Pulmonary oedema and haemoptysis induced by strenuous swimming

Weiler-Ravell, Daniel; Shupak, Avi; Goldenberg, Ilan; Halpern, Pinchas; Shoshani, Oren; Hirschhorn, Gil; Margulis, Arkady

doi:10.1136/bmj.311.7001.361

Cited by 98 publications

(105 citation statements)

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“…4 It has been reported that most patients do not have recurrence of symptoms. 3 Owing to gravity dependent increases in pulmonary capillary pressure, signs are usually present on the right side (as in our patient).…”

Section: Discussionmentioning

confidence: 53%

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Pulmonary oedema precipitated by cold water swimming

Biswas

Shibu²,

James³

2004

Br J Sports Med

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The case is reported of a physically fit man, who, while training for a triathlon, developed pulmonary oedema secondary to swimming in cold water. Pulmonary oedema is usually caused by a combination of exercise and cold water, resulting in an increase in cardiac preload and after load, which causes an increase in pulmonary capillary pressure. Most cases improve spontaneously and quickly with no recurrence of symptoms. CASE REPORTA 36 year old man was admitted to our hospital complaining of shortness of breath and haemoptysis. He was physically fit and training for a local triathlon competition when the problem occurred. He had been swimming in the sea, wearing a wet suit, for about 10 minutes when he started to feel slightly short of breath. He loosened his wet suit and let the cold water in. However, his breathing worsened. He continued to swim for half a mile more. He started to cough up blood stained sputum. He returned to the shore at this stage and was more short of breath. He denied aspirating any seawater. He borrowed his daughter's salbutamol inhaler and took a few puffs. He presented to his general practitioner about 90 minutes after the incident. The general practitioner heard crackles on his right side and referred him to hospital. He presented to the hospital 8-9 hours after the incident.He is known to have had type 1 diabetes for 13 years treated with insulin. He is a non-smoker, drinks about 4 units of alcohol a week, and works as a pharmacist.On admission to the ward, he was comfortable at rest. His blood pressure was 125/73 mm Hg, pulse 60/min, and oxygen saturation 94% on room air. Jugular venous pressure was not raised, and there was no pedal oedema. There were crackles on the right side of the chest. Cardiovascular examination was normal with no murmur heard.He improved quickly on the ward and was asymptomatic with no drugs prescribed. INVESTIGATIONSThe following are the results of the investigations carried out.

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Section: Discussionmentioning

confidence: 53%

“…2 Another Israeli study found similar features in young men undergoing military fitness training. 3 The following factors are thought to contribute to the temporary increase in capillary venous pressure.…”

Section: Discussionmentioning

confidence: 99%

Pulmonary oedema precipitated by cold water swimming

Biswas

Shibu²,

James³

2004

Br J Sports Med

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“…The causative mechanism of EIPH was demonstrated experimentally when it was shown that high pulmonary capillary pressures can cause discrete breaks in the endothelium, epithelium, or the entire BGB in mammals (10,50,64,66). Incidences of suspected EIPH (usually presenting as hemoptysis) have been documented in humans as well (15,34,35,61), and evidence that maximal exercise can impair the integrity of the BGB and change the permeability of the capillary membrane was demonstrated by Hopkins et al (16). However, submaximal exercise does not appear to affect the integrity of the BGB in humans or horses (17,48).…”

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confidence: 99%

Morphometry of the extremely thin pulmonary blood-gas barrier in the chicken lung

