Diving and Asthma???

[Dean Harry]

Dear world,

I was after an opinion.....My girlfriend and I decided that we would do some recreational diving and enrolled in a scuba course.

As part of the course we had to get a diving medical done. I passed, however she did'nt....

The results came back that she 'may have a slight underlying asthma'....

She is 23 years old and has never had asthma in her life....never had any symptoms, never used any medication for it, never even suspected it. She swims regualrly and can out swim me quite easily without getting any weezing or anything like that.

At the time she took the test she was getting over a cold and I suspect this is what they sent her for tests for...

From everything I have read in the last few days she should have been cleared to dive....

I would be very interested in hearing from people that may have had this happen to them and if and how they got around it or from anyone that is an asthmatic and dives often without any problems.

Regards,

Dean Harry

 

[large_diver]

Hi Dean Harry,

In case you miss my reply on scubadiving.com....

==============================================

I have mild asthma myself and have done some research on this topic. That being said -- I AM NOT A DOCTOR.

I was diagnosed with mild asthma about 10 years ago -- allergy induced only. Never had any problems while exercising, in cold air, etc. When I enrolled in my scuba class last year, I was deceitful and wrote "no" to the "do you have asthma" on the medical questionnaire. I'm not recommending that your girlfriend do this. I did it because I know exactly what causes my asthma (dogs and cats), I have no exposure to these animals on an ongoing basis, and I hadn't experienced wheezy conditions in 8-10 years. I have 25 dives under my belt with no problems.

This past fall after I stopped diving for the season, my wife came up with the brilliant idea to adopt 2 cats. In a moment of weakness I agreed ("oh honey, the kids will love them"). Anyway, about 2 months ago, I spent a long weekend cooped up in the house with the kids and cats, rolling all over the floor, playing with the cats, etc. My wheezing came on strong. This made me do 2 things -- (1) avoid the cats and the floor; and (2) go see an allergist with some knowledge of diving physiology to evaluate my ability to continue diving. Luckily, I checked out OK and I have a good plan to stay "wheeze-free" and to dive safely.

Bottom line here is that you should get your girlfriend checked out by a doctor that has some knowledge of diving medicine after she has gottn over her cold and wheezy symptoms. Most doctors will simply say "don't dive" -- this is the low risk, easy answer for them.

Take a look at the thread below from the YMCA scuba web-site regarding diving and asthma. Very helpful info.

Good luck and dive safe -- this is a serious issue.

http://www.ymcascuba.org/ymcascub/asthmatc.html

 

[DocVikingo]

Hi Dean Harry,

Given your girlfriend's negative history, and the fact that she was not entirely healthy at the time of examination, it would be wise to return to your physician, or to seek a second opinion from a pulmonologist.

In the meantime, a piece on asthma & diving appeared in my Dec '00 "Dive Workshop" column in "Rodale's Scuba Diving" magazine. Here is an unedited copy:

"Can I Dive With Asthma?

Asthma is a chronic but often largely controllable obstructive pulmonary disease that affects about eight to 10 percent of children and five to eight percent of adults in the U.S. Signs and symptoms include shortness of breath, wheezing, tightness in the chest and lasting cough. The potential adverse impact of a severe attack under water is obvious, and could be fatal. Arterial gas embolism (AGE) as a result of air trapping from the constriction and plugging characteristic of this disease has also been a frequent, but as yet inconclusive, concern.

Asthma Triggers
Asthma is a hypersensitivity of the respiratory tract, and can be triggered as a reaction to a variety of conditions including stress, cold or exercise, or allergens such as pollen and certain foods and medications. The asthmatic’s body reacts to these triggers, in varying order and severity, by constriction of smooth muscle in the bronchi and bronchioles, inflammation of the airway and increased mucous production. Attacks tend to be recurrent rather than continuous, and there is often much that can be done medically to reverse breathing difficulties when they do occur. In addition, since many of the precipitants of an attack are known, they can be avoided or controlled.

