Symptom Duration, Recurrence, and Long-Term Effects of Swimming-Induced Pulmonary Edema

Abstract

BackgroundSwimming-induced pulmonary edema (SIPE) has been reported to subside within 24 to 48 h, but comprehensive follow-up studies on symptom duration and long-term effects are missing.Research QuestionWhat are the symptom duration, recurrence, and long-term effects of SIPE?Study Design and MethodsA follow-up study was conducted, based on 165 cases of SIPE from Sweden’s largest open-water swimming event with 26,125 people participating during 2017-2019. Data on patient characteristics, clinical findings, and symptoms were collected on admission. Telephone interviews at 10 days and 30 months were performed to explore symptom duration, recurrence of SIPE symptoms, need for medical evaluation, and long-term effects of self-assessed general health and physical activity level.ResultsFollow-up at 10 days was performed for 132 cases and at 30 months for 152 cases. Most of the patients were women, and their mean age was 48 years. At the 10-day follow-up, symptom duration > 2 days after the swimming race was reported by 38%. The most common symptoms were dyspnea and cough. In patients monitored for 30 months, recurrence of respiratory symptoms during open-water swimming was reported by 28%. In multivariable logistic regression, asthma was independently associated with both symptom duration > 2 days and recurrence of SIPE symptoms (P = .045 and P = .022, respectively). Most participants reported equal or improved general health (93%) and physical activity level (85%) after experiencing SIPE, but 58% had not swum in open water since the event.InterpretationThe present large cohort study challenges the established hallmark of SIPE symptom duration < 48 h, whereas SIPE recurrence was in the previously reported range. At 30 months, most patients reported unchanged self-assessed general health and physical activity level. These findings add to our understanding of the course of SIPE and can provide evidence-based information to swimmers and health care professionals. Swimming-induced pulmonary edema (SIPE) has been reported to subside within 24 to 48 h, but comprehensive follow-up studies on symptom duration and long-term effects are missing. What are the symptom duration, recurrence, and long-term effects of SIPE? A follow-up study was conducted, based on 165 cases of SIPE from Sweden’s largest open-water swimming event with 26,125 people participating during 2017-2019. Data on patient characteristics, clinical findings, and symptoms were collected on admission. Telephone interviews at 10 days and 30 months were performed to explore symptom duration, recurrence of SIPE symptoms, need for medical evaluation, and long-term effects of self-assessed general health and physical activity level. Follow-up at 10 days was performed for 132 cases and at 30 months for 152 cases. Most of the patients were women, and their mean age was 48 years. At the 10-day follow-up, symptom duration > 2 days after the swimming race was reported by 38%. The most common symptoms were dyspnea and cough. In patients monitored for 30 months, recurrence of respiratory symptoms during open-water swimming was reported by 28%. In multivariable logistic regression, asthma was independently associated with both symptom duration > 2 days and recurrence of SIPE symptoms (P = .045 and P = .022, respectively). Most participants reported equal or improved general health (93%) and physical activity level (85%) after experiencing SIPE, but 58% had not swum in open water since the event. The present large cohort study challenges the established hallmark of SIPE symptom duration < 48 h, whereas SIPE recurrence was in the previously reported range. At 30 months, most patients reported unchanged self-assessed general health and physical activity level. These findings add to our understanding of the course of SIPE and can provide evidence-based information to swimmers and health care professionals. Take-Home PointsStudy Question: What are the symptom