(Chest. 2001;120:1021-1022.)
© 2001
American College of Chest Physicians
Unusual Freshwater Near-Drowning Syndrome in a Hospitalized Postlobectomy Patient*
Helen Sogoloff, MD;
Rafael Barrera, MD;
Robert Ginsberg, MD, FCCP and
Diane Stover, MD, FCCP
*
From the Pulmonary Critical Service (Dr. Sogoloff), Pulmonary Service, Department of Medicine; the International Oncology Program (Dr. Barrera); and the Division of General Medicine (Dr. Stover), Memorial Sloan-Kettering Cancer Center, New York, NY; and the Division of Thoracic Service (Dr. Ginsberg), Toronto General Hospital, Toronto, Canada.
Correspondence to: Rafael Barrera, MD, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021
 |
Abstract
|
|---|
Near-drowning syndrome depends on the duration of submersion, the
amount of fluid aspirated, and the severity of hypoxia. We report a
case in which a patient developed ARDS shortly after undergoing a left
upper lobectomy and a chest wall resection for a lung carcinoma. On
further investigation, the ARDS was caused by near-drowning in a basin
of freshwater: the patient’s face was submerged by the patient’s
companion as part of a cultural tradition of trying to clean his lung.
We believe that this case presents the etiology of freshwater
near-drowning syndrome due to an ethnogenic practice not previously
reported.
Key Words: ethnic diversity • fresh water • near-drowning
|
Introduction
|
|---|
Near
-drowning syndrome depends on the duration of submersion, the amount of
fluid aspirated, and the severity of hypoxia. We report a case in which
ARDS secondary to freshwater near-drowning syndrome developed in a
patient shortly after undergoing a left upper lobectomy and a chest
wall resection for a lung carcinoma.
|
Case Report
|
|---|
A 67-year-old Korean man was admitted to our hospital
for resection of a left upper lung carcinoma. His medical history was
remarkable for interstitial pulmonary fibrosis, cardiomyopathy, and
atrial fibrillation. The preoperative workup showed a left ventricular
ejection fraction of 68%. Preoperative pulmonary function testing
revealed mild restrictive lung disease, and a ventilation-perfusion
scan showed about 50% function in the right and the left lung. The
patient underwent a left upper lobectomy and a chest wall resection. He
was extubated immediately after the resection and transferred to the
regular floor the day after the surgery.
The patient showed no signs of distress until the second postoperative
day, when he developed acute respiratory failure requiring intubation
and mechanical ventilation. At that time, the patient was febrile to
39.2°C, with a heart rate of 132 beats/min. The chest radiograph
showed left-side postsurgical changes with new diffuse bilateral
infiltrates (Fig 1
). The WBC count was elevated to 18.2 x 109/L,
with an absolute neutrophil count of
14.4 x 109/L. The serum electrolytes and renal
function findings were normal. The arterial blood gas measures were as
follows: pH, 7.51; PCO2, 38 mm Hg;
PO2, 41 mm Hg; and oxygen saturation
on 70% oxygen, 81%. The alveolar-arterial oxygen pressure gradient
was 50 mm Hg. There was no evidence of hematologic abnormalities. The
patient was intubated, administered mechanical ventilation, and
transferred to the ICU.
The initial differential diagnosis included nosocomial
pneumonia, pulmonary embolism, exacerbation of the underlying lung
disease, congestive heart failure, pulmonary hemorrhage, and
postpneumonectomy pulmonary edema. The diagnostic workup included
cultures, bronchoscopy, bilateral lower extremities ultrasound, and a
computed axial tomography scan of the chest. This workup showed no
evidence of infection, pulmonary embolus, pulmonary hemorrhage or
postpneumonectomy pulmonary edema. The bronchoscopy showed copious
clear secretions without mucus plugs or evidence of purulence. The
echocardiogram at that time showed bilateral atrial enlargement with no
significant gradient across the mitral valve, thus ruling out pulmonary
edema secondary to postoperative fluid shift, uncompensated
cardiomyopathy, and atrial fibrillation. The patient was treated with
imipenem and gentamicin, corticosteroids, and active diuresis.
The next day, the patient markedly improved. His inspired oxygen
requirement was 40%, and his ventilator mode was changed from
controlled mechanical ventilation to synchronized intermittent
mandatory ventilation. Four days following intubation, the patient
tolerated continuous positive airway pressure and was successfully
extubated. The chest radiograph showed minimal abnormalities (Fig 2
).
