Pulmonary oedema induced by strenuous swimming: a field study

Shupak, Avi; Weiler-Ravell, Daniel; Adir, Yochai; Daskalovic, Y; Ramon, Yitzchak; Kerem, D

doi:10.1016/s0034-5687(00)00109-2

Cited by 69 publications

(88 citation statements)

References 17 publications

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“…18 All were exercising at a high workload when they developed dyspnea and cough associated with production of pink frothy sputum.…”

Section: Swimming-induced Pulmonary Edemamentioning

confidence: 99%

“…17 Shupak et al described the development of acute pulmonary edema in healthy, highly trained military divers who were swimming in a long-distance competitive swim. 18 All were exercising at a high workload when they developed dyspnea and cough associated with production of pink frothy sputum. 19 Subsequent cardiac evaluation demonstrated normal cardiac function.…”

Section: Swimming-induced Pulmonary Edemamentioning

confidence: 99%

“…Since that report, numerous other reports of swimmers who developed pulmonary edema while swimming competitively have emerged. [20][21][22] All of the military swimmers reported by Schupak et al 18 had hydrated excessively prior to swimming to avoid dehydration during their long exposure. Miller et al reported on 70 subjects seen in their emergency department for treatment of swimming-induced pulmonary edema (SIPE).…”

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Pulmonary Aspects of Exercise and Sports

Bové

2016

Methodist DeBakey Cardiovascular Journal

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Although the lungs are a critical component of exercise performance, their response to exercise and other environmental stresses is often overlooked when evaluating pulmonary performance during high workloads. Exercise can produce capillary leakage, particularly when left atrial pressure increases related to left ventricular (LV) systolic or diastolic failure. Diastolic LV dysfunction that results in elevated left atrial pressure during exercise is particularly likely to result in pulmonary edema and capillary hemorrhage. Data from race horses, endurance athletes, and triathletes support the concept that the lungs can react to exercise and immersion stress with pulmonary edema and pulmonary hemorrhage. Immersion in water by swimmers and divers can also increase stress on pulmonary capillaries and result in pulmonary edema. Swimming-induced pulmonary edema and immersion pulmonary edema in scuba divers are well-documented events caused by the fluid shifts that occur with immersion, elevated pulmonary venous pressure during extreme exercise, and negative alveolar pressure due to inhalation resistance. Prevention strategies include avoiding extreme exercise, avoiding over hydration, and assuring that inspiratory resistance is minimized. Figure 1. Pulmonary capillary wedge pressure (PCWP) measured during increasing exercise intensity, determined by oxygen consumption (VO 2 ), in well-trained (circles) and average-trained (squares) men with a mean age of 29.6. Note that the well-trained subjects preserved normal levels of PCWP until they reached high levels of exercise, while the average-trained men demonstrated increases in PCWP at lower levels of exercise intensity. Adapted from Stickland et al. 4MDCVJ | XII (2) 2016 94 houstonmethodist.org/debakey-journal of interstitial hemorrhage and fluid accumulation following a high workload in one horse that developed EIPH. West et al. 9 suggested that two factors contributed to this problem in horses: (1) They were likely to have a congenital weakness of pulmonary capillaries that resulted in capillary rupture at high pulmonary venous and capillary pressure, and (2) they developed high pulmonary venous pressure due to failure of the left ventricle with subsequent elevation of LV end diastolic pressure during high workloads.Human studies of lung responses to high workloads 10 corroborate the studies of West et al. to some extent. Zavorsksy et al. 11 studied individuals under several different workloads and performed lung imaging to document the presence or absence of lung edema. Radiographic image readers were blinded to the exposures and reported visual evidence of lung fluid. In individuals undergoing a diagnostic graded exercise test, no evidence of lung edema was noted. However, 15% of individuals who ran on a treadmill at 70% of maximum capacity for 2 hours demonstrated evidence of pulmonary edema, as did 65% of those who ran at maximum capacity for 7 minutes. Similar findings were noted in female athletes.12 Pingitore et al. examined 48 athletes before and aft...

