Immersion Pulmonary Edema in dive accidents

[Thalassamania]

I know that most definitions say that IPE is "rare", but all these recent articles and studies seem to be questioning that.

Both of the last two issue of Divers' Alert Mag had IPE articles / stories.

Like I said, diagnosis de jure, what'll it be next week?

 

[InTheDrink]

Like I said, diagnosis de jure, what'll it be next week?

Somewhat trite, no?

The important part, to my mind at least, is that the treatment for IPE is different to treating other types of diving illness. Importantly, positive pressure respiration is a tool that needs to be in people's kit.

I appreciate that IPE does seem to be the new bogey man. But as someone who's had a hit and nearly didn't make it out I can appreciate that focus on this issue is not unwarranted. We mightn't get it right every time sure, but I firmly believe this condition isn't quite as rare as people currently think.

John

 

[Bubbletrubble]

During an emergency, I don't think most of us non-medical people would be trying to diagnose the situation. We would try to help the person the best we could by aborting the dive as safely as possible, administering continuous oxygen until EMS takes over, and performing CPR if necessary - exactly as many of us are trained. The emergency response to IPE is the same as to other diving incidents/illnesses - on our part.

Thank you for mentioning this. That should be the take-home message to the general diving audience regarding IPE.

So far, here's what we know about IPE in divers:

• It's a rare condition, yet probably somewhat underreported.
• We don't understand the pathogenetic mechanism which underlies the condition.
• As currently structured, first aid response guidelines would address IPE appropriately even in the absence of a definitive diagnosis.
• IPE in divers in many cases has been shown to be survivable, given the appropriate first aid response.

Considering the above, I don't think IPE warrants the increased attention we're seeing in this and other SB threads. Others are free to disagree with me on this point.

If a diver is having problems breathing, the course of action is clear: abort the dive, obtain first aid (if necessary), and seek professional medical attention. I don't think Joe Blow diver needs to know about the possibility of IPE to scare him into carrying out such actions. Breathing problems, caused by anything, are serious enough.

 

[InTheDrink]

Thank you for mentioning this. That should be the take-home message to the general diving audience regarding IPE.

So far, here's what we know about IPE in divers:

• It's a rare condition, yet probably somewhat underreported.
• We don't understand the pathogenetic mechanism which underlies the condition.
• As currently structured, first aid response guidelines would address IPE appropriately even in the absence of a definitive diagnosis.
• IPE in divers in many cases has been shown to be survivable, given the appropriate first aid response.

Considering the above, I don't think IPE warrants the increased attention we're seeing in this and other SB threads. Others are free to disagree with me on this point.

If a diver is having problems breathing, the course of action is clear: abort the dive, obtain first aid (if necessary), and seek professional medical attention. I don't think Joe Blow diver needs to know about the possibility of IPE to scare him into carrying out such actions. Breathing problems, caused by anything, are serious enough.

Hi Bubble,

As you know, I very much respect your opinion. I must however disagree with your post. Current treatment of dive illnesses does NOT cater for IPE, certainly not as is well understood by people with basic rescue training. I cannot fathom why you think people should be left in the dark about IPE and efficacious ways to treat it.

I know I am biased given my history. But I still don't *believe* it's quite as rare as we currently think. Awareness of it therefore should be promoted.

YMMV.

John

 

[Jax]

John, I'm not sure the readers know you were a victim of IPE.

Would you repost a link to your story?

 

[InTheDrink]

John, I'm not sure the readers know you were a victim of IPE.

Would you repost a link to your story?

Of course. http://www.scubaboard.com/forums/accidents-incidents/395096-pulmonary-oedema-incident.html

My understanding of what happened is evolving, although only getting murkier really.

My real sadness is that I wonder how many people died when this condition hit that were labelled heart attacks/panic/drowning. Semantics perhaps but somehow important to those left behind. And also, positive pressure respiration could make ALL the difference.