The day after extubation, the nurse noticed that the patient’s
companion was attempting to submerge the patient’s face into a basin
filled with water. On questioning, the patient indicated that he was
aspirating water to clean sinuses and lungs and explained that this was
a daily routine for cleaning airways in his family. He also recalled
that on postoperative day 1, while performing this ritual, he had a
severe coughing and choking spell while his face was submerged in tap
water. The patient spontaneously took a couple of breaths while his
face was underwater. The patient’s companion confirmed this. This
"technique" was witnessed by the housestaff but reported only under
direct questioning. An empiric nonscientific poll of Korean and
Korean-American doctors and nurses revealed that all of them knew
someone who had practiced this method of clearing sinuses and lungs,
although it failed to identify any person who actually practices this
technique. We believe our patient had a freshwater near-drowning
syndrome as a cause of the postsurgical complication.
|
Discussion
|
|---|
The course of victims of near-drowning syndrome depends on the
duration of submersion, the amount of fluid aspirated, and the severity
of hypoxia. It is hard to estimate how much aspirated fluid is required
to cause near-drowning, but Modell et al1
reported that in
dogs, aspiration of as little as 2.2 mL/kg of body weight produces a
decrease in PaO2 to approximately 60
mm Hg within 3 min. Pearn2
showed that aspiration of 2.5
mL/kg increases the intrapulmonary shunt from 10% to as much as 75%.
The hypotonic nature of freshwater affects surface tension properties
of pulmonary surfactant and makes the alveoli unstable.3
Complete or partial alveolar collapse causes loss of ventilation in the
face of preserved perfusion, resulting in intrapulmonary shunting and
hypoxemia. Also, the presence of water in the alveoli damages type II
pneumocytes and prevents the production of new
surfactant.4
The combination of these insults may damage
the alveolar capillaries and interstitium and lead to
ARDS.5
ARDS develops within 48 h in approximately
40% of near-drowning victims. Recovery from this syndrome occurs in
approximately 80% of cases,6
7
as happened with our
patient. The only effective treatment is reversal of hypoxemia with
mechanical ventilatory support.7
8
Use of antibiotics and
steroids could be detrimental, and use of surfactant should be
considered experimental.1
9
10
11
12
|
Conclusion
|
|---|
Looking back at our case, an unusual conclusion emerges. Cultural
diversity is a reality, and no matter how unusual some of the beliefs,
rituals, and sociologic patterns may be to an outsider, the physician
cannot ignore the patient’s background. A complete history and
physical examination should now include questions regarding
culturally specific practices.
Received for publication September 8, 2000.
Accepted for publication February 20, 2001.
|
References
|
|---|
-
Modell, JH, Graves, SA, Ketover, A (1976) Clinical course of 91 consecutive near-drowning victims. Chest 70,231-238[Abstract/Free Full Text]
-
Pearn, JH (1985) The management of near-drowning. BMJ 291,1447-1452
-
Giammona, ST, Modell, JH (1967) Drowning by total immersion: effects on pulmonary surfactant of distilled water, isotonic saline and sea water. Am J Dis Child 114,612-616[Medline]
-
Modell, JH, Calderwood, HW, Ruiz, BC, et al (1974) Effects of ventilatory patterns on arterial oxygenation after near-drowning in sea water. Anesthesiology 40,376-384[ISI][Medline]
-
Smyrnios NA, Irwin RS. Near-drowning. In: Rippe JM, Irwin RS, Alpert JS, eds. Intensive care medicine. 2nd ed. Boston, MA: Little, Brown and Company, 1991; 532
-
Oakes, DD, Sherck, JP, Maloney, JR, et al (1982) Prognosis and management of victims of near-drowning. J Trauma 22,544-549[ISI][Medline]
-
Levin, DL, Morris, FC, Toro, LO, et al (1993) Drowning and near-drowning. Pediatr Clin North Am 40,321-356[ISI][Medline]
-
Bergquist, RE, Vogelhut, MM, Modell, JH, et al (1980) Comparison of ventilator patterns in the treatment of freshwater near-drowning in dogs. Anesthesiology 52,142-148[Medline]
-
Sadcheva, RC (1999) Near drowning. Crit Care Med 15,281-296
-
McBrien, M, Katumba, JJ, Mukhtar, AJ (1993) Artificial surfactant in the treatment of near drowning. Lancet 342,1485-1486
-
Anker, AL, Santora, T, Spivey, W (1995) Artificial surfactant administration in an animal model of near drowning. Acad Emerg Med 15,499-500
-
Orlowski, JP, Abulleil, MM, Phillips, JM (1989) The hemodynamic and cardiovascular effects of near-drowning in hypotonic, isotonic, or hypotonic solutions. Ann Emerg Med 18,1044-1049[CrossRef][Medline]
TOP
Abstract
Introduction
