+ Reply to Thread
Page 4 of 5 FirstFirst 1 2 3 4 5 LastLast
Results 31 to 40 of 49

Thread: Immersion Pulmonary Edema (IPE) at 291'

  1. #31
    RBW Member dreamdive has disabled reputation dreamdive's Avatar
    Join Date
    May 2007
    Location
    Delray Beach, FL
    Posts
    1,244
    Pathfinder, rEvo, Explorer

    Meg, PrismII, Titan, Optima, 7

    Re: Immersion Pulmonary Edema (IPE) at 291'

    Quote Originally Posted by Loanwolf  View Original Post
    Statin's and blood pressure meds are the most common.
    There is no evidence that anti-hypertensives and statins should cause this since they don't increase vascular pulmonary pressures. Patient's taking these meds may be cardiovascularly compromised and perhaps they had a bout of Congestive Heart Failure resulting in pulmonary edema rather than experiencing Immersion Pulmonary Edema.

    Guess we will have to wait for more evidence.

  2. #32
    RBW Member dreamdive has disabled reputation dreamdive's Avatar
    Join Date
    May 2007
    Location
    Delray Beach, FL
    Posts
    1,244
    Pathfinder, rEvo, Explorer

    Meg, PrismII, Titan, Optima, 7

    Re: Immersion Pulmonary Edema (IPE) at 291'

    Quote Originally Posted by hawai  View Original Post
    Hello,
    and thanks for the precise account and write up. Personally I would have never thought that there would be any reason to flame somebody for such a good job.

    My personal 0.02$ worth of guesswork around the incident:
    - exposure protection: brrrrr, never would I have dared to do something like that in a wetsuit, chapeau!

    - borrowed hood: I'm personally a real sissy when it comes to things around my throat. Could the tightness of the hood around the throat have contributed to an increased WOB? Especially while inhaling? Although the "negative pressure edema" is a bit of a ghost entity, increased inspirational WOB with relative negative intrapulmonary pressure might have been a contributing factor.

    - acute management under water: have you considered b/o to OC at all? I know that seems a big nono to solve a problem by b/o, but in this case it might have had some merits. By going OC you would have decreased your inspirational WOB because almost every reg I ever had in my mouth delivered gas with more or less pressure support. Although that might not be as beneficial as having a true continuous positive airway pressure (CPAP) system, it might at least have made breathing as such feel easier. In my experience lowering the WOB in all respiratory distress that gives people the feeling of "not getting enough air" is crucial and makes them feel better immediately. I'm actually quite surprised that you weren't put on CPAP at the hospital.

    So, again thanks for sharing your experience and I hope you aren't offended by my smartarseing. And btw thanks to dreamdive for the information and the hard work on the literature review (safes me from doing it myself).

    Cheers
    Hansjoerg
    Hansjoerg,

    I've noticed you keep referring to this as "negative pressure pulmonary edema". This is not it! Immersion pulmonary edema is different from NPPE. Also, the pathophysiology of NPPE is actually quite clear, especially in anesthesia. You probably just got the terms confused, but I wanted to make sure they are kept separate.

    I can tell you also that I have bailed to OC, just in case I was inhaling an irritant from my CCR causing this. It made no difference! CPAP or any other form of positive pressure ventilation may actually INCREASE work of breathing! In pulmonary edema with positive pressure you will work harder as you are trying to exhale against increased pressure. I can tell you also, that I started to wheeze because of it! CPAP works in cases of obstructive sleep apnea because it keeps the airway open. PEEP may help prevent atelectasis by keeping alveoli expanded that would otherwise collapse. There is some thought that positive pressure ventilation will decrease edema because it counteracts the pressure differential across the alveoli. Sure, before we reintubate patients and put them on a ventilator, we may give them a trial of CPAP or other, but that does not always work. That being said, a diuretic such as Lasix may not work either since this is not caused by volume overload.

    What works is getting out of the water and in relatively little time, the edema will decrease. I had rales 2/3's up my lungs bilaterally on auscultation. In less than 12 hours, they have completely resolved and the chest x-ray was completely normal!

    I think the key is early recognition and then aborting the dive. From what I have read, most of the time the symptoms start as early as 15 - 30 minutes into the dive. Depending on your depth, you may not have accumulated too much deco, yet or have ventured too far into a cave. Staying calm and decreasing work load is key. When things get really hard or you do have to work, increasing oxygen concentration may also help since your PO2 (in blood) may be decreased. i.e. When I got back to the boat, Chris noticed that my lips were quite blue! Breathing a 100% O2 and resting on the boat improves the situation. About 20 minutes out of the water, my coughing was almost gone!

