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Swimming Induced Pulmonary Edema (SIPE)

Triathletes are a rare breed.  We tend to expect a lot from ourselves and often push the envelope in order to reach our goals.  We test ourselves in training.  We analyze our stats. We watch what we eat. We work on visualization and set goals to prepare us for race day, and hope all things will align and we'll be rewarded with the perfect race.  We push through pain and discomfort in order to reach the finish line.

Sometimes, we find that we do not have as much control as we thought and our bodies decide to stop us in our tracks.  Suddenly, the measured structure we live within is altered beyond our control and we are left in a state of disbelief.

Swimming Induced Pulmonary Edema, or SIPE, is an emerging condition that affects athletes in the swim portion of triathlon events. "Symptoms include marked respiratory distress, wet-sounding popping or crackling in the lungs with breathing, a “junky” rattling cough, and the hallmark; coughing up pink, frothy blood-tinged sputum.  When it occurs during exercise, one of the first sensations is shortness of breath that is substantially out of proportion to the effort being expended. SIPE is believed to occur from a combination of factors that creates what can be thought of as a “perfect storm” that leads to capillary leak". There is not a lot of publicity given to SIPE, perhaps because there is not enough information published about it at this point, but we are learning more about this condition every day and are actively working to expand our knowledge base of possible common triggers.

It would seem odd that a perfectly healthy, competitive triathlete, should suffer from this type of condition given the level of fitness and amount of time we spend training at intensity in tough conditions. What we can gather is that a combination of factors contribute to the capillary leak in the lungs leading to the onset of SIPE, and once the 'flood' begins, continuing to push through will not alleviate the condition. This can be a very frightening experience since it generally occurs in the swim portion of an event, when an athlete is far from shore and in the thrashing swim pack. It's particularly distressing when it happens to an experienced swimmer, with no history of illness.

My occurrences of SIPE:
In my case, the first occurrence of SIPE was at the Mooseman ½ Iron race in June 2007.  I began experiencing shortness of breath at 750m into the swim.  I felt tightness in my chest – almost like an asthma attack, or that my wetsuit was too tight.  Then, fluid began to build in my lungs and I developed a slight ‘cough’.  I ended up doing the ‘backstroke’ for the last 750m of the swim in order to get to shore.  At that point, tried to keep racing and pushed through the complete bike leg, then had to stop at the beginning of the run as I was completely unable to get oxygen and was wheezing. That was 4 hours and 17 minutes into the event.  I ended up in an ambulance on oxygen, and was released on site once my breathing improved.

The second time I had it happen was on July 22, 2007 at Ironman USA in Lake Placid.  This time, it was much worse.  750m into the swim, I experienced the same 'tightness' in my chest and shortness of breath.  I stopped at the 1km mark into the swim and loosened my wetsuit in hopes it might provide some relief.  It didn’t.  I continued to swim and the gradual build up of fluid in my lungs began.  I was struggling to stay above water in the last kilometre of the swim, and luckily there was a kayaker who spotted me in trouble and came to my aid.  He could see I was in distress and told me he would stay with me all the way into shore.  I swam the last leg of the swim by holding the kayak for air, and taking 10-20 strokes when I had enough oxygen to continue.  I could hear the crowd and see the shore in the distance, but I couldn’t propel myself to get there.  I felt as though I might drown.  At the swim exit, I began coughing up pink frothy foam.  Fortunately, the medical staff identified that there was a problem and pulled me from the race.  They administered Lasix and oxygen on site and then transferred me to Saranac Lake Hospital by ambulance.  Tests at the hospital confirmed that I had suffered pulmonary edema (fluid in my lungs), that it was not ‘cardiac’ related – my heart was fine.  The pink frothy foam was actually ‘blood’ that had seeped into my lungs due to a capillary breach.

