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Immersion pulmonary edema/lung squeeze---HELP!

Thread Status: Hello , There was no answer in this thread for more than 60 days.
It can take a long time to get an up-to-date response or contact with relevant users.

Ol Dirty Diver

Well-Known Member
May 8, 2006
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I am composing this thread to present my own alarming case with immersion pulmonary edema/lung squeeze, in hopes of receiving some feedback about how I should handle my situation. I also think it's worthwhile to present interesting cases pertaining to this topic, to contribute to the body of knowledge that we are accumulating on this perplexing issue in this forum.

I did already read the most recent thread concerning immersion pulmonary edema ("Depth, pressure and squeeze"), which did somewhat address my issue, but I find that several of the factors involved in my case differ from those presented thus far. I have also tried to read most of the threads about lung squeeze, which seems to me to be very related to immersion pulmonary edema, and is perhaps synonymous in certain cases, but full-on lung squeeze (coughing up blood, impaired breathing for several days or weeks, etc.) sounds more severe than my cases of immersion pulmonary edema.

I actually experienced a rather bad dose of immersion pulmonary edema in my dive today. The following symptoms were present:
  • highly impaired breathing
  • audible "rales" during my exhalations
  • occasionally coughing up sputum, which had a light-pink tinge (does this imply that red blood cells were in it? or is plasma normally this color?)
  • throughout the rest of the day my breathing has been somewhat impaired, and rales can be heard when I exhale with effort
I was attempting to dive up to a depth of 108ft/33m today, which I have done several times before (PB depth is currently 120ft). I warmed up over the course of 20 min. by diving to 45ft, 65ft, then 85ft. I have tried to do FRC for warm-up before, but I have instigated my edema problem during my warm-up by doing that before, so now I stick to normal full-breath dives during my warm-up. BTW, I do not pack for my freedives. Anyway, nothing felt out-of-the-ordinary during my warm-up, so I dropped all the way down to the floor (just past 100ft), hung out on the bottom for only 5sec, then felt a bit more labored than usual on my way up. From the effort my heart rate got a bit high, and I had a hard time settling it down over the course of my 6+ min. surface interval. I then made another dive to the floor, barely hung out on the bottom, and felt yet more labored on the way up. This time upon surfacing I had to cough and heard and felt the tell-tale signs up my typical "leaky lungs" problem. I essentially aborted my dive plan at this point, and barely dove any more as I breathed weakly and waited for my accompanying scuba divers below to come back up.

This is essentially what have I dealt with in about one out of every three dives, throughout almost the entire past year. I dive up to twice a week, but some times endure spells where I don't dive for a couple of weeks. It's clear that my lungs are very susceptible to fluid filling, which I am calling immersion pulmonary edema rather than lung squeeze, because my episodes don't sound quite as severe as lung squeeze:
  • I have had the problem occur many times in much shallower water than lung squeeze would be expected to happen, such as in as little as 25ft of water. I have heard lung squeeze defined as only occurring once you surpass residual lung volume depth, although I know that's arguable.
  • Fluid remains in my lungs and my breathing is impaired throughout the rest of the day, but all symptoms usually abate by the next day, rather than sticking around for several days or even weeks as I have heard in serious cases of lung squeeze.
  • I have never coughed up blood, although I finally noticed today that the sputum I can cough up during an episode has a slight pink tinge.
The only factor that I have realized to be clearly associated with my incidence of the problem is that I am always rather cold when it happens. In spite of Hawai'i's relatively balmy waters, I can still get shivering cold in a 3mm open cell wetsuit when the water is as "warm" as 80˚F/27˚C (presumably due to my rather low body fat, 5.1%). So I am actually almost always some degree of uncomfortably cold in the water, depending on whether I had to do some surface swimming or not.

