Jun 252014
 

9-7-12. Updated in 2013 and 2014 (see updates at the end of this post)

Every heard of it? Swimming Induced Pulmonary Edema – SIPE. I had not. But after reading an article written by a triathlete in this year’s NY City Ironman Triathlon (link below), I was sufficiently alarmed. This is something every open water swimmer and triathlete should learn about. This condition can affect even healthy, well-conditioned and highly trained athletes.

SIPE is a form of pulmonary edema first discovered in the mid 1990s. Athletes most affected are divers, swimmers, and triathletes. From Wikipedia:

SIPE occurs when fluids from the blood leak abnormally from the small vessels of the lung (pulmonary capillaries) into the airspaces (alveoli)…

As with other forms of pulmonary edema, the hallmark of SIPE is cough productive of pink, frothy or blood-tinged sputum. Symptoms include (from Wikipedia):

Shortness of breath out of proportion to effort being expended.
Crackles, rattling or ‘junky’ feelings deep in the chest associated with breathing effort – usually progressively worsening with increasing shortness of breath.
Cough, usually distressing and productive of copious pink, frothy or blood-tinged sputum

Contributing factors to SIPE are the temperature of the water, constriction from wetsuits, and even pre-race adrenaline. Other factors may include: direct injury to the lungs; heart problems, infection, hypertension and even fish oils.

Here are some articles I reviewed to learn more about SIPE:

  1. This is the article that initially caught my eye: Why I Also Almost Died During the 2012 New York City Ironman Triathlon
  2. Here is an article from an Endurance Triathlete website: http://www.endurancetriathletes.com/sipe.html
  3. This article is written by a triathlete who also happens to be a heart surgeon: http://athletesheart.blogspot.com/2012/04/swimming-induced-pulmonary-edema-sipe.html
  4. In this American Journal of Emergency Medicine article, the authors note potential contributing factors of hypertension and fish oils in athletes who have experienced SIPE. http://www.journals.elsevierhealth.com/periodicals/yajem/article/PIIS0735675709004021/abstract

As the first article indicates, an athlete must find that balance between pushing hard and wanting to finish a race with understanding and recognizing signs of what could be a serious problem. The triathlete in the NY marathon did not want to stop, but he did know that something wasn’t quite right. He may be alive today because he stopped. No race or event is worth dying for. There will always be another opportunity to compete. Listen to your body, and when it gives you warning signs, heed them.

_________________

Update 9-7-12. In an email today from usopenwaterswimming.org, they had a great section on S.I.P.E. I’ve copied and pasted their posting (not yet showing on their website). 

Swimming Induced Pulmonary Edema (SIPE)

This month we are going to partially reprint an article which appeared 4 years ago in our newsletter. This reprint is prompted by a recent post titled “Why I almost Died During the New York City Ironman Triathlon” at http://ht.ly/djjoE. It is written by a triathlete about her experience with SIPE.

Swimming Induced Pulmonary Edema or SIPE is a rare condition which occurs sometimes in open water swimming. The following is an e-mail interview conducted with Dr. Jolie Bookspan who has studied condition.

1. What is pulmonary edema and why should swimmers know or be concerned about it?

Edema means too much fluid accumulation. Fluid suddenly fills the lungs. The left side of the heart is not pumping properly. It can cause athletes to have to stop a race. Sometimes it can cause serious illness and death.

2. Is it more likely to occur in cold water?

It seems to be more likely in cold water. It has occurred in surface swimmers and scuba divers in both cold and warm water. Cold is only one of the several proposed causes.

Causes or contributors seem to be things that increase cardiac preload and afterload, including immersion in water, cold water, heavy exercise, negative pressure breathing (like breathing with a snorkel, and swimming with the chest below the surface and even the slight elevation of the head to breathe in), and drinking too much water or other fluids before swimming. Don’t drink lots of water before swimming.

3. What are the signs and symptoms?

Unusually shortness of breath (not just fatigue) and coughing bloody froth. No chest pain. With a stethoscope you can hear rales, an abnormal rattling breathing sound. Chest x-rays show the classic pattern of pulmonary edema. When blood oxygen in the arteries is checked, arterial O2 may be lowered.

4. Do wet suits provide any measure of protection against PE?

Difficult to say since it has occurred in people with and without wet suits. I haven’t seen charts where the numbers of each predisposing possibility, like protective garments and temperature, were compared.

5. Can medical personnel easily detect PE?

Pulmonary edema is not subtle. The person is usually gasping and spitting pink froth, and asking for help with a worried look. A swimmer who develops shortness of breath and cough in a race may have something else like exercise induced asthma.

6. What is the first aid if PE is suspected?

Get them out of the water. Sit them up to elevate the head, if conscious. Give them 100% oxygen by mask, and get them to the emergency facility.

6. If PE is untreated and the athlete continues to the race/swim, what could happen?

Depends how serious. Symptoms can resolve on their own, or they can get worse. There have been deaths. We wonder how many people who suddenly went under were not drowning but developed pulmonary edema? There is no way yet to tell. Drowning also produces pulmonary edema (after the fact). Repeat cases of pulmonary edema can occur in the same person.