Diving with Asthma
Until the mid-1990s, asthma was largely considered an absolute contraindication to diving. However, thinking in the medical and professional dive community has rather radically altered since then, and those with asthma can now be certified under certain circumstances. Although they differ somewhat, the YMCA, BASC and Undersea and Hyperbaric Medicine Society each offer protocols guiding medical clearance to dive.

For example, the YMCA criteria include a requirement that all asthmatics have normal resting and exercise pulmonary function tests with no degradation after exercise. The criteria allow those taking routine preventative medications to be evaluated while continuing their treatment. Also required is the ability to exercise and tolerate stress without becoming symptomatic while on maintenance medications, and the absence of a need for “rescue” inhalers during times of stress or exertion.

If you suffer from asthma, it’s clearly unwise to deny or minimize this condition to yourself, or hide it from your instructor or the operators with whom you dive. Scuba can involve some of the asthma triggers discussed above, such as cold and exercise. If you have asthma and want to dive, or are already diving without medical clearance, it is critical that you consult a physician to obtain an appropriate pulmonary workup and permission to dive."

Hope you found this helpful.

DocVikingo

 

[scubadoc]

Agree with all that this might not be asthma - but you still want to find out what the abnormalities were that caused the doctor to make his/her decision not to certify your girl-friend for diving. These decisions are not made capriciously and should be looked into with a second opinion.

In addition, here is the diagnostic protocol for checking for asthma as recommended by the YMCA.

Asthmatic Screening for Potential SCUBA Students

1) Pulmonary Function Tests
a) normal resting and exercise studies (including normal tests for flow rates, static lung volumes, and vital capacity)
*There should not be a degradation in pulmonary function after exercise. To qualify for SCUBA training the drop in peak or mid expiratory flow between rest and exercise may not exceed 20 percent.
b) testing should be performed with patient on routine preventive medication
c) Methacholine challenge testing is contraindicated

2) Functionally Stable
a) the asthmatic is able to exercise and tolerate stress without becoming symptomatic while on his maintenance medications
b) asthmatic does not require "rescue" inhalers, etc. during times of stress or exertion

Hope this is helpful!

 

[Dean Harry]

Hi again...

c) Methacholine challenge testing is contraindicated

Do you know if this test can be acurate when the paitent has a cold or the flu?

She passed everything except this test.....

Thanks
Dean

 

[scubadoc]

Methacholine induces easily reversible bronchospasm in an individual with subclinical asthma, cough variant asthma, or exercise induced asthma.

Results might be affected by an respiratory infection. One should not eat or drink any food or liquid containing caffeine six hours before testing. This includes coffee, tea, cola, chocolate. Exercise and exposure to cold air should be avoided for at least two hours before testing. If there is a respiratory infection, this test will need to rescheduled. You need to be free from respiratory infections for six weeks prior to performing this challenge test.

The methacholine challenge test is used to determine the presence of reactive airway disease, which may occur whether or not chronic inflammation is present. If you have had severe bronchospasm (asthma attack) in the past the use of this test is possibly dangerous - and thus the contraindication of the test to find out if an asthmatic may dive.

The test probably should be repeated after her viral infection subsides and recommendations made on the basis of her history, further testing and second opinion.

 

[Heads Up]

I have allergy induced asthma and have been cleared to dive by a dive doctor. Similar to the above, I have not experienced any problems at depth. On the contrary, sometimes after a dive, I feel BETTER - my breathing feels 'refreshed' (the only way I can describe it). My queries are:

1. Anybody else experienced this?
2. (For the Docs) Have there been any studies into this (i.e. can breathing compressed air either at the surface or at depth be demonstrated to IMPROVE tidal flows etc?)

Just curious

 

[rcohn]

Scubadoc,

The methacholine challenge test is used to determine the presence of reactive airway disease, which may occur whether or not chronic inflammation is present. If you have had severe bronchospasm (asthma attack) in the past the use of this test is possibly dangerous - and thus the contraindication of the test to find out if an asthmatic may dive.