Here are some of the peculiarities to my case:
  • As often as I dive, I would expect the problem to happen just about every time, but it has happened very unpredictably. I have had some diving days in the 60 - 100ft+ range where the problem never presented itself, or at least not noticeably so (i.e., I avoided rales). And some times these successful dives were in the same week as unsuccessful dives where I experienced the problem. In cases of lung squeeze, most individuals seem to be very susceptible to having it happen again, certainly within as short a time frame as a week...But as I mentioned, I sometimes seem to defy this.
  • I have had a few dives where I got really cold (shivering), and it didn't come on.
  • Many individuals have pointed out an association between the onset of lung squeeze with experiencing contractions at depth. I have never detected this myself, and I usually don't even experience any contractions in most of my deep dives since I am down for only 1:30 - 1:45.
  • Fast descent rates have been implicated in lung squeeze; I am usually only descending ~1m/s, which I don't consider fast. And that is usually my peak velocity when I am freefalling past 80ft...I am not even descending that fast during the first 10m, when some have pointed out that it is important to go slow.
  • As far as I know, I am usually not overhydrated before diving.
  • I get over incidents of the edema relatively quickly. Usually by 24hrs I feel fine and can't detect any more breathing impairment. I am a competitive triathlete, and I have not been able to detect that my performance has suffered at all from my problem. My lungs seem to perform their duty very well during workouts once I've recovered from an episode (whereas I have been downright pathetic when I've attempted to workout on the same day as a bad dive). So at least I feel pretty sure that I'm not causing any cumulative damage to my lungs, as least not any that would impair my endurance activity performance.
 

Ol Dirty Diver

Well-Known Member
May 8, 2006
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Several of the aspects of my problem don't seem to resemble those of the lung squeeze incidents I've read thus far, perhaps making my case somewhat unique. The main confounding aspect is that I can have it come on in much shallower water than you'd ever expect for it to happen. As I mentioned, I had it happen once in water of only 25ft depth, which was a time I was particularly cold because I attempted to put my wetsuit on in the water instead of having it on before I got in the water. The worst incident ever was the very first time it happened, in Feb. 2006. I was only diving up to 40ft deep, and I was very cold that dive because I didn't yet own a full wetsuit. I allowed my condition to get very bad that time, because I kept attempting to dive after the onset of the fluid in my lungs (so I kept coughing harshly throughout the rest of my dive). It was my first time experiencing it, so I didn't know any better, and there were lots of fish around so I wanted to keep spearfishing. I wonder if that first horrible episode actually caused permanent trauma to my lungs, thereby creating my lasting susceptibility to the problem, as has been mentioned to be the case with victims of lung squeeze. The thing is, I was diving no where near my residual volume depth that day (only to 40ft).

I should mention that even though I only observe the obvious symptoms (rales) about one in every three dives, I think the fluid seepage happens to a slight extent nearly every time I dive. I often finish a dive feeling very tired, and it is often very laborious for me to perform relatively easy activites post-dive, such as walking up a steep beach, or carrying my kayak back to my car. I suspect that my lungs may fill with a slight amount of fluid every dive (since I am cold to some degree nearly every dive), thereby impairing my breathing slightly, yet not enough to present the symptom of rales.

Several of you that are exceptionally keen about the physiology of freediving have posted your speculations about the mechanism of and contributing factors of lung squeeze (most of which are not present in my situation). I would like to hear more description of pulmonary edema if anyone is in the know? The descriptions of it that I have read elsewhere are very alarming, including mention of failure of one side of the heart. If the side which pumps blood out of (or into?) the lungs functions weakly, the blood supposedly pools in the lungs, which may result in enough pressure to promote the seepage of blood plasma into the alveoli? Is this extreme description actually pertinent in immersion pulmonary edema, or is the immersion version of pulmonary edema much less serious?

Obviously I am after a solution to my problem, although I know that it will probably not simply be presented promptly to me. My plan is to identify all of the variables that may be contributing to my problem, and attempt to work with each of them. For instance, since being cold has been so clearly associated with my problem (which is also mentioned in descriptions of immersion pulmonary edema), I have ordered a 5mm wetsuit (unheard of in Hawai'i) in hopes of finally staying comfortably warm while diving. If anyone finds that some other aspect(s) of my situation jumps out at them as suspect, please let me know. I have tried to think of what ways I might be different from most other freedivers. The only thing I could think of is that I may do much more cardiovascular training than most divers do (for my triathlons...15hrs+/wk), so that I possess physiological adaptations in my heart/lungs that are somehow unfavorable for freediving.

