non-cardiogenic pulmonary edema

[reefsong]

Recently my husband was diagnosed with non-cardiogenic pulmonary edema after completing the following dive profile and I am looking to see if there is anyone out there with any further experience or explanation about what may have occurred. My husband is a reasonably experienced assistant instructor and was out at one of our local cold water quarries a few weeks ago to help divemaster an open water class of newbies. He's done the same dive dozens of times before and is very familiar with the underwater topography. He is 60 years old and is in excellent physical condition (runs several times a week and lifts weights on most of the others). He does not drink, smoke or drug. It was the first dive of the day and was still quite early so that he'd already had a large cup of coffee with his breakfast and quite a bit of water to drink thereafter. The air temperature was around 50° and the water temp was in the 60's. He had on his usual 7mm farmer john which gave him a core cover of 14mm. He had on a beanie instead of a hood and was not wearing gloves. He completed a typical, nonstressful 20 minute dive to 20 feet and surfaced with a student. Immediately upon surfacing he began to experience a generalized squeezing sensation across his chest bilaterally which felt like his suit was was several sizes too small. He became quite dyspneic and had difficulty slowly finning on the surface back to shore due to his shortness of breath. He began to develop a cough. No overt chest pain, no nausea, no sweating, no jaw/neck/arm/back numbness or tingling. Just a tight constricted sensation across his chest, extreme dyspnea and a sudden cough with wheeze. He drove himself home after minimal improvement of his symptoms trying to "walk it off" at the quarry. When he got home, we went immediately to the emergency room. His normally low blood pressure of 106-110/70-75 BP was high at 146/90 and his pulse ox was 91%, normal heart and breath rate. His EKG was normal, a full cardiac enzyme panel was negative, as well as a negative d-dimer. His chest XR showed a diffuse pulmonary edema. He was placed on 3L nasal O2 and observed throughout the day while rechecking enzymes at appropriate intervals, which remained negative throughout his stay. While there and under observation, we called DAN which consulted with the ER doc. It was felt that my husband had suffered something that may be called SIPE (swimmer's induced pulmonary edema) and that his acute pulm edema was due to (1) immersion shunting (2) cold water shunting and (3) volume overload due to the large coffee and large water he'd had just before getting in. He spontaneously diuresed 2000cc urine while in the ER and was allowed to go home that night with close followup. His BP and pulse ox had nearly normalized that night and by the next day his BP was back down to normal, his pulse ox was 97% on room air and he had a completely cleared CXR. Given what we could find on the web that night about this condition, we hypothesized that he was at no greater risk for this to occur again and that this was a freak accident that can occur to any diver at any time, whether or not the water is cold. I am ashamed to admit that we elected to test this theory out by going ahead and taking the previously planned dive trip we'd booked for 5 days of non-stressful diving in Grand Turk and have just returned. The above "SIPE"(?) had occurred exactly 6 days before the next day he went diving in Grand Turk. So 6 days later we dove 5 days in a row and he had absolutely no reoccurence of any of his symptoms. Does anyone have any experience with something like this either personally or as someone who helped treat another diver with these symptoms?
I'd be grateful to hear about anyone else's experience on this.

 

[Aquadoc68]

Cannot help you out with the SIPE, but Diving is like walking outside one can get hit by lightning. I did a dive with an instructor down in Key West we punched down to 130fsw stayed 5 min and came up. This guy who had been diving nitrox, tri mix, air and 100%O2, got bent from that dive. No risk factors what so ever. So to tie the story I would say that was a fluke that should not have happened. I would not think without a pre-exhisting ailment, a liter of coffe and a liter of water before a dive would cause PE. JMHO. Sometimes your the windshield sometimes your the bug. I am glad he is fine.

 

[MookieMoose]

