Pulmonary Oedema incident

[Bubbletrubble]

What's worse?
Scenario A: Arriving at the incorrect conclusion due to a paucity of data (e.g., n=2).
Scenario B: Not being able to arrive at any conclusion at all due to insufficient data.

I'd rather be uncertain than incorrect...but that's just me.

People like to think that findings/conclusions in science are black-and-white. That's the exception rather than the rule. Meaningful statistics help us make some sense of the gray areas -- and pretty much everything falls into a gray area.

On a related note, when it comes to medicine, patients like to hear from a doctor: "If you do X, Y, and Z, you will be healthy and you'll live a long life."
Although that kind of talk can be comforting, it is rarely accurate.

Best of luck with everything. It sounds like you are already working with some good physicians.

 

[InTheDrink]

What's worse?
Scenario A: Arriving at the incorrect conclusion due to a paucity of data (e.g., n=2).
Scenario B: Not being able to arrive at any conclusion at all due to insufficient data.

I'd rather be uncertain than incorrect...but that's just me.

People like to think that findings/conclusions in science are black-and-white. That's the exception rather than the rule. Meaningful statistics help us make some sense of the gray areas -- and pretty much everything falls into a gray area.

On a related note, when it comes to medicine, patients like to hear from a doctor: "If you do X, Y, and Z, you will be healthy and you'll live a long life."
Although that kind of talk can be comforting, it is rarely accurate.

Best of luck with everything. It sounds like you are already working with some good physicians.

Well if nothing else you've made me smile

I've been starting to dig through some of the rubicon papers and starting to send along the ones I think might be of interest to my physcian. He will shortly hate me and sign me off fit-to-dive hoping for a fatal recurrence, anything to stop the information overload.

Seriously though. I am taking this all very seriously indeed and am treating any in water activity as potentially risky, including swimming. I'm only just reading some of the rubicon papers but there are examples of swimming related events and from what I can see they do not specify whether exertion was involved. Hence my circumspection towards swimming as well as diving. If you can point me towards something that suggest otherwise please do - it would be immensely helpful.

Whilst n=2 is not statistically interesting, having a doctor that has direct experience of treating two (I)PE cases certainly is.

Finally I'm not so stupid as to believe life is black and white. I'm had a fairly coloured background where in other areas I was many steps ahead of the docs working with me. I don't think they walk on water. However it *is* possible in my case there are low hanging fruit - like lifestyle, medication, type of diving, exercise, etc. - that other candidates wouldn't have. I'm just keeping an open mind.

And it is important always to be positive. IMO.

Thanks,
J

 

[Bubbletrubble]

I think you are entirely within your right to be careful with any in-water activity. That would be a reasonable approach, IMO.
I'd also be interested in hearing what your cardiologist and/or a pulmonary specialist says about your incident after stress testing is conducted.

Swimming = Exertion
In lay terms, it's debatable what level of exertion qualifies as "strenuous."
On the other hand, scientists should define what they mean by "strenuous."
In studies incorporating physical activity in the experimental methodology, the authors will generally describe how they ensured that subjects were putting out a certain level of activity. Often times, for land-based studies, an air-braked cycle ergometer is used. Obviously, such methodologies would have to be modified/adapted to an underwater environment. Assuming that you have access to the full version of the journal article (not just the abstract), look in the "Materials and Methods" section for this info.

Here's an article that's a good starting point for your research:

• Slade, JB, Hattori, T, Ray, CS, Bove, AA, Cianci, P. Pulmonary edema associated with scuba diving. Chest 2001;120,1686-1694.

The "review" part of the article is more useful than the "case reports," IMO.

If there's an article that you've read in its entirety and think would be helpful to your physician, then by all means share it with him.
Use your judgment, though. If you start sending lots of citations to him that are not very relevant, it might become counter-productive.

 

[InTheDrink]

I think you are entirely within your right to be careful with any in-water activity. That would be a reasonable approach, IMO.
I'd also be interested in hearing what your cardiologist and/or a pulmonary specialist says about your incident after stress testing is conducted.

Swimming = Exertion
In lay terms, it's debatable what level of exertion qualifies as "strenuous."
On the other hand, scientists should define what they mean by "strenuous."
In studies incorporating physical activity in the experimental methodology, the authors will generally describe how they ensured that subjects were putting out a certain level of activity. Often times, for land-based studies, an air-braked cycle ergometer is used. Obviously, such methodologies would have to be modified/adapted to an underwater environment. Assuming that you have access to the full version of the journal article (not just the abstract), look in the "Materials and Methods" section for this info.

Here's an article that's a good starting point for your research:

• Slade, JB, Hattori, T, Ray, CS, Bove, AA, Cianci, P. Pulmonary edema associated with scuba diving. Chest 2001;120,1686-1694.

The "review" part of the article is more useful than the "case reports," IMO.

If there's an article that you've read in its entirety and think would be helpful to your physician, then by all means share it with him.
Use your judgment, though. If you start sending lots of citations to him that are not very relevant, it might become counter-productive.

I'm not sure I know how to read one of these reports in their entirety, especially as I don't understand some of the terms used. The best I can do is rule out what I don't think is relevant. I'm not trained in this area and whilst I'll make a stab at it, I'll go on (temporal) recency, (literal) accessibility and similarities to my incident. I'm probably more hampered here than you realise as you're familiar with the process. Not to worry - you've given me some good leads and I'll filter as best I can.

Thanks again for helping out. And now, in the interests of improving my lifestyle and as the clock has struck midnight, I bid you goodnight.

John

 

[duke dive medicine]

One of the interesting aspects of immersion pulmonary edema is the variety of conditions and individuals in which it can occur.