  3. #33
    RBW Member hawai is an unknown quantity at this point hawai's Avatar
    Join Date
    Jun 2012
    Location
    Dunedin,NZ
    Posts
    23
    JJ

    Re: Immersion Pulmonary Edema (IPE) at 291'

    Thanks for the reply,

    Quote Originally Posted by dreamdive  View Original Post
    Hansjoerg,

    I've noticed you keep referring to this as "negative pressure pulmonary edema". This is not it! Immersion pulmonary edema is different from NPPE. Also, the pathophysiology of NPPE is actually quite clear, especially in anesthesia. You probably just got the terms confused, but I wanted to make sure they are kept separate.
    Although I'm still not 100% convinced that there really is such a thing as a NPPE, at least not as a singular entity. But I also fail to see the normality of 0.9% saline and this discussion is probably best done someplace else.
    I mentioned NPPE not as a cause or as being the single problem but as a potential confounder to the quite dramatic development of this case. Single track causality is pretty rare in pathophysiology.

    I can tell you also that I have bailed to OC, just in case I was inhaling an irritant from my CCR causing this. It made no difference! CPAP or any other form of positive pressure ventilation may actually INCREASE work of breathing! In pulmonary edema with positive pressure you will work harder as you are trying to exhale against increased pressure. I can tell you also, that I started to wheeze because of it!
    Interesting experience, my expectation would definitely have been different. When talking about WOB in this case we should probably split it and give inspiratory and expiratory WOB a separate look. Especially in the structurally healthy lung there definitely is an increase in expiratory WOB as I demonstrate to our students on a weekly basis and have experienced myself. From the surface experience I would have expected that the positive airway pressure would at least improve the "air hunger" and subsequent hypoxyaemia. But, well it's as always more complex than you'd expect in the first instance and live would be so boring wouldn't it be like that.



    CPAP works in cases of obstructive sleep apnea because it keeps the airway open. PEEP may help prevent atelectasis by keeping alveoli expanded that would otherwise collapse. There is some thought that positive pressure ventilation will decrease edema because it counteracts the pressure differential across the alveoli. Sure, before we reintubate patients and put them on a ventilator, we may give them a trial of CPAP or other, but that does not always work. That being said, a diuretic such as Lasix may not work either since this is not caused by volume overload.
    Well, if CPAP would only work in OSA I have done a lot of things wrong in the last years
    At least in our little hospital south of sanity CPAP has become a fairly standard supplement to the classical treatment of pulmonary edema. I guess the wide availability of non invasive systems has contributed to that and the somewhat limited ICU capacity too.
    At least I'm not the only one who questioned the Lasix in the case of IPe.

    I think the key is early recognition and then aborting the dive. From what I have read, most of the time the symptoms start as early as 15 - 30 minutes into the dive. Depending on your depth, you may not have accumulated too much deco, yet or have ventured too far into a cave. Staying calm and decreasing work load is key. When things get really hard or you do have to work, increasing oxygen concentration may also help since your PO2 (in blood) may be decreased. i.e. When I got back to the boat, Chris noticed that my lips were quite blue! Breathing a 100% O2 and resting on the boat improves the situation. About 20 minutes out of the water, my coughing was almost gone!
    That seems a very reasonable piece of advice to me.
    Given the boat the 100% were probably ok, but honestly I'm more scared of absorption atelectasis than of a little hypoxia. But having said that, I'm probably one of the few who don't preoxygenate with 100%.
    So if available, this would have been a situation where CPAP would have been my first choice and plan B would have been a r/b with a setpoint of 0.8 to avoid too much nitrogen washed out of the lungs.

    Again, thanks for your comments, having to think out of the box keeps the brain healthy and it is by far better than any weird fan boyish discussion ;)

    Cheers
    Hansjoerg

  4. #34
    Dive Deep and Dive Long Loanwolf is a jewel in the rough Loanwolf is a jewel in the rough Loanwolf is a jewel in the rough Loanwolf is a jewel in the rough Loanwolf is a jewel in the rough Loanwolf is a jewel in the rough Loanwolf is a jewel in the rough Loanwolf's Avatar
    Join Date
    Jan 2008
    Location
    Seattle
    Posts
    712
    rEvo

    Re: Immersion Pulmonary Edema (IPE) at 291'

    Quote Originally Posted by dreamdive  View Original Post
    There is no evidence that anti-hypertensives and statins should cause this since they don't increase vascular pulmonary pressures. Patient's taking these meds may be cardiovascularly compromised and perhaps they had a bout of Congestive Heart Failure resulting in pulmonary edema rather than experiencing Immersion Pulmonary Edema.