John

 

[Bubbletrubble]

Hi Bubble,

As you know, I very much respect your opinion. I must however disagree with your post. Current treatment of dive illnesses does NOT cater for IPE, certainly not as is well understood by people with basic rescue training. I cannot fathom why you think people should be left in the dark about IPE and efficacious ways to treat it.

I know I am biased given my history. But I still don't *believe* it's quite as rare as we currently think. Awareness of it therefore should be promoted.

John, it's not an issue of leaving people in the dark about IPE. I want to make it clear that I am 100% supportive of you sharing your story. It serves as a very informative "case report" to the diving community at large. And, reviewing the specifics of your case, I think the combination of more than one factor (including elevated blood pressure, medications, and the rebreather apparatus) paints a fairly "explainable" picture of what caused your pulmonary edema. DeniseEgg's incident may have been related to the thyroid hormone replacement therapy that a quack had recently implemented. There was no reason for such treatment since she was euthyroid at baseline. Purposefully elevating thyroid hormone to hyperthyroid levels in a normal, healthy patient is certainly not standard of care. It goes without saying that a link between hyperthyroidism and pulmonary hypertension is widely acknowledged.

I am also supportive of efforts to document the epidemiology of IPE.

What I am opposed to is over-hyping/sensationalizing the condition so that the average diver is worrying about IPE as a "killer" that takes the lives of many people participating in the sport. That misrepresents what we currently know. I also think it's premature to speculate on the precise cause of a diver's death when all we have to go on is that he complained of problems breathing shortly before his demise.

Lay-responders who know CPR and have received rescue training are already in a very good position to render the appropriate first aid care to a diver complaining of respiratory problems. EMTs and paramedics are primarily concerned with stabilizing the patient and expeditious transport to a hospital. Knowledge of IPE won't typically affect any of the interventions that they will attempt. Emergency room physicians may not have heard of IPE in the context of scuba diving, but they are certainly aware of how to treat pulmonary edema.

My real sadness is that I wonder how many people died when this condition hit that were labelled heart attacks/panic/drowning. Semantics perhaps but somehow important to those left behind. And also, positive pressure respiration could make ALL the difference.

FYI, positive pressure ventilation using a bag valve mask (BVM) is not without risk. A potential complication is lung-overinflation. If the patient is suffering from pneumothorax (a very real possibility in a diver at the surface complaining of breathing problems), PPV would almost certainly make things worse. When a BVM is used by untrained personnel, it is more likely to result in hyperventilation (decreasing cerebral and coronary perfusion pressures). Over-ventilation can also introduce air into the stomach, leading to vomiting and aspiration of gastric contents.

 

[Ayisha]

Bubbletrubble, I think the awareness that people are talking about is not about how to treat it, but to be aware of risk factors associated with IPE, to try and reduce the risk factors and to recognize it if it manifests itself so it's not ignored. The emphasis is on prevention if possible rather than cure.

BTW, I know one person who was diagnosed with IPE and one who was unconfirmed 20 years ago but suspected it in retrospect. There was also a death confirmed to be IPE by a coroner here in 2003. All 3 were diving. I have asked the two survivors to contact Duke University to give their info if they'll revisit their experiences.

 

[Bubbletrubble]

Bubbletrubble, I think the awareness that people are talking about is not about how to treat it, but to be aware of risk factors associated with IPE, to try and reduce the risk factors and to recognize it if it manifests itself so it's not ignored. The emphasis is on prevention if possible rather than cure.

@Ayisha: OK. I understand what you're saying. So what are the risk factors proven to be associated with IPE?
How can IPE be prevented?

FWIW, breathing problems in a diver should never be ignored, regardless of whether IPE is suspected. Too many different kinds of lung injuries and blood chemistry issues are potentially operative in a scuba diver.

 

[Ayisha]

Bubbletrubble, I'm aware that relationships do not prove causality, so NO risk factors have been PROVEN to be associated with IPE. That would be true of any research where there is no control group and variables that are manipulated - a lot of research that is still valid in showing relationships.

Just because risk factors are not *proven* does not mean we should disregard them. The associations are still helpful in evaluating our risk and how we may be able to mitigate the risk. It certainly doesn't hurt.