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Swimming Induced Pulmonary Edema
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Sharing this from a local forum. A condition to be aware of.

"Swimming induced pulmonary edema (SIPE), a form of high output heart failure. The physiology involves a pooling of the body's blood into the core, and when there is an overload of blood circulation in the core, the weakest link is usually the lung's capillaries so the blood leaks into there. the risk then is of a deprivation of oxygen supply that causes cardiac arrest.

Im sharing this because i think it's really important for triathletes to understand this "high output heart failure" which has an unusual incidence in triathletes and results from this perfect storm of some or all of the following variables that are independent of your fitness/training.

  • use of wetsuit - adds additional extrinsic compression to the extremities that shunts blood up to the core. here, i blame the NY ironman's poor logistics as this was further exacerbated by the fact that we had to wear the wetsuit for 2 hours leading up to the swim.
  • temperature of water - causes blood to pool into core and out of extremities to keep body warm (cold is anything below body temperature, so don't think this only applies in freezing water)
  • pressure of water - water exerts a much larger force on bodily tissues than air does, and the increased pressure forces blood from the skin, muscle, fat etc into the vessels/circulatory system
  • pre-race adrenalin - increases cardiac output AND constricts blood vessels moving blood toward core
  • hydration - increases the volume of blood cells

"
Basically it doesn't matter if you are in great shape, new, veteran, or not. We are all possibly at risk of this cardiac problem because of environmental factors it seems.

I am not a doctor or expert - just opening grounds for a discussion.


_________________________________
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Last edited by: JustinNorCal: Aug 20, 12 14:50
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Re: Swimming Induced Pulmonary Edema [JustinNorCal] [ In reply to ]
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" . . . we had to wear the wetsuit for 2 hours leading up to the swim."

You must have gotten overheated. I've seen people walking around in their wetsuits before a race and don't understand it.

But, couldn't you carry your wetsuit before this race?

Note: I appreciate your post. Good Message.
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Re: Swimming Induced Pulmonary Edema [JustinNorCal] [ In reply to ]
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JustinNorCal wrote:
I am not a doctor or expert - just opening grounds for a discussion.

Here's a couple links (Including the mandatory 10 min warmup now at the Auburn triathlon), and a study co-authored by our own Francois:

http://www.multibriefs.com/...s/acsm/active3-6.htm

http://www.endurancetriathletes.com/AJEM_oct_2010.pdf

These were taken from one of the earlier threads on SIPE, good reads.

John



Top notch coaching: Francois and Accelerate3 | Follow on Twitter: LifetimeAthlete |
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Re: Swimming Induced Pulmonary Edema [TriBeer] [ In reply to ]
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Wasn't me - I am reposting from a local tri teams forum. No way I could sit in my wetsuit that long on dry ground, it's way to tight until you get into the water.

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USAT L1 Coach | BikeFit Certified Fitter | Contributing Writer - Triathlete Magazine | ROKA
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Re: Swimming Induced Pulmonary Edema [JustinNorCal] [ In reply to ]
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"Sharing this from a local forum. Seems to be what is causing a lot of these swim deaths that are heart related."

no. SIPE is NOT causing a lot of these swim deaths. that are heart related. please don't say stuff that is just not born out by the facts.


Dan Empfield
aka Slowman
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Re: Swimming Induced Pulmonary Edema [TriBeer] [ In reply to ]
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At my last oly race the swim start was delayed "by 15 minutes" due to thick morning fog. We couldn't even see the shore buoy. Then the DR postponed the start another 15 minutes. Then another. Then basically said "we start as soon as we can see the second turn buoy. We stood on the beach for 2 hours. I put on the wetsuit about 20 minutes before swim was supposed to start. That left me standing on the beach, in a wetsuit, for 2:20.
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Re: Swimming Induced Pulmonary Edema [Slowman] [ In reply to ]
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Corrected

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Fit Endurance Coaching - Head Coach|Facebook
USAT L1 Coach | BikeFit Certified Fitter | Contributing Writer - Triathlete Magazine | ROKA
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Re: Swimming Induced Pulmonary Edema [Dilbert] [ In reply to ]
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"That left me standing on the beach, in a wetsuit, for 2:20"

this is, in my opinion, a problem. it's not a problem if the air temp is cold enough. but it is a problem if the air temp is warm. but the solution is easy. you take the wetsuit off down to your waist. that solves the problem, unless the air is really warm. the problem is that the RD needs to know to say this to his competitors.