I thank anyone who offers insight regarding my situation. I've got the motivation and fitness to progress much deeper, and I think I've even figured out the compensation method necessary to do so, but my "leaky lungs" will remain an impassable barrier to progression unless I can figure out how to avoid the problem.
 

Ol Dirty Diver

Well-Known Member
May 8, 2006
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As a reward to anyone who read all that, here are a few photos from my crappy dive today, taken by my scuba diver accomplices. The setting is the "Corsair" wreck (109ft) off of Hawai'i Kai in O'ahu:

DSC_0111-1.jpg


DSC_0088-1-1.jpg


DSC_0094-1.jpg


DSC_0053-1.jpg


collage29.jpg


DSC_0235-1.jpg


DSC_0247-1-3.jpg


Yep, I felt like crap in most of those photos in spite of the surrounding beauty.
 
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Kimmo

Well-Known Member
Aug 7, 2001
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I have seen these cases over the years. It sometimes seem to me that there is quite a lot similarities between lung squeeze and HAPE (high altitude pressure edema, mountains). Differend way to get it but quite similar symptoms. It has also seemed that acclimation works for lung squeeze too (really shallow dives first and during two to three weeks little by little deeper and deeper).
It is also really important to learn to relax physically and mentally. I also suggest not to cough in the deep or raise head.
Unfortunatelly it has also seemed that it may be something to do with the certain persons: some people gets it quite easily and quite often and some people does not have seen it ever happen, even in deep dives. Maybe some things in lung physiology (alveolar wall quite thin?)?

