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was experiencing a little known malady I had recently
read about and had witnessed before. His rapid
improvement further corroborated my theory that he
was experiencing immersion pulmonary edema (IPE).
IPE, which is abnormal leakage of fluid from the
bloodstream into the alveoli during immersion, can
occur in anyone immersed in water, even swimmers. The
injured swimmer or diver develops a cough, has difficulty
breathing, develops raspy breathing and often spits up
frothy, blood-tinged liquid from the lungs. The symptoms
may suddenly become acute when the person surfaces,
because this represents the point of greatest ambient
pressure differential between the mouth and the chest.
IPE has been reported in healthy, young individuals such
as triathletes and combat swimmers as well as across the
entire spectrum of the diving community, including people
with reported heart and lung conditions. The onset may be
very rapid or may develop over time and can even worsen
over the course of daily, repeated immersion. During
immersion, especially in cold water, blood is redistributed
from the extremities to the lungs. When the victim is no
longer in the water this edema gradually subsides.
When a diver or swimmer has difficulty breathing,
they may panic, aspirate water and possibly drown. A
diver may skip decompression obligations or ascend
rapidly and experience additional barotrauma. For
this reason, and because the symptoms can resolve
rapidly once the diver is out of the water (often before
reaching the dock or hospital), this phenomenon may
be underreported and often misdiagnosed. Whether
considered a panic attack or a result of ill-fitting or
malfunctioning gear, cases of IPE may be completely
overlooked. Despite the fact that our boat included
safety officers, first responders, dive instructors and
other experts, few of them had ever heard of IPE.
Studies have revealed that several external factors,
including cold water, exercise and high work of
breathing, may create the perfect IPE scenario.
Numerous internal factors, such as hypertension,
other cardiac issues, cardiovascular disease and
excessive hydration, may also increase the likelihood of
experiencing IPE. Some people seem to be susceptible
to IPE; these people include, surprisingly, elite athletes as
well as people with known cardiac and pulmonary issues.
IPE is diagnosed by exclusion (ruling out other
possibilities), so it is vital that anyone experiencing
symptoms seeks immediate medical attention. Other
conditions that could cause similar symptoms, such
as a heart attack or DCI, need to be considered first.
Hyperbaric treatment is not needed for IPE, and
symptoms generally resolve completely in 24-48 hours.
Follow-up care involves medical assessment by a
physician (one trained in dive medicine, if possible) who
can rule out any other issues that need addressing and
look for conditions that may contribute to future IPE
susceptibility before recommending a return to diving.
I’m happy to report that within six hours of the
emergency’s onset, our victim transitioned from his
dive accident to socializing with friends at the end of a
long day. In between was an evacuation, an ambulance
ride, an emergency room assessment, tests and a visit
with a hyperbaric specialist. It was great to have a good
ending to this very serious event, being in the company
of good dive buddies, who all played an important role
in our friend’s rescue and treatment.
Another positive aspect of this experience was the
realization that we were properly prepared to handle a
diving emergency. The boat crew were well trained and
equipped with oxygen and first-aid equipment. Rescuers
stayed calm and levelheaded, as did the victim, who
got himself safely to the surface without missing his
decompression obligations or making a rapid ascent.
This incident highlights the importance of training,
diving research and education. It is foolish, in my
experienced opinion, to dive without DAN dive
accident insurance; even if you never use it, you will be
supporting important work that helps our community
better understand and mitigate diving risks.
AD
References
Moon RE, Martina SD, Peacher DF, et al. Swimming-induced pulmonary edema pathophysiology and risk
reduction with sildenafil. Circulation 2016; 133(10):988-96. doi: 10.1161/circulationaha.115.019464.
Peacher DF, Martina SD, Otteni CE, et al. Immersion pulmonary edema and comorbidities: case series and
updated review. Med Sci Sports Exerc. 2015; 47(6):1128-34. doi: 10.1249/mss.0000000000000524.
Wester TE, Cherry AD, Pollock NW, et al. Effects of head and body cooling on hemodynamics during
immersed prone exercise at 1 ATA. J Appl Physiol 2009; 106:691–700. doi: 10.1152/japplphysiol.91237.2008
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