duration, recurrence, and long-term effects of SIPE?Results: In total, 38% of patients with SIPE reported symptom duration > 2 days and 28% reported recurrence of SIPE symptoms, whereas self-assessed general health and physical activity level were not affected up to 30 months.Interpretation: The present large cohort study challenges the established hallmark that SIPE symptoms subside within 48 h, whereas the recurrence of SIPE fell within the previously reported range. Study Question: What are the symptom duration, recurrence, and long-term effects of SIPE? Results: In total, 38% of patients with SIPE reported symptom duration > 2 days and 28% reported recurrence of SIPE symptoms, whereas self-assessed general health and physical activity level were not affected up to 30 months. Interpretation: The present large cohort study challenges the established hallmark that SIPE symptoms subside within 48 h, whereas the recurrence of SIPE fell within the previously reported range. Swimming-induced pulmonary edema (SIPE) was first described in 1989 and is characterized by cough and dyspnea, sometimes accompanied by frothy sputa and hemoptysis while swimming in open water.1Wilmshurst P.T. Nuri M. Crowther A. Webb-Peploe M.M. Cold-induced pulmonary oedema in scuba divers and swimmers and subsequent development of hypertension.Lancet. 1989; 1: 62-65Abstract PubMed Scopus (154) Google Scholar SIPE is a hydrostatic pulmonary edema hypothetically caused by central pooling of blood and peripheral vasoconstriction during immersion, in combination with strenuous exercise, while swimming in open water.2Koehle M.S. Lepawsky M. McKenzie D.C. Pulmonary oedema of immersion.Sports Med. 2005; 35: 183-190Crossref PubMed Scopus (83) Google Scholar, 3Arborelius Jr., M. Ballidin U.I. Lilja B. Lundgren C.E. Hemodynamic changes in man during immersion with the head above water.Aerospace Med. 1972; 43: 592-598PubMed Google Scholar, 4Bove A.A. Pulmonary aspects of exercise and sports.Methodist Debakey Cardiovasc J. 2016; 12: 93-97Crossref PubMed Scopus (7) Google Scholar The incidence of SIPE varies widely in the published literature (0.01%-26.7%), based on different criteria for SIPE diagnosis, study design, swimming conditions, and differences between study populations.5Spencer S. Dickinson J. Forbes L. Occurrence, risk factors, prognosis and prevention of swimming-induced pulmonary oedema: a systematic review.Sports Med Open. 2018; 4: 43Crossref PubMed Scopus (15) Google Scholar, 6Braman Eriksson A. Annsberg M. Hårdstedt M. [Swimming-induced pulmonary edema in Swedish conditions has been insufficiently studied] [article in Swedish].Lakartidningen. 2017; 114ELXDGoogle Scholar, 7Adir Y. Shupak A. Gil A. et al.Swimming-induced pulmonary edema: clinical presentation and serial lung function.Chest. 2004; 126: 394-399Abstract Full Text Full Text PDF PubMed Scopus (109) Google Scholar, 8Shupak A. Weiler-Ravell D. Adir Y. Daskalovic Y.I. Ramon Y. Kerem D. Pulmonary oedema induced by strenuous swimming: a field study.Respir Physiol. 2000; 121: 25-31Crossref PubMed Scopus (67) Google Scholar, 9Weiler-Ravell D. Shupak A. Goldenberg I. et al.Pulmonary oedema and haemoptysis induced by strenuous swimming.BMJ. 1995; 311: 361-362Crossref PubMed Scopus (104) Google Scholar, 10Smith R. Ormerod J.O.M. Sabharwal N. Kipps C. Swimming-induced pulmonary edema: current perspectives.Open Access J Sports Med. 2018; 9: 131-137Crossref PubMed Google Scholar In the largest cohort study conducted so far, we reported an incidence of 0.44% in a heterogeneous population participating in the Vansbrosimningen open water swimming event in Sweden.11Hårdstedt M. Kristiansson L. Seiler C. Braman Eriksson A. Sundh J. Incidence of swimming-induced pulmonary edema: a cohort study based on 47,600 open-water swimming distances.Chest. 