Dan Empfield
aka Slowman
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Re: Swimming Induced Pulmonary Edema [Slowman] [ In reply to ]
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Slowman wrote:
"That left me standing on the beach, in a wetsuit, for 2:20"

this is, in my opinion, a problem. it's not a problem if the air temp is cold enough. but it is a problem if the air temp is warm. but the solution is easy. you take the wetsuit off down to your waist. that solves the problem, unless the air is really warm. the problem is that the RD needs to know to say this to his competitors.

Yep. We couldn't take the wetsuits off because the RD intended to start "as soon as the fog lifted" and that's what eventually happened. Thefogisliftingthreetwoonebooooooop! And we were swimming, with scant couple of minutes of notice. Me and the fellow I was chatting with recognized the issue. I was going to talk to the RD but I was so hot and exhausted afterwards that I forgot. Besides, with the swim imminent we couldn't make the 300y walk on over to the port-a-potties. That was an even bigger issue.
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Re: Swimming Induced Pulmonary Edema [Dilbert] [ In reply to ]
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" . .. That left me standing on the beach, in a wetsuit, for 2:20."

This image gives me anxiety and hot flashes.

I did a race where I put my wetsuit on and immediately had to take it off. I just got too hot. I swam without it. Not a fan of wetsuits.
Last edited by: TriBeer: Aug 22, 12 10:52
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Re: Swimming Induced Pulmonary Edema [JustinNorCal] [ In reply to ]
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JustinNorCal wrote:
use of wetsuit - adds additional extrinsic compression to the extremities that shunts blood up to the core. here, i blame the NY ironman's poor logistics as this was further exacerbated by the fact that we had to wear the wetsuit for 2 hours leading up to the swim.

Blaming NY IM logistics is a reach. I rode the ferry in IM NY. Just before the ferry docked I got into my wetsuit. I was in my wetsuit no more than 10 minutes before entering the water.
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Re: Swimming Induced Pulmonary Edema [JustinNorCal] [ In reply to ]
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I had posted this in the swim deaths thread.

This is actually what is statistically more prevalent in swim deaths than cardiac events according to what researchers are now finding out via autopsies. It is very good information to be aware of.
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Re: Swimming Induced Pulmonary Edema [Allie] [ In reply to ]
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Can you share that evidence? Or point us where to find it?

I'm not aware of any account of a triathlon swim fatality that's in keeping with SIPE as a cause....and I'm not aware of any autopsy findings in the victims that suggest that diagnosis.

Moreover, I'm not aware of reporting on any athletes rescued from a triathlon swim (alive) where SIPE was established with certainty as a diagnosis.

In fact, all of the swim deaths from 2003-2011 had cardiac arrest as an immediate cause.

Larry Creswell
http://www.athletesheart.org, @athletesheart
Last edited by: lcreswell: Aug 20, 12 18:16
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Re: Swimming Induced Pulmonary Edema [lcreswell] [ In reply to ]
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lcreswell wrote:
Can you share that evidence? Or point us where to find it?

I'm not aware of any account of a triathlon swim fatality that's in keeping with SIPE as a cause....and I'm not aware of any autopsy findings in the victims that suggest that diagnosis.

Moreover, I'm not aware of reporting on any athletes rescued from a triathlon swim (alive) where SIPE was established with certainty as a diagnosis.

In fact, all of the swim deaths from 2003-2011 had cardiac arrest as an immediate cause.

http://www.multibriefs.com/...s/acsm/active3-6.htm anecdotal but still noted frothy sputum upon death, which is indicative of Pulmonary Edema.

These others are not as clear and do point out that the connection is not definitive. One could ask, if someone goes into Acute Pulmonary Edema, how healthy was their heart to begin with? Did they actually go into a torsades de pointes rhythm from a prolonged QT syndrome? A Vtach or Vfib?

http://www.endurancetriathletes.com/AJEM_oct_2010.pdf Mr. Slowtwitch himself was credited in this study.

http://journal.publications.chestnet.org/...px?articleid=1082692 This one just talks about SIPE.

