beta blockers

[kruddis]

Dear All

46-year-old publican came to see me today, 2 weeks after returning from a Greek diving holiday. He told me he had been ‘tight chested’ since he dived to 18 m then came up to 5 m but had trouble descending again over a rock wall. He said the instructor had taken some weights off his belt. So in order to descend he exhaled and let air out of his apparatus, then became short of breath. He returned to the surface slowly. Then coughed for 2 hours coughing up pink frothy sputum. He has not dived since

He is hypertensive treated with bendroflumethiazide and atenolol (beta blocker).

On examination chest was clear SaO2 98% Pulse 76, no temp, PEF 450 l/min

I gave him a peak flow meter and arranged a CXR

What is the likely diagnosis?

 

[Charlie99]

www.diversalertnetwork.org and www.daneurope.org are good sources of reliable diving-related medical information and consultations.

Both websites have both 24hr/day emergency phone numbers, and routine info phone numbers that are staffed during normal workdays.

 

[DivesWithTurtles]

1. I am not a doctor and I don't know squat.

2. I agree with Charlie; Call DAN.

3. It's Immersion Induced Pulmonary Oedema.

 

[Dr Deco]

Immersion-induced pulmonary edema does seem like a good prospect.

References :book3:

Koehle MS, Lepawsky M, McKenzie DC. Pulmonary oedema of immersion.
Sports Med. 2005;35(3):183-90. Review.

Lund KL, Mahon RT, Tanen DA, Bakhda S. Swimming-induced pulmonary edema. Ann Emerg Med. 2003 Feb;41(2):251-6.

Mahon RT, Kerr S, Amundson D, Parrish JS. Immersion pulmonary edema in special forces combat swimmers. Chest. 2002 Jul;122(1):383-4.

Slade JB Jr, Hattori T, Ray CS, Bove AA, Cianci P. Pulmonary edema associated with scuba diving : case reports and review. Chest. 2001 Nov;120(5):1686-94. Review.

 

[mart1]

He is hypertensive treated with bendroflumethiazide and atenolol (beta blocker).

He should not have been diving with this medication in the first place

 

[DocVikingo]

I concur with DivesWithTurtles and Dr Deco that the diver's symptoms and signs are very consistent with immersion-induced pulmonary edema. If this is the dx, peak flow meter testing and CXR performed weeks after the event almost certainly will be negative in an otherwise healthy individual. In any event, a thorough work up for cardiac disease appears prudent.

Mart1 states: "He should not have been diving with this medication in the first place."

The combination regimen of a beta blocker and thiazide diuretic indeed does increase risk during scuba. Inability to meet the possible exertional demands of diving and to stay adequately hydrated rank high among these.

Clearance of the diver on such a drug regimen would at the least require the ability to: (1) tolerate exercise stress testing without chest pain, elevation of blood pressure, abnormal alterations in EKG/arrhythmias or fainting and (2) avoid postural hypotension, low blood potassium and dehydration.

This is educational only and does not constitute or imply a doctor-patient relationship. It is not medical advice with you or any other individual and should not be construed as such.

Regards,

DocVikingo

 

[AggieDad]

I concur with DivesWithTurtles and Dr Deco that the diver's symptoms and signs are very consistent with immersion-induced pulmonary edema. If this is the dx, peak flow meter testing and CXR performed weeks after the event almost certainly will be negative in an otherwise healthy individual. In any event, a thorough work up for cardiac disease appears prudent.

Mart1 states: "He should not have been diving with this medication in the first place."

The combination regimen of a beta blocker and thiazide diuretic indeed does increase risk during scuba. Inability to meet the possible exertional demands of diving and to stay adequately hydrated rank high among these.

Clearance of the diver on such a drug regimen would at the least require the ability to: (1) tolerate exercise stress testing without chest pain, elevation of blood pressure, abnormal alterations in EKG/arrhythmias or fainting and (2) avoid postural hypotension, low blood potassium and dehydration.

This is educational only and does not constitute or imply a doctor-patient relationship. It is not medical advice with you or any other individual and should not be construed as such.

Regards,

DocVikingo

I understand the combination of drugs might have the potential to cause a problem but individually, what are your thoughts? I take 25mg Attenolol daily which gives me a resting heart rate of 55. I exercise almost daily, cardio with some weights, swimming etc. I am overweight. I take a FAA physical every six months with an EKG once per year. BP stays around 110/70 with an occasional drop to 100/55. Does attenolol alone preclude a clearance for diving?
I have been cleared by several doctors but am always open to any advice.

 

[SeaHorseWoman]

bro, how did you know this? you never cease to amaze me.

 

[DocVikingo]

Hi AggieDad,

The diver who has uncomplicated hypertension that is well controlled by a small daily dose of a beta-adrenergic blocker and:

(1) shows no significant adverse reactions to the medication;

(2) is able to engage in regular vigorous physical activity without chest pain, shortness of breath, significant change in blood pressure, dizziness, fainting or other worrisome responses;

(3) passes a full FAA physical every 6 months;

(4) undergoes an annual EKG without abnormal results;

(5) has been cleared for scuba by multiple, knowledgeable physicians;

(6) has no other physical or mental disorders that pose issues for diving;

(7) has been diving without medical incident; and,

(8) feels up for scuba

...would have no apparent reason for concern about meaningfully increased risks to diving from taking 25 mg of atenolol per day.

The diver who wished to undergo additional evaluation could discuss with his physician the possible value of exercise stress testing. Ideally, he would want to achieve 13 METS without problems.

This is educational only and does not constitute or imply a doctor-patient relationship. It is not medical advice with you or any other individual and should not be construed as such.

Regards,

DocVikingo

 

[pescador775]

Atenolol can constrict blood vessels and that is a potential problem. However, 25 mg for a large man might be OK, it is a relatively small dose. One test would be whether the male can get an erection. Heart output can be reduced by Beta blockers. Exercise tolerance suffers as a result. Just something to be aware of. Diuretics sound to me like death awaiting. A diver must remain hydrated. I don't know about the pink froth. Sounds like some aveoli and/or capillaries ruptured.

I have never seen pulmonary edema in divers but evidently, it does happen, reported more often in competitive swimmers than divers. After reading some of the referenced papers, it does seem that Beta blockers could play a role in precipitating the appearance of pink froth. No proof, just a hunch. Constriction of capillaries aggravating the cold water effects of pooling in the core, both causing excess pressure in the lung's blood vessels. Moreover, pressure differentials related to the diver's posture in the water could add to the problem. All very speculative and interesting.
http://www.chestjournal.org/cgi/content/full/126/2/394