Immersion pulmonary edema/lung squeeze---HELP!

[cebaztian]

Some experiences of the same topic from other threads e t c:

freediving - squeeze

[DeepThought]

Can't add much to what has already been written. If it is PE that you're getting I suggest you will do what it takes to never have it happening again, even if it means modifying your diving. Hopfully after a long while without it happening again you could redefine new limits (like descent/ascent rate, less stretch time less warmup dives) that in the past might have resulted in a PE.

I have experienced 'lung squeeze' or pulmonary edema (hard to tell) in shallower than RV depth (shallower than 25m). I suspected contractions or effort at detph.
Although I have not found the reason, I never wanted to experience it again.
I was quite alarmed by that and felt that being an infrequent diver (and with an asthmatic past) I might be more susceptible than others.

I started doing diaphragm and intercostals stretches before diving (maybe 20 minutes but I'm slow).
I reduced my descent/ascent rate to about 0.5-0.7m/s. Maybe even slower in the first few shallower dives - kick, wait, kick.
As for warmup dives, they can sometimes take up to half of my session (if I'm limited by my dive buddy). First dive to around 5 meters to get air out of my suit. A few dives to 10m, a few to 15m, my first dive to 20m might be my 10th or more dive.

I do this mostly because sometimes I have dry spells of months. If I'm in a long vacation and dive everyday (and probably twice a day) after a while I might skip stretching (depends on target depth) and get to 20m in my 3rd dive of the session. I also dive faster.

As for Frenzel, it was hard for me to notice but eventually I realized my diaphragm was still tensing a bit when I equalized, I suggest working on mouthfill and making sure your diaphragm is 100% relaxed while equalizing, it is sometimes hard to tell though.

Also it is hard for me to tell sometimes that I have contractions if I'm 'in the flow'.

It will be hard to tell if it is something in your technique or or physique (having thin alveolar walls and/or pulmonary hypertension sound possible to me). I suggest modifying your technique first, hoping that in time your physique will adapt after a long time with no recurrent events and stretching your limits slowly.

And of course, see a specialist.

[scott]

I am the friend to which Connor refers: the blood in my lungs has happened on and off for the past several years. The diaphram stretches seem like they help, but it hard to fully conclude such, due to the sporadic nature of the incidents (they have not fully stopped).

I finally went to my doctor and got a chest x-ray. The x-rays were negative but it was recommended that I see a pulmonologist for further diagnosis. Unfortunately, I tore my ACL snow-skiing right after Christmas and so have put the pulmonologist on hold while delaing with my knee/surgery.

I will have several months out of the (deeper) water now and if the blood in my lungs happens again once I resume diving, I plan on seeing a specialist.

I'll post any findings at that time.

Thanks,

Scott

[sebastien murat]

Kurt,

A bit late in coming but have recently been doing a bit of research on squeezes and here are some thoughts:

Hypoxia during apnea results in peripheral vasocosntriction.

Hypoxia during eupnea (breathing), e.g., mountaineering, results in peripheral vasodilation (= vasodepression)

Lung expansion above FRC (wet) typically results in reflex vasodepression, so that ascending from depth is like climbing to altitude, albeight in an accelerated way; lungs re-expanding is akin to breathing in. Coupled with a reversing blood shift, i.e., from core to periphery, some pulmonary capillaries would cease to flow, in line with hypoxic pulmonary vasoconstriction. This would result in pulmonary hypertension. Since the pulmonary ciculation is a low pressure system this could result in edema. To further aggarvate the situation, a weakening dive response during ascent would only serve to accelerate this hypoxia, especially if fatigue and swimming is involved. Cold-induced peripheral vasoconstriction would add to the increase in pulmonary blood pressure, just like with mountaineers.

Plenty of divers, however, dive as you do and experience cold, so that the above factors only magnify your particular case: possibly thinner than normal alveolar-capillary membrane from intense convective O2 training (high VO2 max) and higher than normal residual volume (based on edema from doing warm-ups on empty).

Some suggestions:
- if doing bout dives keep your periphery warm and prevent and excessive cold-induced/facially mediated peripheral vasoconstriction (i.e., keep the face warm)
- minimize the work of ascending
- exhale during ascent to maintain your dive response and blood in your lungs(jury still out on this one)


- Get your residual volume actually measured by a respiratory physiologist.