Interestingly, the frothing pulmonary edema occurs in racehorses after hard races. They are blowing bloody nose froth all over, but veterinarians have reassured me that the horses are fine. If it is a person who is frothing, get help.

Although SIPE seems to be a rare condition, open water swimmers and race organizers should be aware of its existence and plan accordingly. A doctor on site will be able to hear the “rales” condition by listening to lungs/breathing with a stethoscope. Also, it is recommended to have oxygen available to administer for anyone suspected of SIPE.

The following excerpt is written by Regan Scheiber and her personal experience with the SIPE after the 40K Memphremagog Marathon swim in Canada.

“It was the summer of 2000 that I experienced my first and only episode of pulmonary edema. I don’t know exactly what combinations of events caused the edema, but I do know this: A week prior to the Magog race, I swam the Atlantic City marathon. It was a close, intense, eight hour race that tested my will to win. I was very dehydrated at the end of the race, but that was normal. That night I started to develop what I thought was a cold or allergic reaction to the water. I had a stuffy nose and felt very rundown. The next day, I drove to Maine to do some lake training in preparation for the Magog race, now less than a week away. I could not shake the sinus cold and would feel the need to cough every time I was horizontal and swimming. A little something would come up, but I thought nothing of it, and just hoped I would be 100% for the race.

I arrived in Magog, Quebec, three to four days before race day. The day before the marathon, all the swimmers participate in a short competition swim for the public, I was definitely not 100%, but my upper respiratory irritation seemed to have calmed down. On race day, the water was a cold 64-65 degrees; it was cloudy, and windy. Not good for someone like me, who was relatively thin, and, as I was about to find out, did not do well in long term cold water conditions. After the first two hours of the race, I started to feel noticeably uncomfortable. I was drinking warm feeds, but it wasn’t enough. My hip flexors cramped up and I had to drag my legs for the remainder of the race. My stroke count went from 84-86 to 76-80 and maintained that pace. I remained fully lucid. Other than a slower stroke rate, I did not show any other alarming signs of hypothermia. (I think at least 4-5 swimmers were pulled from the race that day for hypothermia.)

The last kilometer, I slipped into third place, with nothing left to give. I wasn’t in any respiratory distress, just weak. When I finished the 10 hour swim (one hour longer than the previous year), I stood up in the shallow water and felt fine, just tired. Since my hip flexors were so cramped, I had to pull myself up onto the dock. I landed on my belly. Instantly, I started coughing up fluid that came from my lungs. Within a minute I was shivering so severely, I was put on a stretcher and later sent to the hospital. It took an hour of warm I.V. fluids and a warm blanket to raise my body temperature from 88 degrees to 98 degrees. All the while, I was having trouble catching my breath and was periodically coughing to clear my lungs. Once I was comfortable, I told the doctor about my lungs and he did a chest x-ray. It showed fluid in the lungs, also known as pulmonary edema. My body had started to clear the fluid on its own, but it needed the help of Lasex, a diuretic, to speed the process along. A few hours later, I signed myself out; my only ongoing injury was now the hip flexors.

I took two weeks off to heal and do some light training. I then swam Long Island Sound, winning the women’s race in record breaking time. A year later, I swam the elusive English Channel. The water temperature was 64-66 degrees, and again, my hip flexors cramped up. I dragged my legs, shivered and swam with a slower stroke rate, all the way to France. I did not have pulmonary edema. I was fine, and so was Jane, my daughter, with whom I was three months pregnant.

Did the sinus cold and upper respiratory problem I got after Atlantic City compromise my immune system and make me more susceptible to pulmonary edema, given the right conditions? I don’t know the answer.”

Regan was swimming a very long 9 hour race, but the condition has occurred in swimmers with only 15 – 30 minutes of immersion.

The following article appeared in the American Family Physician, March 1, 2004 issue. It details an incident of SIPE and discusses proper treatment for the condition.

“A healthy 20-year-old United States Navy search and rescue swimmer trainee, who was equipped with only a mask and fins, developed hemoptysis, sharp substernal chest pain, and shortness of breath after performing a dive to a depth of 12 feet. He immediately surfaced and began to cough up pink, frothy sputum and have persistent shortness of breath. His initial oxygen saturation was 70 percent on room air and improved to 86 percent on three liters of oxygen via nasal cannula during ambulance transfer. On arrival at the emergency department, the patient had an oxygen saturation of 100 percent on three liters of oxygen with improved shortness of breath and resolved hemoptysis.

Auscultation of the lungs revealed bilateral rhonchi. The remainder of the physical examination was unremarkable with all vital signs being normal. Electrocardiogram, complete blood count, electrolytes, creatine kinase, troponin, and coagulation studies were all within normal limits. A chest radiograph showed fluffy perihilar infiltrates bilaterally. A chest radiograph taken several hours later showed resolving infiltrates. The patient was diagnosed with swimming-induced pulmonary edema (SIPE) and discharged.

