1
|
Yu E, Valdivia-Valdivia JM, Silva F, Lindholm P. Breath-Hold Diving Injuries - A Primer for Medical Providers. Curr Sports Med Rep 2024; 23:199-206. [PMID: 38709946 DOI: 10.1249/jsr.0000000000001168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
ABSTRACT Breath-hold divers, also known as freedivers, are at risk of specific injuries that are unique from those of surface swimmers and compressed air divers. Using peer-reviewed scientific research and expert opinion, we created a guide for medical providers managing breath-hold diving injuries in the field. Hypoxia induced by prolonged apnea and increased oxygen uptake can result in an impaired mental state that can manifest as involuntary movements or full loss of consciousness. Negative pressure barotrauma secondary to airspace collapse can lead to edema and/or hemorrhage. Positive pressure barotrauma secondary to overexpansion of airspaces can result in gas embolism or air entry into tissues and organs. Inert gas loading into tissues from prolonged deep dives or repetitive shallow dives with short surface intervals can lead to decompression sickness. Inert gas narcosis at depth is commonly described as an altered state similar to that experienced by compressed air divers. Asymptomatic cardiac arrhythmias are common during apnea, normally reversing shortly after normal ventilation resumes. The methods of glossopharyngeal breathing (insufflation and exsufflation) can add to the risk of pulmonary overinflation barotrauma or loss of consciousness from decreased cardiac preload. This guide also includes information for medical providers who are tasked with providing medical support at an organized breath-hold diving event with a list of suggested equipment to facilitate diagnosis and treatment outside of the hospital setting.
Collapse
Affiliation(s)
- Elaine Yu
- University of California San Diego, Department of Emergency Medicine; San Diego, CA
| | | | - Fernando Silva
- Kaiser Permanente Vacaville Medical Center, Department of Emergency Medicine; Vacaville, CA
| | - Peter Lindholm
- University of California San Diego, Department of Emergency Medicine; San Diego, CA
| |
Collapse
|
2
|
Tetzlaff K, Swenson ER, Bärtsch P. An update on environment-induced pulmonary edema – “When the lungs leak under water and in thin air”. Front Physiol 2022; 13:1007316. [PMID: 36277204 PMCID: PMC9585243 DOI: 10.3389/fphys.2022.1007316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 09/08/2022] [Indexed: 11/16/2022] Open
Abstract
Acute pulmonary edema is a serious condition that may occur as a result of increased hydrostatic forces within the lung microvasculature or increased microvascular permeability. Heart failure or other cardiac or renal disease are common causes of cardiogenic pulmonary edema. However, pulmonary edema may even occur in young and healthy individuals when exposed to extreme environments, such as immersion in water or at high altitude. Immersion pulmonary edema (IPE) and high-altitude pulmonary edema (HAPE) share some morphological and clinical characteristics; however, their underlying mechanisms may be different. An emerging understanding of IPE indicates that an increase in pulmonary artery and capillary pressures caused by substantial redistribution of venous blood from the extremities to the chest, in combination with stimuli aggravating the effects of water immersion, such as exercise and cold temperature, play an important role, distinct from hypoxia-induced vasoconstriction in high altitude pulmonary edema. This review aims at a current perspective on both IPE and HAPE, providing a comparative view of clinical presentation and pathophysiology. A particular emphasis will be on recent advances in understanding of the pathophysiology and occurrence of IPE with a future perspective on remaining research needs.