Recently my husband was diagnosed with non-cardiogenic pulmonary edema after completing the following dive profile and I am looking to see if there is anyone out there with any further experience or explanation about what may have occurred. My husband is a reasonably experienced assistant instructor and was out at one of our local cold water quarries a few weeks ago to help divemaster an open water class of newbies. He's done the same dive dozens of times before and is very familiar with the underwater topography. He is 60 years old and is in excellent physical condition (runs several times a week and lifts weights on most of the others). He does not drink, smoke or drug. It was the first dive of the day and was still quite early so that he'd already had a large cup of coffee with his breakfast and quite a bit of water to drink thereafter. The air temperature was around 50° and the water temp was in the 60's. He had on his usual 7mm farmer john which gave him a core cover of 14mm. He had on a beanie instead of a hood and was not wearing gloves. He completed a typical, nonstressful 20 minute dive to 20 feet and surfaced with a student. Immediately upon surfacing he began to experience a generalized squeezing sensation across his chest bilaterally which felt like his suit was was several sizes too small. He became quite dyspneic and had difficulty slowly finning on the surface back to shore due to his shortness of breath. He began to develop a cough. No overt chest pain, no nausea, no sweating, no jaw/neck/arm/back numbness or tingling. Just a tight constricted sensation across his chest, extreme dyspnea and a sudden cough with wheeze. He drove himself home after minimal improvement of his symptoms trying to "walk it off" at the quarry. When he got home, we went immediately to the emergency room. His normally low blood pressure of 106-110/70-75 BP was high at 146/90 and his pulse ox was 91%, normal heart and breath rate. His EKG was normal, a full cardiac enzyme panel was negative, as well as a negative d-dimer. His chest XR showed a diffuse pulmonary edema. He was placed on 3L nasal O2 and observed throughout the day while rechecking enzymes at appropriate intervals, which remained negative throughout his stay. While there and under observation, we called DAN which consulted with the ER doc. It was felt that my husband had suffered something that may be called SIPE (swimmer's induced pulmonary edema) and that his acute pulm edema was due to (1) immersion shunting (2) cold water shunting and (3) volume overload due to the large coffee and large water he'd had just before getting in. He spontaneously diuresed 2000cc urine while in the ER and was allowed to go home that night with close followup. His BP and pulse ox had nearly normalized that night and by the next day his BP was back down to normal, his pulse ox was 97% on room air and he had a completely cleared CXR. Given what we could find on the web that night about this condition, we hypothesized that he was at no greater risk for this to occur again and that this was a freak accident that can occur to any diver at any time, whether or not the water is cold. I am ashamed to admit that we elected to test this theory out by going ahead and taking the previously planned dive trip we'd booked for 5 days of non-stressful diving in Grand Turk and have just returned. The above "SIPE"(?) had occurred exactly 6 days before the next day he went diving in Grand Turk. So 6 days later we dove 5 days in a row and he had absolutely no reoccurence of any of his symptoms. Does anyone have any experience with something like this either personally or as someone who helped treat another diver with these symptoms?
I'd be grateful to hear about anyone else's experience on this.

Immersion pulmonary edema, or SIPE is a bit of a freak occurance, and results precisely from complete immersion in water (up to teh neck, or higher). Why this happens is not very well understood, and can't be predicted very well. In your husbands case, I would suspect that, if he had a lot of water shortly before the dive, that was probably a contributing factor - within the 20 minutes of the dive that water would have been absorbed into his blood, expanding the volume, and this capillary filttration pressures somewhat. The coffee was probably also a contributor. Caffiene is a vasodilator and would have had its own impact on capillary filtration. Sorry I can;t be of more help, but SIPE isn't very that predictable. Glad to hear he's OK.

Cam

 

[Aquadoc68]

In your husbands case, I would suspect that, if he had a lot of water shortly before the dive, that was probably a contributing factor - within the 20 minutes of the dive that water would have been absorbed into his blood, expanding the volume, and this capillary filttration pressures somewhat. The coffee was probably also a contributor. Caffiene is a vasodilator and would have had its own impact on capillary filtration.

I am not an expert in SIPE, BUT I would not want Divers to be scared to drink water or even coffee B4 a dive. That in it's self I have to say would not cause SIPE. I see your theory and physiologicaly makes a little sense, but not in the normal healthy human being. We are frail creatures but not that frail. There are many divers out there with Jacked up BP's and they still dive. When I was in that little 5 week 12 hrs a day school in Key West we were slamming coffee at chow after 2 Hrs of PT, then go to our dive brief in the hour between chow and the actual first day dive we would have to have at least consumed a 1/2 gallon of water. Through out the day we would consume about 10 -12 liters of water. SO I will agree with you on the freak of nature, fluke accident, but I will not agree so much on the H2o and coffe theory. Sorry Reef if this leaves you more confused but..... I don't want any Divers to be scared to drink water the only drink you should avoid while Diving is ETOH. If ya wanna get drunk punch down to 130fsw and enjoy cause when you come back to 90fsw or so no drunk, no hangover, perfect.

 

[MookieMoose]

I am not an expert in SIPE, BUT I would not want Divers to be scared to drink water or even coffee B4 a dive. That in it's self I have to say would not cause SIPE. I see your theory and physiologicaly makes a little sense, but not in the normal healthy human being. We are frail creatures but not that frail. There are many divers out there with Jacked up BP's and they still dive. When I was in that little 5 week 12 hrs a day school in Key West we were slamming coffee at chow after 2 Hrs of PT, then go to our dive brief in the hour between chow and the actual first day dive we would have to have at least consumed a 1/2 gallon of water. Through out the day we would consume about 10 -12 liters of water. SO I will agree with you on the freak of nature, fluke accident, but I will not agree so much on the H2o and coffe theory. Sorry Reef if this leaves you more confused but..... I don't want any Divers to be scared to drink water the only drink you should avoid while Diving is ETOH. If ya wanna get drunk punch down to 130fsw and enjoy cause when you come back to 90fsw or so no drunk, no hangover, perfect.