Hope you've bounced-back
S

[Ol Dirty Diver]

Sebastien,

I appreciate your analysis. I've no doubt that your ideas are plausible...Unfortunately I don't have enough background in physiology to contribute my own analytical discussion. Like you mentioned, I may represent the extreme end of the population that possesses physiological characteristics favoring pulmonary edema, since others get cold and don't experience the same physiopathology. Or perhaps it's simply that I get colder than everyone else, due to low body fat and a mesomorphic build. I have some good news though...

I have completely overcome the pulmonary edema problem. It was very intuitive and obvious to me that being cold and shivering while diving was the primary contributing factor. This was corroborated by finding numerous articles discussing cases of pulmonary edema resulting during Google: %22pulmonary+edema%22+scuba or Google: %22pulmonary+edema%22+swimming. Consistently observed in the majority of the cases were the following factors:

• The victim felt cold due to being in cool water.
• Some degree of physical exertion was involved, varying from the minimal effort of kicking while scuba diving, to race-pace swimming.
• Submersion under water to some depth was involved, which could be as little as directly under the surface in the case of swimming.

I didn't have to understand the mechanism of the physiopathology to realize that a possible solution was simply to be warmer while I'm diving. Even though wearing a wetsuit thicker than 3mm is unheard of in Hawai'i, I did precisely that. In January I ordered a 5mm wetsuit online (since one cannot be found in stores here), and ever since using it I have never experienced the pulmonary edema again. Even though the 5mm is more restrictive and requires me to wear more weight, I am now completely comfortable in the water and never even approach the point of shivering. (Does anyone know if any manufacturer produces a 4mm wetsuit?)

Can I dive deep in spite of my "leaky lungs"? Before acquiring the 5mm wetsuit my PB depth was 120ft/36.5m, the attempt of which did fill my lungs with fluid (which could have been attributed to squeeze rather than pulmonary edema). Upon acquiring the newfound capability of staying warm during my dives, I have gone past 120ft multiple times, to a PB of 146ft/44.5m (which is simply the deepest water I have found around O'ahu; I am eager to go deeper...).

Being keen of the scientific method, I've realized that the ultimate way to validate that being warmer solved my problem is to once again dive with a 3mm wetsuit (or nothing), in order to allow myself to get cold and promote the pulmonary edema again. Without doing this, one could argue that I possibly overcame the susceptibility to pulmonary edema on my own somehow, and that the acquisition of a new wetsuit simply coincided with this. However, I have not been motivated to do a cold dive again; a bout of pulmonary edema is very unpleasant, even though I dealt with it regularly for about a year. Maybe one day this summer I'll try the 3mm suit again if the water warms up some, but even now with a temp. of 80F/26.7C I am very comfortable in my 5mm suit.

One curiosity of mine is that if my lungs are especially susceptible to edema, will this possibly promote thoracic filling when I dive deeper, thus making my condition advantageous? Perhaps lung squeeze some times results from possessing an opposite trait to mine, i.e., having relatively impermeable alveolar walls; if thoracic filling can't occur due to this, lung squeeze is probably inevitable once one surpasses his residual volume far enough. I wonder if the "heavy" feeling I'd detect in my lungs after a few dives, thus indicating that the edema has started, feels just like thoracic filling. The heavy feeling and my impaired breathing would always remain for ~24hrs though, whereas I've heard that lung fluid from thoracic filling subsides within minutes.

Anyway, my problem seems to have been solved, although I don't think anyone is completely sure of the mechanism. I appreciate the input that everyone contributed to my case. I am sure that much useful information could be gathered from this thread when you all or future readers pursue researching this topic further.

[DeepThought]

Originally Posted by sebastien murat

Hypoxia during apnea results in peripheral vasocosntriction.