2021; 160: 1789-1798Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar SIPE is a condition that may be life-threatening, primarily because of the danger of drowning. Among divers experiencing a similar condition usually referred to as immersion pulmonary edema, occasional deaths have occurred.12Cochard G. Arvieux J. Lacour J.M. Madouas G. Mongredien H. Arvieux C.C. Pulmonary edema in scuba divers: recurrence and fatal outcome.Undersea Hyperb Med. 2005; 32: 39-44PubMed Google Scholar However, with timely interruption of swimming and exit from the water, SIPE has been reported to spontaneously subside within 24 to 48 h.13Grunig H. Nikolaidis P.T. B. of swimming induced pulmonary edema: a Physiol. 2017; PubMed Scopus Google Scholar The risk of SIPE recurrence varies in the literature on SIPE is SIPE incidence is and of follow-up Y. Shupak A. Gil A. et al.Swimming-induced pulmonary edema: clinical presentation and serial lung function.Chest. 2004; 126: 394-399Abstract Full Text Full Text PDF PubMed Scopus (109) Google Scholar, 8Shupak A. Weiler-Ravell D. Adir Y. Daskalovic Y.I. Ramon Y. Kerem D. Pulmonary oedema induced by strenuous swimming: a field study.Respir Physiol. 2000; 121: 25-31Crossref PubMed Scopus (67) Google Scholar, 9Weiler-Ravell D. Shupak A. Goldenberg I. et al.Pulmonary oedema and haemoptysis induced by strenuous swimming.BMJ. 1995; 311: 361-362Crossref PubMed Scopus (104) Google Scholar, 10Smith R. Ormerod J.O.M. Sabharwal N. Kipps C. Swimming-induced pulmonary edema: current perspectives.Open Access J Sports Med. 2018; 9: 131-137Crossref PubMed Google H. Nikolaidis P.T. B. of swimming induced pulmonary edema: a Physiol. 2017; PubMed Scopus Google C. J. G. et and of swimming-induced pulmonary edema on 2021; Full Text Full Text PDF PubMed Scopus Google Scholar The risk factors, and long-term effects of SIPE are and comprehensive follow-up studies are during open water swimming and to be to provide swimmers with evidence-based a understanding of the course and long-term effects of SIPE is The of study was to explore symptom duration, recurrence, need for medical evaluation, and long-term effects after experiencing study was based on follow-up from a large heterogeneous cohort of patients with SIPE during Sweden’s largest open water swimming event. Vansbrosimningen is the largest open water swimming event in with people participating The event during a in and of swimming of and in open water health care during the event of a first the and a medical the At the swimmers in need of medical care are swimmers participating in the medical for cough dyspnea, with during or after the were for the M. Kristiansson L. Seiler C. Braman Eriksson A. Sundh J. Incidence of swimming-induced pulmonary edema: a cohort study based on 47,600 open-water swimming distances.Chest. 2021; 160: 1789-1798Abstract Full Text Full Text PDF PubMed Scopus (7) Google M. Seiler C. Kristiansson L. D. C. Braman Eriksson A. Swimming-induced pulmonary edema: criteria by lung Full Text Full Text PDF PubMed Scopus Google Scholar In the present patients with SIPE were to follow-up interviews after 10 days and 30 months. was from the in was from criteria for SIPE at Vansbrosimningen have been and the of the the lung findings of and peripheral were for patients with respiratory In and lung was to pulmonary on were to to the of clinical findings to of pulmonary M. Seiler C. Kristiansson L. D. C. Braman Eriksson A. Swimming-induced pulmonary edema: criteria by lung Full Text Full Text PDF PubMed Scopus Google Scholar SIPE at the in and was based on findings of during lung a peripheral In we to findings for Data from and were to a for SIPE M. Seiler C. Kristiansson L. D. C. Braman Eriksson A. Swimming-induced pulmonary edema: criteria by lung Full Text Full Text PDF PubMed Scopus Google Scholar In the of SIPE on the of a combination of during lung peripheral In the present a 10-day follow-up was conducted on the of SIPE at the the follow-up, we SIPE for patients to SIPE was based on findings of pulmonary edema, in the of the clinical was SIPE the of were patients from but with peripheral = for SIPE at SIPE based on lung and = criteria for SIPE at the in and on lung and peripheral = and > = and = and = and = lung and = = by Hårdstedt et based on lung and = criteria for SIPE at