Collapse
Affiliation(s)
- Kay Tetzlaff
- Medical Clinic, Department of Sports Medicine, University of Tübingen, Tübingen, Germany
- *Correspondence: Kay Tetzlaff,
| | - Erik R. Swenson
- Department of Medicine, University of Washington, Seattle, WA, United States
- Division of Pulmonary Medicine and Critical Care, University of Washington, Seattle, WA, United States
| | - Peter Bärtsch
- Department of Internal Medicine, University of Heidelberg, Heidelberg, Germany
| |
Collapse
|
3
|
Patrician A, Pernett F, Lodin-Sundström A, Schagatay E. Association Between Arterial Oxygen Saturation and Lung Ultrasound B-Lines After Competitive Deep Breath-Hold Diving. Front Physiol 2021; 12:711798. [PMID: 34421654 PMCID: PMC8371971 DOI: 10.3389/fphys.2021.711798] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 07/12/2021] [Indexed: 12/22/2022] Open
Abstract
Breath-hold diving (freediving) is an underwater sport that is associated with elevated hydrostatic pressure, which has a compressive effect on the lungs that can lead to the development of pulmonary edema. Pulmonary edema reduces oxygen uptake and thereby the recovery from the hypoxia developed during freediving, and increases the risk of hypoxic syncope. We aimed to examine the efficacy of SpO2, via pulse-oximetry, as a tool to detect pulmonary edema by comparing it to lung ultrasound B-line measurements after deep diving. SpO2 and B-lines were collected in 40 freedivers participating in an international deep freediving competition. SpO2 was measured within 17 ± 6 min and lung B-lines using ultrasound within 44 ± 15 min after surfacing. A specific symptoms questionnaire was used during SpO2 measurements. We found a negative correlation between B-line score and minimum SpO2 (rs = −0.491; p = 0.002) and mean SpO2 (rs = −0.335; p = 0.046). B-line scores were positively correlated with depth (rs = 0.408; p = 0.013), confirming that extra-vascular lung water is increased with deeper dives. Compared to dives that were asymptomatic, symptomatic dives had a 27% greater B-line score, and both a lower mean and minimum SpO2 (all p < 0.05). Indeed, a minimum SpO2 ≤ 95% after a deep dive has a positive predictive value of 29% and a negative predictive value of 100% regarding symptoms. We concluded that elevated B-line scores are associated with reduced SpO2 after dives, suggesting that SpO2 via pulse oximetry could be a useful screening tool to detect increased extra-vascular lung water. The practical application is not to diagnose pulmonary edema based on SpO2 – as pulse oximetry is inexact – rather, to utilize it as a tool to determine which divers require further evaluation before returning to deep freediving.
Collapse
Affiliation(s)
- Alexander Patrician
- Centre for Heart, Lung & Vascular Health, University of British Columbia, Okanagan, BC, Canada
| | - Frank Pernett
- Environmental Physiology Group, Department of Health Sciences, Mid Sweden University, Östersund, Sweden
| | | | - Erika Schagatay
- Environmental Physiology Group, Department of Health Sciences, Mid Sweden University, Östersund, Sweden.,Swedish Winter Sports Research Centre, Department of Health Sciences, Mid Sweden University, Östersund, Sweden
| |
Collapse
|
4
|
Valdivia-Valdivia JM, Räisänen-Sokolowski A, Lindholm P. Prolonged syncope with multifactorial pulmonary oedema related to dry apnoea training: Safety concerns in unsupervised dry static apnoea. Diving Hyperb Med 2021; 51:210-215. [PMID: 34157738 DOI: 10.28920/dhm51.2.210-215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 02/07/2021] [Indexed: 11/05/2022]
Abstract
Many competitive breath-hold divers use dry apnoea routines to improve their tolerance to hypoxia and hypercapnia, varying the amount of prior hyperventilation and lung volume. When hyperventilating and exhaling to residual volume prior to starting a breath-hold, hypoxia is reached quickly and without too much discomfort from respiratory drive. Cerebral hypoxia with loss of consciousness (LOC) can easily result. Here, we report on a case where an unsupervised diver used a nose clip that is thought to have interfered with his resumption of breathing after LOC. Consequently, he suffered an extended period of severe hypoxia, with poor ventilation and recovery. He also held his breath on empty lungs; thus, trying to inhale created an intrathoracic sub-atmospheric pressure. Upon imaging at the hospital, severe intralobular pulmonary oedema was noted, with similarities to images presented in divers suffering from pulmonary barotrauma of descent (squeeze, immersion pulmonary oedema). Describing the physiological phenomena observed in this case highlights the risks associated with unsupervised exhalatory breath-holding after hyperventilation as a training practice in competitive freediving.