While the exact pathophysiology of SIPE remains uncertain, it is believed to be related to exertion, immersion in cold water, and overhydration. The body’s normal response to exercise is to increase cardiac output to meet the increased oxygen demand. Although an increased cardiac output is known to cause pulmonary edema in racehorses, this increase is rarely enough to produce such an effect in humans.

(1) Cold-water immersion is instrumental in this process because the peripheral vasculature constricts to divert blood away from the extremities in an effort to maintain the core body temperature. This results in a central pooling of blood, leading to an increased preload, increased pulmonary artery pressure, and an increased cardiac output. The vasoconstriction also causes an increase in afterload, which leads to an increase in pulmonary vasculature resistance. The increased cardiac output from exertional activities coupled with an increased preload and afterload from immersion appear to be sufficient to rupture the pulmonary capillary membranes, thus resulting in pulmonary edema. In several documented cases of SIPE, it has been noted that the patients consumed anywhere from two to four liters of water in the hours leading up to their swim in an effort to remain well hydrated.

(2) It is believed that this degree of hydration led to a fluid overload that contributed to the onset of pulmonary edema by increasing the pulmonary capillary pressure.

(3) Patients may present with symptoms, such as cough, dyspnea, hemoptysis, tachypnea, and confusion with hypoxia, after exertional cold water activity such as swimming and scuba diving.

(4) Treatment for patients with SIPE consists primarily of supportive measures such as removing the patient from the wet and/or cold environment and providing supplemental oxygen. Although useful in treating pulmonary edema in racehorses, diuretics are typically not necessary because patients tend to show relief of symptoms soon after being placed on supplemental oxygen.

(5) Full resolution of radiographic findings typically occurs within 24 to 48 hours.”

JASON A. YODER, MS3, ENS, MC, USNR

Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd.Bethesda, MD 20814 ANTHONY J. VIERA, LCDR, MC, USNR. Naval Hospital Jacksonville. 2080 Child St. Jacksonville, FL 32214

REFERENCES

(1.) Hopkins SR, Schoene RB, Henderson WR, Spragg RG, Martin TR, West JB. Intense exercise impairs the integrity of the pulmonary blood-gas barrier in elite athletes. Am J Respir Crit Care Med 1997; 155:1090-4.

(2.) Weiler-Ravell D, Shupak A, Goldenberg I, Halpern P, Shoshani O, Hirschhorn G, et al. Pulmonary oedema and haemoptysis induced by strenuous swimming. BMJ 1995;311:361-2.

(3.) Pons M, Blickenstorfer D, Oechslin E, Hold G, Greminger P, Franzeck UK, et al. Pulmonary oedema in healthy persons during scuba-diving and swimming. Eur Respir J 1995;8:762-7.

(4.) Lund KL, Mahon RT, Tanen DA, Bakhda S. Swimming-induced pulmonary edema. Ann Emerg Med 2003; 41:251-6.

Update 6-25-14. So many have written in about seeing this blog post and sharing their own incredibly scary S.I.P.E. experiences. I received an email from Elaine Howley, Asst. Editor of the U.S. Masters Swimming publication SWIMMER Magazine this month. She wrote an article on S.I.P.E. in the March/April 2013 publication of SWIMMER.  We’ve corresponded on the topic, and she shared with me a Duke study that you might be interested in. 

Elaine spoke with Dr. Moon from Duke last spring. They had been exploring the use of Viagra as a treatment in Immersion Pulmonary Edema (also known as S.I.P.E). When Elaine spoke with Dr. Moon, they were in the study phase, so results should be out or forthcoming. According to the study’s site, however, it looks like it’s still ongoing: http://dukedivemedicine.org/?p=724.   

If you have had Immersion Pulmonary Edema and would like more information about it, or if you would like to participate in the project (Duke pays travel expenses and gives a participation stipend), please contact Dr Moon or Dr. Freiberger at 919-684-6726 or email tonya.manning@duke.edu

 

  27 Responses to “Swimming Induced Pulmonary Edema”

  1. I have very intimate / personal experience with SIPE. In my first Tri, I did not know I was suffering from anything, until I was laying on the bottom of the ocean, no oxygen left in my system. One of the watchers saw me go down, pulled me from the bottom, and I spent the next 90 minutes in an ambulance, then 24 hours in the hospital before a heart surgeon put a probe up my femoral artery, and found no blockages in my heart. My heart specialist told me to try another Tri, I did, and went down again 100 yards into the race.

    I am an avid runner (doing over 50 miles/week), an avid biker (I do the Deathride every year), and an avid swimmer. I am also the father of 4 children….

    While I see the feedback from others about why it happens, I do not believe it has anything to do with cold water, or wetsuits. It does have everything to do with a person’s physiology.

    Steve
    650-218-0408

    • Wow, Steve, you absolutely have an experience that I doubt has been shared by any other. I am so glad or you, and your family that you are here to talk about it. Thank you very much for sharing your perspective. I’d like to give you a call and talk to you more about this.