Hypoxia during eupnea (breathing), e.g., mountaineering, results in peripheral vasodilation (= vasodepression)

Lung expansion above FRC (wet) typically results in reflex vasodepression, so that ascending from depth is like climbing to altitude, albeight in an accelerated way; lungs re-expanding is akin to breathing in. Coupled with a reversing blood shift, i.e., from core to periphery, some pulmonary capillaries would cease to flow, in line with hypoxic pulmonary vasoconstriction. This would result in pulmonary hypertension. Since the pulmonary ciculation is a low pressure system this could result in edema. To further aggarvate the situation, a weakening dive response during ascent would only serve to accelerate this hypoxia, especially if fatigue and swimming is involved. Cold-induced peripheral vasoconstriction would add to the increase in pulmonary blood pressure, just like with mountaineers.

Interesting stuff Seb. It sounds like the ascent part and reversal of the DR is similar to Altitude Sickness which if i'm not mistaken is hypoxia mediated pulmonary hypertension (and cerebral hypertension at times). The latter might be beneficial, no?
I know you usually don't use masks, but have you happen to compare dives (FRC and TLC) with and without sniffing mask air on ascent?
If you dive deep you could regain quite a lot of O2 on the ascent, on the other hand I suppose it cancels the DR even faster and elevates HR.

These posts are a treat, would love to hear more.

[sebastien murat]

Those experiments we did comparing E- and F-dives, several years ago now, had novice and experineced subjects, with the exception of myself all wore masks. I cannot say if the experienced divers re-inhaled the air, maybe they didn't maybe some did, but the HRs were always for an increase with F-dives.

The question is wether exhaling on ascent could prevent a reversal in the DR. If it does great, but then O2 stores are lost and it would also not be energetically efficient from a buoyancy point of view. I need to test this. I'll be testing the guys during the Nat Geo doco in Mallorca in early Oct. Hopefully we'll get a better picture. We're also doing some blood flow measurements u/w to see what happens to brain blood flow during ascent under various conditions. An additional part of the experiments is to to see what happens to PaN2 during diving on E-dives: does it continue to rise or level off? This stuff has never been done before and we should be able to discover some altogether new and interesting things not only ablout hypoxia, but narcosis and DCI also.

S

[sebastien murat]

Deep Thought,

Don't know about cerebral hypertension, but part of the cardiac output would be redistributed to the periphery, which isn't ideal, especially end-apnea where the brain would need all it can.

S

[naiad]

Originally Posted by Ol Dirty Diver

I have completely overcome the pulmonary edema problem. It was very intuitive and obvious to me that being cold and shivering while diving was the primary contributing factor.

Very interesting. I had a bout of mystery lung trouble a couple of years ago which coincided with doing a lot of swimming. It never actually happened while swimming, so it is difficult to tell if it was pulmonary edema, long-term chlorine exposure or both. I do shiver a lot and get cold easily.

[katwoman]

Hey Kurt!

I'm a triathlete from Montreal and have experienced what I believe was SIPE - Swimming Induced Pulmonary Edema... I think there might be a common link between what is happening to both you, and I.

I experience SIPE usually in the first 750m of a competitive triathlon swim - cold water - in a wetsuit. Rapid start with no warm-up, so the lungs seem to be getting overloaded and flood as a result.

I was recently diagnosed with high BP, so have been taking meds to see if that will eliminate high BP as one of the trigger mechanisms.

I was also intrigued when I read that you are a triathlete as well.

You might find this article I co-wrote on 'Slowtwich' - A triathlon forum - interesting : <:: Welcome to Slowtwitch.com ::>: Swimming Induced Pulmonary Edema (SIPE)

I would be happy to share what I know with you, and put you in touch with the research scientists I've been working with to try and figure out what is causing this and how to prevent it...

Kind Regards,
Kat

[naiad]

Originally Posted by Ol Dirty Diver

One curiosity of mine is that if my lungs are especially susceptible to edema, will this possibly promote thoracic filling when I dive deeper, thus making my condition advantageous? Perhaps lung squeeze some times results from possessing an opposite trait to mine, i.e., having relatively impermeable alveolar walls; if thoracic filling can't occur due to this, lung squeeze is probably inevitable once one surpasses his residual volume far enough. I wonder if the "heavy" feeling I'd detect in my lungs after a few dives, thus indicating that the edema has started, feels just like thoracic filling. The heavy feeling and my impaired breathing would always remain for ~24hrs though, whereas I've heard that lung fluid from thoracic filling subsides within minutes.