The problem is that you cannot really capture the data to be able to accurately measure it, so arrhythmia gets the blame without the data to support that in all cases. Bottom line, SIPE does occur and it is quite serious. Even if you are unaware of a death that occurred from it, that doesn't mean you discount it. As one who has had panic attacks in the water and has EIA, it is interesting to read the studies and find out just how little is known about this stuff.
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Re: Swimming Induced Pulmonary Edema [Allie] [ In reply to ]
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I think it's important to be very clear. Above, you asserted that SIPE was statistically more prevalent than heart problems in autopsies of triathlon swim death victims.

That's simply not true.

I don't doubt that SIPE exists. That condition has been well-established and the accounts from our fellow triathletes that you mention are simply fascinating.

The piece from Dr. Dressendorfer is also interesting. But it's important to remember that this is an opinion piece. This isn't a study. This isn't presenting autopsy information from victims. The author's background is such that the article deserves our attention, though. It's most useful for the discussion about SIPE physiology.

Lastly, you questioned the data about arrhythmias. It is a fact that all but 2 of the swim fatality victims from 2003-2011 DID have a fatal arrhythmia when they were rescued from the water and the remaining 2 victims were found in asystole some time after the swim portion had ended.

I've learned in medicine, and with triathlon!, that anything is possible. And in that sense, SIPE may play a role in these deaths. But I'm very skeptical.

Larry Creswell
http://www.athletesheart.org, @athletesheart
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Re: Swimming Induced Pulmonary Edema [lcreswell] [ In reply to ]
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lcreswell wrote:
I think it's important to be very clear. Above, you asserted that SIPE was statistically more prevalent than heart problems in autopsies of triathlon swim death victims.

That's simply not true.

I don't doubt that SIPE exists. That condition has been well-established and the accounts from our fellow triathletes that you mention are simply fascinating.

The piece from Dr. Dressendorfer is also interesting. But it's important to remember that this is an opinion piece. This isn't a study. This isn't presenting autopsy information from victims. The author's background is such that the article deserves our attention, though. It's most useful for the discussion about SIPE physiology.

Lastly, you questioned the data about arrhythmias. It is a fact that all but 2 of the swim fatality victims from 2003-2011 DID have a fatal arrhythmia when they were rescued from the water and the remaining 2 victims were found in asystole some time after the swim portion had ended.

I've learned in medicine, and with triathlon!, that anything is possible. And in that sense, SIPE may play a role in these deaths. But I'm very skeptical.


If you read my post above, you will see that I corrected myself and said that while I don't doubt arrhythmia is the leading cause, I question WHY they occur in the first place.
A V/Q mismatch will cause physiological problems including arrhythmias, pulmonary edema. The bigger question I have is WHY do these people have these to begin with?

Are people developing SIPE in the water and due to the hypoxia going into an arrhythmia? You can't really study that because it isn't a place where you can just go and collect evidence to support the theory for the most part I would think.

The bottom line is that no one really knows. There is a complete lack of information as to why this occurs. At least on dry land (marathons) we have first responders that can work quicker and it is typically a more definitive answer.

Rather than trying to be right here, I am simply asking the questions. It's not like you can recreate the conditions in a lab and there is only so much information you can gain from an autopsy according to my training partner who is a pathologist. I think it is far too simple to just say "They died as a result of a refractory V-Fib"...no kidding....most people do. WHY did they die as a result of the V-Fib is the real concern.
Last edited by: Allie: Aug 21, 12 6:05
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Re: Swimming Induced Pulmonary Edema [Slowman] [ In reply to ]
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SIPE causes cardiac arrest
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Re: Swimming Induced Pulmonary Edema [cbk] [ In reply to ]
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I dont blame the ny ironman. i only think that this further exacerbated the situation. it didn't help, that's all. it wasn't the only cause, for sure. but, wearing a wetsuit increases constriction of blood vessels in your legs and pools the body's blood to the core. wearing it for longer makes this process of blood pooling happen for longer.
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Re: Swimming Induced Pulmonary Edema [andreahimmel] [ In reply to ]
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Hey, I should have started by saying that I am sympathetic to your situation and wish you the very best.

You mean you couldn't even carry a disposable bag with your wetsuit and lube and wear a disposable sweat/warm-up outfit? Perhaps logistics wouldn't allow that....if not, perhaps it is good rethinking having/or the logistics of this race!

Again, wish you the best!