deeply,

- kimmo
 

trux

~~~~~
Dec 9, 2005
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Lung squeeze indeed is a common name for pulmonary edema.

Since you suffer from it repetitively, I'd definitely recommend searching a local pulmonary expert and asking for a thorough examination. The best would be if the physician already had an experience with freediving, and knew its specifics. Knowing you are in Hawaii, I'd not be surprised you could find a doctor well familiar with freediving in one of local clinics.

You could also contact some of the physicians specialized in freediving medical research world-wide, and ask them for recommendations. For example Dr. Ralph Potkin posted a Chest Squeeze Questionnaire on the World Freediving Medical Association's website, so he might be interested in collecting the data from you. You can also try posting on the forum of WFDMA - although it does not seem to bee very living, some of the scientists may peek in and either give you some advices, or recommend you a local physician on Hawaii.
 

cigarlung

Well-Known Member
Jul 6, 2006
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Kurt Seeing A Pulmonoligist And Getting Your Lungs Scaned May Not Be A Bad Idea. I Have Heard Of Young Healthy Guys Throwing Pulmonary Embolisms Which You Probally Know Already Has A Poor Outcome. Throwing A Pe Can Also Give Of Symptoms Similiar To A Heart Attack. Fluid In Lungs Not Resolving On There Own Would Probally Mean A Hospital Stay And Iv Sol Medrol At Best Chest Tube And Perhaps Surgery At Worst. I Am Sure It Would Great Info For The Diving Community To Find Out What You Learn. I Will Have To Get My A And P Book Out And My Merck Manuel And See What I Can Find Out. Thanks For The Interesting Subject Matter Hope This Turns Out To Be Nothing But Perhaps Overtraining For You Good Luck. Rob
 

laminar

Well-Known Member
Aug 13, 2001
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Hi Kurt,

Nicely detailed post.

Some questions arise from your story:

-Were you cold enough to be "tense" in your diaphragm or shivering when you made the dives?
-Was being cold common to all incidences of squeeze?
-What was the effort you expended to descend and ascend? Easy, moderate, laboured, challenging, extreme?
-What kind of equalizing technique do you use?
-What kind of fins are you using? (soft, medium, hard; plastic, fiberglass, carbon)
-Do you have any history of asthma, bronchitis, pneumonia, smoking, second hand smoke exposure, or lung injury?
-How long did you wait after each incident before going diving again?
-Have you ever had the feeling after diving that you couldn't get a full lungful of air, that something was pressing down on your chest?
-Is there any history of cardiovascular disease in your family?
-Are you in decent cardio shape? If so, how would you rate it?

I would recommend getting checked out by a diving doctor to be on the safe side. Not that they will be able to tell you how to avoid getting squeezed, aside from no diving. :duh Anytime you have a bad squeeze, I would recommend taking a week off or more.

I would start off by diving only when you comfortable and not cold or on the edge of shivering. The 5mm or an extra vest would certainly help in relaxing your diaphragm thoughout the dive.

Looking forward to your responses. By the way, GREAT photos!

Pete
 

Ol Dirty Diver

Well-Known Member
May 8, 2006
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Thanks for taking interest Pete.
Some questions arise from your story:

-Were you cold enough to be "tense" in your diaphragm or shivering when you made the dives?
I am pretty much always cold underwater to some degree. It's pretty typical for me to reach the point of shivering, sometimes within 30 min. Thus, my body often is tense and I can't breathe up nearly as well once I'm cold. However, on some dives (such as my last one) I don't even have sufficient time to get really cold before the edema starts happening. Most of my dive buddies, on the other hand, don't get cold (as mentioned, my fat % is exceptionally low). That's why I think being cold almost definitely has something to do with my problem (which is consistent with descriptions of immersion pulmonary edema). It is thus bewildering to me that some serious freedivers intentionally allow themselves to get cold, to promote the dive reflex (as described in the article about Murat's FRC clinic).
-Was being cold common to all incidences of squeeze?
Yes, I believe I have been cold in every one of my incidents. It obviously makes sense for me to test being warm while diving, which I will get to do next dive since I have my newly-arrived 5mm suit now.
-What was the effort you expended to descend and ascend? Easy, moderate, laboured, challenging, extreme?
My effort to descend and ascend has generally been moderate (4lbs of weight with 3mm suit = neutrally bouyant at 10m). On my most recent problem-ridden dive, however, effort to descend was easier because I got to use my new C4 Flaps (stiffness 40) for the first time.
-What kind of equalizing technique do you use?
I equalize using Frenzel. Have not progressed to mouthfill yet (and haven't needed to up to my PB depth of 120ft).
-What kind of fins are you using? (soft, medium, hard; plastic, fiberglass, carbon)
I will usually be using my C4s from now on when diving past 30m, but I have mostly used high stiffness plastic fins and will continue to use them < 25m.
-Do you have any history of asthma, bronchitis, pneumonia, smoking, second hand smoke exposure, or lung injury?
-Is there any history of cardiovascular disease in your family?
-Are you in decent cardio shape? If so, how would you rate it?