Collapse
Affiliation(s)
- Juan M Valdivia-Valdivia
- Neurosurgery Department, St. Joseph's Hospital, Tampa FL, USA.,International Association for Development of Apnea (AIDA International) - Medical and Science Committee, Zurich, Switzerland.,Corresponding author: Professor Peter Lindholm, Department of Emergency Medicine, University of California San Diego, San Diego CA, USA,
| | - Anne Räisänen-Sokolowski
- Pathology, Helsinki University and Helsinki University Hospital, Helsinki, Finland.,The Centre for Military Medicine, The Finnish Defense Forces, Helsinki, Finland
| | - Peter Lindholm
- Department of Emergency Medicine, University of California San Diego, San Diego CA, USA
| |
Collapse
|
5
|
Yanamandra U, Vardhan V, Saxena P, Singh P, Gupta A, Mulajkar D, Grewal R, Nair V. Radiographical Spectrum of High-altitude Pulmonary Edema: A Pictorial Essay. Indian J Crit Care Med 2021; 25:668-674. [PMID: 34316147 PMCID: PMC8286401 DOI: 10.5005/jp-journals-10071-23827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background High-altitude pulmonary edema (HAPE) is a common cause of hospitalization in high altitude areas with significant morbidity. The clinical presentation of HAPE can overlap with a broad spectrum of cardiopulmonary diseases. Also, it is associated with varied radiological manifestations mimicking other conditions and often leading to unnecessary and inappropriate treatment. Patients and methods The primary aim of the study was to study the various radiological manifestations of HAPE through real-world chest radiographs. We present six different chest X-ray patterns of HAPE as a pictorial assay, at initial presentation, and after the resolution of symptoms with supplemental oxygen therapy and bed rest alone. Results HAPE can present as bilateral symmetrical perihilar opacities, bilateral symmetrical diffuse opacities, unilateral diffuse opacities, bilateral asymmetrical focal opacities, and even lobar consolidation with lower zone or less commonly upper zonal predilection. These presentations can mimic many common conditions like heart failure, acute respiratory distress syndrome, pulmonary embolism, aspiration pneumonitis, pneumonia, malignancy, and tuberculosis. Conclusion A holistic clinical–radiological correlation coupled with analysis of the temporal course can help high-altitude physicians in differentiating true HAPE from its mimics. How to cite this article Yanamandra U, Vardhan V, Saxena P, Singh P, Gupta A, Mulajkar D, et al. Radiographical Spectrum of High-altitude Pulmonary Edema: A Pictorial Essay. Indian J Crit Care Med 2021;25(6):668–674.
Collapse
Affiliation(s)
- Uday Yanamandra
- Department of Hematology & Stem Cell Transplant, Army Hospital (R&R), New Delhi, India
| | - Vasu Vardhan
- Department of Pulmonology, Base Hospital, New Delhi, India
| | - Puneet Saxena
- Department of Pulmonology, Army Hospital (R&R), New Delhi, India
| | - Priyanka Singh
- Department of Pulmonology, Army Hospital (R&R), New Delhi, India
| | - Amul Gupta
- Department of Radiology, Base Hospital, New Delhi, India
| | - Deepak Mulajkar
- Department of Oncology, Army Hospital (R&R), New Delhi, India
| | - Rajan Grewal
- Ex Director General, Medical Services (Army), Currently, Vice Chancellor, Sikkim Manipal University, Sikkim, Gangtok, India
| | - Velu Nair
- Department of Haemato-Oncology and Bone Marrow Transplant, Apollo CBCC Cancer Care, Ahmedabad, Gujarat, India
| |
Collapse
|
6
|
Sadler C, Alvarez Villela M, Van Hoesen K, Grover I, Lang M, Neuman T, Lindholm P. Diving after SARS-CoV-2 (COVID-19) infection: Fitness to dive assessment and medical guidance. Diving Hyperb Med 2020; 50:278-287. [PMID: 32957131 DOI: 10.28920/dhm50.3.278-287] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 07/14/2020] [Indexed: 01/19/2023]
Abstract
Scuba diving is a critical activity for commercial industry, military activities, research, and public safety, as well as a passion for many recreational divers. Physicians are expected to provide return-to-diving recommendations after SARS-CoV-2 (COVID-19) infection based upon the best available evidence, often drawn from experience with other, similar diseases. Scuba diving presents unique physiologic challenges to the body secondary to immersion, increased pressure and increased work of breathing. The long-term sequelae of COVID-19 are still unknown, but if they are proven to be similar to other coronaviruses (such as Middle East respiratory syndrome or SARS-CoV-1) they may result in long-term pulmonary and cardiac sequelae that impact divers' ability to safely return to scuba diving. This review considers available literature and the pathophysiology of COVID-19 as it relates to diving fitness, including current recommendations for similar illnesses, and proposes guidelines for evaluation of divers after COVID-19. The guidelines are based upon best available evidence about COVID-19, as well as past experience with determination of diving fitness. It is likely that all divers who have contracted COVID-19 will require a medical evaluation prior to return to diving with emphasis upon pulmonary and cardiac function as well as exercise capacity.
