Thank you for the conscientious updates, Kat. I will be following your return to the action with great interest. I am very glad that you are getting close medical supervision, and do please by all means go easy on the swim.

Good job staying after it, and do keep us up to date. After a liesurely swim, think how much fun you'll have reeling in the competition for the rest of the race!

Best wishes.

Trey

Exercise-induced pulonary edema - especially in fit people - seems usually to be self-limiting, and starts to get better as soon as the victim stops exercising...

Trey, I haven't chimed in here for some time but have been reading the posts. What you describe above seems exactly what I had, and as I posted earlier, the hypertension medication seems to have eliminated this problem. I did IMLOU without any indications of it. Anyway, thanks a lot for your professional insight and help. We're all very appreciative.

In a couple of triathlon race swims over the years I came out of the water coughing up blood. I think it was due to hyperventilating. Not sure, though. Have not had an occurrence since I learned the physiology of hyperventilating (and became a better swimmer).
I know this does not seem related to what happened to you but I thought I'd toss it out there any way since it does have the exercise/coughing up blood commonality.

Thanks for the kinds words JP. And props to you for your amazing go at IMLOU. I read your RR with great interest, humility and perhaps a bit of horror, knowing your history from this thread. You are a tough dude.

IM is very much the story of ordinary people turning impossible adversity into personal triumph. In this thread that comes through in people's attitudes. The universal theme has been "how do I fix this so I can get back to competition?". So thanks to you for getting it started.

I just posted a response to the original Trifan post which describes the same experience you had. I think it was brought on by hyperventilating.

"I am actually a bit surprised that swimming induced pulmonary edema is not more common among triathletes, but then again I'd imagine the diagnosis is missed frequently, so it's probably under-reported by quite a bit. Maybe you can start the Katwoman Swimming Induced Pulmonary Edema Foundation."

I think it is very common. Most triathletes refer to it as a "panic attack" or, like me, hyperventilation. My daughter's boyfriend did his first tri a few weeks ago and could barely move in the water. I had that happen to me 4 years ago when my goggles fogged up at the start and apparently that made me nervous enough that I hyperventilated within 200 yards. I thought I was going to die. I could barely move. Couldn't breath. No problems since then because I make sure I breath properly at the start of the swim.

I think it is very common.

We are planning to conduct a formal survey in then next few months to try to get a good handle on the prevalence of this phenomenon. As you point out, a lot of the awareness of it seems to depend on how it's described, and that's something we're going to need to consider carefully in designing a survey assessment.

Thanks also to Trifan for updating the title of the thread, which may improve our informal case finding.

Thanks for your reply.

Trey

I wanted to toss out (so Trey can dismiss ;) ) whether or not CT scans have been with contrasting solution. The reason I ask is that some of the same symptoms (although I wasn't swimming at the time) happened for me, and were the result of a pulmonary sequestration. It's very rare to be found in adults, but we're not talking about something common here. :)

-Jot

I haven't read through all the posts so I will shortly so excuse me if I'm simply reposting something. While at IMLOU very early on the swim I inhaled quite a bit of water into my lungs (edit: I don't remember actually inhaling water but I could only assume that is what happened up to this point. I had no other explanation for my shortness of breath). I actually think this happened multiple times as my lung capacity felt diminished and resulted in quicker breaths. Once I hit the bike and my torso was in a "prone" position I began to have that gurgling sensation in my breathing. Generating from my lungs. Throughout the bike I would get coughing fits and actually would cough up 2-3 ounces of frothy fluid at a time. I could literally just let it run out of my mouth like I was spitting water. I didn't feel the effects on my lungs/breathing while on the bike. I tried to keep my heart rate and breathing down but I'm sure there was an impact. The coughing attacks were a nuisance and I kept waiting to hurl at any moment do to the force of the coughs needed to dislodge whatever was in my throat/lungs. By the time I hit the run my lung capacity felt like it was about a 1/4 of normal. I'd run 100 meters and be gasping for air unable to catch a breath. As I continued the run I started paying more attention to what I was coughing up. There was definitely blood in it. I'm not sure if this was from my throat being so raw that it was bleeding or from the trauma to my lungs or both. When I hit the finish line one of the volunteer nurses sat me in a chair for a few seconds and walked away. As I was sitting there I got another coughing fit and spit up about 4 ounces of blood and mucous. The nurse thought it was vomit and asked me to get on the gaitor so she could take me to the medics, assuming I was dehydrated. I told her it wasn't vomit. I was coughing up water and blood from my lungs. Her response, "Oh, that's much better. That's considered pulmonary ademia (?)". I convinced her I didn't need the gaitor for transportation and we walked to the med area. I left once there because there were people there that needed attention way more then I. I wasn't hurting in any way. The run didn't kill me because I was so limited. My lungs and throat were irritated. My SO is a nurse so I felt in good hands. Besides they couldn't do anything at the med area except ambulance me somewhere with x-ray abilities. This was told to me by one of the medics at the area and I was fine with that. The only way I could sleep that night without fighting the coughing was to lay on my stomach with a pillow under my chest with my head hanging below my chest. Still occ. I'd wake up coughing needing to expel whatever was in my throat and lungs. When I woke the next morning my eyes were swollen shut due to my head hanging (note to self...). I took me like a week to get my lung capacity back. It was a strange experience. But I can only attribute it to water in my lungs. I'd never experienced the feeling of decreased lung capacity. Maybe I just wasn't prepared well enough for the run. I'm generally not one to make excuses. I'm still trying to figure it out myself.

