Background
- 52-year-old female 5’7” tall and 140 pounds.
- Experienced two episodes of immersion pulmonary edema (IPE) in three years.
Reported Incident
The diver started diving in 2016. From the time she did her first dive, she would return to the surface with a sensation of gurgling in her chest and difficulty breathing. She would often discontinue diving for the day. On her 10th dive, she felt the same sensation but forced herself to do the second dive. About 25 minutes into dive, she felt the same gurgling and difficulty breathing. She made it to the surface and climbed aboard the boat just before losing consciousness. She was taken to the hospital where she spent two days. On arrival, she was blue and in atrial fibrillation. Her blood pressure was 120/80 (it was usually 100/60). They treated her with antibiotics for pneumonia, but she was eventually diagnosed with immersion pulmonary edema (IPE). The doctor prescribed her 12.5 milligrams of metoprolol for atrial fibrillation. She also took 60 milligrams of fluoxetine and 1 milligram of estradiol for menopause and 0.5 milligrams of alprazolam for insomnia. She had one kidney because she donated the other.
She returned to diving two months after the first incident. She bought a new wetsuit because she thought the IPE was due to the tight suit. Over the next three years, she did 14 more dives with no major problems. On her twenty-fifth dive, she started salivating, swallowing, and coughing. She knew this time it was IPE, and she ascended alone because she lost her buddy. At the surface, she could not breathe. The boat was far enough away that she could not swim to it. She fainted but was retrieved by the boat crew and taken to the hospital. This time she didn’t want to stay overnight and returned to the cruise ship. She could not lay down. Instead, she had to sit all night so she could breathe. In the morning, the ship doctor gave her furosemide, a diuretic, and she improved.
Review
Pulmonary edema in divers may be fatal. Difficulty breathing while diving (regardless of what the possible cause may be) should be a warning sign to discontinue diving and exit the water. Mild IPE may spontaneously resolve before it is diagnosed, but if a diver fails to recognize it and stays underwater, the IPE may progress quickly and result in death. IPE is always an emergency. The first aid for IPE at the dive site is to provide oxygen and call EMS. When properly treated, patients recover quickly. Unfortunately, IPE tends to occur again, and divers with a history of IPE-like symptoms should not dive until evaluated and approved by a cardiologist experienced in diving medicine.
Recommendations
In this case, the diver may not have received proper advice the first time. It was risky to go diving while on a cruise ship in remote areas. The diver should not have left the hospital against advice. Once she returned to the cruise ship, she should have notified the ship’s physician immediately in the evening and not waited until the following day, especially because she was still symptomatic and had a history of atrial fibrillation.