    Guess we will have to wait for more evidence.
    Yep it is going to take time. At least with the much more common use of chambers in medical treatment they are finally beginning to test what effects meds have under pressure. Even that said it will be years before anything is published that is conclusive.

  5. #35
    Rebreather addicted wizebt has a spectacular aura about wizebt has a spectacular aura about wizebt has a spectacular aura about wizebt has a spectacular aura about wizebt has a spectacular aura about wizebt has a spectacular aura about wizebt's Avatar
    Join Date
    Nov 2007
    Location
    La Gaude, France
    Posts
    205
    ISC Megalodon

    Inspiration, Sentinel, Dolphin

    Re: Immersion Pulmonary Edema (IPE) at 291'

    Thank for reporting that incident in such details.

    I not an MD but experienced 3 times / 3 years ago Immersion pulmonary edema diving my Sentinel.

    You had the soft version. I had a drowning like feeling after only 8 min into the dive @ 120' (40m), night dive (9pm), no buddy rescue, had to make my way up alone, bailout @ 45' (15m) didn't help, nor breathing and coughing at the surface, no one on the boat, took forever to move to the boat and crawl up on the ladder by myself. Survival exercise
    As no one knew what it was, I didn't went to the hospital, drove home spending the night half seated coughing....
    Pulmonary recovery is fast 15 hours after I was able to run 10k @ lunch time.

    Contributing factors are cold, high po2, stress (depth)?, resistance of breathing (BMCL), and especially hypertension.

    You must have your cardiac condition checked thoroughly and do an effort test.

    You can have no accident history, diving especially with rebreather puts your body under stress.

    Happy that you made it through and that it was recognized and properly investigated.

    Safe dives
    Last edited by wizebt; 20th September 2012 at 13:24.

  6. #36
    RBW Member jaboothtx is an unknown quantity at this point jaboothtx's Avatar
    Join Date
    Dec 2011
    Location
    Austin, TX
    Posts
    15
    Evo+

    Re: Immersion Pulmonary Edema (IPE) at 291'

    Quote Originally Posted by Loanwolf  View Original Post
    I have a question are you or have you taken any meds as of late?

    The commercial dive industry has been seeing a lot of Immersion Edema the last few years. Medications have been the big common factor.
    I answered this on the other board, so I will do so here as well.

    I have no prior history of pulmonary issues and I am a life-long athlete. However, I was diagnosed with breast cancer, left breast, in Jan 2009. No chemo, lumpectomy in Feb 2009, and did brachytherapy with the Contura implant (Contura Multi-Lumen Balloon) in Mar 2009. With early onset menopause in 2006, I am currently on Arimidex - for another 18 months. I also take Effexor (35mg), Calcium, Glucosamine, Milk Thistle, and Vitamin D - all to deal with Arimidex side effects. Arimidex can also cause joint pain, and the day of the incident, I had taken 2 Advil at about 6am. (The dive was at 1pm.)

    Although the lumpectomy and radiation do cause damage to the lymphatic system, I find it hard to imagine that minor left-chest lymphatic damage could cause IPE. Also, most of my deep diving, both OC and rebreather, have been after cancer - and this is the only IPE event that I've suffered. It could well have been a weighting factor though, just like cold and a thick wet suit.

  7. #37
    New Member Simon Mitchell has a reputation beyond repute Simon Mitchell has a reputation beyond repute Simon Mitchell has a reputation beyond repute Simon Mitchell has a reputation beyond repute Simon Mitchell has a reputation beyond repute Simon Mitchell has a reputation beyond repute Simon Mitchell has a reputation beyond repute Simon Mitchell has a reputation beyond repute Simon Mitchell has a reputation beyond repute Simon Mitchell has a reputation beyond repute Simon Mitchell has a reputation beyond repute Simon Mitchell's Avatar
    Join Date
    May 2005
    Location
    New Zealand
    Posts
    683

    Re: Immersion Pulmonary Edema (IPE) at 291'

    Hello,

    There is some interesting discussion about the mechansims of immersion pulmonary oedema here. I had a long talk to Richard Moon about this just a few weeks ago, and even after the exhaustive work he has done at Duke in recent times we still do not fully understand the mechanisms.

    I wrote a speculative interpretation based on knowledge at that time in the Journal of the South Pacific Underwater Medical Society in 2002.