Edit: I still haven't read through the entire thread but I thought it was interesting that I don't recall inhaling anymore than normal amounts of water on my swim. Some water is a natural occ. and happens daily on my pool swims, just a fact of life. I find it somewhat reassuring that others post similar happenings.

Pulmonary sequestration does seem a bit of a stretch. . . .

I'd imagine most of the folks posting to this thread have had a chest x-ray during work-up, and while certainly not as sensitive as a contrast CT, it seems likely that a sequestration big enough to cause florid pulmonary edema would be big enough to see on a CXR. In adults they are ususlly cystic and easily visible, and I wouldn't think you'd need a contrast CT unless you were looking at how it was vascularized. But then again, I'm certainly no expert on that particular problem.

Did you get yours operated on?

Damn, man, that's quite a story, and you are a very persistent competitor I must say. Many of the things you describe are consistent with what others have reported, although a week would seem quite a long time for things to get back to normal. When you have time please do read through the whole thread, or at least pages 2-4 where the core elements of the disussion are (although all of it is interesting). I'd be interested in how your experience compares to the other reports.

Hey Everyone... I'm a TRIATHLETE again!

Raced the Demi-Esprit (1\2 IM) here in Montreal yesterday...

I had met with my cardiologist on Wednesday and we had a long discussion about the event and timing. I explained that Montreal would be a good place to 'test' my 'triggers' and take one step closer to figuring out the mystery of SIPE... based on what we (Trey, Dr. Weiler and I) have tried to piece together, if I could knock out one or more of the possible 'triggers', it may in fact prevent another incident.

I had been taking the BP meds for two weeks, and the numbers were looking good from that aspect. The race was a local one for me, so the doctors were close at hand if need be. The event was held at the Olympic rowing basin - a shallow, long channel with no waves and easy access to get out of the water in an emergency. It was the right time and place to get back in the water.

Race morning was cold, windy and rainy. No problem. I wore my same wetsuit as IMUSA... as I was pulling it on, I began to wonder if a suit with too tight a 'neck' may also be a trigger if it was cutting off circulation - (Trey, you'll have to give us an update on that theory!) - I'm thinking that would cut off circulation to the brain and not have any affect on heart\lung function, but I'm not sure, it was just a though... I got my gear in place and went for a 'pre' race swim warmup.

The water was 72 degrees - cool, but not cold. It felt great to get back in the water, and I settled into a nice easy warmup. I had no fear of the water - even though I haven't gotten back in since IMUSA. At the start, I moved myself to the back of the pack. If I needed to get out of the water, it was easy. When the gun fired, I waited a second or two - not long - and eased into it. I sighted one of the underwater cable lines for the rowing buoys and stated far left out of the traffic. It was SO EASY... no traffic, a nice line to follow - I didn't even have to look up to sight, and I was about 3 feet from shore and could see the bottom. I went really easy and took it slow... as I reached the top end and turned to head back, I picked up the pace slightly... at one point, I had to reel myself back in because I was back up to full swim speed again... didn't want to have anything go wrong at this point as I was about 1500m into it and doing fine. I came out of the water in 37mins27secs, slow for me, but I was still in the race! The bike was windy and wet, but I didn't mind the conditions at all... finished in 2h37m29s - avg. 34.3kmph - very happy... my feet were completely numb from the cold wet conditions... I was still happy... It was rought at first on the run, but I came around in the last half and finished in 1h58m30s - not my fastest, but I was happy... Total time was : 5h18m19s... a PB for me and good enough for 3\14 in my age group... I AM A TRIATHLETE!

