Asthma and diving

[stimpy4242]

I don't think that asthma and anaphylaxis are the same thing. Are they?

You could possibly argue that. However I belive myself there are two sides that are equally understandable. Asthma is caused by an irritation of the passageways, you could argue that anaphylaxis is a response to an allerge hence IgG. I guess you could say that anaphylaxis is a systemic response and asthma only a respiratory response?

On a side note it is argued that because of an increased HR due to epi, then there is an increased myocardial demand for oxygen in an already "hypoxic" patient. However that "negative effect" is quickly offset by the fact that the hypoxic patient quickly is able to increase oxygenation by having airways opened back up.

I continue to stress that epi is a bronchodilator:

The fastest way to relieve an asthma attack is with medicine that makes the airways widen; these medicines are known as bronchodilators. Your body can do this by itself by releasing adrenalinei, or epinephrine; this not only cause your heart to pump faster and stronger, but also makes the airways widen to allow more air to pass (this happens even if you are not an asthmatic -- it's part of the "fight or flight" response to danger that's built into all of us).

Asthma

Thats nearly a quote I almost said myself

 

[frogman159]

EPI pens as the PharmD pointed out are prescribed to asthmatics as a way to fight a sever asthma attack.

Oh, no I didn't!!! I was simply under the impression from an earlier post that one did not realize utility of IM epi- and my purpose was to educate that it is infact used and used safely.

There is no indication, or reason I can comprehend that an asthmatic would be prescribed one of these- outside of them having severe allergies. IM/SQ Epi is no where near 1st line treatment for acute asthma exacerbation

According to the references I frequent (Drug Facts and Comparission) SQ/IM is the route listed for asthma, however keep in mind this is so far down the treatment line, In all likelyhood the route (SQ, IM) probably doesn't matter much and your arguing nothing, if the doc if comfortable with SQ, so be it.

BTW there is no such thing as 1:1 epi- the dose would be so small you couldn't see it, if you could the potency would instantly kill someone on injection. Either you ment 1:1000 or 1mg/ml

 

[stimpy4242]

I meant 1:1000 typically referred to as 1:1 as opposed to 1:10 for 1:10,000 lets not get that particular...

I apologize, I know you did not say prescribe, my fault...although it is prescribed to them...

 

[frogman159]

I meant 1:1000 typically referred to as 1:1 as opposed to 1:10 for 1:10,000 lets not get that particular...

I apologize, I know you did not say prescribe, my fault...although it is prescribed to them...

I've never seen 1:10 either

It would be particular when you hear that long steady monotone beep from the tele monitor

That enough mental mastrubation for me

 

[ScubaDocER]

On a side note it is argued that because of an increased HR due to epi, then there is an increased myocardial demand for oxygen in an already "hypoxic" patient. However that "negative effect" is quickly offset by the fact that the hypoxic patient quickly is able to increase oxygenation by having airways opened back up.

I continue to stress that epi is a bronchodilator:

The fastest way to relieve an asthma attack is with medicine that makes the airways widen; these medicines are known as bronchodilators. Your body can do this by itself by releasing adrenalinei, or epinephrine; this not only cause your heart to pump faster and stronger, but also makes the airways widen to allow more air to pass (this happens even if you are not an asthmatic -- it's part of the "fight or flight" response to danger that's built into all of us).

Asthma

Thats nearly a quote I almost said myself

I had another post in response to this but deleted it and am now placing a new post. This one more accurately reflects what I believe. I think we may be saying similar things from a different perspective. My comments were made with regard to inhospital treatment. I believe yours were made regarding pre hospital treatment. In truth, there is wisdom in both of our perspectives. In the field I am sure paramedics use IM epi for the treatment of asthma. In the ED setting, it is a rarity. The side effects are just not worth it when we have access to medication that will accomplish the same goal while minimizing them. I will state again that I agree with you that Epi is a bronchodilator. I would also state that the circulating epi in your blood stream does not open up constricted airways. If that were the case, we would not need to give nebulized epi at all. We could just want for the circulating epi to get to the lungs and resolve the attack. The truth is that circulating epi is good in low doses and good for fight or flight responses. It does however increase heart rate as well as the work of breathing. It is epi in its nebulized form, which is more beta 2 selective that opens up the airways in asthmatics, not the circulating epi in the blood stream. That's why we don't inject epi into the blood stream of an asthmatic who is having an attack.. It would kill them. Epi is a powerul vasoconstrictor because of its effects on the alpha 1 receptors in the blood vessels. That's why it works in patients who are in shock. The nebulized form has similar effects, just not as strong because it is absorbed more slowly into the blood stream. Asthmatics are taught to use their nebulizers first when having an attack, not to grab an Epipen. Epipens are more useful in treating anaphylactic reactions than asthma attacks. The link that you put in your last most post has more information that you quoted. It also references the effects of Epi on the heart and it's dangerous consequences. That again is why the inhaled route remains the initial treatment of choice. Every paramedic that I have talked to and interacted with has used nebulized epi as their first line treatment. Could IM epi work? I suppose it could. It's just not the initial treatment for an acute attack.