No history of health problems of any sort, and no known family history of such. As mentioned, I am a competitive triathlete (> 15hrs/wk of cardiovascular activity when in season; comparative fitness to majority of population = 9.5+/10). I pointed out that in thinking about how I might differ from most other freedivers, I could only identify the fact that I probably do more cardiovascular training (and particularly, hard, lactate-threshold cardiovascular training) than most. I have mentioned in posts before that I felt cardiovascular fitness was seemingly underappreciated by most freedivers, and that it might be the ultimate limiter of apnea performance. However, maybe it has caused adaptations in my pulmonary system that are somehow unfavorable for freediving?! (e.g., reduced alveolar wall thickness to promote gas exchage?)
-How long did you wait after each incident before going diving again?
Usually my dives are at least 48hrs apart, more likely several days apart. I mentioned that I recover rather quickly from my edema episodes...usually within 24hrs I feel fine (although there very well may still be residual fluid in my lungs that I can't feel). I have on occasion waited an extra long duration before the next dive after an episode, some times a few weeks.
-Have you ever had the feeling after diving that you couldn't get a full lungful of air, that something was pressing down on your chest?
I do often feel that my breathing is slightly impaired and that I am very tired after my dives. As mentioned, I suspect that the edema may happen to some extent on every one of my dives. Only about 1 out of every 3 dives does it reach the point where I can easily hear rales and I feel horrible. But since I often feel so tired after nearly all my dives, whereas my dive buddies don't seem to experience this, I've suspected that perhaps varying degrees of fluid leakage happen to me on every dive depending on various factors, such as the depth I was diving, duration of dive, how cold I was, etc.

The reason I posted my personal case was because I felt like some of the factors involved in it are a bit peculiar in comparison to those in cases presented thus far. To reiterate:
  • My numerous incidents have largely occurred at depths much shallower than one would expect for lung squeeze to happen (i.e., > 35m). I have had it happen under 100ft many times, and even as shallow as 40ft and 25ft on two occasions (on FULL lungs of air...not talking about FRC or negative dives, which I avoid now because they have caused the edema before during warm-up).
  • I have never coughed up blood. As far as I can tell, the fluid is only blood plasma (pink in color though).
  • I recover very quickly from my episodes, usually within 24hrs and always within 48hrs.
You used the term 'squeeze' when referring to my problem, but I honestly don't feel like I'm experiencing full-on lunq squeeze as presented in others' cases. In most other cases the individuals were diving around or past their residual lung volume depth (I don't think I've even reached mine yet), and their episodes included coughing up blood and extended recovery periods. In my reading of cases, it seems apparent to me that a different problem is often mistaken for lung squeeze...That of a ruptured trachea from diving very deep. Individuals that experienced this coughed up blood (which is usually intermixed with frothy saliva or 'spittle'...the bubble-containing property of this material seems consistent with a trachea issue, where air could mix with the blood and saliva), but didn't otherwise feel bad or have their breathing compromised. Many of these individuals are able to keep diving, and have come to accept coughing up the blood since it doesn't seem to affect their diving. In my case, on the other hand, my dive is over once the edema presents itself. It becomes impossible for me to dive deep any more because my lung volume is decreased due to displacement by the fluid. Indeed, if I try, as I descend I can feel the incompressible fluid bubbling up my lungs and in the back of my throat, requiring my utmost control to prevent coughing.
I would recommend getting checked out by a diving doctor to be on the safe side. Not that they will be able to tell you how to avoid getting squeezed, aside from no diving. :duh Anytime you have a bad squeeze, I would recommend taking a week off or more.

I would start off by diving only when you comfortable and not cold or on the edge of shivering. The 5mm or an extra vest would certainly help in relaxing your diaphragm thoughout the dive.
I do intend to see a doctor about this soon, and I have already gathered some good referrals. I have also submitted an inquiry to Dr. Ralph Potkin of WFDMA. In addition, I will apply the following precautions to my diving with extra tenacity from now on:
  • Extend my warm-up and make it more gradual. Instead of attempting to make it to > 30m after only a few warm-up dives, I will spend 2 - 3x longer in my warm-up period, perhaps trying to reach every warm-up depth at least twice before descending further. This idea stems from my observation that I usually avoided my edema problem when I was able to gradually work my way to deeper water, such as over the course of an hour (due to shorediving and spearing fish in gradually deeper water as I worked my way out).
  • Perform more thorax stretching before diving.
  • STAY WARM!!! (by utilizing my new 5mm wetsuit).
Thanks so much for your review.
 

Ol Dirty Diver

Well-Known Member
May 8, 2006
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I think what would really shed some light on my case, and perhaps lung squeeze, is if someone in the know could share more detailed information about pulmonary edema. I never found much good information online...Just found this ("Immersion Pulmonary Edema in Special Forces Combat Swimmers") though. I think the lungs are only one component of the issue. It sounds like other elements such as cardiac output and blood pressure are highly likely to be involved.

