may not be certified. Students who have a sensitivity to disease transmission may perform the skills with a family member or any other diver they know, trust, and are comfortable with…”

PDIC

In his statement, Assistant Training Director K. Mel Murphy stressed that the Professional Diving Instructors Corporation (PDIC) entry-level course standards require training in the use of an alternate air source, additional second-stage, redundant air system/pony bottle, etc.

While sharing air with one regulator is not a requirement of the PDIC entry level course, PDIC instructors may, at their own option, include such training in their course. The PDIC entry level course teaches dive planning and air management to help reduce the need for sharing air.

SSI

In a statement by Gary Clark, Director of Member Services, he emphasized that SSI (Scuba Schools International) believes buddy breathing should only be used as a last resort during out-of-air emergencies because there are safer, more viable options such as alternate air sharing. “There are limited situations, such as when a diver’s buddy has no alternate air source, that make buddy breathing an option However, since alternate air sources have become standard equipment since 1986, these situations are rare. Therefore, buddy breathing is an optional skill in the SSI Teaching System, which instructors are recommended but not required to teach.

The major rational for SSI’s position is the widespread acceptance and use of alternate air sources. A number of other rationales exist. We also stress that divers learn to monitor their SPG first and foremost, because this practice prevents most out-0f-air emergencies from occurring. Of course, the possibility always exists that a diver may encounter an out-of-air situation, so alternate air sharing is the primary method of sharing air”

YMCA

National Scuba Director Frankie Wingert provided this statement regarding buddy breathing: The National YMCA Scuba Program Advisory Committee, after careful consideration and study, has concluded that the training technique of buddy breathing should remain an elemental part of our scuba training program. This decision was reached after consultation with infectious disease experts from the National Institute of Health, the National Communicable Disease Center, university of Florida Medical School, Jacksonville University Hospital, and the Committee Medical Adviser. All agreed that the buddy breathing technique did not represent a significant risk for the transmission of communicable disease, including the HIV Virus, hepatitis B virus or other virulent infections. The Committee will continue to monitor this matter closely and alter its position if any new information or research develops.

The rationale for this position is that even with the redundancy in scuba equipment presently available, and emphasis from all certifying agencies, it is still not unusual to see divers without redundant air sources, e.g., octopus or pony system, so buddy breathing skills are necessary.

The Advisory Committee, as an added precaution, has developed the following guidelines for teaching buddy breathing:

  1. Buddy Breathing should only be performed in the water. Dry runs (passing the regulator from mouth to mouth) out of the water must be avoided.
  2. Students should not be required to perform buddy breathing with everyone in the class. If they object, they may elect to perform this skill with one or two of their fellow students. They should definitely demonstrate their proficiency in the technique with the instructor.
  3. Prior to the actual performance of the skill, the instructor should advise his class that any student with mouth sores, mouth or lip bleeding, or respiratory infections should excuse themselves from the activity until they are well.”

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