    Mitchell SJ. Immerson pulmonary oedema. SPUMS J 2002;32(4):200-203

    Quoting from that article:

    This condition is probably a form of acute onset left ventricular failure, but its pathophysiology is not definitively described. There are probably several important components. Firstly, it is known that immersion itself and the peripheral vasoconstriction associated with either immersion or exposure to cold, both cause a simultaneous increased in cardiac pre-load and after-load as blood volume is centralised and peripheral resistance increases. Not surprisingly, there is an increase in pulmonary artery pressure and therefore pulmonary capillary hydrostatic pressure.

    Secondly, immersion of a diver in an upright position results in the basal lung tissue being exposed to a hydrostatic pressure approximately 15 - 20 cm of water greater than that of the airway pressure at the mouth (and therefore greater than in the airways themselves). This pressure differential is volume-compensated by engorgement of the pulmonary blood vessels which may predispose to capillary stress failure.

    Thirdly, it seems likely that the negative intra-alveolar pressures generated during inspiration are exaggerated during diving due to an increase airways resistance when breathing a dense gas. Finally, and in relation to the latter point, if the diver is breathing from a poorly tuned regulator (or rebreather with high external resistance) that requires increased negative pressures to establish adequate gas flow, this will also enhance negative intra-alveolar pressure.

    It is plausible that this combination of increased pulmonary capillary hydrostatic pressure, pulmonary vessel distension, and exaggerated cyclical negative intra-alveolar pressure during inspiration promotes the transudation of fluid through the capillary walls into the alveoli. This sequence of events would be more likely in a predisposed person whose myocardial response to increased load is impaired. Interestingly, most cases seen by the author recovered spontaneously over a period of hours once the diver was removed from the water.

    Richard's recent work has focussed on trying to detect some sort of individual pre-disposition, such as increased pulmonary vascular reactivity to stimuli such as high PO2, high PCO2, exercise, immersion and other factors. There are a few interesting leads being followed but nothing definitive yet.

    I would not dismiss the potential role for medications. I reported 6 cases in Emergency Medicine in 1999 of which 3 were taking beta blockers. I think it makes sense that any drug with a negative inotropic effect might increase risk of immersion pulmonary oedema. Nothing definitive though. My personal view is that there is a potpourri of risk factors, some of which may be physiological, some environmental, and some equipment related, and if you stack enough of them together on one day, IPE may be the result.

    Finally, in the early days of awareness of this condition we were reasonably comfortable with the concept of return to diving after IPE. However, it has become clear in more recent times that not only do recurrences occur, on some occasions they are fatal. A series of 3 such cases was recently reported in SPUMS journal (now called Diving and Hyperbaric Medicine). See:

    Edmonds C, Lippmann J, Lockley S, Wolfers D. Scuba divers' pulmonary oedema: recurrences and fatalities. Diving Hyperb Med. 2012 Mar;42(1):40-4.

    Unfortunately, decisions to return to diving must now be made with this uncomfortable knowledge in mind. The truth is that hyperbaric physicians are increasingly finding themselves with little choice but to recommend against it.

    Simon M
    Last edited by Simon Mitchell; 25th September 2012 at 03:28.

  8. #38
    Dive Addicts Michael Thornton will become famous soon enough Michael Thornton will become famous soon enough Michael Thornton will become famous soon enough Michael Thornton will become famous soon enough Michael Thornton's Avatar
    Join Date
    Aug 2009
    Location
    Lehi, Utah, United States
    Posts
    364
    Hammerhead, P2, SF2, Flex, Evo

    Inspo, Sent, Optima, Mk15, Dol

    Re: Immersion Pulmonary Edema (IPE) at 291'

    Thanks for that post. Based on the below information what would you suggest one do in response to symptoms? Bail out or not? Change your position in the water (To become more level)? Remove hood, unzip wetsuit? Or just ascend as quickly and safely as possible? Go on O2 at shallow depth? Change set point during shallow stop?
    Thanks
    Michael

    Quote Originally Posted by Simon Mitchell  View Original Post
    Hello,

    There is some interesting discussion about the mechansims of immersion pulmonary oedema here. I had a long talk to Richard Moon about this just a few weeks ago, and even after the exhaustive work he has done at Duke in recent times we still do not fully understand the mechanisms.

    I wrote a speculative interpretation based on knowledge at that time in the Journal of the South Pacific Underwater Medical Society in 2002.