So, IM Florida is up next. I had no feeling of a 'twing' at all, no issues. I think the BP meds, not overhydrating leading up to the race, and doing a swim warmup were the three main factors that I incorporated at this race in order to prevent an attack. I will only be able to tell over time, as the 33% 'risk' factor may have been in my favor yesterday... but, I will continue to proceed with caution and work with Trey, Dr. Weiler and all of you guys to piece SIPE together and find a way to stop it from happening completely...

BTW, my AVG HR was 166 throughout the race... 164 on the bike, 172-183 on the run... I didn't check in the swim, but it sure felt in the 140-150 range to me...

I'll keep ya'll posted.
Kat-Kat-the-Water-Rat

---

5x Ultraman Finisher
18X Ironman Finisher
2013 Ironman World Championship Finisher
2012 Canadian Ultra Distance Female Triathlete of the Year
http://www.endurancetriathletes.com

Hm...of course you're right. I forgot the CXR showed it, the CT was required for definitive diagnosis.

Yes, I had mine operated on. I sure do miss the lung tissue that had to go with it. :) Definitely don't recommend a thoracotomy for entertainment. :)

-Jot

Hey Everyone,

Just thought I'd post an update. I raced IM Florida yesterday and was able to complete the race in 12:34:35. I'm not thrilled with my time, but I am thrilled with my medal and not ending up in the medical tent!

The swim was a full thrash-fest - worse than I've been in in the past. There was no opportunity for a warm-up, as they kept the AG's back behind the pen until the Pro's had started at 6:50. It took 5 minutes to get down to the water at that point, and I jumped in to get some water in my suit and do a few quick sprints. They were calling for us to get out of the water, so I really couldn't get in a warm-up. As I looked back to shore, I realized I was right in the center of the pack - not an 'easy' place to start, but I figured I would go a few rows back and go easy. That strategy wasn't perfect as there were a lot of aggressive large men in that area, so it was full contact until we rounded the 2nd buoy at the 1K mark. I went wide right and found some clean water and things got easier. Loop two was again packed at the turn and my goggles got blown off, one elbow to the ribs and a shot to the face... but I kept going. Out of the water in 1:09 - not great, but not bad for holding back and getting stuck in a lot of traffic.

As I exited, I felt that 'wetness' in my lungs and some fluid was apparent. I figured I was much better than IM USA and the Mooseman, so I would see if I could flush it out. On the bike, I did some deep breathing and coughed up some fluid - not a lot, but enough that my breathing was compromised. I figured if I could control things, I might be able to stay in the race. Sure enough, but the 90K point in the bike, my lungs cleared up and the fluid was gone. At that point, I was able to pick up my bike speed. Prior to that, I just didn't have enough oxygen to fuel my legs - so I went from riding at 28K up to my race pace of 34K... I ended up with a 6:12 bike time, off by about 25 minutes... but I was still in the race.

I ran (well, jogged) the full run with a 4:59:59 time to at least beat my IMCanada time of 12:35!... I felt some shortness of breath, but no fluid...

Why did I still get some fluid. I thought of a heart 'spike' as being a contributing factor. I was at 172 bpm at the half way point of the swim... my peak was 187bpm, and that was on the swim. The bike I was down at 145bpm while I had the fluid in my lungs riding at 28K, then up to 153bpm when I was up to 34K on the 2nd half of the bike. Run was avg. 145bpm....

I have been taking 8mg Atacand for 8 weeks now, and will have my 24 hour BP monitoring results when I get back home, but the self monitoring I was doing indicating I was in a great range avg. 124\76 leading up to the race... So, I think that is under control...