Watson¹,

Fu²,

West³

2007

American Journal of Physiology-Lung Cellular and Molecular Phys

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Watson RR, Fu Z, West JB. Morphometry of the extremely thin pulmonary blood-gas barrier in the chicken lung. Am J Physiol Lung Cell Mol Physiol 292: L769-L777, 2007. First published November 17, 2006; doi:10.1152/ajplung.00355.2006.-The gas exchanging region in the avian lung, although proportionally smaller than that of the mammalian lung, efficiently manages respiration to meet the high energetic requirements of flapping flight. Gas exchange in the bird lung is enhanced, in part, by an extremely thin blood-gas barrier (BGB). We measured the arithmetic mean thickness of the different components (endothelium, interstitium, and epithelium) of the BGB in the domestic chicken lung and compared the results with three mammals. Morphometric analysis showed that the total BGB of the chicken lung was significantly thinner than that of the rabbit, dog, and horse (54, 66, and 70% thinner, respectively) and that all layers of the BGB were significantly thinner in the chicken compared with the mammals. The interstitial layer was strikingly thin in the chicken lung (ϳ86% thinner than the dog and horse, and 75% thinner than rabbit) which is a paradox because the strength of the BGB is believed to come from the interstitium. In addition, the thickness of the interstitium was remarkably uniform, unlike the mammalian interstitium. The uniformity of the interstitial layer in the chicken is attributable to a lack of the supportive type I collagen cable that is found in mammalian alveolar lungs. We propose that the surrounding air capillaries provide additional structural support for the pulmonary capillaries in the bird lung, thus allowing the barrier to be both very thin and extremely uniform. The net result is to improve gas exchanging efficiency. capillary stress failure; lung morphology; bird respiratory physiology; air capillary; extracellular matrix; interstitium IN THE VERTEBRATE LUNG, OPTIMAL thickness of the pulmonary blood-gas barrier (BGB) is affected by opposing selective pressures (65). The barrier thickness is minimized to allow efficient exchange of oxygen and carbon dioxide, yet the capillary walls must also be strong enough to withstand high pulmonary capillary pressures that are incurred during extreme physical exertion. The BGB is composed of three layers: capillary endothelium, an interstitial layer or extracellular matrix, and an epithelial layer (Fig. 1). Combined, these cellular layers are relatively thin, usually measuring Ͻ2 m in total thickness under normal conditions (5,33,36). This three-ply ultrastructure of the BGB appears to be evolutionally well conserved over a variety of vertebrate taxa, indicating that its basic structure is efficient and relatively immalleable (18,25,27,31,33). The strength of the pulmonary capillary walls is likely related to the morphometry of the BGB, where the thickness of the interstitium determines the fragility of the capillaries (5). Where the BGB is thinnest, the interstitial layer is composed of only the fused basement membranes of the endothelium and epithelium laye...

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“…Histologically, alveolar hemorrhage can be classified into three types: 1) pulmonary capillaritis, 2) diffuse alveolar damage, including that associated with connective tissue disease, vasculitis, infection and drug intoxication and 3) bland pulmonary hemorrhage without inflammation (1). There are only a few reports of the onset of alveolar hemorrhage following exercise (2,3) or induced by pheochromocytoma (4-7). However, the mechanisms underlying the development of alveolar hemorrhage remain unclear.…”

Section: Introductionmentioning

confidence: 99%

Paraganglioma-induced Alveolar Hemorrhage

et al. 2015

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A 21-year-old man twice developed sudden dyspnea during running examinations for promotion. Chest computed tomography (CT) revealed lobular ground-glass opacity and centrilobular shadows bilaterally. The bronchoscopy findings were consistent with alveolar hemorrhage, and echocardiography showed severe hypokinesia a few hours later. A mass was subsequently identified along the abdominal aorta on enhanced CT and iodine-131 metaiodobenzylguanidine scintigraphy. Catecholamine oversecretion, which was later confirmed, may have increased the pulmonary vein pressure, thus resulting in the development of an alveolar hemorrhage, and damaged the cardiac muscles as manifested by hypokinesia. Since the patient had not previously developed alveolar hemorrhage during usual exercise, emotional stress superimposed on the physical activity may have triggered the paraganglioma to secrete excessive catecholamines, thus resulting in the observed symptoms.

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Pulmonary oedema and haemoptysis induced by strenuous swimming

Cited by 98 publications

References 3 publications

Pulmonary oedema precipitated by cold water swimming

Pulmonary oedema precipitated by cold water swimming

Morphometry of the extremely thin pulmonary blood-gas barrier in the chicken lung

Paraganglioma-induced Alveolar Hemorrhage

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