I wonder about that too. If I do anything that causes negative pressure in my lungs, even dry forced exhale statics, I get that 'heavy' feeling for a few minutes afterwards. Not sure if that is good or bad, but for now I am careful not to overdo it.

[scott]

Since this thread has become active again, I will update my post from earlier this year. While doing physical therapy after ACL surgery, I told my therapist about the bleeding in my lungs. He gave me some ribcage stretching exercises that I have done now for about six months. I am back in the water and am having no problems at all - no sign or feeling of blood/fluid in my lungs. So, at least in my case, it was just a matter of specific exercises and getting into better shape (the latter in general).

Thanks,

Scott
yae2

[Ol Dirty Diver]

Originally Posted by katwoman

Hey Kurt!

I'm a triathlete from Montreal and have experienced what I believe was SIPE - Swimming Induced Pulmonary Edema... I think there might be a common link between what is happening to both you, and I.

Wow...That was the most comprehensive article on activity-induced pulmonary edema (AIPE) I've ever read. Thank you very much for sharing it. It's interesting that it's difficult to find any other comprehensive, scientific reviews on AIPE out there. I was also surprised that my search through the vast message base of Deeperblue didn't turn up anything specific to PE, although the more familiar issue of lung squeeze is probably closely related. I think it's because PE occurs in a very small minority of individuals, so my fellow divers and the researchers haven't had much impetus to consider the issue seriously. Those of us that have been afflicted by it feel very strongly about it, though, because it's so horrible to experience.

Originally Posted by katwoman

I experience SIPE usually in the first 750m of a competitive triathlon swim - cold water - in a wetsuit. Rapid start with no warm-up, so the lungs seem to be getting overloaded and flood as a result.

I have probably experienced freediving-induced PE to varying degrees at least two dozen times now, but I've never experienced it while swimming. And I have done plenty of swimming in cold pools/open water to the point of shivering, including very hard swim workout sets. Weird, huh?

I've competed in numerous triathlons, including a few involving wetsuits swims. Never noticed PE in these either. The stories in your article are scary. The interesting thing in several of those stories is that you guys wouldn't experience any SIPE in your training swims in the exact same circumstances as your races (i.e., wearing wetsuits in open water), but succumb to it very quickly in your races. I guess your blood pressure may be higher during the races due to higher cardiac output, but I think your blood pressure could possibly be higher for another reason that hasn't been mentioned...Stress from the race.

I mention this because I'm starting to believe that stress has been a consistent factor in my cases. I have done some very deep dives lately (for my ability, that is...down to 58m/192ft), and I didn't really even notice any PE, even though it might be expected, not as abnormal AIPE, but the more expectable "thoracic filling" that occurs in deep freedivers. This diving was done in a Performance Freediving course, where our warm-ups were very thorough, dive conditions were favorable, etc...Essentially, doing the utmost to minimize stress in hopes of pushing our limits and doing personal-best dives. Then, in some spearfishing dives just this past weekend, to a max depth of 25m/80ft, I experienced some light PE. In these dives, conditions were not that great (strong current, kayaking beforehand, etc.), so my stress level was high. And I can recall in nearly all of my past experiences with PE that I was highly-stressed, usually from trying to dive in strong current. Of course, diving in current would coincide with higher cardiac output and thus higher blood pressure from working harder, but I still think that stress is a linking factor in our cases. Perhaps the stress, itself, temporarily increases our blood pressure significantly.

Another interesting thing in some of the cases in your article was that some individuals actually coughed up blood. I always made a distinction between my PE and the condition of lung squeeze that is more familiar to freedivers on the basis that I never coughed up blood...Just yellow blood plasma without the RBCs. I thought the blood could only result if alveoli were ruptured, which is what is believed to happen in lung squeeze; I believed I was not rupturing alveoli in my incidents of PE since it appeared that only plasma was crossing over, through its permeability. But since you've identified some victims of SIPE that coughed up blood, the fundamental difference between lung squeeze and PE that I reasoned may no longer be valid. A possibility, though, is that the blood is not coming from the lungs, but instead the trachea. The very hard coughing accompanying a bad bout with PE may cause trauma to the trachea. There is some belief, though, that the blood emitted in a bout with lung squeeze could also be coming from the trachea instead of the lungs, due, essentially, to tearing the trachea by stretching it under high negative pressure when deep.

