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Discussion of ResultsIt is well known that BUD/S training is extremelyarduous. The extreme physical and psychologicaldemands of the training, in concert with theenvironment in which the training is conducted, frequentlyresults in illness and injury. Pulmonary infectionsare relatively common in this population.Therefore, utilization of BNP as a method for differentiatingthe source of dyspnea in these BUD/Strainees was prudent. Our experience indicates thatplasma BNP is not elevated in SIPE. However, thesefindings may be limited by a delay of up to two hoursfrom symptom onset to blood draw. There is currentlylittle data in the literature describing the amount ofBNP reserve in the ventricular cells. The time coursefor BNP elevations to occur is not incredibly well defined.BNP is significantly elevated above baselinewithin one hour after ventricular septal defect repair inchildrenand BNP rapidly rises (within hours) in the settingof acute myocardial infarction. 29,30 Serial BNPlevels were not drawn in these patients, thus it is theoreticallypossible that BNP levels may have elevatedafter initial diagnostic work-up was performed in theemergency room. This seems unlikely however, in thatBNP levels are thought to increase within a very shorttime period of the development of clinically significantpulmonary edema.Discussion of PatientsThese six patients all experienced symptomsconsistent with SIPE at various points or timeframesduring the same surface bay swim. These swims wereperformed in the lateral decubitus position. Water conditionswere reported as “cold and rough.”These patients share several similarities inpresentation and symptoms, physical examination findings,and laboratory abnormalities. All six patients presentedwith various symptoms of shortness of breath,cough, chest pain/tightness, and hemoptysis. Severalof the patients were noted to be hypoxemic by pulseoximetry in the field. This hypoxia is common inSIPE, as noted in two of three patients reported on byLund et al. and as noted by Adir et al. 16,31 Additionally,mild hypothermia was commonly noted.Several of the individuals’ laboratory studiesexhibit a mild anemia. This slight anemia is commonin BUD/S trainees. One of the three SIPE patients reportedon by Lund et al., exhibited this phenomenon. 16BUD/S trainees admitted to NMCSD for other diagnosessuch as cellulitis and pneumonia, frequentlydemonstrate a mild anemia. Though not specificallyaddressed in the literature, this common finding inBUD/S trainees is likely due to the extreme daily physicalstress of this course of instruction. The anemia isnot likely related to the development of SIPE.CONCLUSIONSwimming induced pulmonary edema is ofclinical significance, particularly in the military, andmost notably in Special Operations trainees and recruits.It is a clinical entity noteworthy for its rapidonset, rapid recovery, and return to full duty. The rapiddiagnosis of this condition by medical personnel coveringstrenuous surface swims in the Naval SpecialWarfare community is critical to avoid serious morbidityand mortality. BNP levels are not elevated inswimming induced pulmonary edema, rendering thislaboratory test of little value in the clinical evaluationof pulmonary edema associated with swimming. Furtherstudy of the pathophysiology, etiology, and treatmentof swimming induced pulmonary edema isrequired.REFERENCES1. Pons M, Blickenstorfer D, Oechslin E, et al. (1995). Pulmonaryedema in healthy persons during scuba diving andswimming. Eur Respir J;8:762-767.2. Slade JB, Hattori T, Ray CS, Bove AA, Cianci P. (2001).Pulmonary edema associated with scuba diving. Chest;Nov;120:1686-1694.3. Siebert U. (2006). Cost-effectiveness of using N-terminal prbrainnatriuretic peptide to guide the diagnostic assessmentand management of dyspneic patients in the emergency department.Am J Cardiol; Sep; 98(6):800-5.4. Berdague P. (2006). Use of N-terminal prohormone brainnatriuretic peptide assay for etiologic diagnosis of acute dyspneain elderly patients. Am Heart J.; Mar; 151(3): 690-8.5. Birks EK, Mathieu-Costello O, Fu Z, Tyler WS, West JB.(1997). Very high pressures are required to cause stress failureof pulmonary capillaries in Thoroughbred racehorses. J.Appl Physiol. 82(5): 1584 – 1592.6. West JB, Tsukimoto K, Mathieu-Costello O, Prediletto R.