I thought the methacoline challenge was not recommended for screening divers because it only determines whether reactive airway disease is present, not whether the subject is well enough controlled to be cleared to dive. Therefore, an exercise stress test is used instead to determine whether an attack is likely to occur during a dive.

To: Heads up,

My asthma is very well controlled so I experience no changes when diving. I do have a friend who claims that diving improves breathing, so (for what it's worth) you are the second person from whom I've heard this claim.

Ralph

 

[scubadoc]

Ralph:

As usual, you are right on the money! The best way to live long and prosper is to get a chronic illness and learn all there is to know about it! You certainly have done that well with asthma.

There are some who feel that all asthma is hyper-responsive bronchoconstriction or reactive airway disease. Exercise is just another cause of this hyperresponsiveness. Recently, the feeling is that inflammation is a major player in the condition, exercise producing only the "early response" and not the "delayed response" with severe inflammation.

The distinction to be made is whether we are screening all divers for 'asthma' or screening asthmatics for control of their disease. In Dean Harry's friend, the problem is one of screening for the disease with Mecholyl and a possible false positive test due to respiratory infection. The test has been known to cause status asthmaticus (a dire emergency) in known asthmatics. This really gets the attention of the pulmonary lab folks in a big hurry.

However, methacholine challenge (or histamine challenge) is a good way to diagnose this hyper-responsiveness in an individual who is suspected of having asthma. It would not be a good way to measure the status of a known asthmatic or the effectiveness of a specific treatment. You are correct that it would not be a good screen for divers to test medication control; exercise testing would be indicated. This was not addressed in the response to Dean Harry, but only to specifically answer his query about his friend and her problem.

There is an excellent article on EIA at this web site:
http://www.physsportsmed.com/issues/jan_96/rupp.htm

 

[AllenP]

THIS IS NOT INTENDED TO BE A REPONSE TO Dean Harry

Asthma is caused by CHRONIC INFLAMATION of the airways, and this CHRONIC INFLAMATION causes them to be hyperresponsive.

Adding "triggers" to this underlying chronic inflamation can cause increased inflamation, increased mucus production, or bronchoconstriction. This is what people refer to as an "asthma attack".

It is important to remember that you still have asthma even when you are not having an attack.

This is ESPECIALLY important for SCUBA divers to remember, because the inflamation also causes mucus, which can "plug up" areas of the lungs, causing a risk of AGE. This chronic inflamation can be present along with these plugs, even when an "attack" is not underway.

I don't mean to discourage asthmatics from diving, there is a whole range of severity from mild to very severe, and there are guidleines already mentioned in other posts about this.

First, you MUST get a DIAGNOSIS from a physician. Not every wheeze means asthma. I highly recomend seeing a specialist if you are a diver, as I have personally seen a low level of understanding of asthma from doctors in my area.

Also, since divers must have EXCELLENT control of thier asthma, and since most asthmatics believe they are under better control than they actually are, I (again) say see a specialist.

You can learn a lot about asthma on the internet, if you have asthma and dive, you should learn as much as you can.

Some words for searches: global initiative asthma expert panel.

Some references:

From the Global Initiative for Asthma (WHO):

"Asthma is a chronic inflammatory disorder of the airways. Chronically inflamed airways are hyperresponsive; they become obstructed and airflow is limited (by bronchoconstriction, mucus plugs, and increased inflammation) when airways are exposed to various stimuli, or triggers." http://www.ginasthma.com/

http://www.ginasthma.com/workshop/ch1/one.html#keypoints

http://www.ginasthma.com/workshop/table.html

From the Expert Panel Report II:
Guidelines for Diagnosis and Management of Asthma
Final version of the report from the National Asthma Education and Prevention Program updating the 1991 Expert Panel Report
National Heart, Lung and Blood Institute
July 1997
NIH Pub. No. 97-4051:

"Asthma, whatever the severity, is a chronic inflammatory disorder of the airways. This has implications for the diagnosis, management, and potential prevention of the disease." http://www.ama-assn.org/special/asthma/treatmnt/guide/guidelin/pathogen/pathdef.htm