I'm not claiming that the water or coffee caused the SIPE - the scientific literature right now can't identifiy a cause beyond immersion. I'm also not suggesting that avoiding water or coffee before a dive would offer any benefit - I think the increased DCS risk from dehydration far outweighs any theoretical concern about SIPE. All I was trying to do is offer a potential physiologic explanation as to how the situation may have arrisen - that is what I thought the original poster was looking for. Reality is that SIPE is pretty unpredictable, and can happen to anyone immersed in water up to their neck at any time.

Dive Safe

 

[divemed06]

SIPE is a fairly uncommom presentation in the ED. Contributing factors seem to be immersion in cold water combined with strenuous exercise. There really is very little research on this topic, with only a few case reports. Keep in mind that there is no association with barotrauma or DCI. Most case reports have delt with swimmers, and not divers. If your husband ever experiences simmilar symptoms, do as you did...go to the hospital. Good luck.

 

[Aquadoc68]

MM, I was not trying to slam or flame, no worries, I was just putting out my educated guess. Everybody's Opinion counts on boards like these and unless they are way out of line . I have seen some pretty freaky shtuff, 1 of my divers after hitting bd of 18'fresh water, and spending 22 minutes there presented with Neuro S/S after 15 min out of water. DCS II right, well after a table 6A he was fine, but not my DMO nor the Naval DMO who pushed him in the tube could explain it. They took him to 60 and held, no relief, punched down to 165 got relief and brought him out on a 6A. I am here to share.

 

[pufferfish]

Hi Reefsong,

Glad to hear you husband is ok and things did not recurr on rechallenge.

We had a fatal case here last year in a 50 or so year old male who was diving in cold water at about 100 feet. I don't know the details of his medical history but final diagnosis was pulmonary edema of scuba diving.

There is a nice report here with 8 scuba cases and a discussion of each one with some follow up. The cause of this condition is likely multifactorial but immersion and cold water seem to be recurrent themes. As the authors mention anything which increases cardiac preload or blood volume would be a risk factor. Peripheral vasocontriction from cold water, assuming horizontal position, tight wet suit, and yes drinking an excessive amount of fluid could tip the balance toward the condition evolving.

Once aspect the authors mention which often is not considered, but is now well documented from other non-diving fields is the ability for particulates in the air stream to induce pulmonary edema. These particulates could be from external sources such as urban air pollution or from internal compressor sources with a poorly maintained compressor. Unfortunately this fine and ultrafine particulate material is not removed by the inlet filter or compressor's stack filtration (< 2.5 um) and passes directly into the tank. One theory is with a sufficient dose of ultrafine particulate the surfactant in the lung is disrupted which leads to pulmonary edema. As with most things in medicine some people seem to be more susceptible than others to these effects.

As you can see in the article the good news is that of the divers who did return to diving none had a recurrence of the condition.

http://www.chestjournal.org/cgi/reprint/120/5/1686

 

[reefsong]

Thank you one and all for your responses. Pufferfish, thank you for printing the link to the Slade article in ChestJournal. We found it and read it with great interest the night we came home from the hospital. Others on the board may also want to read this well written, detailed article. While SIPE apparently could have happened with just the immersion alone, we are convinced that the additional shunting from the cold water, but especially the preload of fluids my husband had on board at the same time, was really what pushed him over the edge. Because SIPE seems to be a rare, somewhat theoretical risk, poorly understood, both my husband and I will continue to stay well hydrated when diving, as we always try to do. The risk of dehydration is certainly greater than the risk of a repeat SIPE. I especially liked Aquadoc's analogy of the risk for SIPE while diving to walking outside and being struck by lightning. It is a risk, but certainly not one you would expect to have repeated after its first rare occurrence.
It is certainly strange to have had such a bizarre thing happen to us. All you can say is....go figure. Thanks again.

 

[Gzimmermanmd]

It sounds like he had what I just experienced in the Cayman Islands. I am a physician and experienced SOB at 15 feet while decompressing after diving the wall. Was at 80 feet for a short time had been diving all week without any problems.I did not swallow any water did not have a panic attack I have been diving on and off for 30 years, I was sucking very hard to breath probably a faulty gauge and developed negative pressure pulmonary edema/ We see it in the operating room in young very fit patients that can generate very high negative pressure against a closed glottis I spent 2 days in ICU in Caymans By the way the health care there is excellent but they call all these incidents :non fatal drowning .