RESUMEN
Swimming-induced pulmonary edema (SIPE) occurs during swimming and scuba diving, usually in cold water, in susceptible healthy individuals, especially military recruits and triathletes. We have previously demonstrated that pulmonary artery (PA) pressure and PA wedge pressure are higher during immersed exercise in SIPE-susceptible individuals versus controls, confirming that SIPE is a form of hemodynamic pulmonary edema. Oral sildenafil 50 mg 1 h before immersed exercise reduced PA pressure and PA wedge pressure, suggesting that sildenafil may prevent SIPE. We present a case of a 46-yr-old female ultratriathlete with a history of at least five SIPE episodes. During a study of an exercise submerged in 20°C water, physiological parameters before and after sildenafil 50 mg orally were as follows: O2 consumption 1.75, 1.76 L·min; HR 129, 135 bpm; arterial pressure 189/88 (mean 121.5), 172/85 (mean 114.3) mm Hg; mean PA pressure 35.3, 28.8 mm Hg; and PA wedge pressure 25.3, 19.7 mm Hg. She has had no recurrences during 20 subsequent triathlons while taking 50 mg sildenafil before each swim. This case supports sildenafil as an effective prophylactic agent against SIPE during competitive surface swimming.
Asunto(s)
Edema Pulmonar/prevención & control , Citrato de Sildenafil/uso terapéutico , Natación/fisiología , Vasodilatadores/uso terapéutico , Femenino , Hemodinámica/efectos de los fármacos , Humanos , Persona de Mediana Edad , Edema Pulmonar/fisiopatología , Presión Esfenoidal Pulmonar/efectos de los fármacos , Prevención SecundariaRESUMEN
BACKGROUND: Swimming-induced pulmonary edema (SIPE) occurs during swimming or scuba diving, often in young individuals with no predisposing conditions, and its pathophysiology is poorly understood. This study tested the hypothesis that pulmonary artery and pulmonary artery wedge pressures are higher in SIPE-susceptible individuals during submerged exercise than in the general population and are reduced by sildenafil. METHODS AND RESULTS: Ten study subjects with a history of SIPE (mean age, 41.6 years) and 20 control subjects (mean age, 36.2 years) were instrumented with radial artery and pulmonary artery catheters and performed moderate cycle ergometer exercise for 6 to 7 minutes while submersed in 20°C water. SIPE-susceptible subjects repeated the exercise 150 minutes after oral administration of 50 mg sildenafil. Work rate and mean arterial pressure during exercise were similar in controls and SIPE-susceptible subjects. Average o2 and cardiac output in controls and SIPE-susceptible subjects were: o2 2.42 L·min(-1) versus 1.95 L·min(-1), P=0.2; and cardiac output 17.9 L·min(-1) versus 13.8 L·min(-1), P=0.01. Accounting for differences in cardiac output between groups, mean pulmonary artery pressure at cardiac output=13.8 L·min(-1) was 22.5 mm Hg in controls versus 34.0 mm Hg in SIPE-susceptible subjects (P=0.004), and the corresponding pulmonary artery wedge pressure was 11.0 mm Hg versus 18.8 mm Hg (P=0.028). After sildenafil, there were no statistically significant differences in mean pulmonary artery pressure or pulmonary artery wedge pressure between SIPE-susceptible subjects and controls. CONCLUSIONS: These observations confirm that SIPE is a form of hemodynamic pulmonary edema. The reduction in pulmonary vascular pressures after sildenafil with no adverse effect on exercise hemodynamics suggests that it may be useful in SIPE prevention. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00815646.
Asunto(s)
Edema Pulmonar/tratamiento farmacológico , Edema Pulmonar/fisiopatología , Conducta de Reducción del Riesgo , Citrato de Sildenafil/uso terapéutico , Natación/fisiología , Adulto , Gasto Cardíaco/efectos de los fármacos , Gasto Cardíaco/fisiología , Frío/efectos adversos , Prueba de Esfuerzo/efectos de los fármacos , Prueba de Esfuerzo/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Consumo de Oxígeno/efectos de los fármacos , Consumo de Oxígeno/fisiología , Edema Pulmonar/etiología , Presión Esfenoidal Pulmonar/efectos de los fármacos , Presión Esfenoidal Pulmonar/fisiología , Citrato de Sildenafil/farmacología , Vasodilatadores/farmacología , Vasodilatadores/uso terapéuticoRESUMEN
PURPOSE: Immersion pulmonary edema (IPE) occurs in swimmers (especially triathletes) and scuba divers. Its pathophysiology and risk factors are incompletely understood. This study was designed to establish the prevalence of preexisting comorbidities in individuals who experience IPE. METHODS: From 2008 to May 2010, individuals who had experienced IPE were identified via recruitment for a physiological study. Past medical history and subject characteristics were compared with those available in the current body of literature. RESULTS: At Duke University Medical Center, Durham, NC, 36 subjects were identified (mean age = 50.11 ± 10.8 yr), of whom 72.2% had one or more significant medical conditions at the time of IPE incident (e.g., hypertension, cardiac dysrhythmias or structural abnormality or dysfunction, asthma, diabetes mellitus, overweight or obesity, obstructive sleep apnea, hypothyroidism). Forty-five articles were included, containing 292 cases of IPE, of which 24.0% had identifiable cardiopulmonary risk factors. Within the recreational population, cases with identifiable risk factors comprised 44.9%. Mean age was 47.8 ± 11.3 yr in recreational divers/swimmers and 23.3 ± 6.4 yr in military divers/swimmers. CONCLUSIONS: Cardiopulmonary disease may be a common predisposing factor in IPE in the recreational swimming/diving population, whereas pulmonary hypertension due to extreme exertion may be more important in military cases. Individuals with past history of IPE in our case series had a greater proportion of comorbidities compared to published cases. The role of underlying cardiopulmonary dysfunction may be underestimated, especially in older swimmers and divers. We conclude that an episode of IPE should prompt the evaluation of cardiac and pulmonary function.