    Mitchell SJ. Immerson pulmonary oedema. SPUMS J 2002;32(4):200-203

    Quoting from that article:

    This condition is probably a form of acute onset left ventricular failure, but its pathophysiology is not definitively described. There are probably several important components. Firstly, it is known that immersion itself and the peripheral vasoconstriction associated with either immersion or exposure to cold, both cause a simultaneous increased in cardiac pre-load and after-load as blood volume is centralised and peripheral resistance increases. Not surprisingly, there is an increase in pulmonary artery pressure and therefore pulmonary capillary hydrostatic pressure.

    Secondly, immersion of a diver in an upright position results in the basal lung tissue being exposed to a hydrostatic pressure approximately 15 - 20 cm of water greater than that of the airway pressure at the mouth (and therefore greater than in the airways themselves). This pressure differential is volume-compensated by engorgement of the pulmonary blood vessels which may predispose to capillary stress failure.

    Thirdly, it seems likely that the negative intra-alveolar pressures generated during inspiration are exaggerated during diving due to an increase airways resistance when breathing a dense gas. Finally, and in relation to the latter point, if the diver is breathing from a poorly tuned regulator (or rebreather with high external resistance) that requires increased negative pressures to establish adequate gas flow, this will also enhance negative intra-alveolar pressure.

    It is plausible that this combination of increased pulmonary capillary hydrostatic pressure, pulmonary vessel distension, and exaggerated cyclical negative intra-alveolar pressure during inspiration promotes the transudation of fluid through the capillary walls into the alveoli. This sequence of events would be more likely in a predisposed person whose myocardial response to increased load is impaired. Interestingly, most cases seen by the author recovered spontaneously over a period of hours once the diver was removed from the water.

    Richard's recent work has focussed on trying to detect some sort of individual pre-disposition, such as increased pulmonary vascular reactivity to stimuli such as high PO2, high PCO2, exercise, immersion and other factors. There are a few interesting leads being followed but nothing definitive yet.

    I would not dismiss the potential role for medications. I reported 6 cases in Emergency Medicine in 1999 of which 3 were taking beta blockers. I think it makes sense that any drug with a negative inotropic effect might increase risk of immersion pulmonary oedema. Nothing definitive though. My personal view is that there is a potpourri of risk factors, some of which may be physiological, some environmental, and some equipment related, and if you stack enough of them together on one day, IPE may be the result.

    Finally, in the early days of awareness of this condition we were reasonably comfortable with the concept of return to diving after IPE. However, it has become clear in more recent times that not only do recurrences occur, on some occasions they are fatal. A series of 3 such cases was recently reported in SPUMS journal (now called Diving and Hyperbaric Medicine). See:

    Edmonds C, Lippmann J, Lockley S, Wolfers D. Scuba divers' pulmonary oedema: recurrences and fatalities. Diving Hyperb Med. 2012 Mar;42(1):40-4.

    Unfortunately, decisions to return to diving must now be made with this uncomfortable knowledge in mind. The truth is that hyperbaric physicians are increasingly finding themselves with little choice but to recommend against it.

    Simon M

  9. #39
    CCR Diva scubagrunt is a glorious beacon of light scubagrunt is a glorious beacon of light scubagrunt is a glorious beacon of light scubagrunt is a glorious beacon of light scubagrunt is a glorious beacon of light scubagrunt is a glorious beacon of light scubagrunt is a glorious beacon of light scubagrunt is a glorious beacon of light scubagrunt is a glorious beacon of light scubagrunt is a glorious beacon of light scubagrunt is a glorious beacon of light scubagrunt's Avatar
    Join Date
    May 2005
    Location
    Washington
    Posts
    1,127
    meg & rEvo

    inspo, optima, KISS, submatix

    Re: Immersion Pulmonary Edema (IPE) at 291'

    Well it's official. Per-dive Viagra for all

  10. #40
    Down to no good kwinter has a reputation beyond repute kwinter has a reputation beyond repute kwinter has a reputation beyond repute kwinter has a reputation beyond repute kwinter has a reputation beyond repute kwinter has a reputation beyond repute kwinter has a reputation beyond repute kwinter has a reputation beyond repute kwinter has a reputation beyond repute kwinter has a reputation beyond repute kwinter has a reputation beyond repute kwinter's Avatar
    Join Date
    Sep 2005
    Location
    NJ - USA
    Posts
    2,326
    JJ, Flex

    rEvo III, Optima, GEM

    Re: Immersion Pulmonary Edema (IPE) at 291'

    Mel, step away from the keyboard.
    Ken

    Quote Originally Posted by Dsix36  View Original Post
    Just remember that listening to an idiot such as myself may very well get your arse dead.

+ Reply to Thread
Page 4 of 5 FirstFirst 1 2 3 4 5 LastLast

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts