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SCD 2014: Swimming and Diving
SCD 2014: Swimming and Diving
SCD 2014: Swimming and Diving
SCD 2014: Swimming and Diving
SCD 2014: Swimming and Diving
SCD 2014: Swimming and Diving
SCD 2014: Swimming and Diving
SCD 2014: Swimming and Diving
SCD 2014: Swimming and Diving
SCD 2014: Swimming and Diving
SCD 2014: Swimming and Diving
SCD 2014: Swimming and Diving
SCD 2014: Swimming and Diving
SCD 2014: Swimming and Diving
SCD 2014: Swimming and Diving
SCD 2014: Swimming and Diving
SCD 2014: Swimming and Diving
SCD 2014: Swimming and Diving
SCD 2014: Swimming and Diving
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SCD 2014: Swimming and Diving

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Richard E. Moon, MD

Richard E. Moon, MD

Published in: Health & Medicine, Sports
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  • 1. Richard Moon, MD Depts. of Anesthesiology and Medicine Duke University Medical Center Durham, NC, USA Death in Swimming and Diving From Kat Calder-Becker
  • 2. Compressed Gas Diving Lundgren CEG, Fahri LE Pulmonary Vascular Physiology & Pathophysiology, 1989
  • 3. Cause of Death in Scuba Diving (n=814) 70% 84% 97% 99% 100% 0% 20% 40% 60% 80% 100% 0 100 200 300 400 500 600 Cumulative Frequency Denoble PJ, et al. Undersea Hyperb Med 35:393, 2008
  • 4. 43 Year Old Female Triathlete  Healthy, nonsmoking female, experienced triathlete. After swimming 750 m in half ironman, choking and dyspnea. Given O2 by EMTs, released after 1 hour  Thyroid levels, echo, CXR, V/Q scan normal  Two months later: chest tightness during swim after the same distance. Pink, frothy sputum. SpO2 73%. CXR showed pulmonary edema. Admitted to hospital; clinically improved after O2, furosemide
  • 5. Immersion Pulmonary Edema 0 50 100 150 Exercise Cold O2 Ice + O2 Normals IPE 0 50 100 150 200 Exercise Cold O2 Ice + O2 MeanArterialPressure (mmHg) ForearmVascularResistance (ArbitraryUnits) * * * * * * * * *P< 0.05 vs. Normals
  • 6. Immersion Pulmonary Edema in Military Divers Weiler-Ravell D, et al. BMJ 311:361, 1995  30 men in a military swimming time trial over 2.4 km in the open sea, water temperature 23°, supine position wearing a bathing suit, using fins  Each drank about 5 L water during the two hours preceding the exercise  8/30 developed shortness of breath, forcing 5 of them to terminate swim prematurely
  • 7. Immersion Pulmonary Edema in Triathletes Miller CC III, et al. Am J Emerg Med 28:941, 2010  Electronic survey via USA Triathlon  1400 respondents, 20 (1.4%) reported having experienced “Cough productive of pink frothy or blood-tinged secretions”  Associated variables with univariate analysis: hypertension, fish oil use, wetsuit use, long course* (*1.9 km swim, 90 km ride, 21.1 km run, or greater)  Associated factors using multiple logistic regression: Variable OR (CI) P Hypertension 5.38 (2.15,3.48) 0.0003 Female gender 2.75 (1.26,6.02) 0.02 Long course 3.30 (1.50,7.27) 0.003 Fish oil use 2.66 (1.28,5.54) 0.009