  2. Just had a 42yo male patient report episode of what clinically appears to be SIPE. The closest I have heard of this before is “Dry Drowning” episode in an 8-10 year old male who apperantly swallowed large amout of swimming pool water went home and died several hours later after being taken to ER by family -DX: dry drowning. My patient called me while I was out to dinner about 1700 hs with complaint of hemoptysis after and during swimming workout. He swims intensively 2-3 times per week plus aerobic exercise 4-5times per week. Medications include over the counter asprin, fish oil 4000mg -6000mg daily, Metropolol, 5mg Methadone/daily 60mg oxycodone tid prn. His diagnosis include Hypertension controlled by the fish oil and beta blocker. The shoulder and knee chronic pain are addressed with aerobic + swimming and pain meds. I referred him to ER where work up (12-lead EKG, CBC,Elyte panal, pulse ox and chest X-Ray were all reported out as “normal”). At this point 6hours later, my patient c/o chest soreness minimal cough no more hemoptysis. My daughter saw your article on SIPE. I think this very well may be my patient’s diagnosis. Thanks, Dr. Gregory

  3. I had an experience 3 days ago. Training for a half ironman, we prepared to do some open water swimming with a wetsuit. The water was 70 degrees. I jumped in the river and immediately noticed something wasn’t right.. I floated for a few minutes.. let water into my wetsuit thinking I just needed to adjust to the wetsuit. I attempted to start swimming and could not get enough air. I reverted to breast stroke, back stroke, never being able to catch my breath. After 20 minutes as I was on my back I could hear my lungs crackling. I went back to the dock, and started coughing up bloody sputum. Lungs revealed , crackles in the bases and expiratory wheezing. I have no medical history except for resolved Graves Disease. I was taken to the ER and continued coughing for 3 more hours. They treated me with O2, neb treatments, racemic epi, solu-medrol, magnesium sulfate. Labs were normal except for an elevated BUN, clear chest x-ray. I was discharged approximately 5 hours after onset. Although my x-ray was negative it is believed i suffered with SIPE.

    • Wow, what an awful experience Susan. I do hope you are on the road to recovery and able to return to the open water. U.S. Masters Swimming has done some write ups recently in their SWIMMER Magazine. Definitely worth reading. Specifically, the March-April 2013 issue had an article on SIPE titled “The Big Squeeze” written by Elaine K. Howley. You can see a blip of the article here: http://www.usmsswimmer.com/issue.php?i=50. If you are a member of U.S. Masters Swimming, you can get your hands on that magazine. Hope that helps and sure hope you can return to swimming.

  4. Folsom, CA (June 8, 2014)
    Yesterday, I had a near death experience.
    My first Triathlon & I am physically in the best shape of my life. I had done the work to be able to cover the 1/2 mile swim in a Sprint Triathlon. Though running is my strongest discipline. I’m 52 yrs, 6’0 tall & 185 lbs. athletic with no history of heart problems. I was confident in my training & knew I would do well.
    Things to consider: Water temperature about 65 degrees (swimmable without a wet suit); my first Triathlon; first time donning a wet suit; well hydrated the night before; drank a Monster Energy drink before my race; wearing the right size wet suit- (Orca-men’s large size 8). Felt a little tight in the chest area but figured that to be normal for a Tri wetsuit which is supposed to be like a second skin.
    What happened on this day: I drank a Monster Energy drink before my race which may or may not have been a contributing factor. I donned my wet suit but realized I forgot to do a warm up jog before putting it on. So I took a short jog with the wet suit on. It became abnormally hard to breath & I struggled to finish my warm up. Just figured it to be from the tightness of the wetsuit. Took a short swim in the lake before my race to get acclimated to the wet suit & water. My game plan was to stay to the right (the side I take my breaths on) staying away from the chaos in the middle, stay calm, go out easy & finish strong.
    The race started & about 25 yds into the swim I knew something was wrong!! I take a breath every 2 strokes & still could not get enough oxygen to my lungs. Felt like I was going to have a asthma attack or worse, a heart attack. At this point I wanted to take the wet suit off but was out in the lake & didn’t want to swim all the way back to shore to do this. I didn’t feel panicked cuz this is my first open water swim or by the chaos going on in front of me but was panicked because I could not breath & get enough oxygen in my lunges. Thought I was going to drown so I flipped to my back & kicked the majority of the way. Swallowed some water a few times. I felt like quitting but was determined to finish.
    I was able to take off my wet suit a little less than halfway thru the swim. Thanks to a lifeguard on a jet ski. A couple other swimmers, who I assume had the same issues breathing, had done the same. It helped but I was not the same. I still had to swim on my back & still was gasping for oxygen. I even started wheezing & spitting out froth from my lunges. 46 minutes in with a few rest stops along the way, I was able to complete the swim. The last one in!
    The bike ride was ok as I caught a few participants along the way but when it came to the run portion of the the race (mind you, my best discipline of the 3), I had to resort to walking part of the way (which I never do) because I could not get enough oxygen in my lungs. I also was coughing & spit out some red colored froth which scared me cuz I assumed it to be either blood or the GU pack I downed during the bike (although, I don’t know what color the GU was inside). So I assumed it was blood. Today, the day after, I still can’t take deep breaths & feel a wheezing in my chest. This has never happened to me & it scared me enough to find out if anyone else has experienced this. Thank goodness for the internet & forums like this. So glad to find this article as the symptoms were so right on. I originally read about “Exercise Induced Asthma” which I thought it was & could very well be too, but SIPE more defines my experience to the T.
    Thanks for sharing….I feel more informed about my near death experience!