(1991). Stress failure in pulmonary capillaries. J Appl Physiol.Vol 70, Issue 4 1731-1742.7. Reeves JT, Groves BM, Cymerman A, Sutton JR, WagnerPD, Turkevich D, Houston CS. (1990). Operation Everest:Cardiac filling pressures during cycle exerise at sea level.Respir Physiol. May-Jun;80(2-3):147-54.8. Bernheim AM, Kiencke S, Fischler M, et al. (2007). Acutechanges in pulmonary artery pressures due to exercise andexposure to high altitude do not cause left ventricular diastolicdysfunction. Chest; 132:380-387.9. Hopkins SR, Schoene RB, Henderson WR, Spragg RG, MartinTR, West JB. (1997). Intense exercise impairs the integrityof the pulmonary blood-gas barrier in elite athletes. AmJ Respir Crit Care Med; 155:1090-4.10. Ludwig B, Mahon RT, Parrish JS. Pulmonary edema incombat swimmers: Clinical and bronchoalveolar lavagedescription demonstrating stress failure of the pulmonarycapillaries. Undersea and Hyperbaric Medicine Vol 31Number 3: C-42,318.48Journal of Special Operations Medicine Volume 9, Edition 3 / Summer 09
11. Norsk P, Bonde-Petersen F, Warberg J. (1986). Central venouspressure and plasma arginine vasopressin in man during waterimmersion combined with changes in blood volume. Eur JAppl Physiol;54:608-16.12. Arborelius M Jr, Ballidin UI, Lilja B, Lundgren CE. (1972).Hemodynamic changes in man during immersion with thehead above water. Aerosp Med;43(6):592-8.13. Sheldahl LM, Tristani FE, Clifford PS, Hughes CV,Sobocinski KA, Morris RD. (1987). Effect of head-outwater immersion on cardiorespiratory response to dynamicexercise. J Am Coll Cardiol; 10(6):1254-8.14. Pons M, Blickenstorfer D, Oechslin E, et al. (1995). Pulmonaryedema in healthy persons during scuba-diving and swimming.Eur Respit J;8:762-767.15. Keatinge WR, McIlroy MB, Goldfien A. (1964). Cardiovascularresponses to ice cold showers. J Appl Physiol; 19:145-1150.16. Lund KL, Mahon RT, Tanen DA, Bakhda S. (2003). Swimming-inducedpulmonary edema. Ann Emerg Med; 41:251-256.17. Hong, S. K., P. Cerretelli, J. C. Cruz, and H. Rahn. (1969).Mechanics of respiration during submersion in water. J. Appl.Physiol; 27: 535-538.18. Parker JC, Townsley MI, Rippe B, et al. (1984). Increasedmicrovascular permeability in dog lungs due to high peakairway pressures. J Appl Physiol; 57:1809-1816.19. Weiler-Ravell D, Shupak A, Goldenberg I, Halpern P,Shoshani O, Hirschhorn G, Margulis A. (1995). Pulmonaryedema and haemoptysis induced by strenuous swimming.BMJ;:311:362.20. Mahon RT, Norton D, Krizek S, et al. (2002). Effects of wetsuitson pulmonary function studies in Basic UnderwaterDemolition/SEAL (BUD/S) trainees in the United StatesNavy. Abstract presented at 35th Annual Undersea and HyperbaricMedicine Society Scientific Meeting; June 28-30;La Jolla, CA.21. Krishnaswamy P, Lubien E, Clopton P, Koon J, Kazanegra R,Wanner E, Gardetto N, Garcia A, DeMaria A, Maisel AS.(2001). Utility of B-natriuretic peptide levels in identifyingpatients with left ventricular systolic or diastolic dysfunction.Am J Med; Sep; 111(4):274-9.22. Yamamoto K, Burnett JC, Jougasaki M, Nishimura RA, BaileyKR, Saito Y, Nakao K, Redfiled MM. (1996). Superiorityof brain natriuretic peptide as a hormonal marker ofventricular systolic and diastolic dysfunction and ventricularhypertrophy. Hypertension. Dec; 28(6):988-994.23. Nagaya N, Nishikimi T, Okano Y, Uematsu M, Satoh T, KyotaniS, Kuribayashi S, Hamada S. (1998). Plasma brain natriureticpeptide levels increase in proportion to the extent ofright ventricular dysfunction in pulmonary hypertension. JAm Coll Cardiol. Jan;31(1):202-8.24. Maisel AS, Krishnaswamy P, Nowak RM, et al. (2002).Rapid measurement of B-type natriuretic peptide in theemergency diagnosis of heart failure. N Engl J Med;347:161.25. Tanimoto K, et al. (2004). Usefulness of brain natriureticpeptide as a marker for separating cardiac and noncardiaccauses of syncope. Am J Cardiol. Jan; 93(2).26. Scharhag J, et al. (2005). Independent elevations of N-terminalpro-brain natriuretic peptide and cardiac troponins inendurance athletes after prolonged strenuous exercise. AmHeart J. Dec; 150(6).27. Yoder JA, Viera AJ. (2004). Management of swimming-inducedPulmonary Edema. American Family Physician. 3/1/2004, Vol. 69Issue 5, p1046-1049.28. Shupak A, Weiler-Ravell D, Adir Y, Daskalovic YI, RamonY, Kerem D. (2000). Pulmonary edema induced by strenuousswimming: A field study. Respir Physiol. Jun;121(1):25-31.29. Mainwaring RD, Parise C, Wright SB, Juris AL, Achtel RA,Fallah H. (2007). Brain natriuretic peptide levels before andafter ventricular septal defect repair. Ann Thorac Surg.Dec;84(6):2066-9.30. Mukoyama M, Nakao K, Obata K, Jougasaki M, YoshimuraM, Morita E, Hosoda K, Suga S, Ogawa Y, Yasue H, et al.(1991). Augmented secretion of brain natriuretic peptide inacute myocardial infarction. Biochem Biophys Res Commun.Oct 15;180(1):431-6.31. Adir Y, Shupack A, Gil A, Peled N, Keynan Y, DomachevskyL, Weiler-Ravell D. (2004). Swimming-induced pulmonaryedema clinical presentation and serial lung function.Chest. Aug; 126(2).Brain Natriuretic Peptide Levels In Six Basic Underwater Demolitions/SEAL Recruits Presenting withSwimming Induced Pulmonary Edema (SIPE)49