After my two occurrences of SIPE in 2007, I raced at Ironman Florida that same year with a very mild case of SIPE, which cleared itself halfway through the bike, so I was able to finish the race.  I continued through the entire 2008 triathlon season at the Early Bird Sprint Tri, the Mooseman 1/2 Ironman, Ironman Germany, Timberman 70.3, Muskoka 70.3, and Ironman Florida with no occurrences of SIPE

The 2009 season began with SIPE free races at the Early Bird Sprint Tri, Tinman 1/2 Ironman, Graham Beasley 1/2 Ironman and Ironman Lake Placid - where I conquered the demons of 2007! Then, I had another mild occurrence of SIPE at The Canadian Iron 226 on Sept. 5th, with no warning or reason - 3,500m into the swim.  It came on gradually, near the end of the swim as I began to build some speed in the closing meters of the race, my breathing tightened and I felt fluid in my throat and lungs. I exited the water with the 'wet' cough, and lack of oxygen.  This was a mild incident for me, and I chose to continue to race - while closely monitoring my condition. I pushed through on the bike, but had some difficulty breathing and some fluid up until the 100K mark.  By the time I started out on the marathon, I was in survival mode and decided to walk it, as running was putting too much strain on my system.   I finished the race, but realized how hard it is to continue with that type of impairment. I thought I had figured out my triggers and method of prevention, but the 'tell-tale' crackles in my lungs, wet cough and shortness of breath reminded me that I can't close the chapter on SIPE just yet.

Ironman Cozumel was the last race of my 2009 season, and I was very much at ease with the warm water, 'non-wetsuit' swim. I took extra care to keep my pace easy and controlled and had no issues what-so-ever in the swim!  I exited the water with clear lungs and full power and proceeded to hammer the bike!  

For 2010, I raced SIPE free at Ironman Brazil, but it returned for Ironman France, in one of the roughest swims I've done to date. There was no 'water' warm up on race morning, and we were held in 'starting' pens. It was a mass start, and the crush of bodies, punching, kicking and grabbing, was out of control. There was no clear path, and contact remained throughout the swim. I felt the build of SIPE come on at the first turn buoy, and couldn't stop it. I tried to slow things down and prevent the onset, but there was no break in the dense pack, so I just kept going. I do recall the feeling of my wetsuit being very tight in the chest, and back of my knees, which was an odd sensation. I finished the swim, with a bit of a struggle, then started out on the bike, with a wet cough of blood and mucous. I was cautious to monitor my progress as I rode, and fortunately, the wet cough dried up at about the 60K mark on the bike. My lungs 'hurt', but the scenery was breathtaking and I was inspired to continue on and finish the race.  After getting the 'green light' from my cardiologist, I went on to race Ironman Canada in August.  I was rather nervous, since France had been another bad day, but was extra careful to follow my pre-race routine and race morning warm up.  I was able to get in the water prior to racing for a good warm-up, and then started wide and at the back of the pack.  I made sure I keep the pace slow and controlled throughout the swim and stayed out of traffic.  Fortunately, I was able to keep things under control and raced SIPE free.

With the race calendar getting more serious for 2011, I was on a quest to find more answers about the condition that was plaguing me and was looking for a common thread and techniques to try to prevent it from re-occuring.

In the fall of 2010 I learned of a study being conducted at Duke University by Dr. Richard Moon on Immersion Pulmonary Edema (IPE) - also know as SIPE.  I was fortunate enough to qualify for this study, due to my past history of occurrences, so I headed off to the Duke Center for Hyperbaric Medicine on February 14 & 15, 2011 to become an official 'lab-rat'!  You can click here to read about my experience and also view the web gallery of photo's here.  Preliminary results suggested that in my case, the use of Sildenafil, aka Viagra, reduced my PAP/PCWP which could be a mechanism in the onset of IPE/SIPE.

After the testing at Duke, and the race calendar for 2011 coming at me head-on - including Ultraman Canada - I sought out the expertise of Emilio De Soto, founder and designer of De Soto Triathlon clothing and wetsuits. I wanted his advice on wetsuit fit, and style options since one of the suspected triggers of SIPE is the 'constrictive' nature and 'squeeze' factor of the wetsuit forcing blood up into the torso. Emilio immediately suggested I try the De Soto t1 First Wave and fitted me for the 2-peice t1. Given the unique concept of this 'two-piece' design, you can order the top and bottom sizes to suit your body type - which gives this suit a better overall fit. The new suit arrived within a few days and immediately it felt great in the water, with a much more flexible and 'softer' fit than my previous suit.

I spent the first part of the 2011 race season doing long 'test' swims in open water, then took on shorter races from Sprint, Olympic and Half Ironman distances then went on to race in Ultraman Canada - all with NO SIPE occurrence.  The final race of 2011 was a return trip to Ironman Cozumel, which was sans-wetsuit and SIPE free - so a perfect 2011 season was in the books!