Collapse
Affiliation(s)
- Charlotte Sadler
- Department of Emergency Medicine, School of Medicine, Division of Hyperbaric Medicine, University of California, San Diego, California, USA.,Corresponding author: Dr Charlotte Sadler, Department of Emergency Medicine, Division of Hyperbaric Medicine, School of Medicine, University of California, San Diego, California, USA,
| | - Miguel Alvarez Villela
- Montefiore Medical Center/Albert Einstein College of Medicine, Department of Medicine, Division of Cardiology, Bronx, NY, USA
| | - Karen Van Hoesen
- Department of Emergency Medicine, School of Medicine, Division of Hyperbaric Medicine, University of California, San Diego, California, USA
| | - Ian Grover
- Department of Emergency Medicine, School of Medicine, Division of Hyperbaric Medicine, University of California, San Diego, California, USA
| | - Michael Lang
- Department of Emergency Medicine, School of Medicine, Division of Hyperbaric Medicine, University of California, San Diego, California, USA
| | - Tom Neuman
- Department of Emergency Medicine, School of Medicine, Division of Hyperbaric Medicine, University of California, San Diego, California, USA
| | - Peter Lindholm
- Department of Emergency Medicine, School of Medicine, Division of Hyperbaric Medicine, University of California, San Diego, California, USA
| |
Collapse
|
7
|
Zhu Z, Lian X, Zeng Y, Wu W, Xu Z, Chen Y, Li J, Su X, Zeng L, Lv G. Point-of-Care Ultrasound-A New Option for Early Quantitative Assessment of Pulmonary Edema. ULTRASOUND IN MEDICINE & BIOLOGY 2020; 46:1-10. [PMID: 31575429 DOI: 10.1016/j.ultrasmedbio.2019.08.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 06/20/2019] [Accepted: 08/05/2019] [Indexed: 06/10/2023]
Abstract
The aim of the work described here was to investigate the value of point-of-care ultrasound (POCUS) in the early assessment of the severity of pulmonary edema in rabbits. A rabbit oleic acid (OA)-induced pulmonary edema model was used. Thirty-two New Zealand rabbits were randomly divided into four groups: a control group and three pulmonary edema groups (mild, moderate and severe). Features of transthoracic B-line artifacts (BLA), blood pH, PaO2 and PaCO2, serum inflammatory factors, lung coefficient (LC), lung wet-to-dry weight ratio (W/D) and lung histopathology were assessed. BLA features and severity of pulmonary edema were semiquantitatively scored. Correlations between the number of BLA and PaO2, PaCO2, serum inflammatory factors, LC and W/D were analyzed. An additional 8 rabbits with severe pulmonary edema were used as the verified group, in which the lung was divided into ex vivo BLA (BLA-ev)-free (BLA-ev-free) and BLA-ev-clustered subregions depending on the features of BLA-ev recorded by ex vivo lung ultrasound. Lung specimens from each subregion were collected for histopathological examination. Relationships between features of BLA-ev and lung histopathological abnormalities were analyzed. With increasing doses of OA, number of BLA, W/D and levels of serum inflammatory factors decreased. Meanwhile, lung pathologic abnormalities were aggravated. In addition, time of appearance of BLA, blood pH and PaO2, and PaCO2 decreased dose dependently on OA (p < 0.05). Number of BLA was linear positively correlated with severity of pulmonary edema (r = 0.953, p < 0.05). Consistently, the features of BLA-ev reflected the severity of lung histopathological abnormalities (r = 0.936, p < 0.05). Thus, POCUS is useful in the early quantitative assessment of the severity of pulmonary edema.
Collapse
Affiliation(s)
- Zhixing Zhu
- Department of Pulmonary and Critical Care Medicine, Second Affiliated Hospital of Fujian Medical University, Respirology Medicine Centre of Fujian Province, Fujian, China
| | - Xihua Lian
- Department of Ultrasound Medicine, Second Affiliated Hospital of Fujian Medical University
| | - Yiming Zeng
- Department of Pulmonary and Critical Care Medicine, Second Affiliated Hospital of Fujian Medical University, Respirology Medicine Centre of Fujian Province, Fujian, China
| | - Weijing Wu
- Department of Pulmonary and Critical Care Medicine, Second Affiliated Hospital of Fujian Medical University, Respirology Medicine Centre of Fujian Province, Fujian, China
| | - Zhirong Xu
- Department of Ultrasound Medicine, Second Affiliated Hospital of Fujian Medical University
| | - Yongjian Chen
- Department of Ultrasound Medicine, Second Affiliated Hospital of Fujian Medical University
| | - Jingyun Li
- Collaborative Innovation Center for Maternal and Infant Health Service Application Technology, Quanzhou Medical College, Quanzhou City Luoyang River, China
| | - Xiaoshan Su
- Department of Pulmonary and Critical Care Medicine, Second Affiliated Hospital of Fujian Medical University, Respirology Medicine Centre of Fujian Province, Fujian, China
| | - Liqing Zeng
- Department of Ultrasound Medicine, Maternal and Child Health Hospital of Fujian Province, Fujian, China
| | - Guorong Lv
- Department of Ultrasound Medicine, Second Affiliated Hospital of Fujian Medical University; Collaborative Innovation Center for Maternal and Infant Health Service Application Technology, Quanzhou Medical College, Quanzhou City Luoyang River, China.
| |
Collapse
|