I had also opened up the neck of my wetsuit on the 2nd lap, still wondering if the constriction of the suit could be a factor.

We did two swims on the course leading up to the event and everything was great - no issues - same water, same wetsuit - just slow and easy to start, so thats the only difference.

All in all, I'm happy I was able to complete the race and control the relatively small amount of fluid I had upon the swim exit... but, I couldn't RACE it... which is somewhat frustrating...

So, now we have more work to do. I'm sure you have questions Trey!

Thanks for listening.
Kat

---

5x Ultraman Finisher
18X Ironman Finisher
2013 Ironman World Championship Finisher
2012 Canadian Ultra Distance Female Triathlete of the Year
http://www.endurancetriathletes.com

Hello Kat:

I did watch the board in the morning yesterday and was glad to see you out of the water in a pretty good time given the conditions.

Many people have mentioned that warm up is a factor as well as the "fight or flight" sympathetic discharge that goes with the anxiety and alarm of a mass start and unruly pack swim.

My best guess based on your description is that you had some degree of capillary leakage in the water and it took the first half of the bike to resolve. As I mentioned previously, once your pulmonary capillaries are compromised they remain in a hyperpermiable state for some time, and you may have needed to lose some central blood volume through dehydration to take the pressure off of them. On the run, decreased diffusing capacity from the capillary injury combined with dehydration could explain your shortness of breath. ACE inhibitors can also affect your fluid balance, especially over those kinds of durations of exercise and likely in warmer conditions than you're used to.

If you have some collagen fibrosis in your heart, that may take time - a year or more - to resolve with continuous ACE inhibitor therapy.

Have you talked to your sports doc? I know you said you speak with him by phone frequently.

Hey Trey,

Thanks for 'tracking' me on race day - I saw your post from the race day forum - nice to know you're watching!

I was thinking exactly that - If I could keep it under control, eventually the flooding would subside - which it did. I haven't talked to my doc yet. I figured I would see him when I go back, since my SIPE was very mild this time, and I seem to have no lasting effects. I'm very happy I was able to finish and keep moving forward.

The 'spike' in HR and the craziness of the mass start could certainly be a factor... Saturday was the most chaotic swim I've ever been in.

I'll let you know if the doc has any further comments...

Thanks Trey!
Kat

---

5x Ultraman Finisher
18X Ironman Finisher
2013 Ironman World Championship Finisher
2012 Canadian Ultra Distance Female Triathlete of the Year
http://www.endurancetriathletes.com

Hopefully the fact that your episode was less troublesome than before means you're making progress. When did it start? While you were in the water or only after you got out? Did you feel like the distance of the swim was a factor? What if anything seems different to you than the last two races where you weren't affected?

I estimate it started at about the 1.5 mile mark. The first turn of the swim is where I'm guessing I spiked at 187 - the crush was crazy, lots of pushing and bodies everywhere. When I exited the water to finish the first loop, I felt a small amount of fluid. I checked my HR at that point and it was 174. When I started the 2nd loop, I relaxed and made sure to stay wide and try to take it easy. It was a bit less crazy, except at the turn again. The final stretch felt good and I picked up some speed at that point.

When I exited the swim, I could feel a bit of 'gurgling' and knew I would have to be careful and kept thinking if I was patient, it may drain by itself, so I just kept slow and steady on the bike.

If I could have done a proper warmup, I think that would have helped. Only having a few moments to do some quick sprints wasn't ideal, and looking back at the massive pack was quite a site!... I think overall, I was in good control given the conditions.

---

5x Ultraman Finisher
18X Ironman Finisher
2013 Ironman World Championship Finisher
2012 Canadian Ultra Distance Female Triathlete of the Year
http://www.endurancetriathletes.com

Hi Kat/Trey,

Thanks so much for posting the article on SIPE. Reading it hit me like a ton of bricks. I've had two instances in the last 3 years and it was ultimately chalked up to Asthma- never had Asthma before, but started using an inhaler before my open water swims and it seemed to help. But in reading the full thread- (there goes a workday I'll have to pay back)- it just appears that I've avoided the perfect storm in the times I've avoided it. I'll share my story to see if there are other pieces to the puzzle.

