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Steele S, Brahmbhatt S, Patel D. Swimming-Induced Pulmonary Edema: Evaluation, Diagnosis, and Treatment. Curr Sports Med Rep 2024; 23:124-129. [PMID: 38578489 DOI: 10.1249/jsr.0000000000001157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
ABSTRACT Swimming-induced pulmonary edema (SIPE) is a rare but life-threatening acute illness that can occur in otherwise healthy athletes and individuals. Also known as immersion pulmonary edema, SIPE presents in swimmers, snorkelers, and SCUBA divers. It occurs in persons under heavy exertion in cold water temperatures, leading to coughing, shortness of breath, and sometimes blood-tinged sputum. Under these conditions, there is increased pulmonary vascular pressure, which may ultimately lead to pulmonary edema. This article synthesizes the latest data on the prevalence, pathophysiology, etiology, risks, short- and long-term complications, and the efficacy of supportive medical treatment interventions.
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Affiliation(s)
- Stephen Steele
- Eisenhower Health Sports Medicine Fellowship, George and Julia Argyros Health Center, La Quinta, CA
| | - Sunny Brahmbhatt
- Eisenhower Health Sports Medicine Fellowship, Eisenhower Medical Center, Rancho Mirage, CA
| | - Devak Patel
- Eisenhower Health Sports Medicine Fellowship, Eisenhower Medical Center, Rancho Mirage, CA
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Wolff D, Castagna O, Morin J, Lehot H, Roffi R, Druelle A, Blatteau JÉ. Characterizing Immersion Pulmonary Edema (IPE): A Comparative Study of Military and Recreational Divers. SPORTS MEDICINE - OPEN 2023; 9:108. [PMID: 37979071 PMCID: PMC10657341 DOI: 10.1186/s40798-023-00659-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 11/13/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Immersion Pulmonary Edema (IPE) is a common and potentially serious diving accident that can have significant respiratory and cardiac consequences and, in some cases, be fatal. Our objective was to characterize cases of IPE among military trainees and recreational divers and to associate their occurrence with exposure and individual background factors such as age and comorbidity. We conducted a retrospective analysis on the medical records and diving parameters of all patients who were treated for IPE at the Hyperbaric Medicine Department of Sainte-Anne Military Hospital in Toulon, France, between January 2017 and August 2019. In total, 57 subjects were included in this study, with ages ranging from 20 to 62 years. These subjects were divided into two distinct groups based on exposure categories: (1) underwater/surface military training and (2) recreational scuba diving. The first group consisted of 14 individuals (25%) with a mean age of 26.5 ± 2.6 years; while, the second group comprised 43 individuals (75%) with a mean age of 51.2 ± 7.5 years. All divers under the age of 40 were military divers. RESULTS In 40% of cases, IPE occurred following intense physical exercise. However, this association was observed in only 26% of recreational divers, compared to 86% of military divers. Among civilian recreational divers, no cases of IPE were observed in subjects under the age of 40. The intensity of symptoms was similar between the two groups, but the duration of hospitalization was significantly longer for the recreational subjects. CONCLUSION It seems that the occurrence of IPE in young and healthy individuals requires their engagement in vigorous physical activity. Additionally, exposure to significant ventilatory constraints is a contributing factor, with the intensity of these conditions seemingly exclusive to military diving environments. In contrast, among civilian recreational divers, IPE tends to occur in subjects with an average age twice that of military divers. Moreover, these individuals exhibit more prominent comorbidity factors, and the average level of environmental stressors is comparatively lower.
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Affiliation(s)
- Dorian Wolff
- SAMU 95, Hôpital NOVO, Pontoise, France
- Emergency Department Begin Military Hospital (HIA Begin), Saint-Mandé, France
| | - Olivier Castagna
- Underwater research team-ERRSO, Military Biomedical Research Institute-IRBA, Toulon, France.
- LAMHESS (UPR 6312, Université de Nice, Nice, France.
- Diving Medicine Consultation Services and Hyperbaric Chamber, Ste Anne Military Hospital (HIA Ste Anne), Toulon, France.
