Hemoptysis Due to Breath-Hold Diving Following Chemotherapy and Lung Irradiation

Abstract

A male patient, age 60 years, presented with a chief complaint of coughing up blood. He had been in his usual state of health until the day of admission, when he went breath-hold diving in Monterey Bay, off the coast of northern California. At the time of his dives, the water temperatures usually average around 55˚F. The patient completed five dives, each to a depth of approximately 13 meters (~ 40 feet) and each lasting approximately 90 seconds. Hyperventilation preceded each dive, but no other maneuvers, such as glossopharyngeal insufflation ("lung packing"), were performed. The patient was unsure about diaphragmatic contractions performed against a closed glottis during immersion. After his fifth dive, he noted "slight irritation" in his chest that was immediately followed by a series of five coughs, over a period of 5 minutes. He expectorated an estimated 1 /2 to 1 tablespoon of blood with each cough; approximately, 4 tablespoons of blood in total. He noted wheezing but did not feel short of breath.The patient's past medical history was significant for T2N3M0 stage IIIc invasive ductal carcinoma of the left breast, for which he had undergone a left modified radical mastectomy and axillary lymph node dissection 10 months prior to presentation. He had been treated with adjuvant chemotherapy 6 months prior to presentation that included doxorubicin, cyclophosphamide, and paclitaxel followed by adjuvant radiation therapy administered in 1.8 Gray (Gy) fractions, Breath-hold diving, also known as free-diving, describes the practice of intentional immersion under water without an external supply of oxygen. Pulmonary hemorrhage with hemoptysis has been reported as a complication of immersion and breath-hold diving in young healthy athletes. We report the case of a 60-year-old man with a history of radiation and chemotherapy for breast carcinoma, who developed the abrupt onset of hemoptysis in the setting of swimming and breath-hold diving. A computed tomography (CT) scan of the chest demonstrated an area of ground glass opacification, suggestive of pulmonary hemorrhage, superimposed on a background of reticular opacities within the prior radiation field. A follow-up CT scan of the chest, obtained 2 months after presentation, demonstrated resolution of the ground glass opacification, but persistence of fibrotic features attributable to prior radiation therapy. We postulate that prior irradiation of the chest resulted in lung injury and fibrosis which, in turn, rendered the affected region of the lung susceptible to "stress failure," due to an increase in the transcapillary pressure gradient arising from immersion and breath-hold diving. Patients with a history of lung injury resulting from chest irradiation should be cautioned about pulmonary hemorrhage and hemoptysis as a potential complication of swimming and breath-hold diving.

Enfermedad de riesgo vital de origen respiratorio o alérgico en el deporte

“…Una historia de neumotórax espontáneo 37,38 , ciertos defectos congénitos pulmonares 39,40 , infecciones de las vías respiratorias bajas 41,42 , la limitación crónica del flujo aéreo 43 , la sensibilización previa a ciertos alimentos, a picaduras de insectos y el asma, en concreto 44 , serán las afectaciones más comunes y que deberemos tener muy en cuenta. En el ámbito de la neumología la mayoría de las enfermedades observadas producen una dificultad respiratoria al ejercicio que en la práctica nunca pondrá en riesgo la vida del paciente, dado que la intensidad del ejercicio está limitada por la propia enfermedad respiratoria; también es cierto que sí existen enfermedades que por sus caracterís-ticas deben tenerse en cuenta, sobre todo si además del estrés físico hay un estrés ambiental al que se somete al organismo 45,46 . En principio, el paciente respiratorio que puede llegar a hacer ejercicio de alta intensidad, estructurado y considerado deporte, incluso a un alto nivel, es el que padece asma.…”