    • Joe – I am absolutely stunned about your story and the other stories that swimmers are sharing here on this blog post. I just gave an open water clinic yesterday and talked about S.I.P.E. and the signs to look for. While I didn’t help you before the event, I’m really glad to know you stumbled on this. We need more information and coverage on this very dangerous condition. Meanwhile, I hope you are able to return to the water. Continue to seek out more information through U.S. Masters Swimming, USA Swimming, U.S.A.T. and other reputable sites.

  5. 21 June – Sprint Triathlon in Leutershausen, Germany 500m swim, 25K bike, 5K run

    I am a 52 year old female, in excellent shape – about 5’9″ , around 150lbs. I have never been in a triathlon before – this was a first time, bucket list kind of thing…

    I have been an avid runner my whole life competing in Cross Country, 5K and 10K – usually top 5 in my age category especially in the last 10 – 15 years. I have also been a very strong swimmer – and have an open water diving certification. Last EKG was normal. I trained for weeks for this event, biking, running and swimming the actual course completely with no issues. The water temperature on race day was 18.5 C (64F) – but I had already been swimming in these conditions. Yesterday, I had no wetsuit but I felt relaxed in the water as the race started. My first 100 meters was OK – I was kind of sporadic and just trying to hang in with the crowd. The second 100 meters was better, more relaxed and cadenced. At about the half way point, I started to feel a panicked sensation, and I could not control my breathing. By 400 meters, I was coughing and spitting up what I thought was river water ….and gasping for breath. I barely made it out of the water and coughed up pink foam for about 10 minutes – I knew this was serious, so I considered dropping out right then. I slowly got on the bike and after about 5 or 6 km I realized that I was in serious trouble. I turned back. After I got back to the race start area, I started to feel better…but very perplexed and worried about what happened. Very sad for not finishing this race – first time ever I quit. I attributed it to swallowing or inhaling river water during the first 100 meters of my swim. Some points –

    I did not over hydrate
    I had previous swims in the same river at the same temp with no issues
    No wetsuit
    Previous days dinner – 300 grams of fresh salmon filet (could that be enough fish oils to cause prob?)

    I will be flying back to the states next week for vacation – I intend to have a full work up then. Today I feel much better and thanks to your information, I believe I had a SIPE episode.

    Thank you so much for having this forum!
    Cathy

    • Cathy – Wow! Thank you for sharing your experience. If this can happen to you, it can happen to any athlete out there. I’ll post an update to the article with a study underway at Duke University. I think you’ll find it fascinating! Again, thank you for writing in!

  6. I was so happy to come across your discussion of SIPE. I’m a 60 year old female and I have been doing triathlons for 6 years. Prior to starting triathlons I was a runner and a cyclist but had never swam in my life, having a fear of being in water over my head. I determined to learn and have been taking swim lessons regularly. I have improved greatly. People and coaches who watch me swim are puzzled by why I still occasionally struggle so extremely in the swim portion of a race and everyone just assumes that it is all in my head and anxiety based. Although I know that I get anxious, I also know that there is something that happens to me physically. I had gone more than a year without incident and thought that I had it conquered but this year it has returned with increasing frequency. My most urgent incident occurred just this week. I had an unsuccessful swim in the Chicago World Triathlon Olympic distance. the water was sub 65 degrees, it was a jump-in start with less than 2 minutes to acclimate.Less than 400 meters in I knew I was in trouble (extreme shortness of breath and a crackling sound coming from my lungs). I tried to calm myself down but by 780 meters I required assistance. Upon returning home I was so disappointed that I was determined to get right back in the water and continue training. 2 days later a friend and I went out to the lake where no one was in the water but the two of us. We started out together to do a circle of the lake. I was wearing a wetsuit and I had the orange flotation device I had purchased recently. I’m a slow swimmer but my friend checked on me periodically. She reached the end and made the turn. I reached the end and made the turn. A couple minutes later, I saw her turn to check on me. I waved and she went on. Immediately I felt a sense of overwhelming fatigue. I stopped to rest and it became hard for me to catch a full breath. I decided to swim to shore but I couldn’t. I thought “well at least I have the flotation device, I’ll just lay on it and kick toward shore.” I pulled it forward but my legs would not work. My breath became more and more labored. I was actually gasping to get air. I tried to call my friend but she couldn’t hear me. I was probably no more than 30 yards from shore but I couldn’t get there. I saw a little girl on the beach almost 1/4mile away. I waved and yelled I need help but she didn’t do anything. I debated whether I should try to wave again because it took so much energy and I had very little left. I tried again but she just stood on the beach. I was now in full panic. I tried to loosen my wetsuit without luck so I did something very stupid. I undid the flotation device from my waist because it felt too tight. I tried one more time to call for help. I now was afraid that I would soon pass out. Just then a man called to me from the bushes along the shore. He dove in to try and help me but he was not a strong swimmer. Luckily he was able to grab the strap from my flotation device and tow me to shore. Someone called 911 and before long I was in in ambulance headed for the ER. I was there for two day worth of testing. They kept asking if I had been submerged -no. Had I passed out- no. Had I swallowed large amounts of water- possibly but I don’t remember swallowing any more than the usual small amounts from swimming. I had very low oxygen, a horrible rattling in my chest, completely pale. As much as I wished I could bring up what was in my lungs, I never did and never have had the “frothy sputum” that seems to be the hallmark of SIPE. I just had a cough, a rattling in my chest and a need to keep unsuccessfully trying to clear my throat. As with all the other stories, my tests were all normal; healthy heart (EKG, Echo,heart cath, CTPA) with the exception of a spike in my triponen level which caused them to put me on blood thinners until it returned to normal after 12 hours.