I just noticed the "LinkBack" at the bottom of this page today. Apparently my post sparked a thread on a French diving forum ("[ame="http://www.plongeur.com/forums/showthread.php?t=28355"]Forums plongée Plongeur.com - Oedème pulmonaire et apnée[/ame]"), in which it sounds like some knowledgable users are posting some interesting insight. I used Google's translator to try to read the thread, with insufficient results. If anybody on here can read French, I'd be most obliged if you could read that thread and share with us any notable information from it.
 

laminar

Well-Known Member
Aug 13, 2001
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I am pretty much always cold underwater to some degree. It's pretty typical for me to reach the point of shivering, sometimes within 30 min. Thus, my body often is tense and I can't breathe up nearly as well once I'm cold. However, on some dives (such as my last one) I don't even have sufficient time to get really cold before the edema starts happening. Most of my dive buddies, on the other hand, don't get cold (as mentioned, my fat % is exceptionally low). That's why I think being cold almost definitely has something to do with my problem (which is consistent with descriptions of immersion pulmonary edema). It is thus bewildering to me that some serious freedivers intentionally allow themselves to get cold, to promote the dive reflex (as described in the article about Murat's FRC clinic).

Getting cold and shivering are two different things. I've done no suit dives in 8-14C water which vasoconstrict you in only a few seconds. Once that happens I make about 2-3 deep recreational dives before getting out. During that time, I am relaxed, not even close to shivering. The only time I'm tense is during a no suit dive when the surface temp is much higher, say 18-21C and there's a big thermocline of 8-12C at about 15m. Then it takes a lot of concentration to relax. But my body and especially my diaphragm is relaxed. It's quite the opposite if I've been in the water too long with a wetsuit (vasoconstriction is inhibited and less intense). My core is the first to tense up so that's when I get out. I used to dive while shivering, now I never do.

As mentioned, I am a competitive triathlete (> 15hrs/wk of cardiovascular activity when in season; comparative fitness to majority of population = 9.5+/10). I pointed out that in thinking about how I might differ from most other freedivers, I could only identify the fact that I probably do more cardiovascular training (and particularly, hard, lactate-threshold cardiovascular training) than most. I have mentioned in posts before that I felt cardiovascular fitness was seemingly underappreciated by most freedivers, and that it might be the ultimate limiter of apnea performance. However, maybe it has caused adaptations in my pulmonary system that are somehow unfavorable for freediving?! (e.g., reduced alveolar wall thickness to promote gas exchage?)

I've exprienced what felt like mild edema after a particularly hard set on a Concept 2 rowing machine - lactate threshold intervals. Edema is apparently not uncommon among race horses (I don't have an citations handy, though).

Your training adaptations for triathlon could be a factor. I don't know enough about that side of exercise physiology to comment, though.

I do often feel that my breathing is slightly impaired and that I am very tired after my dives. As mentioned, I suspect that the edema may happen to some extent on every one of my dives. Only about 1 out of every 3 dives does it reach the point where I can easily hear rales and I feel horrible. But since I often feel so tired after nearly all my dives, whereas my dive buddies don't seem to experience this, I've suspected that perhaps varying degrees of fluid leakage happen to me on every dive depending on various factors, such as the depth I was diving, duration of dive, how cold I was, etc.

If that's the case, I would be really careful! You mention further down in your post that you'll change your warm-ups to add more shallower dives. I would disagree with that plan. I think your goal should be to dive at a depth that results in no injury or feeling of breathlessness whatsoever. What's the use of making a 30m dive if it results in an unpleasant experience. When I suffered from my squeezes (yes, more severe and perhaps a different category from what you're experiencing), I started from scratch. I had to do this several times until diving FRC worked for me. I would stay shallow at whatever depth keeps you indicident free. What I've realized over the years is that breath holding long enough to get really, really deep is pretty easy. You can learn how to equalize well enough to hit 60m pretty easily. But what is not understood is how different people react to being in an hyperbaric environment. Most of all, I've realized that it is always better to progress more slowly than we want to, especially when it comes to lung issues. Be confident in the fact that you have the ability to dive deep. Now all that matters is whether your body is ready yet. It is humbling to realize that it's not just about concentration and skill and nerve, but that your body has it's own limits that you need to heed.

In addition, I will apply the following precautions to my diving with extra tenacity from now on:
  • Extend my warm-up and make it more gradual. Instead of attempting to make it to > 30m after only a few warm-up dives, I will spend 2 - 3x longer in my warm-up period, perhaps trying to reach every warm-up depth at least twice before descending further. This idea stems from my observation that I usually avoided my edema problem when I was able to gradually work my way to deeper water, such as over the course of an hour (due to shorediving and spearing fish in gradually deeper water as I worked my way out).