the in and on lung and peripheral = and > = and = and = and = lung and = edema on = = by Hårdstedt et edema on = based on lung and = were edema on = = by Hårdstedt et = lung = medical SIPE = swimming-induced pulmonary criteria for SIPE at the in and on lung and peripheral = and > = and = and = and = lung and = by Hårdstedt et were missing. in a = lung = medical SIPE = swimming-induced pulmonary Data on patient characteristics, clinical findings, and symptoms were collected at the M. Kristiansson L. Seiler C. Braman Eriksson A. Sundh J. Incidence of swimming-induced pulmonary edema: a cohort study based on 47,600 open-water swimming distances.Chest. 2021; 160: 1789-1798Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar on swimming in open water the as the swimming race and of dyspnea cough while swimming in open water was medical the or during follow-up were to provide their medical were and interviews were conducted at 10 days and 30 months by of the C. D. and M. not by after the by of The during the interviews were for by our Most of the were as A of swimmers had previously SIPE and the for and on general health and physical activity level were and from the and a for M. J. The Swedish of from Full Text Full Text PDF PubMed Scopus Google J. C. A. and in a Med. Scopus Google Scholar At both the on symptoms, symptom duration, of respiratory symptoms while swimming in open water after SIPE, need for medical after SIPE, and of physical and swimming the months. duration in the was as < to 2 to and days at the 10-day and of to 10 > 10 days to > to < months, and months at the and a was at 10 days the of swimming the the In the follow-up medical after the experiencing SIPE had affected their general health and physical activity level. general health and physical activity level were on a and on a The to are in characteristics, are as with or as with and are as with The of patients with SIPE symptoms during open water swimming was as was the of patients with SIPE symptoms at open water swimming or after the and multivariable logistic were conducted for the of symptom duration > 2 days and recurrence of The and conditions in of and asthma at as The was to for of physical activity and the the swimming race with the the for and were for and A P < was In total, 26,125 people in Vansbrosimningen in 2017-2019. participants were at the for respiratory symptoms and of 165 a of The 10-day follow-up was conducted for 132 SIPE cases and the follow-up for 152 cases of the patients a of SIPE in different years. of patients was at 10 days in both the patient in patients were at 30 months. 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Shupak A. Gil A. et al.Swimming-induced pulmonary edema: clinical presentation and serial lung function.Chest. 2004; 126: 394-399Abstract Full Text Full Text PDF PubMed Scopus (109) Google H. Nikolaidis P.T. B. of swimming induced pulmonary edema: a Physiol. 2017; PubMed Scopus Google C. J. G. et and of swimming-induced pulmonary edema on 2021; Full Text Full Text PDF PubMed Scopus Google Swimming-induced pulmonary in Med PubMed Scopus Google Scholar, S. Swimming-induced pulmonary Med. Full Text Full Text PDF PubMed Scopus Google Scholar, H. A of in a Med J. Scopus Google Scholar, D. R. in with swimming induced pulmonary edema Med. 9: PubMed Google Scholar, H. J. M. pulmonary edema in a Med. Scopus Google Scholar, J. M. M. J. L. J. swimming-induced pulmonary edema: a from the Scopus Google Scholar, H. D. Swimming-induced pulmonary oedema in a Med. PubMed Scopus Google Scholar, C. Swimming-induced pulmonary edema in an Med. Scopus Google Scholar, J. H. B. S. Swimming-induced pulmonary Med Google Scholar, M. Swimming-induced pulmonary edema in a a Hyperb Med. 2017; Google Scholar, R. Pulmonary oedema by water J Sports Med. 2004; Google Scholar has been to SIPE and has been as a H. Nikolaidis P.T. B. of swimming induced pulmonary edema: a Physiol. 