    I apologize for this long response. Although I am happy to know that there is a possible diagnosis, I don’t know where to go from here. I don’t want to give up a sport that I have come to love but I don’t know if I am in danger of becoming the next tragic triathlon story. I’m signed up for my 3rd 70.3 in September but I fear I may have to cancel.

    • Cindy – yowza! As you can see, you are not alone and others continue to reach out and share their stories. I encourage you to connect up with the folks at Duke University that I mention in the recent update. Definitely share this information with your doctor. And if they don’t know of SIPE, get to a pulmonologist.

  7. My story is not as scary or intense as the others, but I wonder if I might have had a mild form of SIPE two days ago during the Columbia Irongirl Sprint Triathlon. I have never heard of this condition until I searched the symptoms I had. I have done this race two years prior and never had an issue before. The difference at the start of the race was the water temperature was considerably cooler (wet suits were permitted) and we entered the water 2 people at a time. In the past, we entered the water with our entire age group all together and had a few minutes to get acclimated. As soon as I entered the water (I was not wearing a wet suit) and tried to start my stroke, I could not catch my breath. It happened almost immediately. I was not fatigued or panicked or nervous, but I could barely breath. That meant, I could not put my head in the water at all. I was basically barely moving and thinking I would keep going and get it together. I made it to the first kayak for support, thinking to myself that I would get acclimated and try again. I had no luck. Tried putting my head in the water to swim freestyle and again had no luck. Then the coughing started. I was worried that I might not make it to the next kayak. But somehow I managed. I hung on for awhile, then I gave it another shot. Made it to the next kayak, all the while not putting my head in the water (because breathing was so difficult). By this time I was more than 1/2 way through the short .62 mile distance. And I was getting tired because I was swimming so inefficiently. Then by some miracle, I was able to count my strokes. I would do 8 breast strokes and 5-6 freestyle strokes. When I was able to get my head in the water, I definitely heard some crackling but I just thought to myself that it was odd. So, I was able to make the distance, but I wonder if it was easier for me since it was such a short distance. I was able to finish the entire race. A day later, I have a severely sore throat leading into the chest a little, which has never happened before after a race. So, now I am terrified to swim in a race again. This was very scary, but again definitely not as serious as the other stories mentioned above..

    • Barb – thanks for writing in. That does sound scary and concerning. Please consider following up with your physician and go in with some information about SIPE. Being uncomfortable in the open water, no matter what the cause, definitely puts a damper on things. Hope you can continue training in a pool! Cokie

  8. I cannot believe I managed to finish the St Pölten half-Ironman today (in 6hrs vs my goal of sub-5…).

    I am 42 yo and train approximately 8hrs per week consistently. Pretty much every time I swim OW My body reacts the same way with all the typical SIPE symptoms.

    In previous triathlons and training sessions however, the symptoms have reversed pretty fast pnce I am out of the water. One minute I have to float on my back because it feels as if I am about to suffocate/drown and the next minute I am comfortably pushing 20mph on the bike!

    Today was something else though! I did free-stroke for 200 yards but the had to turn to breast-/back stroke for the remainder of the swim which took me 56 minutes (vs 38 in my most recent other half-Ironman race where I was at least able to switch back and forth between free stroke and breast stroke). The bike was ok, I did not push it as hard as I usually do since I had given up on my sub 5-hr finish due to the near death-experience in the swimming leg. Uphill I felt that my breathing was a bit restricted but not too bad.

    The RUN HOWEVER! Wow! I should be able to run a half-marathon comfortably in 90 minutes but today had to walk for a quarter of the running leg. I walked 200 yards every half-mile and finished the run in 1:48, constantly coughing up bloody foam and getting out of breath.

    I am now back in my hotel. It is 5 hours since I finished the race but am still coughing lots and am restricted in taking deep breaths. I did not seek any medical attention as I assumed it will get over by itself. Maybe an incorrect assumption, I don’t know yet.

    My biggest worry is that I have aigned up for a full Ironman distance race which is in 6 weeks time. It is the only one I intend to do before returning to my “running career”. How on earth am I going to finish the swimming leg of the race?!

    I am desperate for advice!