| | - Jean Morin
- Diving Medicine Consultation Services and Hyperbaric Chamber, Ste Anne Military Hospital (HIA Ste Anne), Toulon, France
| | - Henri Lehot
- Diving Medicine Consultation Services and Hyperbaric Chamber, Ste Anne Military Hospital (HIA Ste Anne), Toulon, France
| | - Romain Roffi
- Diving Medicine Consultation Services and Hyperbaric Chamber, Ste Anne Military Hospital (HIA Ste Anne), Toulon, France
| | | | - Jean-Éric Blatteau
- Diving Medicine Consultation Services and Hyperbaric Chamber, Ste Anne Military Hospital (HIA Ste Anne), Toulon, France
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Kristiansson L, Seiler C, Lundeqvist D, Braman Eriksson A, Sundh J, Hårdstedt M. Symptom Duration, Recurrence, and Long-Term Effects of Swimming-Induced Pulmonary Edema: A 30-Month Follow-Up Study. Chest 2023; 164:1257-1267. [PMID: 37414334 PMCID: PMC10635841 DOI: 10.1016/j.chest.2023.06.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 06/28/2023] [Accepted: 06/29/2023] [Indexed: 07/08/2023] Open
Abstract
BACKGROUND Swimming-induced pulmonary edema (SIPE) has been reported to subside within 24 to 48 h, but comprehensive follow-up studies on symptom duration and long-term effects are missing. RESEARCH QUESTION What are the symptom duration, recurrence, and long-term effects of SIPE? STUDY DESIGN AND METHODS A follow-up study was conducted, based on 165 cases of SIPE from Sweden's largest open-water swimming event with 26,125 individuals participating during 2017-2019. Data on patient characteristics, clinical findings, and symptoms were collected at admission. Telephone interviews at 10 days and 30 months were performed to explore symptom duration, recurrence of SIPE symptoms, need for medical evaluation, and long-term effects of self-assessed general health and physical activity level. RESULTS Follow-up at 10 days was performed for 132 cases and at 30 months for 152 cases. Most of the patients were women, and their mean age was 48 years. At the 10-day follow-up, symptom duration > 2 days after the swimming race was reported by 38%. The most common symptoms were dyspnea and cough. In patients at 30-month follow-up, recurrence of respiratory symptoms during open-water swimming was reported by 28%. In multivariable logistic regression, asthma was independently associated with both symptom duration > 2 days and recurrence of SIPE symptoms (P = .045 and P = .022, respectively). Most participants reported equal or improved general health (93%) and physical activity level (85%) after experiencing SIPE, but 58% had not swum in open water since the event. INTERPRETATION The present large cohort study challenges the established hallmark of SIPE symptom duration < 48 h, whereas SIPE recurrence was in the previously reported range. At 30 months, most patients reported unchanged self-assessed general health and physical activity level. These findings add to our understanding of the course of SIPE and can provide evidence-based information to swimmers and health care professionals.
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Affiliation(s)
- Linda Kristiansson
- Center for Research and Development, Uppsala University/Region Gävleborg, Gävle, Sweden; School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; Sandviken North Primary Health Care Center, Sandviken, Sweden.
| | - Claudia Seiler
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; Center for Clinical Research, Dalarna-Uppsala University, Falun, Sweden; Department of Anesthesiology and Intensive Care, Falun Hospital, Falun, Sweden
| | | | | | - Josefin Sundh
- Department of Respiratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Maria Hårdstedt
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; Center for Clinical Research, Dalarna-Uppsala University, Falun, Sweden; Vansbro Primary Health Care Center, Vansbro, Sweden
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Moon RE. Swimming-Induced Pulmonary Edema: Imperative to Follow Up. Chest 2023; 164:1077-1078. [PMID: 37945188 DOI: 10.1016/j.chest.2023.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 08/09/2023] [Indexed: 11/12/2023] Open
Affiliation(s)
- Richard E Moon
- Department of Anesthesiology; Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Medical Center, Durham, NC.
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Abstract
Pulmonary physiology is significantly altered during underwater exposure, as immersion of the body and increased ambient pressure elicit profound effects on both the cardiovascular and respiratory systems. Thoracic blood pooling, increased breathing gas pressures, and variations in gas volumes alongside ambient pressure changes put the heart and lungs under stress. Normal physiologic function and fitness of the cardiovascular and respiratory systems are prerequisites to safely cope with the challenges of the underwater environment when freediving, or diving with underwater breathing apparatus. Few physicians are trained to understand the physiology and medicine of diving and how to recognize or manage diving injuries. This article provides an overview of the physiologic challenges to the respiratory system during diving, with or without breathing apparatus, and outlines possible health risks and hazards unique to the underwater environment. The underlying pathologic mechanisms of dive-related injuries are reviewed, with an emphasis on pulmonary physiology and pathophysiology.
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Affiliation(s)
- Kay Tetzlaff
- Department of Sports Medicine, University Hospital of Tuebingen, Tuebingen, Germany
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Hårdstedt M, Seiler C. Swimming-Induced Pulmonary Edema: Respiratory Pathogens as a Potential Risk Factor. Chest 2023; 163:1009-1010. [PMID: 37164569 DOI: 10.1016/j.chest.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 01/03/2023] [Indexed: 05/12/2023] Open
Affiliation(s)
- Maria Hårdstedt
- Center for Clinical Research Dalarna-Uppsala University, Falun, Sweden; School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; Vansbro Primary Health Care Center, Vansbro, Sweden.
| | - Claudia Seiler
- Center for Clinical Research Dalarna-Uppsala University, Falun, Sweden; School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; Department of Anesthesiology and Intensive Care, Falun Hospital, Falun, Sweden
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Rigler C, Menon G, Lipworth S, Langrish JP, Kipps C, Shanmuganathan M, Smith R. Case Series of Triathletes with Takotsubo Cardiomyopathy Presenting with Swimming-Induced Pulmonary Edema. TRANSLATIONAL SPORTS MEDICINE 2022; 2022:3602505. [PMID: 38655156 PMCID: PMC11022776 DOI: 10.1155/2022/3602505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 08/09/2022] [Indexed: 04/26/2024]
Abstract
Objectives To report three cases of triathletes who presented with swimming-induced pulmonary edema (SIPE) following water immersion. They were subsequently diagnosed with Takotsubo cardiomyopathy (TCM). Design Retrospective case series. Method All cases were recreational athletes competing in mass participation triathlons between June 2018 and 2019. They were initially managed by the event medical team and subsequently at the local tertiary level hospital. Written consent was gained from all the subjects. Results The three triathletes were aged between 50 and 60 years, two were females, and all presented with acute dyspnoea on exiting the water. Two also presented with chest pain and haemoptysis. A diagnosis of SIPE was suspected by the medical event team on initial presentation of low oxygen saturations and clinical signs of pulmonary oedema. All were transferred to the local emergency department and had signs of pulmonary oedema on chest radiographs. Further investigations led to a diagnosis of TCM with findings of T wave inversion in anterolateral electrocardiogram leads and apical hypokinesia on transthoracic echocardiogram and unobstructed coronary arteries. Conclusions This case series presents triathletes diagnosed with SIPE and TCM following the open water swim phase. It is unclear whether the myocardial dysfunction contributed to causation of SIPE or was the result of SIPE. Mass participation race organizers must be prepared that both SIPE and TCM can present in this population. Those presenting with an episode of SIPE require prompt evaluation of their cardiac and pulmonary physiology. Further research is required to ascertain the exact nature of the relationship between TCM and SIPE.
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Affiliation(s)
- Caitlin Rigler
- Department of Sport and Exercise Medicine, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Gautam Menon
- Department of Sport and Exercise Medicine, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Samuel Lipworth
- Emergency Department, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Jeremy P Langrish
- Department of Cardiology, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Courtney Kipps
- Institute of Sport, Exercise and Health, Division of Surgery and Interventional Sciences, University College London, London, UK
| | - Mayooran Shanmuganathan
- Department of Cardiology, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Ralph Smith
- Department of Sport and Exercise Medicine, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford, UK
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Tetzlaff K, Swenson ER, Bärtsch P. An update on environment-induced pulmonary edema – “When the lungs leak under water and in thin air”. Front Physiol 2022; 13:1007316. [PMID: 36277204 PMCID: PMC9585243 DOI: 10.3389/fphys.2022.1007316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 09/08/2022] [Indexed: 11/16/2022] Open
Abstract
Acute pulmonary edema is a serious condition that may occur as a result of increased hydrostatic forces within the lung microvasculature or increased microvascular permeability. Heart failure or other cardiac or renal disease are common causes of cardiogenic pulmonary edema. However, pulmonary edema may even occur in young and healthy individuals when exposed to extreme environments, such as immersion in water or at high altitude. Immersion pulmonary edema (IPE) and high-altitude pulmonary edema (HAPE) share some morphological and clinical characteristics; however, their underlying mechanisms may be different. An emerging understanding of IPE indicates that an increase in pulmonary artery and capillary pressures caused by substantial redistribution of venous blood from the extremities to the chest, in combination with stimuli aggravating the effects of water immersion, such as exercise and cold temperature, play an important role, distinct from hypoxia-induced vasoconstriction in high altitude pulmonary edema. This review aims at a current perspective on both IPE and HAPE, providing a comparative view of clinical presentation and pathophysiology. A particular emphasis will be on recent advances in understanding of the pathophysiology and occurrence of IPE with a future perspective on remaining research needs.