I don't want to necessarily debate the merits of Epi, how it's used, and how it works. I would rather focus on how being educated about asthma and how the body works could affect divers with asthma and Instructors who chose to train them.

Let me approach it this way. If you are an Instructor who wishes to train a diver with asthma, then you should be educated about asthma and what to do in the event of an attack. Initially, if the attack begins underwater, you must get them to the surface. As dangerous as it is to ascend while having an attack, it is more so than leaving them at depth. Once they ascend, check for the presence of SQ emphysema, difficulty breathing, wheezing, or a tension pneumothroax. The Adam's apple will be shifted to one side. Ask for medical assistance IMMEDIATELY. Have someone call 911. A mild attack can become severe very quickly. Be prepared to administer CPR or treat this as you would any other medical emergency the way you learned in your Rescue class. ABC's. Make sure they have an open AIRWAY. Make sure they are BREATHING. Make sure that have CIRCULATING blood flow or a pulse. Know where your students medication is BEFORE you enter the water. I would have it where it can be accessed as easily as the surroundings will permit. Place the student on 100% oxygen. The more they are breathing the better. Be aware that compressed air has no moisture. Dehumidified air can make the attack worse. Try to calm the diver as much as possible. Stress can worsen the attack. There is no way to predict when an attack will occur. Be vigilant and watch for it to happen. If you don't anticipate it, it may overwhelm your student who is already extremely task loaded. Use good judgment. If the student is showing ANY signs of respiratory distress before the dive or after a dive, they should not be placed back in the water. It is a more serious gamble. Preparation and the knowledge of what to look for and what to do can be the difference between life and death.

This thread originally dealt with the management of asthma and diving. That should be its focus. I respect the views of anyone who chooses to express them. I will challenge those whose views I believe reflect erroneous and potentially dangerous information. Your views are not wrong, just coming from a different perspective. For asthmatics and Instructors I would want this thread to remain educational and informative. I look forward to returning to that.

 

[offthewall1]

Back to the original topic... and to gain information for those diving with or considering diving with asthma.

I believe it was indicated somewhere in this thread that once an asthma attack begins, the only way to relieve it is with some form of medical treatment... i.e an inhaler. It seems we can all agree there are three types of asthma... mild, moderate and severe.

Is this also the case for attacks? Meaning are there mild, moderate and severe attacks?

If so, in a mild attack and sometimes moderate... will the issue relieve itself without an inhaler? Is a rescue inhaler generally only needed during a severe attack?

I bring this up in getting back to my own diagnosis (I'll be a case study if you will.) My doctors have told me that my shortness of breath is asthma. I'm still not convinced.

On a recent dive day... I was diving in 41F degree water in a drysuit with a fairly restrictive latex neck seal. My breathing was fine throughout the entire dive. After a 35 minute dive, I exited the water. Immediately upon reaching the exit point and getting out of the water (air temp was about 38F degrees,) breathing got a little more difficult as I climbed up the rocks. I then had to walk up a steep hill wearing about 68 lbs of gear in the cold air with a tight latex neck seal. Halfway up the hill I was gasping for breath. By the time I made it to the top of the hill I could barely draw a breath in and had to sit down. After sitting down, my breathing slowly returned to normal and after about 2 minutes normal breathing had resumed without the use of an inhaler.

Is this asthma? Does it sound like cold induced asthma given the fact that I was fine throughout the dive breathing compressed air... but started having difficulty in the cold air exerting myself going up a hill with 68 lbs of gear - or does it indicate more that perhaps I'm not in the same shape I was 20 years ago? Is this asthma given I needed no inhaler to return to normal very quickly?

I'm not really asking for a diagnosis... but if I have asthma... wouldn't I need an inhaler to bring my breathing back to normal within 2 minutes of such an attack? Or can the body heal itself so quickly without intervention?

My objective in this whole thread is to let people know that short of having thorough testing done, a diagnosis of asthma may or may not be correct. You should push your doctor to thoroughly evaluate possible causes of difficulty breathing... not just accept "asthma" as a diagnosis without supportive testing. It may be something else - something as simple as being out of shape... or as serious as a heart issue.

My second point is that asthma is not an absolute NO for diving. Absent a valid diagnosis for myself, I still know many people with asthma who dive (and have for many many years - hundreds and some thousands of dives) without incident. It is important as has been stressed - to know your triggers and to sit out dives where there is any question about your current physical and mental condition.