Among triathletes, the term "swimming-induced pulmonary edema" is popular and, thanks largely to one of our first study subjects, the word is getting out in that community. See Endurance Triathletes - Swimming Induced Pulmonary Edema (SIPE) - Immersion Pulmonary Edema (IPE). The triathlete (or competitive swimmer, or combat diver) who suffers from SIPE is a superbly fit individual who probably has an increased susceptibility to the condition and, in the heat of competition, his/her extremely high cardiac output simply overwhelms the pulmonary circulation. The "why" is something that's still under investigation.

Contrast that with the diver who has some underlying cardiac issues that are reasonably well-controlled on the surface. When he gets in the water, there's a large influx of blood into the torso, including the pulmonary vasculature. This means that the amount of blood entering the left side of his heart from his lungs (a.k.a. preload) is increased. Maybe he's also underweighted and has to kick extra hard to get down. His heart can't keep up with the increased preload and level of exercise, the blood backs up in his pulmonary circulation, and he suffers an incident of flash pulmonary edema.

Are both of these cases of immersion pulmonary edema? Arguably yes, because immersion is involved, but the etiologies are completely different.

John's case is especially interesting because of the number of factors involved. For example, he was diving a rebreather with an automatic diluent valve that had insufficient flow to adequately compensate for increasing depth, and inhaled pretty hard against a collapsed counterlung. Increased work of breathing in the rebreather has already been mentioned - negative pressure can be problematic in back-mounted counterlungs.

Negative pressure pulmonary edema is a condition that's been documented in recently extubated surgery patients, but never in a diver as far as I know. As John's already mentioned, it may have played a role, but we'll probably never know for sure.

Thanks to John for sharing the details of his incident, and to everyone participating here.

Best regards,
DDM

 

[InTheDrink]

Thanks Eric, and for your support to date with this incident.

I agree, I'm not sure we'll ever know conclusively what caused it but hopefully if I remove any of the potential triggers (bar immersion) I'll be able to get back in the water again.

Seeing cardio tomorrow, will be interesting to hear what he has to say.

John

 

[InTheDrink]

If anyone's interested, seems we have a hat trick of IPE over on YD - I Learned About Diving From That...

 

[duke dive medicine]

If anyone's interested, seems we have a hat trick of IPE over on YD - I Learned About Diving From That...

Interesting case. It seems a bit more complex to be blamed simply on IPE and I'm not sure how his bike injury would tie in with it. I think they need to dig a little deeper with this fellow.

 

[Cruisin Home]

InThe Drink

I suffered a case of IPE which I would consider "moderate" in my twenties (now in late 40's). I have never had a relapse. Still to this day I wonder what the cause. I can say that I was deep, suffered from sinus/allergies, and was a cold dive. Luckily noticed problem with breathing and got to surface ok. Felt like I had a chest cold for a few days. At the time I had never heard of IPE and always attributed to my sinus/allergies and possible cold.

Only a few years later I had a 'severe" case of PE at my home, later attributed to exposure to an epoxy that I was working with in my basement shop. My lungs filled up unbelievably fast and very soon I was gasping for air. could barely speak when I called 911. Scary.. Told physcian of my earlier dive experience and that was then I was told about IPE.

Never had problems since but I did have a very successful sinus surgery and treatment for my seasonal allergies.

No cardiac abnormalities of any kind. Was in Triathlete physical shape for both incidents.

My takeaway from my own experience is to be very conscious of my body, my breathing etc. and to abort a dive at the hint of anything wrong. It seems if I read your case right that you were having mild reactions in an earlier dive, maybe an early warning sign.

Should have cardiac checkup, also looking for a congenital abnormality called PFO.

My guess is there are alot more cases of IPE, particularly of the mild or moderate types that are not well reported.

My thought is it could share etiology with High Altitude PE (HAPE).

 

[InTheDrink]

Cardio apt.
Cardiogram ok, something potentially slight suspect, to be confirmed/rejected following next round of tests.
Undiagnosed high blood pressure (160/90). I was not aware of this prior to going to the docs a couple of weeks back. This appears to be the major bogeyman in my incident - at this point.
A medication I take infrequently but did on the day of the incident, propranolol (a type of beta blocker). I take this when doing presentations or occasionally prior to a dive if I think I might be task loaded. I can’t explain how stupid it sounds now looking back in retrospect. The propranolol is unlikely in isolation to have caused the issue but it could have been a contributory factor. It reduces the amount of work your heart can do.
Other medication: ruled out as potential contributor.

Next steps:
Echocardiogram
Stress test cardiogram
24 blood pressure test
Meet up again with Cardio 9th Dec and decide on next steps (e.g. MRI on kidneys, there is another type of PO called Flash Pulmonary Oedema caused by narrowing of arteries into the kidneys that the doc may want to explore)

Big lesson learned – please read
I didn’t disclose that I was taking any medication on the medical form. I didn’t think it was relevant. I now realise how irresponsible this was. Even though the medication may have had nothing to do with the incident, it *could* have had. I was not just potentially placing myself at risk, I was also potentially placing others at risk. My incident certainly did put Simon at significant risk. The beta-blocker may/may not have had anything to do with the incident but it *could* have ergo I negligently placed him at risk.

I have apologised to him for this. I urge anyone out there that is currently being less than straightforward on their medical forms to think for a minute, and realise that it’s not just their own life they’re potentially jeopardising: they’re also risking anyone else that is diving with them.

This also goes for medicals. If you're not in good shape, then don't just think it's you that you could be putting at risk. Get checked out and signed off by a proper dive physician. Your GP is not a dive physician.

I’ll post back once I get more information from my tests. For the moment I’m out of the water for another 3 months at least.

Thanks,
John