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Immersion pulmonary edema (IPE)

Diver experienced difficulty breathing at the surface after an uneventful dive. I just completed a scuba refresher course and was participating in a shore dive in an ocean environment as part of a group led by a divemaster. I am a 46-year old male, 75 in (1.9 m) and 247 lbs (112 kg). I have no significant medical history and regularly participate in 30-40 minutes of cardio walking, 3-4 times a week.

This was my first dive in approximately two years and was my eighth dive in total. I was wearing a 7 mm wetsuit and neoprene boots. Surface water temperature was 74°F (23°C). The swim to the dive site was approximately 400 yards (366 m) and uneventful. I descended behind the divemaster at a controlled rate along a buoy line. Bottom temperature was approximately 65°F (18°C). I was breathing air. The dive profile included a maximum depth of 37 ft (11 m) and a total in-water dive time of 46 minutes. My ascent was controlled and uneventful.

A few minutes after surfacing, I was having increasing difficulty catching my breath and developed a nagging cough. I noticed my shortness of breath worsening over the course of a few minutes. I was then towed to the shore, and medical assistance mobilized. After arriving onsite, paramedics administered oxygen by continuous flow mask and oral albuterol (a bronchodilator). I was taken to the local hyperbaric facility, where decompression sickness was ruled out. I was then transported to the local emergency department by helicopter and given Lasix (a diuretic). At the emergency department, a chest X-ray revealed fluid in my lungs. I was monitored overnight with continuous oxygen administration and released the next morning. Symptoms were mostly resolved at the time of discharge, although I noted rawness in my lungs that lasted approximately 24 hours. This diver experienced classic symptoms of immersion pulmonary edema (IPE). IPE, also known as swimming-induced pulmonary edema (SIPE), is a condition that has been described in scuba divers, snorkelers, triathletes, and military swimmers. The condition is characterized by dyspnea (shortness of breath), hemoptysis (coughing up bloody sputum), and symptoms of respiratory distress. Extreme fatigue and a sensation of 'wet' lungs are also common. Symptoms are not depth-dependent, meaning IPE can occur with any immersion. It has been theorized that IPE results from increased pulmonary artery pressure in part triggered by immersion in susceptible individuals.

During immersion, blood is rerouted from the periphery to the core resulting in increased blood volume in the thorax and thus increased pressures in the pulmonary vasculature. Development of IPE may be from this effect in concert with a multitude of other contributing factors including cold water, hyper-hydration, uncontrolled hypertension, heavy exertion, and high breathing resistance (particularly on inhalation). As with this case, it is important to note that not all of these factors may be present for a case to develop. IPE has been reported in warm water and with immersed activity of varying exertion. Given the possible severity of the condition or the possibility of other serious conditions presenting with similar symptoms, it is recommended that medical attention is provided.

While research is assessing the contribution of different factors, there is currently no way to predict susceptibility to IPE. Mild symptoms of IPE may be initially discounted, delaying attention to the acuteness of the situation. As in this case, it is important for divers to be familiar with the condition so symptoms can be recognized and appropriate action taken. While a diver experiencing symptoms should leave or be assisted out of the water as quickly as possible, proper procedures must be followed to do so safely. For example, completing obligatory decompression helps to avoid other potentially serious problems. If symptoms occur at depth, the victim should communicate with their buddies, evaluate surface safety, and make a controlled ascent. Once in a safe place out of the water, exertion should be limited, oxygen provided, and medical evaluation arranged. The diver in the situation described above reacted appropriately to the dangerous situation. He relayed his symptoms to his dive buddies and requested assistance back to the shore so that he could be medically evaluated.


~Stefanie D. Martina


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