Originally Posted by katwoman

I was recently diagnosed with high BP, so have been taking meds to see if that will eliminate high BP as one of the trigger mechanisms.

I will make it a point to get a physical examination soon to check on my BP. I seriously doubt that I have BP though.

Originally Posted by katwoman

I was also intrigued when I read that you are a triathlete as well.

Since abnormal PE doesn't seem to happen in many freedivers, I've tried to think of what unique characteristics I have as a freediver. I don't know of many who are serious endurance athletes, so I've suspected that my training as a triathlete is possibly a factor, and that the idea of having thinner alveolar walls as an adaptation from training is plausible (never found a reference to this yet though). Of course many freedivers undoubtedly practice endurance activities too, especially the most competitive ones, many of which have demonstrated that they do most of their training "dry" (i.e., lots of cardiovascular training on land), then enter the ocean to do dive-specific training only a few weeks before their performances (e.g., Pipin, Tanya Streeter, Mandy-Rae Cruickshank). But I've never seen in their training programs the really intense, above lactate-threshold training that many serious endurance athletes perform (e.g., 10 x 400m intervals at the track). Perhaps this highest level of cardiovascular training is required to develop the adaptation of thinner alveolar walls. I'm curious to find out if Topi Lintukangas (former professional Ironman triathlete) or Stephane Mifsud (very active athlete, judging from his promotional videos), two successful professional freedivers, ever experienced PE, considering their high levels of cardiovascular training.

Ultimately, though, I think this will all be attributable to some characteristic(s), perhaps genetically-derived, that are unique to the few of us that do experience AIPE...Something like the "diastolic dysfunction" mentioned in your article. There are so many other divers and athletes out there that can tolerate the possible contributing factors of PE we've noted without pathology; e.g., plenty of freedivers get cold (or even intentionally allow themselves to get cold for enhanced peripheral vasoconstriction) without experiencing PE; in triathlons plenty of other swimmers are working at high cardiac workload without having to stop midway to clutch a kayak and cough up blood; etc. There's got to be something fundamentally different about us. It definitely doesn't occur randomly; we are at risk of it happening repeatedly. I'm confident that I could fill my lungs with plenty of fluid by going out and diving with no wetsuit, in case any researcher wanted to observe it.

I'll keep in touch with you.

[wes]

Kurt,

Here is my 2 cents. I think you have combined two thing, being tense and not having good lung flexibility. I have a brother in law who is a triathelete and is in awesome shape and has a huge massive chest and can hardly bend over to touch his toes and also can hardly sit still and relax. When he visited our house in the country he always wanted some music on as the quiet drove him nuts!!

So extrapolating from this I think you have large lungs and large lung capacity but can only exhale maybe half way that you should be able to due to "patterened" breathing while running and swimming training, essentially taking 1/2 breaths all the time. Then when you freedive and are tense, maybe sometimes tense from cold or not, thus the variability, you lungs become even more "ridgid".

The good news is that this is easy to measure with a spirometer (I think this is right term) and cooperative doctor. Then if you find that you can exhale less than normal, and agree with me that you are a "tense" person the thing to do is learn to relax, yoga class is very good, astanga is very good if they teach with synchronized breathing and do lung flexibility excercises.

Another thing is that if you do negative dives for warmup to do them quickly, go down then right up for if you wait at the bottom the you can have fluid build up in your lungs, this is what I have been told, though I think its more the above in your case.

Hope this helps - Cheers Wes Lapp

[Ol Dirty Diver]

Originally Posted by wes

Kurt,

Here is my 2 cents. I think you have combined two thing, being tense and not having good lung flexibility. I have a brother in law who is a triathelete and is in awesome shape and has a huge massive chest and can hardly bend over to touch his toes and also can hardly sit still and relax. When he visited our house in the country he always wanted some music on as the quiet drove him nuts!!

