INTRODUCTION:We aimed to document identified cases of immersion pulmonary edema (IPE) in divers from Oceania (the Indo-Pacific region) from January 2002 to May 2018, inclusive.METHOD:Cases were identified using various sources, including searches of the Divers Alert Network Asia-Pacific (DAN AP) Fatality Database, published case reports, and interviews with survivors who had reported their incident to DAN AP. Where available, investigations, pathology and autopsy results were obtained. Only incidents diagnosed as IPE by diving physicians or pathologists with experience in the investigation of diving accidents were included. Individual case histories and outcomes, together with brief individual summaries of the associations and possible contributing factors were recorded.RESULTS:Thirty-one IPE incidents in divers from Oceania were documented. There were two surface snorkelers, 22 scuba air divers and seven nitrox divers which included three closed-circuit rebreathers (CCR). The mean (SD) age was 53 (12) years, 58% of victims were females, and the average dive profile was to a maximum depth of 19 meters of seawater for 25 minutes. Six victims (19%) had previous episodes of IPE. There were nine recorded fatalities. Cardiac anomalies dominated the associated or possible contributing factors. These included valvular disease in 29%, transient cardiomyopathies in 26% and dysrhythmias in 16%.CONCLUSIONS:Previously reported associations of IPE such as exertion, stress, cold exposure, negative inspiratory pressure, hypertension, overhydration, ascent or surfacing, tight wetsuit, aspiration and certain medications were identified. Cardiac conditions were frequent and included chronic disorders (valvular pathology, coronary artery disease) and transient disorders (dysrhythmias, transient myocardial dysfunction, takotsubo or stress cardiomyopathy). It is likely that the chronic cardiac disorders may have contributed to the IPE, whereas the transient cases could be either sequelae, contributors or coincidental to the IPE.

Aim: To review incidents of immersion pulmonary edema (IPE) from Oceania, to determine the demographics, diving parameters, and comorbidities that may be related to this disorder. Method: Incidents of IPE, most of which were documented by Divers Alert Network Asia-Pacific (DAN AP) or reported in our medical literature, were analyzed. They included interviews with the survivors and a review of available medical records. Only incidents diagnosed as IPE by specialist diving physicians or pathologists with experience in the investigation of diving accidents were included. Results: Thirty-one IPE incidents in divers from Oceania were documented. There were two surface snorkelers, 22 scuba air divers and seven nitrox divers, which included three closed-circuit rebreathers (CCR). The mean (SD) age was 53 (12) years, 58% of victims were females, and the average dive profile was to a maximum depth of 19 msw for 25 minutes. Six victims (19%) had previous episodes of IPE. There were nine recorded fatalities in this cohort. Medical comorbidities were recorded in 68%, with 42% being cardiac. The latter included valvular disease in 29%, transient cardiomyopathies in 26% and dysrhythmias in 16%. Conclusion: IPE was more likely in middle-aged females, in experienced divers, and during ascent or after surfacing. Commonly reported associations such as exertion, stress, cold exposure, negative inspiratory pressure, hypertension, overhydration, tight wetsuit, aspiration and certain medications were identified. This series supports the hypothesis that the elderly IPE subjects are likely to have comorbidities and be susceptible to IPE recurrences and fatalities unless the contributing factors can be identified and addressed.

The evolution of scuba divers pulmonary edema is described. When discovered in 1981, it was believed to be a cold-induced response in a submerged, otherwise healthy, scuba diver. The clinical features are described and discussed, as are the demographics. An alleged prevalence of 1.1% was complicated by problematic statistics and an apparent increase in reported cases. Recurrences both while diving and swimming or snorkeling were common. More recent case reports and surveys are described, identifying predisposing factors and associations, including cardiac pathology. Stress cardiomyopathies, reversible myocardial disorder or Takotsubo cardiomyopathy, may complicate the presentation, especially in older females. Relevant cardiac investigations and autopsy findings are reviewed. Disease severity and potential lethality of scuba divers pulmonary edema became more apparent early this century, and these influence our current recommendations to survivors. First aid and treatment are also discussed.

Diving is a rapidly developing sport in the UK. It is therefore probable that most doctors qualifying now will have some contact with divers as patients and a growing number of them will be faced with diving related disorders. Few, however, will have had any teaching in the specific physiology, pathology or management problems associated with diving. This new edition of a well established textbook will bring this area of medicine to their notice and stimulate their

A 67-year-old female scuba diver developed a typical immersion pulmonary oedema (IPE), but investigations strongly indicated Takotsubo cardiomyopathy (TC). The cardiac abnormalities included increased cardiac enzymes, electrocardiographic anomalies and echocardiographic changes, all reverting to normal within days. This case demonstrates a similarity and association between IPE and TC, and the importance of prompt cardiac investigations both in the investigation of IPE and in making the diagnosis of TC.