David
* Ironman for Life! (Blog) * IM Everyday Hero Video * Daggett Shuler Law *
Disclaimer: I have personal and professional relationships with many athletes, vendors, and organizations in the triathlon world.
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Re: Swimming Induced Pulmonary Edema [david] [ In reply to ]
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thanks david. no doubt, i could have figured a way to do just that. but, it didnt occur to me. the race was really logistically complex - we had to take a ferry to transition the day before with most of the stuff we'd need on raceday. it's an intense period of coordination and packing just the right stuff so i didn't really get to think about a wide spectrum of things beyond the necessities. i wouldnt have known that was a necessity, or a preferred thing to do, at the time, so it wouldnt have occurred to me anyhow, particularly given that that just adds another layer of things to do pre-race.

but, you're totally right.

so maybe that should be a lesson here to everyone - try to wait as long as possible to put on the wetsuit. i definitely wish i had!
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Re: Swimming Induced Pulmonary Edema [JustinNorCal] [ In reply to ]
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Four years ago ST posted an article written by Dan about swim deaths and SIPE, so this is not a new phenomenon. (go to the Training section on the opening page)

As an experienced competitive swimmer and OWS (recreational) as a teenager right through to my sixties I would never have considered myself a candidate for any form of swimming problem and I can say, honestly, that I have experienced symptoms which I would consider consistent with SIPE. They were mild enough that on the day were ignored, although I might be more carefull now. I also believe that many do the same and have a mindset that does not allow them to back off.

I have to believe that wetsuits are a principal cause, along with the habit of wearing a full, zipped up race suit and HRM exacerbating the situation.

Without doubt a warmup (in or out of the water), and a sensible swim attitude, for any distance from sprint to IM would help. The conditions for tragedy will always exist, whether we like it or not.

That's life.
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Re: Swimming Induced Pulmonary Edema [lcreswell] [ In reply to ]
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While I can't certainly point to a pile of evidence, I know of a person who had diagnosed swimming induced pulmonary edema after being pulled from a triathlon swim.

Or rather, I know a person who had pulmonary edema after being pulled from a swim, that evening when I heard from her husband that she was at Hopkins with pulmonary edema and they had no idea what had happened I sent them information on SIPE and at that point they realized that's what it was.

In the interest of confidentiality and all that I won't post her name, but I can absolutely confirm it, this is someone I know well.

So no, I can't say that it is a factor in any death, I can confirm that it has happened at least once in a tri that I have personal experience with.
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Re: Swimming Induced Pulmonary Edema [andreahimmel] [ In reply to ]
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andreahimmel wrote:
I dont blame the ny ironman. i only think that this further exacerbated the situation. it didn't help, that's all. it wasn't the only cause, for sure. but, wearing a wetsuit increases constriction of blood vessels in your legs and pools the body's blood to the core. wearing it for longer makes this process of blood pooling happen for longer.

IMNYC said many months ago that regardless of the water temperature, wetsuits would be allowed, presumably in the interests of swimmer safety in light of the prior deaths at the NYC Triathlon. Presumably also, this was based on the theory that wetsuits offer buoyancy as an aid to weaker swimmers, therefore safer.

However, is it possible then, that allowing wetsuits regarless of the water temperature could in fact be more dangerous? The buoancy benefit for weaker swimmers is surely outweighed by the more serious risks of constriction, assuming tight wetsuits are a contributing factor to some of these swim deaths?
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Re: Swimming Induced Pulmonary Edema [Kevin in MD] [ In reply to ]
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Kevin, thanks for sharing that story with us. It is very similar to the stories of SIPE in non-triathlon settings.

Not to push if it would concern you about confidentiality for the athlete, but we could learn from this.

Any chance you could share more details about how things unfolded at the race? The sequence of events leading up to being "pulled"? How she was recognized as being in distress? How she was rescued? The initial on-site care....or thinking about the cause of her problems?

Larry Creswell
http://www.athletesheart.org, @athletesheart
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Re: Swimming Induced Pulmonary Edema [lcreswell] [ In reply to ]
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I read the article from 2007- now I have questions. Main question how is it treated?

What happens once they figure someone experienced SIPE & taken to a hopsital, give them oxygen, make sure everything is okay & go on your way?


Its to scary to think, that many of us probably experienced some form of SIPE while racing but did not know or at the time & still do not know now.


Is it something that will go away on its own over time? There has been a few questionable swims, that I shrugged off as a panic attack but could have been more serious.
Last edited by: ChrisC42780: Aug 21, 12 9:32
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