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“…18 All were exercising at a high workload when they developed dyspnea and cough associated with production of pink frothy sputum.…”

Section: Swimming-induced Pulmonary Edemamentioning

confidence: 99%

Section: Swimming-induced Pulmonary Edemamentioning

confidence: 99%

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confidence: 99%

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Pulmonary Aspects of Exercise and Sports

Bové

2016

Methodist DeBakey Cardiovascular Journal

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“…12 The mechanism by which cold-water immersion and exercise lead to a pulmonary capillary leak is probably related to a sudden increase in right ventricular preload and increased pulmonary artery pressures. [10][11][12][13] Increased preload is due to cold-induced venoconstriction, which can lead to an increase in the left ventricular afterload; and this, in turn, can contribute to pulmonary edema. Even if a swimmer is wearing a wetsuit, vasoconstriction can occur.…”

Section: Commentarymentioning

confidence: 99%

“…Even if a swimmer is wearing a wetsuit, vasoconstriction can occur. [10][11][12][13] Excessive volume loading before exercising may also play a role as 8 cases of SIPE were identified in military recruits who drank 5 L of water before exercise. 14 Interestingly, there have been no reports of SIPE in Olympic swimmers, but there is one case published of a triathelete who developed dyspnea with slight hypoxia and right-sided pulmonary crackles some 8-9 hours after the swim.…”

Section: Commentarymentioning

confidence: 99%

Answer

Deady

Glezos

Blackie

2006

CJEM

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T he correct answer to this Diagnostic Challenge is swimming-induced pulmonary edema (SIPE). Cardiogenic pulmonary edema is an unlikely diagnosis in this case. Even without knowing the results of serial troponin determinations, the diagnosis of acute myocardial infarction leading to severe congestive heart failure would be almost impossible with a normal ECG; and as indicated below. Of note, a delayed echocardiogram revealed a normal ejection fraction, suggesting a non-cardiogenic etiology.Food-associated, exercise-induced anaphylaxis has been described, 1 especially in teenaged women, and it can produce pulmonary edema; 2 however, this patient lacked wheals and gastrointestinal symptoms, as well as vascular collapse, which are key features of the syndrome.Cold urticaria may often involve the respiratory tract (hoarseness, dyspnea and wheezing), gastrointestinal and the cardiovascular systems (hypotension, tachycardia and arrhythmia), 3 and shock-like symptoms have been reported after aquatic exposures. 4,5 However, most typically patients with this condition develop diffuse pruritus and wheals with angioedema, 3 and our patient had none of these manifestations. CommentaryIn racing thoroughbreds, marked increases in pulmonary vascular pressures contribute to stress failure of pulmonary capillaries 6,7 causing lung bleeding. After brief, vigorous exercise in elite human athletes with a previous history suggestive of lung bleeding, increased concentrations of red blood cells and protein have been demonstrated in broncho-alveolar lavage fluid. These findings imply that intense exercise can impair the integrity of the pulmonary capillaries of the blood-gas barrier (BGB). 8 Chest CT scans of highly trained athletes after a triathlon competition demonstrated enhanced lung density and greater numbers of opacities suggesting an increase in pulmonary extravascular fluid. 9 Although rare in people exercising on land, pulmonary edema is more routinely reported in individuals participating in swimming or other immersion-related sports. 10 Adir and coworkers describe a series of 70 teen athletes who, over a 3-year period, developed SIPE. 10 All cases occurred in trainees who were swimming semi-reclined in warm https://www.cambridge.org/core/terms. https://doi

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Hyperbaric Conditions

Doolette

Mitchell

2010

Comprehensive Physiology

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Exposure to elevated ambient pressure (hyperbaric conditions) occurs most commonly in underwater diving, during which respired gas density and partial pressures, work of breathing, and physiological dead space are all increased. There is a tendency toward hypercapnia during diving, with several potential causes. Most importantly, there may be reduced responsiveness of the respiratory controller to rising arterial CO₂, leading to hypoventilation and CO₂ retention. Contributory factors may include elevated arterial PO₂, inert gas narcosis and an innate (but variable) tendency of the respiratory controller to sacrifice tight control of arterial CO₂ when work of breathing increases. Oxygen is usually breathed at elevated partial pressure under hyperbaric conditions. Oxygen breathing at modest hyperbaric pressure is used therapeutically in hyperbaric chambers to increase arterial carriage of oxygen and diffusion into tissues. However, to avoid cerebral and pulmonary oxygen toxicity during underwater diving, both the magnitude and duration of oxygen exposure must be managed. Therefore, most underwater diving is conducted breathing mixtures of oxygen and inert gases such as nitrogen or helium, often simply air. At hyperbaric pressure, tissues equilibrate over time with high inspired inert gas partial pressure. Subsequent decompression may reduce ambient pressure below the sum of tissue gas partial pressures (supersaturation) which can result in tissue gas bubble formation and potential injury (decompression sickness). Risk of decompression sickness is minimized by scheduling time at depth and decompression rate to limit tissue supersaturation or size and profusion of bubbles in accord with models of tissue gas kinetics and bubble formation and growth.

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Pulmonary oedema induced by strenuous swimming: a field study

Cited by 69 publications

References 17 publications

Pulmonary Aspects of Exercise and Sports

Pulmonary Aspects of Exercise and Sports

Answer

Hyperbaric Conditions

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