Brief Report
Swimming-induced pulmonary edema in triathletes,☆☆

https://doi.org/10.1016/j.ajem.2009.08.004Get rights and content

Abstract

Background

Pulmonary edema related to water immersion has been reported in military trainees and scuba and breath-hold divers, but rarely in the community. To date, no risk factors for this phenomenon have been identified by epidemiological methods. Recently, sporadic reports of swimming-induced pulmonary edema (SIPE) have emerged in the triathlon community. We surveyed the population of a national North American triathlon organization (USA Triathlon) to determine prevalence of and risk factors for symptoms compatible with SIPE.

Methods

We surveyed the population of USA Triathlon through the organization's monthly newsletter distribution channel. We evaluated prevalence of symptoms compatible with pulmonary edema, and then followed up with a case-control study that included additional cases we had identified previously, to identify risk factors for this condition among triathletes.

Results

Symptom history compatible with SIPE was identified in 1.4% of the population. Associated factors identified in multivariable analysis included history of hypertension, course length of half-Ironman distance or greater, female gender and use of fish oil supplements. Of the 31 cases reported, only 4 occurred in the absence of any associated factors.

Conclusions

The identification of hypertension and fish oil in particular as risk factors raise questions about the role of cardiac diastolic function in the setting of water-immersion cardiac preload, as well as the hematologic effects of fish oil. Mechanistic studies of these risk factors in a directly observed prospective cohort are indicated.

Section snippets

Background

Pulmonary edema of immersion has been reported in select populations such as submersion divers [1], [2], [3], [4] and combat swimmers [5], [6], but only sporadically in the community setting [7]. Aside from the studies of combat swimmers, who are typically subjected to intense swimming trials, often after massive hydration, no reports of more than a dozen community-based cases have appeared in the literature. Termed swimming induced pulmonary edema (SIPE), the phenomenon has been difficult to

Methods

No validated, community-based pulmonary edema questionnaire has appeared in the literature, so it was necessary for us to develop a survey for this purpose. We reviewed the symptom criteria described previously by Weiler-Ravell et al [5], but since we did not have the benefit of direct examination of our participants as Weiler-Ravell’s group had, we limited our case definition to “cough productive of pink frothy or blood-tinged secretions” for the analysis. This description is both

Results

The age distribution of the overall USA Triathlon population, excluding juniors, is shown in Fig. 1A. USAT statistics on newsletter reading rates indicate that approximately one percent (about 1,400) of the emailed newsletters are opened at each mailing. USAT surveys were returned by 1423 respondents over three cycles of distribution, which indicates that we received responses from 1.3% of the total population, but closer to 1/3 of the people who actually opened the newsletter. Of the 1423

Discussion

This is the first study to report a population-based estimate of SIPE prevalence in community triathletes, and is the first to report statistical risk factor associations in any population. Symptoms compatible with swimming-induced pulmonary edema are estimated to occur in 1.4 percent of triathlon participants in North America, as represented by the membership of the USA Triathlon organization. This is consistent with and well within statistical error of the prevalence of 1.8% reported by Adir

Acknowledgments

We are grateful to the Board of USA Triathlon, Inc., which distributed the prevalence survey, and to the members of the organization who participated in the survey. We are also grateful to Dan Empfield, publisher of slowtwitch.com, who hosted the discussion forum that facilitated the virtual meeting of the first few cases.

The three authors collaboratively designed the survey. Ms. Calder-Becker maintained the case directory. Dr. Miller and Dr. Modave analyzed the data. Dr. Miller wrote the

References (19)

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This research was supported by departmental funds.

☆☆

No conflicts pertinent to the work presented in this article exist for any author.

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