I can not say enough about the professional postings on this thread. This is one of the best threads I have ever seen on scubaboard... so again... I thank you all.

 

[TSandM]

I don't think your symptoms sound like asthma. They sound like me Climbing a steep hill in gear is a lot of work! If you had the feeling that it was difficult to move air in and out of your lungs, while you were exercising, that would be more suggestive of asthma.

Asthma definitely comes in grades. Mild asthma (a minimimal amount of wheezing, without having to work hard, or drop your oxygen saturation) may remain fairly constant for days, without worsening or resolving. This is a frequent finding in patients with respiratory infections. It may also remit without treatment, over time. Severe asthma (patient experiencing respiratory distress, using chest and neck muscles to move air, very tight bronchospasm) will not remit without treatment.

What we don't know is how much bronchospasm you have to have before you're at risk for pulmonary barotrauma. That's the hard call. That's why the recommendation is that you have to be ASYMPTOMATIC to dive. And I'm sure it's also the reason that the recommendations say that you should be able to keep yourself asymptomatic without the use of rescue medications in order to dive.

And I have to say I have found this thread fascinating, because it appears that there is something on scubaboard that's more inflammatory than Spare Air, and that's IM epinephrine

 

[ScubaDocER]

I agree with TSandM that your symptoms do not sound consistent with asthma. You did not mention wheezing which is typically an aspect of asthma. It resolved spontaneously which is also a rarity. You are correct in that attacks can be categorized as mild, moderate, and severe. These are subjective designations clinically and reflect the asthmatics degree of distress and the likelihood that the attack will lead to respiratory failure. I also wanted to reiterate that mild, moderate, and severe descriptions are more of a dry land designation rather than one you can use underwater. Once you have BEGUN an attack at depth, I would categorize your situation as severe and emergent because of the inaccessibility of life saving treatment. It's not necessarily the amount of wheezing, but how close the asthmatic is to succumbing to actually not breathing, or the length of the attack itself. The problem is that the attack deprives the asthmatic of appropriate ventilation and promotes fatigue the longer it is sustained. I am sure that there are asthmatics whose attacks have stopped on their own. Almost all that I have seen clinically have required treatment. This of course does not include any asthmatic whose symptoms stopped early without treatment and did not seek medical attention. I cannot say that all attacks require treatment, only that all of the attacks that I have seen have required treatment. That is my concern regarding asthma and diving. I am not the scuba police and have no desire to tell people what they can and cannot do. I would however want to educate divers and Instructors about the dangers that exist and the realistic consequences of their choices before they actually get in the water. People will always find a way to do what they want to do. There are also people who just want to know the facts and be educated about their decisions. Others have asked why Instructors and the medical community have not always supported asthmatics and diving. I have tried to address that.

Offthewall1 : I would ask your doctor to set you up with a pulmonologist if you want a more definitive answer to your asthma question. I think they are best suited to say yeah or nay. Most asthmatics that I have seen have known that they have had asthma since they were little. Sometimes adults will develop a relative of asthma called reactive airway disease (RAD). This is not true asthma, but more of a predictable trigger that stimulates wheezing. Discuss the options with your doctor and pulmonologist and see if they can give you definitive answers. Not being in the same shape as your were 20 years ago is not asthma, just time that catches up with us all .

I did not intend for IM epi to be the new controversial topic . It's not really that much of a buzz word. Just became so through this thread. I am glad we are back on topic.

 

[aascubagirl]

What an educational thread for me as an instructor. I regularly encounter folks who have asthma, who think they might have asthma, who used to have asthma 15 years ago, all who want to dive. This thread helped to give me a better picture of the risks, even if there is a medical clearance, associated with an asthmatic diving. Many mahalos from someone in the field!

 

[offthewall1]

Not that anyone cares... but here are the results of a Pulmonary Function Test I just had done yesterday...

The doctor told me "I show no signs of having asthma or any other pulmonary issue."

This again is an interesting result for me. Three different doctors over the years diagnosed me with asthma... and stated that it was allergen induced. It seems however that since there was no sign of asthma whatsover - asthma (according to the pulmonologist) has never been a problem for me.

Apparently I can and do get severe allergies which cause restrictive breathing... not not true asthma.

I'm posting this as a note to all of you who have had a doctor say to you "You have asthma." If you have not had the pulmonary functions test done, there is at least a chance that you do not have asthma. You may have severe allergies or as others on the board have pointed out - bronchitis or some other type of problem.

While it was a relief to have the test done (which by the way is the easiest medical test I've ever had to do) leaving no excuse to put it off... it brings into question the competency of three medical professionals over the years - all whom diagnosed and treated me the same way (all wrong.) So in closing, I encourage you not to accept a diagnosis of asthma unless your doctor has ordered a pulmonary functions test. This ismple test will bring you closer to the truth.

Happy Diving!