Hemoptysis Provoked by Voluntary Diaphragmatic Contractions in Breath-Hold Divers

Kıyan, Esen; Aktaş, Şamil; Toklu, Akın Savaş

doi:10.1378/chest.120.6.2098

Cited by 46 publications

(36 citation statements)

References 9 publications

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“…Loss of motor control (defined as the presence of hypoxic signs first appearing after surfacing without complete loss of consciousness) is reported to occur in up to 10% of divers during breath-hold competitions [14]. In addition, cases of haemoptysis following breath-hold dives have been reported [15][16][17]. Rupture of the alveolocapillary membrane may be caused by elevation of the pulmonary transcapillary wall pressure due to decreases in intrathoracic pressure when total lung volume at depth approaches RV [16].…”

Section: Lung Hyperinflation: Foe or Friend?mentioning

confidence: 99%

Lung hyperinflation: foe or friend?

Eichinger

Walterspacher²,

Scholz³

et al. 2008

Eur Respir J

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Breath-hold divers employ glossopharyngeal insufflation (GI) in order to prevent the lungs from compressing at great depth and to increase intrapulmonary oxygen stores, thus increasing breath-hold time.The presented case study shows the physiological data and dynamic magnetic resonance imaging (dMRI) findings of acute hyperinflation, deliberately induced by GI, in a breath-hold diver and discusses the current state of knowledge regarding the associated hazards of this unique competitive sport.Static and dynamic lung volumes and expiratory flows were within the normal range, with vital capacity and peak expiratory flow being higher than the predicted values. Airway resistance and diffusing capacity of the lung for carbon monoxide were normal. Static compliance was normal and increased five-fold with hyperinflation. dMRI revealed a preserved shape of the thorax and diaphragm with hyperinflation. A herniation of the lung beneath the sternum and enlargement of the costodiaphragmatic angle were additional findings during the GI manoeuvre. After expiration, complete resolution to baseline was demonstrated.Hyperinflation can be physiological and even protective under abnormal physical conditions in the sense of acute adaptation to deep breath-hold diving. Dynamic magnetic resonance imaging is adequate for visualisation of the sequence of the glossopharyngeal insufflation manoeuvre and the complete reversibility of deliberate hyperinflation.

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Section: Lung Hyperinflation: Foe or Friend?mentioning

confidence: 99%

Lung hyperinflation: foe or friend?

Eichinger

Walterspacher²,

Scholz³

et al. 2008

Eur Respir J

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“…5 Diaphragmatic movement against a closed glottis during diving causes a negative intra-alveolar pressure and can further exacerbate the bulging of pulmonary capillaries resulting in an increase in transcapillary pressure gradient that can lead to capillary rupture. 6 We speculate that pre-existing focal lung damage from radiation therapy 3 months prior placed this patient at increased risk for capillary stress failure and alveolar hemorrhage. This is suggested by the finding of ground glass opacification present on the initial CT scan of the chest, consistent with alveolar hemorrhage, that was localized to a region of the lung that had been in the prior radiation field.…”

Section: Discussionmentioning

confidence: 86%

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

Gutsche

Kuschner

2012

Clinical Medicine & Research

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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.

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“…1). Because the intrathoracic pressure is likely already negative at greater depths, additional negative-pressure waves might well contribute to alveolar hemorrhage damaging the pulmonary capillaries [10] in which pressure is considerably increased due to the blood shift (see below).…”

Section: Breath Holding: Easy-going and Struggle Phasementioning

confidence: 99%

Effects of Breath-Hold Deep Diving on the Pulmonary System

Schipke¹,

Lemaître²,

Cleveland³

et al. 2019

Respiration

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This short review focuses on pulmonary injury in breath-hold (BH) divers. When practicing their extreme leisure sport, they are exposed to increased pressure on pulmonary gas volumes, hypoxia, and increased partial gas pressures. Increasing ambient pressures do present a serious problem to BH deep divers, because the semi-rigid thorax prevents the deformation required by the Boyle-Mariotte law. As a result, a negative-pressure barotrauma (lung squeeze) with acute hemoptysis is not uncommon. Respiratory maneuvers such as glossopharyngeal insufflation (GI) and glossopharyngeal exsufflation (GE) are practiced to prevent lung squeeze and to permit equalizing the paranasal sinuses and the middle ear. GI not only impairs venous return, thereby provoking hypotension and even fainting, but also produces intrathoracic pressures likely to induce pulmonary barotrauma that is speculated to induce long-term injury. GE, in turn, further increases the already negative intrapulmonary pressure, thereby favoring alveolar collapse (atelectasis). Finally, hypoxia seemingly not only induces brain injury but initiates the opening of intrapulmonary shunts. These pathways are large enough to permit transpulmonary passage of venous N₂ bubbles, making stroke-like phenomena in deep BH divers possible.

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Hemoptysis Provoked by Voluntary Diaphragmatic Contractions in Breath-Hold Divers

Cited by 46 publications

References 9 publications

Lung hyperinflation: foe or friend?

Lung hyperinflation: foe or friend?

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

Effects of Breath-Hold Deep Diving on the Pulmonary System

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