Leading up to my first attack- I had Bronchitis in May 2005 and it was better by June. We were on a training weekend in Placid and after a night of beers (lots- so note I was Dehyrated) we went for our swim a 5am the next morning, I don't even think I drank much more then a glass of water. I was first in and started swimming the course and the rest 6 others soon followed and passed me. I was feeling tired and sluggish, but chalked it up to the night before. By around the 750m mark it was getting harder to breath but I continued to the 1km turn around. When I got there two of my friends were waiting and wanted to see if I felt ok- as I treaded water, my chest was feeling tighter and my breathing was more uncomfortable and I agreed to swim out of the lake with one of the guys. As I continued my lungs felt they had flooded with fluid and the breathing was much heavier and I got very uncomfortable and eventually, about 200m from shore went into a full on panic. My buddy pulled me in to the dock and I was able to climb out on my own.

From that point, my lungs felt full of fluid and I had raspy breathing and I was coughing up phlem. I didn't check the colour and I wasn't coughing up red foam as some people have described. My lungs cleared 50% in 2 hours and the rest by the afternoon.

A number of tests were done around the heart and I was fine. The conclusion was it must have been my first Asthma attack- I was never Asthmatic before.....

I started using Asthma medication when training and racing and perhaps it was just psychosomatic, now I'm not sure, but certainly felt better using it (may be related to the bout of Bronchitis)

August 2005
Followed a rigid schedule of prep for the swim, including a 15 minute run 60 mins prior to race start, followed by Asthma medication (well tested process for Exercise Induced Asthma) and had no problem in the swim with my lungs

IM Aug 2005 and IM 2006
Followed same prep and had no issues with the swim

Half IM July 2007
Not sure that I did the same Asthma prep. Did a 5 minute swim warmup. Within 5 minutes of getting in the water for the swim, my chest felt tight. I stopped and started again- stay calm stay calm- stopped, started, stopped again. I started to realize eventually that it's happening again, but if I swim and don't put my body vertical that it doesn't appear to be worsening (the water pressure on the chest) so I just calmly swam through. It's a double loop, so walked on the beach coughing- talked myself back into the water knowing there were kayaks and boats everywhere and pushed through loop 2. There was definitely fluid in my lungs, but didn't cough up blood or red foam here either.

Took my Asthma medication in the transition and with some coughing on the bike, my lungs recovered after about 30 minutes, then I was able to drop the hammer.

Aug 2007 Race
Anxiety at play here now- still not sure if I did my Asthma prep phase here. The swim start was tighter so it was hard to find space and went into an tightening lungs with all the thrashing, but got clear water, calmed my body down and then dropped the hammer in the swim and my lungs were fine.

I don't have high blood pressure or Diabetes. It has been commented recently that I was low on Potassium.

I intend to visit my Dr on Thursday to discuss this. The other confusing part was, the Allergist that I saw in Nov heard my story and indicated I was an anomaly, as with Exercise Induced Asthma, it usually happens running/biking- and they will tell the Athlete to take up swimming, because the moist air helps. I am the opposite....the descriptions from forum are very similar to my experience, fortunately mine appears to be not as extreme and I might be able to manage by replicating the Asthma prep (who knows!) and not hydrating before the swim in addition to getting my body acclimated to the water before the gun goes off.

Sent you an email. We can bring it back out to the forum if you'd like to do that.

In reading through your notes I have the following observations:

Your impression that your first episode was triggered by a prior bout of bronchitis is plausible. The alveolar capillary membranes are among the thinnest membranes in the body and things like inflammation and physical stress from coughing can weaken them. So being two months out from bronchitis with a lingering cough might be related. You may also have some overlapping asthma or at least airway reactivity as well. Don’t think that SIPE excludes exercise-induced asthma completely. The positive methacholine challenge likely means something.

Being upright in the water is also consistent with worsening symptoms. The deeper your legs are the greater the hydrostatic compression of them by the water, and therefore the greater volume of peripheral blood forced into the central circulation. I hade my first SIPE episode doing upright water running to rehab an injury. Just for future reference, if your lungs start to produce fluid again in the water and you feel that you need to rest and freestyle is too hard, try switching to sidestroke rather than letting your legs sink. You may still have problems with the down side lung but the upper one should clear and you can slow down quite a bit. I would not do backstroke because it would likely interfere with cough clearance.