2017; PubMed Scopus Google C. J. G. et and of swimming-induced pulmonary edema on 2021; Full Text Full Text PDF PubMed Scopus Google D. R. in with swimming induced pulmonary edema Med. 9: PubMed Google J. H. B. S. Swimming-induced pulmonary Med Google after from swimming-induced pulmonary J Med. PubMed Scopus Google Scholar However, have symptoms to for 48 h, up to 10 S. Swimming-induced pulmonary Med. Full Text Full Text PDF PubMed Scopus Google H. J. M. pulmonary edema in a Med. Scopus Google R. S. H. pulmonary J Med. Full Text Full Text PDF PubMed Scopus Google Scholar, M. R. Swimming-induced pulmonary oedema an condition with J Med. 2017; 35: Full Text Full Text PDF Scopus Google Scholar, G. A. S. et al.Swimming-induced immersion pulmonary edema while can be Hyperb Med. Google Scholar, pulmonary Med PubMed Scopus Google Scholar of to can for of the reported in to to is sometimes based on symptom duration, the to of pulmonary edema, the to from or the to physical Y. Shupak A. Gil A. et al.Swimming-induced pulmonary edema: clinical presentation and serial lung function.Chest. 2004; 126: 394-399Abstract Full Text Full Text PDF PubMed Scopus (109) Google H. Nikolaidis P.T. B. of swimming induced pulmonary edema: a Physiol. 2017; PubMed Scopus Google C. J. G. et and of swimming-induced pulmonary edema on 2021; Full Text Full Text PDF PubMed Scopus Google Scholar after an of SIPE has lung with in and up to h, with the in up to after Y. Shupak A. Gil A. et al.Swimming-induced pulmonary edema: clinical presentation and serial lung function.Chest. 2004; 126: 394-399Abstract Full Text Full Text PDF PubMed Scopus (109) Google Scholar These findings SIPE, be with our of symptoms 2 In the present patients with symptoms or need for medical within 10 days that symptoms of SIPE can after of pulmonary edema on The large of patients in study had symptoms for 2 days that the to for SIPE to be 30 months, 28% of patients with SIPE reported of respiratory symptoms while swimming in open These most of patients reported that had swum in open water after experiencing SIPE, the risk of was by the that of participants reported respiratory symptoms while open water the race in of from most study of our recurrence is within the of Y. Shupak A. Gil A. et al.Swimming-induced pulmonary edema: clinical presentation and serial lung function.Chest. 2004; 126: 394-399Abstract Full Text Full Text PDF PubMed Scopus (109) Google Scholar, 8Shupak A. Weiler-Ravell D. Adir Y. Daskalovic Y.I. Ramon Y. Kerem D. Pulmonary oedema induced by strenuous swimming: a field study.Respir Physiol. 2000; 121: 25-31Crossref PubMed Scopus (67) Google Scholar, 9Weiler-Ravell D. Shupak A. Goldenberg I. et al.Pulmonary oedema and haemoptysis induced by strenuous swimming.BMJ. 1995; 311: 361-362Crossref PubMed Scopus (104) Google Scholar, 10Smith R. Ormerod J.O.M. Sabharwal N. Kipps C. Swimming-induced pulmonary edema: current perspectives.Open Access J Sports Med. 2018; 9: 131-137Crossref PubMed Google C. J. G. et and of swimming-induced pulmonary edema on 2021; Full Text Full Text PDF PubMed Scopus Google Scholar The recurrence of SIPE reported in the literature is between and and varies on the of study the and of the of the study and SIPE Y. Shupak A. Gil A. et al.Swimming-induced pulmonary edema: clinical presentation and serial lung function.Chest. 2004; 126: 394-399Abstract Full Text Full Text PDF PubMed Scopus (109) Google Scholar, 8Shupak A. Weiler-Ravell D. Adir Y. Daskalovic Y.I. Ramon Y. Kerem D. Pulmonary oedema induced by strenuous swimming: a field study.Respir Physiol. 2000; 121: 25-31Crossref PubMed Scopus (67) Google Scholar, 9Weiler-Ravell D. Shupak A. Goldenberg I. et al.Pulmonary oedema and haemoptysis induced by strenuous swimming.BMJ. 1995; 311: 361-362Crossref PubMed Scopus (104) Google Scholar, 10Smith R. Ormerod J.O.M. Sabharwal N. Kipps C. Swimming-induced pulmonary edema: current perspectives.Open Access J Sports Med. 2018; 9: 131-137Crossref PubMed Google H. Nikolaidis P.T. B. of swimming induced pulmonary edema: a Physiol. 