Immersion Induced Pulmonary Edema (IPE)

[Serota]

I have experienced IPE twice in the last few months and before I start selling my dive gear would like to hear from anyone who has dealt with it or has relevant information. The basic symptoms involve shortness of breath while underwater, followed by severe wheezing and weakness upon surfacing. Basically, ones lungs are filling with fluid. Once above water the symptoms resolve within a fairly short time. What literature I have found and correspondence with DAN offer no explanation for the condition and finds no correlation with the nature of the dive (depth, duration etc..) or the diver (age, fitness level, having experienced IPE before, etc..).

The first time it happened to me was last spring just as we were turning the dive near Henley's Castle jump in P3. The difficulty of breathing got worse and worse on the way out and was extremely frightening. When I finally got my head back above water, my buddy could hear my wheezing 10' away and said it sounded like a severe asthma attack. It took me a long time to eventually get my gear off and get out of the water. Within 2 hours the symptoms were gone. I took 2 months off and did a simple dive at Ginnie without problem, followed by a couple of dives at P1, also without issue. Thinking it must have been a one-time event, I recently experienced it again in the roaring flow of Anderson Spring, but recognizing what was happening turned the dive immediately and got out quickly and only had modest wheezing for a while, but now that I see that I am prone to IPE, I am very reluctant to try diving again.

If anyone has experience or thoughts on this matter, I would enjoy hearing them in the open forum or by PM.

[benjamin]

You might want to get your heart checked.

[Sludge]

This will sound really stupid (but I would be inclined to grasp at straws if someone were to tell me I had to stop diving), but before I quit cave diving I would consider ONLY doing scooter dives, so that my breathing rate never got high.

[MORGAN]

You might want to get your heart checked.

Yup - including a stress test and an echocardiogram.

When you're on land, fluids (blood, lymph, interstitial fluid etc.) are being pulled by gravity down into your lower body and legs. When you're immersed, this fluid migrates back toward your central circulation. Your kidneys manage the increased fluid load by excreting it; hence immersion diuresis. (And my inability to get through even a 40 minute dive without peeing.)

If the left side of your heart, (which receives blood from the lungs and pumps it out to the rest of the body) is not pumping effectively, (for which there are a variety of causes), blood and pressure backs up into the lungs. In the lungs, blood in the pulmonary capillaries is separated from air in the alveoli only by the very thin alveolar/capillary membrane, and fluid (plasma - the liquid part of the blood) can be pushed across the A/C membrane into the alveoli leading to pulmonary edema.

There are other causes of pulmonary edema, but immersion pulmonary edema is likely to have a cardiac component. Exertion is apt to make it worse. Perhaps one of the diving physicians on the forum will give us some additional information.

Mike (not a physician - a critical care RN)

[amphipod06]

check your inbox

Dive safe,

Celia

[sea2summit]

I agree with Russell, work load sounds like it could be a factor but you said no issues in Ginnie soo hmmm.

Other thing that comes to my mind is the dry air could be irritating your lungs? It'd be interested to see if you could induce this in the pool then attempt to replicate it on a rebreather.

Either method really might just be grasping at straws but with a try before throwing the towel.

Good luck.

[Gary]

I'm pretty sure the underlying casue of Pulmonary Edema (fluid buildup in the lung cavity) doesn't start and build up to be a problem in the space of a dive and then go away.

My own Pulmonary Edema I thought I might have gotten a lung expansion injury in the swimming pool that caused it - but no such luck.

Pulmonary Edema is caused by the body not draining fluid from the vaccume cavity of the lungs as quickly as it builds up. Mike explaination is new to me. My own PE was 24/7 from lymphic system not draining effectively. I was having problems sleeping laying down and when I was standing it felt like I had heavy bean bags laying on my kidneys. I was short of breath just walking across the room - and of course I went diving anyway.

Not being able to catch your breath underwater is an uncomfortable sensation. Having had a lot of uncomfortable situations underwater I just delt with it and continued the dive. (Panic is overrated. I don't think it is a good idea on a dive - and not being able to breathe is no exception. Slowing down and figuring out whatever is wrong and deciding how to deal with it is almost always a better solution. In my case I decided that pain and inability to breathe was no reason to call the dive... )

By chance I had a CAT scan Friday before the dive and got the results Monday. I learned a lot about that "tapping thing" doctors do on your back every time you go to the doctors for a check-up. Turns out they are tapping to figure out the level of fluid - how full of fluid your lung cavities are. when they tap on the level with the fluid it sounds different (and it clearly feels different) then when they tap on air filled space.