Hard to say about the asthma / inhaler pretreatment. What inhaler are you using? Based on your description it looks to me like your asthma pretreatment involves a judicious warm-up in addition to inhaler use, and warm-up has at least anecdotally been associated with less recurrence in people who have had multiple episodes. If you do have a touch of exercise-induced asthma the inhaler might be just enough to keep your airways from getting twitchy and causing you to pull increased negative inthrathoracic pressure, which can assist the alveolar flooding process.

What has been the role of cold water or wetsuit use in your episode history? Can you see any associations there?

As far as the next step goes, certainly a good blood pressure workup is important. Are you taking any other medications? Is there any heart disease, high blood pressure or diabetes in your family?

Thanks Trey!

I'm using Ventolin- I've avoided the addition of the steroid inhalers to "fix" my lungs to this point. But it's tempting, because wouldn't I get unusually big pipes and beat all my friends in the races? I digress.

My pretreatment is at 60 mins out, I go for a 15 min run, then 5 min stretching then the inhaler at 30 mins out. Then I hit the water at about 15 mins to racetime for some swimming.

I don't know about the affect on cold. I've done some colder swims (Alcatraz, Muskoka), but the races where it happened were cool but certainly not frigid (Peterbrough and Lake Placid) and I was wearing a wetsuit for both episodes and for any swim I've done since the first episode- not really interested in sinking to the bottom if it happens again.

Not taking any medications. Blood pressure is ok-but I will bring that up with the Dr on Thursday, my mother's is high. No heart disease. Sister has acid reflux, but not me as far as I know.

Ventolin is Albuterol. It's a bronchodilator that's been on the market for quite some time that is mostly a beta 2 receptor agonist. No anti-inflammatory properties to speak of. I think it's likely that the warmup ritual is the important part, but that's just a guess. There aren't any studies looking at bronchodilators related to SIPE.

Wetsuits are almost always involved as well, and could contribute to leg and trunk compression, but a randomized clinical trial would be required to sort that out since wetsuit wearing is so common in competition.

Do speak to the Dr. about BP. As far as I know that's the only potentially modifiable risk factor. Warm up and hydration maybe too, but unfortunately there aren't any prevention studies out there. Hopefully if we can continue to identify cases we can get some ideas for prevention efforts going forward.

Thanks again for checking in.

Let us know what the doc has to say.

It has been commented recently that I was low on Potassium.

Rob:

I forgot to comment on this before. Please mention this to your Dr. and see if you can get the potassium repeated. If it's still low, they should run an Aldosterone level for you.

So my Family Doctor had nothing to offer. I had a comprehensive workup (Blood, Heart, Stress Test) the first time I experienced this so he didn't suggest further tests although I convinced him to run another round of blood work.

I sent a letter and article on SIPE to my Asthma/Allergist that is looking at my Asthma issue in relation to these attacks. He might have more interest in followup investigation as he was intrigued by the issue. Exercise Induced Asthmatics are told to go swimming, he said I'm the opposite, so it didn't make sense. I think he will be very interested in what the answer is. So we will see what comes from followup with him.

An Emergency nurse friend suggested I look it up at www.pubmed.com.

There are a couple of articles I hadn't seen before and what I've concluded is that we are guaranteed to develop Hypertension if we have had a SIPE attack.

Another article implicates Diatolic Dysfuntion as well.

http://www.pubmedcentral.nih.gov/...332&blobtype=pdf

So, I await followup from my Asthma specialist to see what/who I might see next.

Here is a summary of one of the studies:
Wilmshurst PT, Nuri M, Crowther A, Webb-Peploe MM.
Department of Cardiology, St. Thomas' Hospital, London.
The effect of cold and/or a raised partial pressure of oxygen was examined in eleven people with no demonstrable cardiac abnormality but who had pulmonary oedema when scuba diving or surface swimming, and in ten normal divers. These stimuli induced pathological vasoconstriction in the pulmonary oedema group, nine of whom also showed signs of cardiac decompensation when so stimulated. The pulmonary oedema patients have been followed-up for an average of 8 years. Seven have become hypertensive. Except for the onset of lone atrial fibrillation in one normotensive female diver and development of Raynaud's phenomenon in a normotensive man, there have been no cardiovascular events and no deaths.