  • Perform more thorax stretching before diving.
  • STAY WARM!!! (by utilizing my new 5mm wetsuit).
Thanks so much for your review.

Again, I'd start with a max depth that you would do near shore, say 30-40 feet and try that for some time, making as many relaxed dives as you can until you get chilled then get out. I would also slow your descent. I think most people when diving near shore or recreationally with no specific depth in mind, tend not to descend straight down, as if on a depth line. Rather they dive following a slope or the bottom, which is easier on the chest and thorax. I would aim for .65 m/s - .80 m/s as your descent speed. Although our cases may be different, I think it's a reasonable precaution since I believe the speed of descent makes it harder to relax and gives the body less time to adjust to the increasing pressure.

I read the French thread. I'm not up on my medical terms in French, but this is a general overview:

Diamox said he experienced something similar, but with stabbing pains in his chest during a 4-5 month period. He underwent all sorts of exams, x-rays, ultrasound (I think), blood test, hyperbaric chamber, and in the end didn't discover anything. Then he contacted the AIDA doctor Affriat, who gave him some advice (he doesn't say what). He worked on the flexibility of his chest and diaphragm and reduced his cardio. He felt his cardio wasn't a factor (3 times a week for 45min). In Diamox's opinion, it is a lack in adaptation of the thoracic tissues that is agravated by an forced equalization, fear of the depth attempted, a sudden turn at the bottom etc...

Oceanman's post (from another thread) addresses the usual info and closes with the idea that it is a lack of time to adapt:

* ne pas plonger assez souvent / not diving enough
* mauvaise maitrise de la compensation / not having mastered equalization
* tout effet mécanique sur la cage thoracique (contractions, virage au fond, usage des bras en immersion libre ou sans palme etc...) / physical effects on the thoracic cage from contractions, turn at the bottom, using arms in free immersion, or no-fins, etc..
* descendre trop vite / descent is too rapid
* avoir froid / being cold


I've read about regular pulmonary edema from immersion. I'll look for the citation. Swimmers and scuba divers can suffer from it. I wonder if someone can comment on exercise edema in highly trained athletes like yourself.

Hope this helps!

Pete
 
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Ol Dirty Diver

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May 8, 2006
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Thanks so much for your time and consideration, Pete.
I think your goal should be to dive at a depth that results in no injury or feeling of breathlessness whatsoever. What's the use of making a 30m dive if it results in an unpleasant experience.
I may have misled you by mentioning that I go spearfishing, thus indicating that I am only a recreational diver. I am not diving to 30m and below to catch fish...I am doing it because I want to be a competitive freediver! I want to go to the national or world freediving championships some day and toe the line with you, Eric, Martin, Herbert, etc. :) It is often the case that individuals with a competitive background in one sport can become very successful in another in a short amount of time due to carrying over their fitness and competitive drive. I was hoping that my background in triathlon (in which I am no pro, but a top amateur) would help me in freediving, but obviously I am being limited by my body to some extent. I do truly believe that my cardiovascular training for triathlon could be synergistic with the mental and pulmonary training for apnea though...

I acknowledge and intend to pay heed to all of your advice. Unfortunately the feeling of my edema coming on is very subtle, usually no more than the slight feeling of my lungs being "heavier", which might easily be mistaken for having pushing it a bit on the last effort or not breathing up enough. And as I mentioned, I have had the edema problem come on in water as shallow as 25ft! Alas, it is that unpredictable. In any case, staying shallower for a while and working my way back up more gradually couldn't hurt.

I'll be sure to let you know if I elucidate any mind-blowing discoveries as I continue my investigation...But don't hold your breath. ;)
 

tylerz

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Jun 19, 2002
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Reading your thread on Hawaii Skin diver, I think it is getting more possible that you are following a red herring in identifying it as pulmonary edema. The most striking identifier of that is the fact that you are coughing up lots of phlegm without blood in it. The fatigue and rales are certainly suggesting you have fluid in your lungs, but without the symptoms of thoracic pains/throbs, blood, or residual volume, I would say it is more likely a fluid is draining into your lungs from a source other than alveoli.

To test if the fluid is coming from above the epiglottis you could dive to your depths, as long as you stay head down on every dive throughout the whole dive, and prior to turning around close your epiglottis and maintain it as such until you surface. At the surface immediately spit and remove your mask, clearing your sinuses. Pay close attention to whether there is a sense of phlegm above the epiglottis and then sense whether you feel the same in your trachea, both before opening the epiglottis. Do this on each dive.

Hope you get to the bottom of your concerns.
 
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trux