Page 1 and 2: Volume 9, Edition 3 / Summer 09 Jou
Page 3 and 4: An 18D deworms a camel during a “
Page 5 and 6: Field Evaluation and Management of
Page 7 and 8: The circumferential anchoring strip
Page 9 and 10: In doing so, all the skin is closed
Page 11 and 12: NATO SOF Transformation and theDeve
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Page 15 and 16: sion of a physician, and limited pr
Page 17 and 18: REFERENCES1. James L. Jones, “A b
Page 19 and 20: This article is the first of two me
Page 21 and 22: Figure 4 : A Special Forces medic c
Page 23 and 24: exposure. Conversely, the customary
Page 25 and 26: 7. Ted Westmoreland. (2006). Attrib
Page 27 and 28: first three days of injury, althoug
Page 29 and 30: 9. Markgraf CG, Clifton GL, Moody M
Page 31 and 32: the only sign of OCS may be elevate
Page 33 and 34: E. The canthotomy allows for additi
Page 35 and 36: 33. Rosdeutscher, J.D. and Stradelm
Page 37 and 38: Tinnitus, a Military Epidemic:Is Hy
Page 39 and 40: The development of chronic NIHL pro
Page 41 and 42: supplied by diffusion. During expos
Page 43 and 44: similar to those of other authors,
Page 45 and 46: promising effect on tinnitus. Howev
Page 47 and 48: ADDITIONAL REFERENCESHoffmann, G; B
Page 49 and 50: et al. demonstrated that both right
Page 51: TYPICAL CHEST RADIOGRAPH FINDINGS I
Page 55 and 56: ABSTRACTS FROM CURRENT LITERATUREMa
Page 57 and 58: tourniquet times are less than 6 ho
Page 59 and 60: tal from July 1999 to June 2002. In
Page 61 and 62: Operation Sadbhavana: Winning Heart
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Page 65 and 66: of the X chromosome. Notable is tha
Page 67 and 68: AUTHORS*75th Ranger Regiment6420 Da
Page 69 and 70: Casualties presenting in overt shoc
Page 71 and 72: PSYCHOLOGICAL RESILIENCE AND POSTDE
Page 73 and 74: spondents without PTSD (M = 4.6, SD
Page 75 and 76: patients, whereas the mean score of
Page 77 and 78: 29. Whealin JM, Ruzek JI, Southwick
Page 79 and 80: average, time between return from d
Page 81 and 82: ing functioning in both PTSD (Zatzi
Page 83 and 84: Editorial Comment on “Psychologic
Page 85 and 86: Blackburn’s HeadhuntersPhilip Har
Page 87 and 88: The Battle of Mogadishu:Firsthand A
Page 89 and 90: Task Force Ranger encountered enemy
Page 91 and 92: Peter J. Benson, MDCOL, USACommand
Page 93 and 94: Numerous military and civilian gove
Page 95 and 96: Anthony M. Griffay, MDCAPT, USNComm
Page 97 and 98: This is a great read that speaks di
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Page 101 and 102: Rhett Wallace MD FAAFPLTC MC SFS DM
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LTC Craig A. Myatt, Ph.D., HQ USSOC
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LTC Bill Bosworth, DVM, USSOCOM Vet
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Europe, Mideast, Africa and SWAU.S.
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SOF and SOF Medicine Book ListWe ha
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TITLE AUTHOR ISBNCohesion, the Key
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TITLE AUTHOR ISBNI Acted from Princ
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TITLE AUTHOR ISBNRats, Lice, & Hist
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TITLE AUTHOR ISBNThe Healer’s Roa
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TITLE AUTHOR ISBNGuerilla warfare N
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TITLEAUTHORBlack Eagles(Fiction)Bla
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TITLE(Good section on Merrill’s M
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GENERAL REFERENCESALERTS & THREATSB
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Aviation Medicine Resources: http:/
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LABORATORYClinical Lab Science Reso
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A 11 year old boy whose tibia conti
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Meet Your JSOM StaffEXECUTIVE EDITO
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Special Forces Aidman's PledgeAs a
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