So extrapolating from this I think you have large lungs and large lung capacity but can only exhale maybe half way that you should be able to due to "patterened" breathing while running and swimming training, essentially taking 1/2 breaths all the time. Then when you freedive and are tense, maybe sometimes tense from cold or not, thus the variability, you lungs become even more "ridgid".

The good news is that this is easy to measure with a spirometer (I think this is right term) and cooperative doctor. Then if you find that you can exhale less than normal, and agree with me that you are a "tense" person the thing to do is learn to relax, yoga class is very good, astanga is very good if they teach with synchronized breathing and do lung flexibility excercises.

Thanks for your thoughts, Wes. I am quite familiar with the idea that having poor thorax flexibility may contribute to lung squeeze. On the contrary, I suspect that I possess good thorax flexibility (but I'll let you know otherwise if I get to have that checked on). I have done my fair share of packing and reverse packing exercises, but I believe my decent chest flexibility may actually be due more to my cardiovascular training. I used to average 15+ hrs/wk of high-quality training, all of which time was spent exercising my breathing muscles and expanding my chest constantly. I believe this has definitely helped rather than harmed my freediving.

During my training, I hardly breathe with only "1/2 breaths all the time". Many years ago I figured out diaphragmatic breathing on my own, which I incorporated into my running in order to avoid the terrible side stitches I used to get early on. Since getting into freediving a few years ago, I realized the value of the diaphragmatic breathing in freediving, and figured I'd make an effort to practice it all the more while running. With it I can keep my breathing rate extremely low, even up to a relatively high effort level, compared to most other runners (me = 10 - 15 breaths/min...compared to others' 45 - 60 breaths/min).

I am a recent graduate of the Performance Freediving advanced course, and I know you've also been a student of theirs. My constant weight PB was established there only a few weeks ago at 58m (which was not accompanied by any noticeable thoracic filling, as I would have expected), and I could still clear my ears at that depth. My PB static is 7:11. So I know a thing or two about freediving... I don't think I could reach the level I'm at if I didn't know how to relax or access the majority of my lung volume.

Originally Posted by wes

Another thing is that if you do negative dives for warmup to do them quickly, go down then right up for if you wait at the bottom the you can have fluid build up in your lungs, this is what I have been told, though I think its more the above in your case.

I was going to mention this for the other freedivers that experience PE, although I don't think there are many out there. It's definitely true that negatives can cause premature filling, as I used to be able to instigate PE in my first 10 min. of diving by doing an FRC (this is when I was only wearing a 3mm suit and getting cold fairly quickly). But this advice should be heeded by all freedivers. Apparently, some (like Annabel and Jessica on the Big Island) practice "hanging" negatives in their warm-up. The onset of PE or thoracic filling is usually very subtle, so that you wouldn't detect immediately when it has begun. But once it has started, you shouldn't be able to fill your lungs to their fill capacity any more, and you'll have lost some amount of your alveolar surface area for gas exchange, thus limiting performance. I've heeded this advice from Kirk, especially with my susceptibility to PE; I only allow myself one negative in my warm-up instead of multiple, and I make sure to avoid hanging out at the turnaround.

As I mentioned a while back, I pretty much completely overcame my problem with PE by getting a thick enough wetsuit so that I could finally stay warm. So I have solved the problem for myself. But for these individuals that experience PE while swimming, it is still unpredictable. The explanations you and the other contributors to this thread have supplied may apply to me, but they are not all that relevant in these cases of SIPE, which is clearly the same pathology as my freediving-induced PE. For example, with regard to your explanation of being too tense, would you argue that only those swimmers experiencing PE are getting cold and keeping their bodies too tense, while all the other swimmers unafflicted by PE are not? I'd say that the very act of swimming tenses the whole body up, so it's not just that a few swimmers are always tense and getting PE while the rest are not. The underlying cause, which I must share with those susceptible to SIPE, is related to some rare characteristic deeper in the physiology; it is not just attributable to some deficiency that we share in our technique. We are trying to figure out just what this physiological trait(s) is. You almost have to experience it yourself to realize how hopelessly inexplicable it is, especially since so few individuals experience it that it gets much recognition (as evidenced by the doctors misdiagnosing and dismissing it in one of stories in Kat's article). Fortunately, it seems so rare that most of you will never have to deal with it.