~~~~~
Dec 9, 2005
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Tyler's idea is interesting and certainly worth of testing. As for the French forum, Laminar already translated the principal. I just add that they often quote "Broussolle", which is a relatively new (2006) and quite extensive (880 pages) book about physiology in diving and seems to be The Bible for French divers. Unfortunately it does not look there is any English version available.

Broussolle B., Méliet J.-L. coord. Coulange M.
Physiologie et médecine de la plongée
ISBN 978-2-7298-2983-4

Besides mentioning squeeze and blood shift as factors in lung edema, they also quote left auricular pressure (!?), and lung arterial hypertension in secondary response to hypoxia as edema factors listed in Broussolle.

As for the advices from Dr. Affriat - Diamox indeed does not tell it directly, but it looks like the main reason seemed to be the tension, hence the diaphragm flexibility exercises. Having seen your photos, and your exceptional 6-pack, I see that your abdomen is very strong, but I can also imagine that the impact on the diaphragm flexibility may be negative.

I really think though that you should visit a pulmonoligist and have you examined. Although it is not sure he finds anything, at least it can give you some clues, and it can exclude some of the causes or permanent damage.

The theoretic discussion here on the forum is great and will help many others, but each specific case may be slightly different. Doing any conclusion only on subjective symptoms may not be sufficient - having more objective data from laboratory exams is certainly better.

Wish you to get rid of the edemas quick!
 
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tylerz

Well-Known Member
Jun 19, 2002
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To test if the fluid is coming from above the epiglottis you could dive to your depths, as long as you stay head down on every dive throughout the whole dive, and prior to turning around close your epiglottis and maintain it as such until you surface. At the surface immediately spit and remove your mask, clearing your sinuses. Pay close attention to whether there is a sense of phlegm above the epiglottis and then sense whether you feel the same in your trachea, both before opening the epiglottis. Do this on each dive.

Rereading this, by saying maintaining head down throughout the whole dive, I meant to imply the descent part of the dive. That was somewhat ambiguous.

Also, at the beginning of writing the post I meant to also emphasize that my thoughts should not take away from pursuing having your situation assessed by a doctor. By the end of my post I forgot to mention it. Trux's post reminded me of that.
 

cdavis

Well-Known Member
Jan 21, 2003
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Kurt,

To add one small data point to this discussion:

A friend of mine has been experiancing erratic squeeze/edema type syptoms, rales, fluid in the lungs, spitting small amounts of blood, etc after diving to depths far less than residual volume. He tried doing diaphram stretches and they have been working.

Keep us informed on your progress and good luck,

Connor
 

DeepThought

Freediving Sloth
Sep 8, 2002
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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

Well-Known Member
Apr 11, 2001
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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

Well-Known Member
May 18, 2004
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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

Well-Known Member
May 8, 2006
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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 [ame="http://www.google.com/search?hl=en&q=%22pulmonary+edema%22+scuba&btnG=Search"]scuba diving[/ame] or [ame="http://www.google.com/search?hl=en&q=%22pulmonary+edema%22+swimming&btnG=Search"]swimming[/ame]. 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.
 
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