    • Theo – I believe it is imperative that you see a doctor for this, and one who understands what SIPE is. While you have been able to recover each time, it doesn’t sound normal to have this happen time and time again. You are putting yourself at risk. This is not something to mess with! Go seek help. Cokie

  9. This thread has been so enlightening. I’ve been doing triathlons for 11 years. I was a pretty strong runner going in to triathlon, and learned to swim later in life at the age of 28 in order to start doing triathlons. I just assumed I was having panic attacks in the water, because the first year I did triathlon I experienced extreme SOB, coughing, feeling like my chest was tight. When I’d get out the bike would be so much harder than it should have been given my level of training, and the run was a slow jog just to get through. Fast forward years, I thought it had gone away, and this past May I was in my first Olympic distance tri of the season, first OWS of the year. New wetsuit. I had done a warm up in the water in my wetsuit. Seemed fine. Water temp mid 60’s. Really didn’t feel that cold, and I’m very sensitive to cold temps. I blame my hypothyroid for that. (I’m in the process of getting that corrected, I hope). However 100y In here comes the SOB, the cough, the struggle. For the first time in 9 years I considered quitting. It was a two loop course and thought I might have to quit after one loop, or even just get pulled. Somehow I told myself to just slow down, one stroke at a time and keep going. I made it in, and finished the tri, with much slower times than training would have led me to anticipate. The worst was for a week my chest hurt so bad, taking a deep breath was so painful. I had a cough, but never saw pink tinged sputum. I do take fish oil, 1280mg omega-3 daily. I’m wondering if I shouldn’t. That wetsuit has not been reused, as it was tighter on my neck than my old one. I am a nurse in a rural area, we have no pulmonologists, closest would maybe be 2.5 hrs away. I have an internal med MD, but he is very much of a wait and see person, and not a sports minded MD. He’d just recommend to stop doing OWS’s. Tri career over. I really doubt any of the other local MD’s would be any better. It’s tough living rurally sometimes. I did a 70.3 in June, swam very slowly and did ok. My first 140.6 is in two weeks, and I’m concerned about the length of time of that swim. It will be my first OWS at that distance, and though I’ve gone that far in the pool, the pool has never caused the kind of problems I have with OWS. I will try not to over hydrate. I will wear my old wetsuit. I’m wondering about quitting the fish oils. I don’t quite understand the connection there. But, if it would reduce my chance of SWIP, then I’d ditch them, at least for awhile. Thoughts? Thanks so much.

    • Wow, another one! I think they still don’t know all the causes, but you’ve hit on several suspicions that many of the experts have been discussing: fish oil, cold water, wetsuits compressing the chest wall (and an adrenaline rush at the beginning of the event).

      If I were you I’d do whatever it took to connect up with a pulmonologist and one that has treated SIPE. That cough and then your chest hurting for a week is concerning. None of us wants to give up what we love! I’ve been pulled away from my swimming for weeks and months at a time (umpteen times!!) for various athletic-related surgeries. Its never fun and no other sport quite satisfies me.

      Both my parents died from different lung diseases. My Mom at 69 with emphysema (she had been a heavy smoker) and my Dad at 76 from Interstitial Lung Disease (god awful disease). I’m just really sensitive to anything dealing with the lungs and so grateful I’ve got healthy, powerful lungs. They are nothing to take for granted!

  10. I am so happy to have found this article. To be able to put a name to what has happened to me on a few occasions when open water swimming is such a relief. After running races for a number of years, I decided to learn to swim so that I could participate in Triathlons.

    After taking lessons in a pool for about a year, I felt like I was ready to take my new skills to the ocean. I purchased a wetsuit and off I went. It was a swim clinic to preview the course I would swim for my first Tri. The cold temp of the ocean water took my breath away and I was unable to put my face in the water. I decided to start swimming with my head up toward the first buoy. By the time I rounded the buoy my breathing was so labored I had to flip on my back. I struggled badly to finish the swim and by the time I made it back to shore I could barley catch my breath. I felt the rattling in my chest and then the coughing up of pink foam began. Dismayed, my husband took me straight to the emergency room. My oxygen levels were so low, that they took me in straight away and put me on a nebulizer. I was kept there until my oxygen levels were back to normal and I was sent home with antibiotics and steroids. There was no official diagnosis. It was just thought that I had swallowed too much water.

    Determined to complete the Tri, I went back out into the ocean a few days later and had a couple of successful swims, so felt I good about completing Tri. On the day of the Tri, I felt really good in the swim until I rounded the last buoy to head back to shore. Seemingly from nowhere, my breathing became labored, there was the rattling in my chest and I had to flip over on my back to finish. The rest of the Tri was awful. I had to walk on the run portion which is my strongest leg. I didn’t cough up the pink foam, but I had the rattle in my chest and labored breathing for the rest of the day.

