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 are 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 would like 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".

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.

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.  We are actively working to expand our knowledge base of what the common triggers are in order to prevent it from happening. 

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 kilometer 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 couldn’t propel my body 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.

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.

With the help and dedication of Dr. Charles C. Miller III - aka 'Trey' - and my cardiologist, we are trying to identify my triggers and work to prevent a recurrence of SIPE. We discovered that I had mild-hypertension so I began taking Atacand (16mg) in Sept. 2007.  We think over hydration and lack of a proper warm-up on race morning could also be factors. I have been careful begin the swim slowly and build my speed and to monitor fluid intake carefully leading up to race day, and on race morning. The wetsuit is another factor that may contribute to SIPE, but don't have any evidence to suggest it is part of the problem since I've raced in the same suit for 3 years now - with and without SIPE.

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 occurrence 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 on the system to continue through 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 wore a Kiwami Torpedo Speedsuit and 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, but 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. At this point, I am actively following up on the return of my SIPE and hope the doctors and researchers might be able to understand more in the next few months. Ironman Canada in Penticton will be my next test.

I will continue on my quest to find more answers as to why this conditions exists, and how to prevent it. Efforts to initiate in-depth clinical research in this area are currently being pursued.

If anyone has suffered something similar, or has updates, I'm all ears and will share whatever I find out as well, feel free to contact me at : triathlonteam@gmail.com