The 2012 race season began with at trip to Spain to tackle Ironman Lanzarote, then onwards to Ultraman Canada and then Ironman Mont Tremblant - all with NO SIPE!  To finish the 2012 season, I raced at the Ultraman World Championships in Hawaii - taking on a 10K open water swim to start the epic 3 day journey.  This time, the wind and current was a true test of my ability to conquer SIPE and I'm thrilled to say I once again remained SIPE free and made my way across yet another finish-line. This was the completion of the third Ultraman event and Ironman Mont Tremblant earlier in the season had marked my 13th Ironman finish in 14 starts - the only DNF was in Lake Placid in 2007 - so for me, it's been a victory to continue to live out my dreams and safely return to the water.

In March of 2013, I was fortunate enough to return to the Duke Center for Hyperbaric Medicine to take part in a 2nd study being conducted by Dr. Richard Moon and his team which was funded by the U.S. Navy. This time, they were looking specifically at the effect of exercise on cardiac function while immersed to “the neck” in water and how over-hydration and systolic heart function may play a key factor in the onset of SIPE. You can click here to read about my experience and also view the web gallery of photo's here. 

I was once again fascinated by the science and discovery that’s taking place in the dive chamber at Duke, and being able to spend time with this incredible group of researchers was another giant step in my journey to better understand IPE/SIPE. I believe they are making advancements in understanding the complexity of SIPE and through their meticulous studies and ongoing quest for answers, hopefully someday soon we will be able to pin-point the triggers and perhaps prevent the onset of this condition. I will post updates here as soon as they become available, but am willing to say that they are on to something in the ‘chamber’!

Possible Prevention:
I continue to work with Dr. Charles C. Miller III - aka 'Trey' - and my cardiologist, to identify my triggers and are working to prevent a recurrence of SIPE. An early discovery in the process showed that I had mild-hypertension so I began taking Atacand (8mg) in Sept. 2007. In addition, concerns about wetsuit fit, overhydration, no warm-up prior to race start may act together to form this 'perfect storm'.  I am now very careful with fluid intake leading up to an event and don't overhydrate leading up to a race.   I also try to do a warm up on race morning by either getting into the water if possible, or do an easy jog to the race venue. I also wait until the last minute before putting on my wetsuit to keep the compression and 'heat' inside the suit to a minimum. Cold water is also thought to be a trigger, so If I am able to get in the water prior to the start and become acclimatized to the temperature, that's great, if not I'm careful to start at the back of the pack then swim slowly and build up my speed.  All of these small things can add up as potential contributors so I take the time and effort to stack the odds in my favour on race day.

I will continue on my quest to find the answers as to why this condition exists, and have posted as much information as I can here on my web page. Understanding more about this condition and how to prevent it will take time, but I am determined to figure it out. If anyone has suffered from SIPE, feel free to contact me at : triathlonteam@gmail.com
Stay safe...

  Below are the photo galleries and reports from my two visits to the Duke Center for Hyperbaric Medicine  
  2011 Gallery       2013 Gallery  
  2011 Report       2013 Report  
  Additional resources: Click below for related articles!  
  Click here for an in-depth article written by Elaine Howley for the March/April issue of 'Swimmer Magazine'.  
  Click here for an article on ' Why Triathletes are Dying?' in Men's Journal Magazine  
  Click here for an article by Scott Tinley in Triathlete Magazine  
  Click here for my 'letter to the editor' regarding in Triathlete Magazine  
  Click here for an article published on slowtwitch.com at the request of Dan Empfield  
  Click here for an article by Theresa Wallace in Triathlon Magazine Canada  
  Click here for an article from the New York Times by Christie Aschwanden  
  Click here for a sidebar mention from Triathlon UK Magazine by Fiona Duffy  
  Click here for a diagnostic challenge by Dr. Brian Deady  
  Click here for clinical presentation by Daniel Weiler-Ravell in CHEST  
  Click here for a paper by Daniel Weiler-Ravell in BMJ

  Click here for our research paper published in the AJEM  
  Click here for our Wikipedia page on SIPE  
  Click here for a case study done by Eric Carter and Michael S. Koehle on IPE/SIPE in Female Triathletes.  
  Click here to check out my first visit to DUKE University in Feb 2011 to participate in an IPE study!  
  Click here to check out my second visit to DUKE University in March 2013 to participate in a follow-up IPE study!