2017; PubMed Scopus Google C. J. G. et and of swimming-induced pulmonary edema on 2021; Full Text Full Text PDF PubMed Scopus Google Scholar The of SIPE during open water that a water is associated with induced pulmonary oedema in a systematic and Sports Med 2018; PubMed Scopus Google Scholar However, in with a study of respiratory symptoms were reported swimming in a swimming in our C.C. Swimming-induced pulmonary edema in J Med. Full Text Full Text PDF PubMed Scopus Google Scholar the risk of recurrence of SIPE an to have been as risk for immersion pulmonary edema in C.E. pulmonary edema and and Sports PubMed Scopus Google C. J. A. pulmonary edema: an of cases from Hyperb Med. PubMed Google Scholar In deaths during was in immersion pulmonary oedema as a Med. 2016; PubMed Scopus Google Scholar In our of patients with SIPE, of women, a of was with the Swedish population G. G. A. et Swedish and Med. PubMed Scopus Google Scholar In we a of asthma with has been reported for the Swedish population H. L. A. B. in respiratory symptoms and asthma in to studies in J. Full Text Full Text PDF PubMed Scopus Google J. L. et the in PubMed Scopus Google Scholar asthma was independently associated with both symptom duration > 2 days and SIPE symptoms after that SIPE and asthma may in a of symptoms and a of symptom a of SIPE may an asthma in patients with is of a between asthma or and the development of most patients with SIPE had previously a of swimmers SIPE, the of asthma as a risk for SIPE not be in the present but for Most patients with SIPE care had for pulmonary edema to water patients a of to the have been the or a of However, patients had is of a of patients reported the swimming race not the follow-up of 30 months, and of the patients reported a of or has been reported as a condition both in SIPE and immersion pulmonary edema C.C. Swimming-induced pulmonary edema in J Med. Full Text Full Text PDF PubMed Scopus Google A. G. et for immersion pulmonary edema in scuba divers: a Hyperb Med. PubMed Google Scholar and an incidence of has been reported in P.T. Nuri M. Crowther A. Webb-Peploe M.M. Cold-induced pulmonary oedema in scuba divers and swimmers and subsequent development of hypertension.Lancet. 1989; 1: 62-65Abstract PubMed Scopus (154) Google Scholar of the cases of during the follow-up have been to or at the of the swimming of the of a in the present we not the of and pulmonary risk and long-term of SIPE not self-assessed general health and physical activity level up to 30 months for a of for a of swimming are as to swimming was at follow-up with the the swimming race in In our swimmers usually swimming the Vansbrosimningen but not on a swimming in were in because of the to swimming was for the and of the SIPE have been a general of swimming in not of swimming in open A of study is the large cohort of Vansbrosimningen swimmers of both and with swimming the of the M. Kristiansson L. Seiler C. Braman Eriksson A. Sundh J. Incidence of swimming-induced pulmonary edema: a cohort study based on 47,600 open-water swimming distances.Chest. 2021; 160: 1789-1798Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar The present are because of the large of SIPE cases monitored a are the of participants to follow-up and the that the were as with the to and However, with a large of SIPE cases with literature on were and the of multivariable be as was the in criteria the study However, with at the of the we that the of findings of pulmonary edema on or the was the of criteria of respiratory symptoms while swimming were not by clinical or that symptoms were caused by SIPE, as the patients their symptoms to a SIPE In follow-up and be we to symptoms and with the The of a of the can present of the study we a The present large cohort study challenges the established hallmark of SIPE duration of < 48 h, whereas the recurrence of SIPE was within the previously reported range. to the follow-up after SIPE, self-assessed general health and physical activity level were not affected by experiencing These provide information on and long-term for event and health care professionals. was by the for and and the for

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