  • 8. “Drowning from the Inside”: SIPE?  19 year old novice diver. Experience: 18 hours pool training, 7 dives  As he and buddy snorkeled to a wreck he began coughing and choking. Buddy swam to a ferry dock, called the Coast Guard. Victim found 3½ hours later by rescue divers  Weather fair, air temperature 47°F, water visibility 20 feet. Chop on the surface. Divers had been swimming against the tide. Tank full of air with no harmful contaminants. Valve and regulator functioned normally. All hoses and fittings in good condition  Coroner listed the cause of death as asphyxia secondary to aspiration of salt water Tabeling BB. In: Waite CL (Ed). Case Histories of Diving and Hyperbaric Accidents. UHMS, 1988
  • 9. Heart Volume During Immersion Lange L, et al. Pflügers Arch 352:219, 1974 0 250 500 750 1000 Upright Supine Immersed HeartVolume(mL)
  • 10. Hemodynamics of SIPE-Susceptible Individuals and Effect of Sildenafil  10 volunteers with a history of one or more SIPE episodes, 20 controls  6 minutes of immersed exercise in 20°C water  Repeat after oral sildenafil 50 mg  Direct measurement of arterial, PA pressure, PA wedge pressure SIPE-Susceptible Controls M/F 4/6 18/2 Age mean±SD (y) 41.6±7.8 36.2±8.3 Age range 31-53 23-50
  • 11. PAP and PAWP During Cold (20°C) Immersed Exercise * * *P< 0.01 vs. controls Post-sildenafil 50 mg
  • 12. Hypothesis SIPE susceptible individuals can be identified by respond to cold water immersed exercise with excessive elevations of PA pressures due to decreased venous compliance (↑ central redistribution of blood) and/or impaired diastolic LV filling AVO Immersed
  • 13. 41 Articles Reporting SIPE 1984-2014: 292 Cases 53% 47% Civilian Miltary 0 40 80 120 160 Military Civilian Predisposing Factors No Predisposition CARDIAC ABNORMALITIES Hypertension 24 Wall motion abn. 21 Alcoholic cardiomyopathy 1 Takotsubo 4 Myocard. ischemia 21 LVH 9 Mitral regurgitation 4 Atrial fibrillation 2 PVD 1 CARDIAC RISK FACTORS Elevated lipids 16 Sleep apnea 4 Diabetes 4 PULMONARY CONDITIONS Asthma 4 Exercise-induced cough 1
  • 14. SIPE Mechanisms in fit, young athletes? Navy SEALS Triathletes  Excessive hydration  Higher exertion levels → higher PAP, PA wedge pressure  Excessive venoconstriction → greater central blood redistribution  Impaired diastolic LV filling → higher LVEDP  Co-morbid cardiac conditions
  • 15. Triathlon Deaths
  • 16. Triathlete Autopsies Current study  50 triathlon deaths 2009-2013  42/50 (84%) deaths occurred in swim portion  Age 47±8 years (range 33-64); M/F=5/3  Autopsies obtained for 18 deaths • 10/18 (56%) LVH • 6 CAD (one mild) • 1 acute myocarditis Harris et al (JAMA 303:1255, 2010)  14 deaths in USA Triathlon sanctioned races 2006-8  Age 44±10 years (range 28-65); M/F=11/3  13/14 deaths occurred in swim portion  9 autopsies: 6/9 (67%) had LVH  13/14 deaths occurred in swim portion
  • 17. LVH Prevalence (Heart Weight) 0 20 40 60 80 100 Healthy Population* General Population* Triathletes‡ Triathlete Deaths Men Women Combined Percent *Levy D, et al. Am J Cardiol 59:956, 1987 ‡Douglas PS, et al. Am J Cardiol 80:1384, 1997 *P=4.3x10-11 vs. triathletes)
  • 18. Conclusions: Death in Swimmers, Divers  Death in divers can be due to drowning, gas bubble disease (gas embolism and decompression sickness), cardiac death  SIPE is caused by high pulmonary vascular pressures during immersed exercise  Pathophysiology of SIPE: combination of immersion, heavy exercise, cold water with additional factor, such as reduced LV diastolic compliance ± increased cold-induced venoconstriction  Co-morbidities common in civilian cases of SIPE  SIPE can be a cause of death

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