Discovering and correcting the underlying cause is probably the best idea.

Even if the underlying cause can not be corrected it turns out there is still hope. If all else fails the doctors can contact cement the lung surface to the inside of the lung cavity and eliminate the need for a vaccume filled lung cavity.

[apitkin]

I'm pretty sure the underlying casue of Pulmonary Edema (fluid buildup in the lung cavity) doesn't start and build up to be a problem in the space of a dive and then go away.

...

Discovering and correcting the underlying cause is probably the best idea.

Even if the underlying cause can not be corrected it turns out there is still hope. If all else fails the doctors can contact cement the lung surface to the inside of the lung cavity and eliminate the need for a vaccume filled lung cavity.

Unfortunately, we don't really know what causes immersion pulmonary edema. It can easily happen in the space of a dive and then resolve afterwards. It has been described in swimmers (a large series from the literature was from Israeli military recruits doing training swims) and divers under all conditions - deep, shallow, warm, cold, young and old. It doesn't necessarily indicate any cardiac problem.

A more incisive question is why we don't get pulmonary edema all the time, given the incredible job that the lungs normally succeed in doing, which is keeping a very large surface area of blood in close contact with alveolar gas without fluid leaking into those alveoli. There are probably many reasons why leakage can occur, and we don't understand all of them.

Most authorities on the subject believe it is multifactorial. Having one episode probably does predispose to subsequent events. There is a loose association with left ventricular diastolic dysfunction.

Andy

[rongoodman]

Here is a fairly long thread about a similar incident. I believe there was one reported on Yorkshire Divers this summer too.

[denisegg]

The above story on SB was about me. My IPE was very severe and surfacing did not resolve it. It started as an easy dive with no stressors but as we went down the chimney at JB and hit around 94ft deep, my chest got tight and it became hard to breathe. I got out of the flow to the right and remained still to ease my breathing but it did not help. Then I began to cough. I turned the dive and as quickly as possible made my way out of the cave. We were 15 minutes into the dive when it happened. My total dive time was 23 minutes. It got harder and harder to breathe on the way out. Nothing helped. As I saw the ambient light of the mouth of the cave I was so weak I could barely swim. I began to purge the regulator in my mouth because I was starved for air and right before exiting the cave was crawling on my hands and knees. Upon surfacing I continued to cough constantly. I began coughing up pink froth and my face was blue. I was helped to the ground and helped out of my drysuit and gear. I was taken by ambulance to the local hospital where my dive buddy contacted DAN and they gave the doctors instructions to either intubate me or put me on a CPAP and start administering a diuretic to get rid of the excess fluid that had accumulated in my lungs and body. My cardiologist later told me I was within minutes of being put on a ventilator. I was then transferred to Dothan by ambulance and was seen by a cardiologist. After numerous tests, ekgs, echo cardiogram, heart cath, x rays, mri, the doctor could find nothing wrong with me but an elevated thyroid level. An endrocrinologist saw me while I was still in the hospital and told me to get off armour thyroid given to me by another doctor. I saw two pulmonary doctors after being released from the hospital. They could not find anything wrong with me. I waited about 6 weeks and went back to all of the doctors again and all of them released me saying they could not find anything wrong with me. I waited a few more weeks and went to a local internal medicine doctor where I once again had a full blood panel done and everything was normal, including my thyroid levels after getting off the armour thyroid. Of the 5 doctors I saw, none of them had ever heard of IPE(one of the pulmonary doctors was on DAN's list). I took printouts with me from the DAN website to give to them. I was also in contact with a researcher from Duke University in charge of the IPE study being conducted in conjunction with DAN and the Navy.
Alot of good information was brought up on the thread about my incident.
I waited a couple of months and after getting absolutely no answers what so ever from any doctors, I tried diving again. But I am progressing slowly. I started with some easy shore dives, then springs and about a month ago some cavern dives. I plan to do some intro cave dives this month. I am not sure when I will do full cave dives again. I am taking it slow and easy. I now have an 02 bottle on hand every time I dive. I plan to take a CPR/1st Aid/Oxygen Admin class in December.
I finally had to make a decision to try it again. Since none of the doctors or researchers could tell me why it happened, they could not tell me if it would happen again. They would not give me permission to dive again. I had to make that decision myself. I am more aware of how my body feels now and if I don't feel in top form, I won't go. I exercise on the treadmill and I cut out caffeine and soda. I try to balance my water intake now, not too much, not too little. I try to stack the odds in my favor.