Vibenz
Registered
Anyone here that can shed some light on the causes and risks of Immersion Pulmonary Edema? Are there risk factors to be aware of and does a person having experienced it have a greater risk of experiencing it again?
Question Acute Immersion Pulmonary Edema
- Thread starter Vibenz
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Immersion Pulmonary Edema
Immersion pulmonary edema (IPE) is observed in swimmers and divers with no apparent underlying medical condition. Our experts answer your IPE questions.
dan.org
I had a student hit by this on her first checkout dive. I think I posted on here somewhere, since she gave me permission to share details.
She ended up seeing multiple docs, including one DAN recommended, to evaluate her fitness for future training. The upshot in her case was that she should never dive again, and especially not in cold water.
I didn't read the link @smiffy6four posted, but assumes it covers the basics of risk (older folks, colder water, women more than men, poor physical condition, cardiopulmonary health issues, etc.). For what it's worth, my student wasn't quite the prototype for risk. She was female, which has a higher risk. She was 37 years old at the time, so not really old enough to be in the highest risk groups. She was not out of shape. She was training for a half-marathon, ran one two weeks after the incident, and won her age group in one a month later.
In her case, I suspect the issue was she was very long and lean. As her extremities cooled, blood pooled in her core more than it would for most folks. This created the elevated pulmonary blood pressure that pushed fluid into her lungs.
TBH, I think I (as an instructor) got lucky in her case. At the surface, I'm guessing her oxygen saturation was around 75%. It was measured at 80% when medics arrived, after being on the surface for perhaps 15 minutes and on oxygen for at least 10 minutes. And after having cleared a lot of liquid from her lungs. Her faring well (IMHO) depended on the following:
1. She was in awesome physical condition at the time, in terms of aerobic capacity. I'm guessing that (for perhaps multiple reasons I'd be speculating wildly about, since I'm not an MD) helped keep her conscious and functional.
2. Signs and symptoms hit at the surface, not underwater. (As soon as she hit the surface she started spewing out yellowish-brown foam. In large volume.
3. I was not at the max limit for students, and had a DM with me.
4. I had competent students who could assist on shore (e.g., call 9-1-1, keep an eye on the victim while I jettison my gear and grab the oxygen, etc.).
5. As an instructor/DM/student group, we handled it "right." If you want details, I think they're posted somewhere. If not, I'm happy to tell you what we did.
She ended up seeing multiple docs, including one DAN recommended, to evaluate her fitness for future training. The upshot in her case was that she should never dive again, and especially not in cold water.
I didn't read the link @smiffy6four posted, but assumes it covers the basics of risk (older folks, colder water, women more than men, poor physical condition, cardiopulmonary health issues, etc.). For what it's worth, my student wasn't quite the prototype for risk. She was female, which has a higher risk. She was 37 years old at the time, so not really old enough to be in the highest risk groups. She was not out of shape. She was training for a half-marathon, ran one two weeks after the incident, and won her age group in one a month later.
In her case, I suspect the issue was she was very long and lean. As her extremities cooled, blood pooled in her core more than it would for most folks. This created the elevated pulmonary blood pressure that pushed fluid into her lungs.
TBH, I think I (as an instructor) got lucky in her case. At the surface, I'm guessing her oxygen saturation was around 75%. It was measured at 80% when medics arrived, after being on the surface for perhaps 15 minutes and on oxygen for at least 10 minutes. And after having cleared a lot of liquid from her lungs. Her faring well (IMHO) depended on the following:
1. She was in awesome physical condition at the time, in terms of aerobic capacity. I'm guessing that (for perhaps multiple reasons I'd be speculating wildly about, since I'm not an MD) helped keep her conscious and functional.
2. Signs and symptoms hit at the surface, not underwater. (As soon as she hit the surface she started spewing out yellowish-brown foam. In large volume.
3. I was not at the max limit for students, and had a DM with me.
4. I had competent students who could assist on shore (e.g., call 9-1-1, keep an eye on the victim while I jettison my gear and grab the oxygen, etc.).
5. As an instructor/DM/student group, we handled it "right." If you want details, I think they're posted somewhere. If not, I'm happy to tell you what we did.
From the article in the link, quoting Dr. Doug Ebersole:
This experience led me believe that many of the people who suffered from immersion pumonary edema while they were diving were already suffering from pulmonay edema before they were diving and didn't realize it. The diving may have only exascerbated an existing condition.
Divers with conditions such as hypertension or underlying cardiovascular disease, especially those with weakened heart muscle function, are less able to tolerate these physiologic changes and are thus more prone to pulmonary edema.
I had a significant surgery a couple years ago, and in the extended recovery time I was expected to be prone to pulmonary edema, and so I was prescribed a diuretic. As I recovered, my bouts of pulmonary edema came and went, becoming less and less frequent. (BTW, no problems now.) When I was suffering from it, its effects varied, ranging from mildly out of breath to quite debilitating.This experience led me believe that many of the people who suffered from immersion pumonary edema while they were diving were already suffering from pulmonay edema before they were diving and didn't realize it. The diving may have only exascerbated an existing condition.
There is immersion pulmonary edema/swimming-induced pulmonary edema and then there is pulmonary edema brought on by immersion in someone with underlying medical conditions that increase the risk of pulmonary edema.
In anyone regardless of physical condition, immersion negates the effect of gravity on the blood in the intravascular space, which results in a net increase of fluid volume in the blood vessels in the torso. Cold water causes the blood vessels in the extremities to constrict and compounds this.
"Pure" (not a medical term) immersion pulmonary edema is most often seen in high-level athletes like military combat divers and triathletes. It is thought to be related to a combination of extremely high cardiac output and an underlying decreased vasodilatory response in the pulmonary arteries that would not declare itself outside of heavy in-water exercise. In other words, in some people, the pulmonary arteries don't dilate enough to accommodate the additional blood coming from a highly conditioned heart during heavy exercise while immersed, which increases the pressure in the arteries and can lead to pulmonary edema.
Immersion pulmonary edema can also occur in people with underlying medical conditions like congestive heart failure who may be relatively stable while outside of water. The effects of immersion tip them toward pulmonary edema. They may or may not have the above-mentioned blunted vasodilatory response in the pulmonary arteries.
Risk factors are primarily vigorous swimming in cold water. Other risk factors include being a triathlete or combat swimmer; and underlying cardio/cardiovascular conditions like CHF, hypertension, and cardiomyopathy. A person who has experienced immersion pulmonary edema is at high risk of it happening again.
Best regards,
DDM
clownfishsydney
Contributor
See an article I wrote about a friend who died on a dive I organised. At the bottom there are two links to some papers on IPE. Michael McFadyen's Scuba Diving Web Site
I'm sorry for your loss, even if over a decade ago. Carol's signs and symptoms on the surface and those of my student are eerily similar. I don't like to think about what would have happened if my student had done a longer dive: This was a class, and we had an "air hog" that forced us to minimize the tour portion.
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