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Affiliation(s)
- Kay Tetzlaff
- Medical Clinic, Department of Sports Medicine, University of Tübingen, Tübingen, Germany
- *Correspondence: Kay Tetzlaff,
| | - Erik R. Swenson
- Department of Medicine, University of Washington, Seattle, WA, United States
- Division of Pulmonary Medicine and Critical Care, University of Washington, Seattle, WA, United States
| | - Peter Bärtsch
- Department of Internal Medicine, University of Heidelberg, Heidelberg, Germany
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Barouch LA. Swimming-Induced Pulmonary Edema. JACC Case Rep 2022; 4:1094-1097. [PMID: 36124149 PMCID: PMC9481897 DOI: 10.1016/j.jaccas.2022.05.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/27/2022] [Accepted: 05/19/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Lili A. Barouch
- Address for correspondence: Dr Lili A. Barouch, Johns Hopkins University School of Medicine, Department of Medicine, Division of Cardiology, 5450 Knoll North Drive, Suite 170, Columbia, Maryland 21045, USA. @LiliBarouch
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Wilmshurst P. Swimming-Induced Pulmonary Edema. Chest 2022; 162:277-278. [DOI: 10.1016/j.chest.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 04/06/2022] [Indexed: 11/26/2022] Open
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Seiler C, Kristiansson L, Klingberg C, Sundh J, Braman Eriksson A, Lundeqvist D, Nilsson KF, Hårdstedt M. Swimming-Induced Pulmonary Edema: Evaluation of Prehospital Treatment With CPAP or Positive Expiratory Pressure Device. Chest 2022; 162:410-420. [PMID: 35288117 PMCID: PMC9424325 DOI: 10.1016/j.chest.2022.02.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/22/2022] [Accepted: 02/23/2022] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Swimming-induced pulmonary edema (SIPE) occasionally occurs during swimming in cold open water. Although optimal treatment for SIPE is unknown, non-invasive positive pressure ventilation (NPPV) is an option for prehospital treatment. RESEARCH QUESTION Is NPPV a feasible and safe prehospital treatment for SIPE, and which outcome measures reflect recovery after treatment? STUDY DESIGN AND METHODS A prospective observational study was conducted at Vansbrosimningen, Sweden's largest open water swimming event, from 2017 through 2019. Swimmers with a diagnosis of SIPE and with peripheral oxygen saturation (Spo2) of ≤ 95%, persistent respiratory symptoms, or both were eligible for the study. NPPV was administered on site as CPAP by facial mask or as positive expiratory pressure (PEP) by a PEP device. Discharge criteria were Spo2 of > 95% and clinical recovery. Four outcome measures were evaluated: Spo2, crackles on pulmonary auscultation, pulmonary edema on lung ultrasound (LUS), and patient-reported respiratory symptoms. RESULTS Of 119 treated individuals, 94 received CPAP, 24 received treatment with a PEP device, and one required tracheal intubation. In total, 108 individuals (91%) were discharged after NPPV for a median of 10 to 20 min and 11 individuals (9%) required hospital transfer. NPPV resulted in increased Spo2 from a median of 91% to 97% (P < .0001) together with improvement of six patient-reported respiratory symptoms (median numerical rating scales, 1-7 to 0-1; P < .0001). No significant decrease in auscultation of crackles (93% vs 87%; P = .508) or pulmonary edema on LUS (100% vs 97%; P = .500) was seen during NPPV treatment. INTERPRETATION NPPV administered as CPAP or via a PEP device proved feasible and safe as prehospital treatment for SIPE with a vast majority of patients discharged on site. Spo2 and patient-reported respiratory symptoms reflected recovery after treatment, whereas pulmonary auscultation or LUS findings did not.
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Affiliation(s)
- Claudia Seiler
- Department of Anesthesiology and Intensive Care, Falun Hospital, Falun, Sweden; Center for Clinical Research Dalarna-Uppsala University, Falun, Sweden; School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
| | - Linda Kristiansson
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; Sandviken North Primary Health Care Center, Sandviken, Sweden; Center for Research and Development, Uppsala University/Region Gävleborg, Gävle, Sweden
| | - Cecilia Klingberg
- Department of Anesthesiology and Intensive Care, Falun Hospital, Falun, Sweden
| | - Josefin Sundh
- Department of Respiratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | | | | | - Kristofer F Nilsson
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Maria Hårdstedt
- Center for Clinical Research Dalarna-Uppsala University, Falun, Sweden; School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; Vansbro Primary Health Care Center, Vansbro, Sweden
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Swimming-Induced Pulmonary Edema: New Data Sheds a Light on True Incidence. Chest 2021; 160:1594-1595. [PMID: 34743842 DOI: 10.1016/j.chest.2021.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 07/08/2021] [Indexed: 11/21/2022] Open
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