    I continued to swim in the pool and waited several years before attempting open water swimming again. Last year I swam in the ocean a few times. I recall having a mild case of SIPE i.e. The rattling in my chest one time. I successfully completed an ocean swim sprint Triathlon. This year I decided to start swimming in the lake before tackling the ocean, thinking it would make the transition easier. My first lake swim ended with a case if SIPE. All symptoms minus the pink foam. I barely made it 250 yards! After that I adapted to the lake well and swam there many times no problem. A few weeks ago, we moved to the ocean. Again, I barley made it 250 yards and wound up with a mild case of SIPE. A week later, I attempted another ocean. This time I had the worst case of SIPE since my first ocean swim all those years ago. All symptoms including the pink foam. I got back out there a few days later and swam just fine. No SIPE. I have an ocean swim Tri next week and have no idea what will happen. It’s very frustrating to not know the trigger and very scary how it can come on seemingly out of nowhere. I do believe the tightness of the wetsuit and the cold water temp combo may have something to do with it, as it’s never happened in the pool. But it doesn’t explain why it’s ok some days and not others. I’m not a big fish eater and I don’t typically drink a lot before a swim, so I don’t believe thise to be a factor in my case. I’m so glad people are researching this and hopefully more info on this will be found in the near future.

  11. Wow! Reading these articles are scary. My story is a little different as it’s not mine. This summer my 12 year old daughter has been sick a lot. Out of no where she would get this horrid cough. We brought her in the first couple of times and it was always, use your inhaler and come back if you get a fever. Yesterday and the day before she was at the beach. She came home yesterday and was once again coughing horribly. My husband and I were laying in bed and I said, it’s so weird but I think she’s getting sick every time she swims. We thought back and every time she’s gotten this cough she had been swimming previously. I don’t believe she’s had the pink froth because I think she would have mentioned it but she does get the wicked cough, slightly rattling lungs and sever fatigue. It sounds like there is nothing that a doctor can really do but I will be making her an appt today. I’m so glad my husband found this article online. Thank you!

  12. I have experienced similar symptoms during my last 2 open water swim sessions with a wetsuit. I complete about 2000 yards in the pool once each week with no issues. I tried 500 in the open water with a wetsuit and experienced wheezing and shortness of breath disproportionate to my exertion. I didn’t cough up pink foam or have the cackling breathing. I was thinking (hoping) my wetsuit was simply too tight.. Any thoughts?

    • Hi Josh – hard to say, but it could be just the wetsuit, could be exercise induced asthma, or a lighter case of SIPE. Heck, could be a combo of any of those and even air temp and water temp. Can’t be sure but my suspicions are on the wetsuit. It can be physically constraining not to mention psychological! First time I swam in one I thought I was going to have to rip it off of me in the water. I could feel that panicky feeling building in me as I just was not used to having something press near my throat. Try taking your wetsuit to the pool and replicating the swim there. Be sure and have someone with you in case you run into any kind of trouble. Good luck!

  13. This site helped me self diagnose a SIPE experience from an open water swim in Lake Michigan yesterday. I’m 60, in very good physical condition and training for my first sprint tri. Following a brief warmup swim, I quickly ran out of breath. Treading water, floating on my back, nothing helped. Panicked, I swam to the sea wall and was able to pull myself out of the water after hanging on the wall breathless for 10 minutes. I sat down and started coughing up bloody froth, knowing I hadn’t taken water in during the swim. It took another 15 minutes before I could walk. I met up with the training group I was with embarrassed at my epic fail. I didn’t know till I got home and researched my symptoms that I had SIPE. Better today, but duathlons are now in my future… no more Tri’s. I consume lots of fish oil, I was hydrated, and took ibuprofen for a headache before the swim, but I will not risk another episode simply by eliminating these risk factors. I’m a safety consultant and it doesn’t make sense to risk my life to prove I can swim open water. I hope anyone who swims open water recognizes the symptoms before it is too late. I consider myself lucky… except for my toes that were shredded by the barnacles on the sea wall!

    • Gary – thank you SO much for posting your experience. I’m so sorry you went through that. I would very much encourage you to follow up with a pulmonologist and have your lungs checked out. Good luck and I”m glad you are okay now and competing in the other sports. I’m hopeful you can return to swimming at some point.

  14. 2 weeks after open water swimming, no wetsuit, not competition, but with the complication of extreme forced water into my face during fast boat ride accident, after the swim. I suddenly got very tired & have had a fever for a week, with awful cough, some foamy, some mucous, & the chest rattle that’s scary. I wake up trying to cough up. Yesterday I went to a clinic, and am on antibiotics. They seem to help, yet the rattle & some cough persists. I need some down time to let the medicine work. I’m a strong multi-athlete 59 yr old with years of open water swimming. I used to surf. I’ve been captain of a raft through Grand Canyon rapids many times. I worked as a life-guard & pool manager one summer. The edcaution about drowning is sobering. I wear my PFD to swim now, or stay close to shore. SIPE info here is the closest I’ve found to explain what’s up with my breathing, yet it’s not explained. Please be safe swimmers. Drowning is silent & fast. surviving the race is the best winning.

    • Cynthia – thanks for writing in. Going through an event like that has to be frightening. I’m so glad you went to the doc. If things persist, share the SIPE information with your doc or even go see a pulmonologist. Wishing you the best, Cokie

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